Shared Decision-Making and Cardiovascular Complications of Androgen Deprivation Therapy: an Educational Initiative for Oncology Team Members in Colorado, USA.

Patients with prostate cancer may experience side effects of androgen deprivation therapy (ADT) such as cardiovascular (CV) complications. Oncology team members should actively communicate with patients about these complications. On the other hand, shared decision-making (SDM) has been shown to improve patient-physician communication. We developed brochures focused on CV complications of ADT and SDM. We proceeded to deliver these brochures to participating oncology offices and then carried out a survey of team members in these offices. We obtained responses from 31 oncology team members. Our survey revealed that about half of the participants (48%) rarely applied SDM in their oncology practice, and only about one-third (32%) sometimes applied SDM. After reading our brochures, the majority of respondents could correctly answer questions about SDM and CV complications of ADT. Improvement in scores after reading our materials was significant for both CV complications of ADT and SDM (e.g., CV complications of ADT: z = 6.153, p-value < 0.001, and SDM z = 6.456, p-value < 0.001). Implementation of SDM and an improved awareness of the CV complications of ADT can lead to significant benefits. It is therefore important to take steps to further raise such implementation and awareness among oncology team members in other geographic locations and clinical settings.

Knowledge and awareness of biosimilars among oncology patients in Colorado, USA.

Aim: We aimed to improve oncology patients' knowledge and awareness of biosimilars. Subsequently, we conducted an assessment of this knowledge by use of an anonymous online survey. Patients & methods: Printed materials discussing major topics related to biosimilars were developed during Phase I of our educational initiative. The brochures contained a link to the online survey. Results: A total of 79 patients responded to our survey. More than 70% of survey participants selected the correct definition of biosimilars and nearly 80% did so on questions focused on regulation, adverse reactions reporting and cost issues related to biosimilars. Conclusion: Our results indicate a good level of both knowledge and awareness of major topics concerning biosimilars among our survey participants.

Enhancing knowledge and awareness of transthyretin cardiac amyloidosis and shared decision-making among cardiology team members in Colorado, USA via an online educational initiative.

OBJECTIVES: Our project aimed to increase knowledge of noninvasive diagnostic modalities (including bone radiotracer scintigraphy), raise suspicion of transthyretin cardiac amyloidosis (ATTR-CA), and improve cardiology team member's awareness and knowledge of shared decision-making (SDM), as well as the quality of SDM communication between cardiology team members and patients. METHODS: An online educational module and survey was developed and cardiology team members in Colorado, USA, were invited to participate. This online educational module included various important topics related to ATTR-CA (e.g., the cause of ATTR-CA, endomyocardial biopsy, and noninvasive methods to diagnose ATTR-CA) and SDM (e.g., benefits of SDM, the role of SDM in the diagnosis of ATTR-CA, implementation of SDM in cardiology practice, and the 3-talk model). RESULTS: There were 34 survey respondents, over one-third of whom were cardiologists. Most respondents agreed on the importance of diagnosing ATTR-CA at an early stage, and about three-quarters of the survey takers agreed that bone scintigraphy can reliably diagnose ATTR-CA without the need for endomyocardial biopsy. Concern over increased time commitment was the leading barrier to the implementation of SDM in respondents' clinical practice. The majority of respondents identified the correct answer regarding ATTR-CA and SDM after reading the online educational module. This improvement in scores after exposure to the online educational module was statistically significant. CONCLUSION: Baseline knowledge and awareness of various issues related to ATTR-CA was relatively low among cardiology team members. Participants' knowledge was enhanced through our effective online educational program. Prospective educational projects focused on various methods of detecting ATTR-CA as well as other amyloid conditions in diverse clinical settings will remain important.

Improving awareness of several combination therapies for acute myeloid leukemia among oncology and hematology team members in Colorado, USA.

INTRODUCTION: Although several combination therapies for acute myeloid leukemia (AML) have emerged recently, there has been a lack of published surveys and educational projects focused on these important treatment options. We aimed to improve the oncology team members' knowledge and awareness of several FDA approved combination therapies for AML, including glasdegib (DAURISMO®), venetoclax (VENCLEXTA®), GO (MYOLOTARG®),CPX-351 (VYXEOS®), and midostaurin (RYDAPT®). Additionally, we aimed to examine these teams' perspectives, views, and attitudes towards these topics and finally identify barriers to the implementationof such therapies in clinical practice. METHOD: Initially, we developed booklets and then distributed them to each participating oncology and hematology office. Subsequently, all participating oncology and hematology team members were asked to complete an anonymous online survey to test their knowledge of and attitudes toward the subjects. MAIN RESULTS: There was a total of 52 survey respondents. The correct answer regarding various combination therapies for AML was identified by nearly 70% or more of survey takers. The level of awareness of project subjects significantly improved after reading our printing materials. Many survey respondents were motivated to learn more about combination therapies for AML as well as discuss these topics with others. CONCLUSIONS: Our booklets effectively improved understanding and awareness of combination therapies for AML. Future studies should explore awareness, knowledge, and perception of other new and emerging combination therapies for AML among oncology and hematology team members in other areas.

Knowledge and awareness of biosimilars and shared decision-making among gastroenterology team members in Colorado, USA.

Background: There are gaps in gastroenterologist team members' understanding of various topics related to biosimilars. We aimed to examine perspectives, views, and attitudes toward biosimilar and shared decision-making (SDM) among gastroenterology team members in Colorado, USA. The ultimate goal was to increase knowledge and awareness of biosimilars and SDM. Research design and methods: We developed educational materials focused on biosimilars and SDM and distributed them to each participating gastroenterology office. Subsequently, we conducted a survey of all team members from participating offices. Results: Responses were obtained from 54 gastroenterology team members. Most respondents identified the correct answer regarding biosimilars, the nocebo effect, and SDM. Almost half (47.2%) of respondents scored their level of awareness regarding biosimilars prior to reading our educational materials as poor, and nearly one quarter (26.4%) indicated so for SDM. Improvement in scores after reading our materials was significant for both biosimilars and SDM (i.e. biosimilar: z = 6.276, p-value <0.001 and SDM z = 6.328, p-value <0.001). Conclusions: Educational efforts effectively increased the low baseline knowledge and awareness of biosimilars and SDM among gastroenterology team members. More educational projects focused on biosimilars and SDM are needed to reduce the nocebo effect and prevent hampering of the cost-savings of biosimilars.

Changing trends in the evaluation of ejection fraction in patients hospitalized with acute myocardial infarction: the Worcester Heart Attack Study.

BACKGROUND: Extent of left ventricular dysfunction in patients with acute myocardial infarction (AMI) is an important predictor of subsequent morbidity and mortality. It is unclear, however, how often ejection fraction (EF) findings are evaluated in the setting of AMI, and the characteristics of patients who do not have their EF evaluated, particularly from the more generalizable perspective of a population-based investigation. PURPOSE: The purpose of this study was to examine nearly 3 decade long trends (1975-2003) in the evaluation of EF in patients admitted with confirmed AMI (n = 12,760) to all greater Worcester (Massachusetts) hospitals during 14 annual periods. RESULTS: The percentage of patients undergoing evaluation of EF before hospital discharge increased substantially between 1975 (4%) and 2003 (73%). Despite these encouraging trends, approximately one quarter of patients in our most recent study year did not receive an EF evaluation. In the mid-1970s through mid-1980s, radionuclide ventriculography was typically used to assess EF, whereas echocardiography was most often used to evaluate EF during more recent periods. Predictors of not undergoing an evaluation of cardiac function included older age, shorter length of hospital stay, code status limitations, dying during hospitalization, Medicare insurance, several comorbidities, and a recent non-Q-wave myocardial infarction. CONCLUSIONS: The results of this community-wide study suggest that a considerable proportion of patients with AMI fail to have their EF evaluated. Efforts remain needed to optimize the use of cardiac imaging studies and link the results of these studies to improved patient outcomes.

Therapies for acute heart failure in patients with reduced kidney function: a community-based perspective.

BACKGROUND: Limited data exist describing the management of patients with decreased kidney function at the time of hospital presentation for acute heart failure (HF). STUDY DESIGN: Nonconcurrent prospective study. SETTING & PARTICIPANTS: Patients hospitalized with clinical findings of decompensated HF (n = 4,350) at all 11 greater Worcester, MA, medical centers in 1995 and 2000. Patients were categorized into varying levels of kidney function based on their estimated glomerular filtration rate (eGFR). PREDICTOR: GFR estimates from serum creatinine levels measured at the time of hospital admission. OUTCOMES: Hospital receipt of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), beta-blockers, digoxin, and diuretics. MEASUREMENTS: Hospital charts were reviewed for prescribing of disease-modifying cardiac therapies, as well as therapies designed to provide symptomatic relief from HF. RESULTS: Average eGFR in our study sample was 64.4 +/- 33.1 mL/min/1.73 m(2), and patients were categorized further into 3 eGFR levels of less than 30 (n = 569), 30 to 59 (n = 1,488), and 60 mL/min/1.73 m(2) or greater (n = 2,293) for comparative purposes. Patients with greater eGFRs (>or=60 mL/min/1.73 m(2)) were more likely to be treated with ACE inhibitors/ARBs (56% versus 39%) and digoxin (51% versus 46%) during hospitalization for HF than patients with lower eGFRs (<30 mL/min/1.73 m(2); P < 0.05). Patients with lower eGFRs (<30 mL/min/1.73 m(2)) were more likely to be prescribed beta-blockers than patients with greater eGFRs (>or=60 mL/min/1.73 m(2); 46% versus 39%; P < 0.01). Use of ACE inhibitors/ARBs increased between 1995 and 2000 in 2 of the 3 eGFR groups examined: eGFRs less than 30 mL/min/1.73 m(2) (33% in 1995; 42% in 2000) and eGFRs of 60 mL/min/1.73 m(2) or greater (51% in 1995; 59% in 2000). Use of beta-blockers increased appreciably in all 3 eGFR groups (<30 mL/min/1.73 m(2), 27% in 1995; 58% in 2000; >or=60 mL/min/1.73 m(2): 25% in 1995; 49% in 2000). However, less than one third of all patients were treated with both disease-modifying therapies in 2000. LIMITATIONS: We were unable to classify patients into those with systolic versus diastolic HF. CONCLUSIONS: Our results suggest that use of disease-modifying therapies for patients hospitalized with clinical findings of acute HF and decreased kidney function remains less than desirable. Educational programs are needed to enhance the management of patients with decreased kidney function who develop HF.

Biosimilar Knowledge Among Oncology/Hematology Team Members in Colorado, USA: An Educational Initiative and Follow-Up Survey.

BACKGROUND: No data exist regarding oncology/hematology team members' knowledge of and views on biosimilars in Colorado, USA. Published research has suggested that health professionals may have a poor understanding of many issues related to biosimilars. OBJECTIVES: Our goal was to increase oncology/hematology team members' knowledge of biosimilars and then use an anonymous online survey to assess the knowledge gained. We also aimed to examine oncology/hematology team members' overall interest in the subject and their motivation to learn more about biosimilars in the future. METHODS: In phase I of the project, we developed printed materials covering many topics related to biosimilars, such as definition, regulation, and interchangeability, and the potential of biosimilars in optimal combination therapy for cancer. We distributed our brochures to each participating oncology/hematology office in Colorado. The oncology/hematology team members were then asked to complete the survey. RESULTS: A total of 62 team members responded to our survey. Nearly three-quarters of participants were oncology nurses or oncology nurse practitioners. More than 90% of survey respondents identified correct answers about the definition, regulations, interchangeability, safety, cost issues, and use of biosimilars in oncology and in older patients with cancer. Overall, and compared with those who had low levels of interest and motivation, significantly more (p < 0.05) study participants were interested in the subject of biosimilars [57 (92%) vs. 5 (8%)], motivated to learn more about them [59 (95%) vs. 3 (5%)], and interested in sharing information about biosimilars with colleagues and patients [51 (82%) vs. 11 (18%)]. CONCLUSION: Our results demonstrate that oncology/hematology team members participating in our study became familiar with many important issues related to biosimilars. Many survey respondents were highly motivated to participate in future training focused on biosimilars, which should pave the way for new educational projects in the area.

Decompensated heart failure in the setting of kidney dysfunction: a community-wide perspective.

BACKGROUND: Patients with heart failure (HF) and kidney disease have a poor long-term outlook which has provided impetus for the identification of factors of prognostic importance and more fully understanding the impact of kidney dysfunction in patients with HF. OBJECTIVES: Our objectives were to describe the characteristics, hospital treatment practices, as well as hospital and long-term outcomes in patients with varying degrees of kidney dysfunction who were hospitalized with acute HF at all medical centers in a large New England metropolitan area. METHODS: Residents of the Worcester metropolitan area hospitalized with clinical findings of decompensated HF at 11 greater Worcester medical centers during 1995 and 2000 comprised the study sample. Kidney function was classified into 4 categories of estimated glomerular filtration rate (eGFR) for purposes of analysis: <30 (n = 569), 30-44 (n = 725), 45-59 (n = 763), and > or =60 (n = 2,293) ml/min per 1.73 m(2). RESULTS: The average age of the study sample was 76 years and 57% were women. Patients with severe kidney dysfunction were less likely to receive angiotensin-converting enzyme inhibitors, diuretics and digoxin during hospitalization for acute HF compared to patients with more normal kidney function. Patients with lower eGFR levels had higher in-hospital and post-discharge death rates in comparison to those with higher levels of eGFR. CONCLUSION: Our results demonstrate the impact of renal impairment on the prognosis of patients with decompensated HF. Our findings highlight the less than optimal management of these high-risk patients. Increased surveillance and enhanced treatment of patients with HF and kidney dysfunction remains warranted to improve the survival outlook of these patients.

Improving awareness of several combination therapies for acute myeloid leukemia among oncology and hematology team members in Colorado, USA

ABSTRACT Introduction: Although several combination therapies for acute myeloid leukemia (AML) have emerged recently, there has been a lack of published surveys and educational projects focused on these important treatment options. We aimed to improve the oncology team members' knowledge and awareness of several FDA approved combination therapies for AML, including glasdegib (DAURISMO®), venetoclax (VENCLEXTA®), GO (MYOLOTARG®),CPX-351 (VYXEOS®), and midostaurin (RYDAPT®). Additionally, we aimed to examine these teams' perspectives, views, and attitudes towards these topics and finally identify barriers to the implementationof such therapies in clinical practice. Method: Initially, we developed booklets and then distributed them to each participating oncology and hematology office. Subsequently, all participating oncology and hematology team members were asked to complete an anonymous online survey to test their knowledge of and attitudes toward the subjects. Main results: There was a total of 52 survey respondents. The correct answer regarding various combination therapies for AML was identified by nearly 70% or more of survey takers. The level of awareness of project subjects significantly improved after reading our printing materials. Many survey respondents were motivated to learn more about combination therapies for AML as well as discuss these topics with others. Conclusions: Our booklets effectively improved understanding and awareness of combination therapies for AML. Future studies should explore awareness, knowledge, and perception of other new and emerging combination therapies for AML amongoncology and hematology team members in other areas.

Mathematical model of blunt injury to the vascular wall via formation of rouleaux and changes in local hemodynamic and rheological factors. Implications for the mechanism of traumatic myocardial infarction.

BACKGROUND: Blood viscosity is fundamentally important in clinical practice yet the apparent viscosity at very low shear rates is not well understood. Various conditions such as blunt trauma may lead to the appearance of zones inside the vessel where shear stress equals zero. The aim of this research was to determine the blood viscosity and quantitative aspects of rouleau formation from erythrocytes at yield velocity (and therefore shear stress) equal to zero. Various fundamental differential equations and aspects of multiphase medium theory have been used. The equations were solved by a method of approximation. Experiments were conducted in an aerodynamic tube. RESULTS: The following were determined: (1) The dependence of the viscosity of a mixture on volume fraction during sedimentation of a group of particles (forming no aggregates), confirmed by published experimental data on the volume fractions of the second phase (f2) up to 0.6; (2) The dependence of the viscosity of the mixture on the volume fraction of erythrocytes during sedimentation of rouleaux when yield velocity is zero; (3) The increase in the viscosity of a mixture with an increasing erythrocyte concentration when yield velocity is zero; (4) The dependence of the quantity of rouleaux on shear stress (the higher the shear stress, the fewer the rouleaux) and on erythrocyte concentration (the more erythrocytes, the more rouleaux are formed). CONCLUSIONS: This work represents one of few attempts to estimate extreme values of viscosity at low shear rate. It may further our understanding of the mechanism of blunt trauma to the vessel wall and therefore of conditions such as traumatic acute myocardial infarction. Such estimates are also clinically significant, since abnormal values of blood viscosity have been observed in many pathological conditions such as traumatic crush syndrome, cancer, acute myocardial infarction and peripheral vascular disease.

Trauma associated with acute myocardial infarction in a multi-state hospitalized population.

INTRODUCTION: Trauma has been suggested, in case series, as one of the nonatherosclerotic mechanisms leading to acute myocardial infarction (AMI), the leading cause of death in the US. AMI following non-penetrating injury has been shown to carry significant morbidity and mortality. OBJECTIVE: To determine whether hospitalized injuries in a large multi state population are associated with increased risk of AMI during the initial hospital stay. METHODS: Statewide injury hospital discharge data were collected from 19 states in 1997. Affected body regions of interest included thoracic, abdominal or pelvic, spine or back and blunt cardiac injury (BCI). The outcome of interest was AMI which was identified based on ICD-9-CM discharge diagnoses for the same visit. Unadjusted and adjusted multivariate logistic regression analyses were performed. RESULTS: Independent of confounding factors and coronary arteriography (CA) status, BCI was associated with 2.6-fold increased risk for AMI in persons 46 years or older. When the diagnosis of AMI was confirmed by CA, BCI was associated with 8-fold risk elevation among patients 46 years and older and a 31-fold elevation among patients 45 years and younger. Abdominal or pelvic trauma, irrespective of confounding factors and CA status, was associated with a 65% increase in the risk of AMI among patients 45 years and younger and 93% increase in the risk of among patients 46 years and older. When the diagnosis of AMI was confirmed by CA, abdominal or pelvic trauma was associated with 6-fold risk elevation among patients 46 years and older. CONCLUSION: Direct trauma to the heart, as characterized by a diagnosis of BCI, was observed to carry the greatest risk for AMI. Abdominal or pelvic trauma also increased the risk for AMI. Longitudinal studies are warranted to better understand the relationship between trauma and AMI.

Mathematical model describing erythrocyte sedimentation rate. Implications for blood viscosity changes in traumatic shock and crush syndrome.

BACKGROUND: The erythrocyte sedimentation rate (ESR) is a simple and inexpensive laboratory test, which is widespread in clinical practice, for assessing the inflammatory or acute response. This work addresses the theoretical and experimental investigation of sedimentation a single and multiple particles in homogeneous and heterogeneous (multiphase) medium, as it relates to their internal structure (aggregation of solid or deformed particles). METHODS: The equation system has been solved numerically. To choose finite analogs of derivatives we used the schemes of directional differences. RESULTS: (1) Our model takes into account the influence of the vessel wall on group aggregation of particles in tubes as well as the effects of rotation of particles, the constraint coefficient, and viscosity of a mixture as a function of the volume fraction. (2) This model can describe ESR as a function of the velocity of adhesion of erythrocytes; (3) Determination of the ESR is best conducted at certain time intervals, i.e. in a series of periods not exceeding 5 minutes each; (4) Differential diagnosis of various diseases by means of ESR should be performed using the aforementioned timed measurement of ESR; (5) An increase in blood viscosity during trauma results from an increase in rouleaux formation and the time-course method of ESR will be useful in patients with trauma, in particular, with traumatic shock and crush syndrome. CONCLUSION: The mathematical model created in this study used the most fundamental differential equations that have ever been derived to estimate ESR. It may further our understanding of its complex mechanism.

Blunt trauma to large vessels: a mathematical study.

BACKGROUND: Blunt trauma causes short-term compression of some or all parts of the chest, abdomen or pelvis and changes hemodynamics of the blood. Short-term compression caused by trauma also results in a short-term decrease in the diameter of blood vessels. It has been shown that with a sudden change in the diameter of a tube or in the direction of the flow, the slower-moving fluid near the wall stops or reverses direction, which is known as boundary layer separation (BLS). We hypothesized that a sudden change in the diameter of elastic vessel that results from compression may lead not only to BLS but also to other hemodynamic changes that can damage endothelium. METHODS: We applied Navier-Stokes, multiphase and boundary layer equations to examine such stress. The method of approximation to solve the BL equations was used. Experiments were conducted in an aerodynamic tube, where incident flow velocity and weight of carriage with particles before and after blowing were measured. RESULTS: We found that sudden compression resulting from trauma leads to (1) BLS on the curved surface of the vessel wall; (2) transfer of laminar boundary layer into turbulent boundary layer. Damage to the endothelium can occur if compression is at least 25% and velocity is greater than 2.4 m/s or if compression is at least 10% and velocity is greater than 2.9 m/s. CONCLUSION: Our research may point up new ways of reducing the damage from blunt trauma to large vessels. It has the potential for improvement of safety features of motor vehicles. This work will better our understanding of the precise mechanics and critical variables involved in diagnosis and prevention of blunt trauma to large vessels.

Circle of Willis atherosclerosis, Alzheimer's disease and the Dean number.

The important role of atherosclerosis in pathophysiology of Alzheimer's Disease has become evident. Mechanisms such as hyperlipidemia, inflammation, abdominal obesity and insulin resistance are important yet they may not fully explain the specific involvement of the Circle of Willis in these pathologies. The Circle of Wills is a complex geometrical structure which has several areas with different curvature as well as various branching angles of vessels composing the circle. The hemodynamics in this region should take into account the Dean number which indicates the influence of curvature on the resistance to blood flow. Thus, areas with various curvature and angles may have different hemodynamics and there are certain areas in the Circle of Willis that are more likely to develop atherosclerotic changes. Therefore, this could suggest the novel pathophysiological pathway resulting from the geometric peculiarities of the Circle of Willis. One of the directions of future research is to examine whether specific areas of the Circle of Willis are more likely to develop atherosclerotic changes compared to other ones. Selective areas of the Circle of Willis affected by atherosclerotic changes could indicate the primary role of atherosclerosis promoting Alzheimer's disease although other pathophysiological mechanisms suggesting the opposite direction should be also examined in prospective studies.

The role of erythropoietin in the "stroke belt" phenomenon.

Global geographic disparities in stroke mortality rates are substantial. In the US alone, higher stroke mortality rates are reported in the Southeast part particularly along the coastline while lower rates have been observed in the Mountain region. The phenomenon has been called the "stroke belt". Although many theories have attempted to explain such nonrandom distribution of stroke mortality rates, no conclusive explanations have been drawn so far. I hypothesize that this nonrandom stroke distribution is related to regional differences in individual levels of erythropoietin (EPO), a hormone, which production depends on the tissue hypoxia due to variation in altitude. If successful, future studies based on this hypothesis may open up new avenues for treatment of such an important health issue as stroke. More importantly, future studies based on this theory may shed the lights on the mechanism of stroke as well as other diseases which have nonrandom geographic distribution not only in the US but also internationally.