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Ebach DR, Jester TW, Galanko JA, Firestine AM, Ammoury R, Cabrera J, Bass J, Minar P, Olano K, Margolis P, Sandberg K, Linnville TM, Kaplan J, Pitch L, Steiner SJ, Bass D, Moses J, Adler J, Gulati AS, Wali P, Pashankar D, Ivanova A, Herfarth H, Wohl DA, Benkov KJ, Strople J, Sullivan J, Tung J, Molle-Rios Z, Saeed SA, Bousvaros A, Kappelman MD. High Body Mass Index and Response to Anti-Tumor Necrosis Factor Therapy in Pediatric Crohn's Disease. Am J Gastroenterol 2024:00000434-990000000-01056. [PMID: 38445644 DOI: 10.14309/ajg.0000000000002741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Obesity is common among patients with pediatric Crohn's disease (PCD). Some adult studies suggest obese patients respond less well to anti-tumor necrosis factor (TNF) treatment. This study sought compares anti-TNF response and anti-TNF levels between pediatric patients with normal and high body mass index (BMI). METHODS The COMBINE trial compared anti-TNF monotherapy with combination therapy with methotrexate in patients with PCD. In this secondary analysis, a comparison of time-to-treatment failure among patients with normal BMI vs BMI Z -score >1, adjusting for prescribed anti-TNF (infliximab [IFX] or adalimumab [ADA]), trial treatment assignment (combination vs monotherapy), and relevant covariates. Median anti-TNF levels across BMI category was also examined. RESULTS Of 224 participants (162 IFX initiators and 62 ADA initiators), 111 (81%) had a normal BMI and 43 (19%) had a high BMI. High BMI was associated with treatment failure among ADA initiators (7/10 [70%] vs 12/52 [23%], hazard ratio 0.29, P = 0.007) but not IFX initiators. In addition, ADA-treated patients with a high BMI had lower ADA levels compared with those with normal BMI (median 5.8 vs 12.8 μg/mL, P = 0.02). IFX trough levels did not differ between BMI groups. DISCUSSION Overweight and obese patients with PCD are more likely to experience ADA treatment failure than those with normal BMI. Higher BMI was associated with lower drug trough levels. Standard ADA dosing may be insufficient for overweight children with PCD. Among IFX initiators, there was no observed difference in clinical outcomes or drug levels, perhaps due to weight-based dosing and/or greater use of proactive drug monitoring.
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Affiliation(s)
- Dawn R Ebach
- Division of Gastroenterology, Hepatology, Pancreatology, and Nutrition, University of Iowa, Iowa City, Iowa, USA
| | - Traci W Jester
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph A Galanko
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ann M Firestine
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rana Ammoury
- Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
| | - Jose Cabrera
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Julie Bass
- Department of Pediatrics, Children's Mercy Medical Center, UMKC School of Medicine, Kansas City, Missouri, USA
| | - Phillip Minar
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Kelly Olano
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Peter Margolis
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Kelly Sandberg
- Boonshoft School of Medicine, Wright State University and Department of Medical Affairs, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Tiffany M Linnville
- Department of Pediatrics, Atrium Health Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Jess Kaplan
- Division of Pediatric Gastroenterology, Mass General Hospital for Children, Boston, Massachusetts, USA
| | | | - Steven J Steiner
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dorsey Bass
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, California, USA
| | - Jonathan Moses
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Medicine Children's Health, Palo Alto, California, USA
| | - Jeremy Adler
- Department of Pediatrics, University of Michigan-C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Prateek Wali
- Karjoo Family Center for Pediatric Gastroenterology, Hepatology, and Nutrition, Upstate Golisano Children's Hospital, SUNY Upstate Medical Center, Syracuse, New York, USA
| | - Dinesh Pashankar
- Pediatric Gastroenterology and Hepatology, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hans Herfarth
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - David A Wohl
- University of North Carolina Institute of Global Health and Infectious Diseases, Chapel Hill, North Carolina, USA
| | - Keith J Benkov
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer Strople
- Division of Pediatric Gastroenterology, Ann & Robert Lurie Children's Hospital, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jillian Sullivan
- Children's Hospital of Vermont, University of Vermont, Burlington, Vermont, USA
| | - Jeanne Tung
- Oklahoma Children's Hospital, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | | | - Shehzad A Saeed
- Boonshoft School of Medicine, Wright State University and Department of Medical Affairs, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Athos Bousvaros
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Boccieri M, Craig R, Zhang X, Firestine AM, Long MD, Kappelman MD. Racial and ethnic differences in the degree of participation and retention in a decentralized cohort study of COVID-19 immunization in patients with inflammatory bowel diseases. J Clin Transl Sci 2024; 8:e31. [PMID: 38384911 PMCID: PMC10880004 DOI: 10.1017/cts.2024.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/14/2023] [Accepted: 01/03/2024] [Indexed: 02/23/2024] Open
Abstract
Introduction Disparities in the recruitment of minority populations in research are well-documented. However, the degree of participation and retention of minorities following enrollment is less known, particularly in decentralized studies. Although decentralized clinical research methods may allow researchers to engage broader study populations with less participation burden, they may present different retention challenges. To evaluate racial and ethnic differences in the degree of participation after enrollment in a decentralized study, we analyzed data from a cohort of patients with inflammatory bowel diseases following COVID-19 immunization. Methods We compared by race and ethnicity the following post-enrollment participation metrics: response to > 50% of follow-up surveys, donation of a blood sample for antibody testing, consent to use of bio samples for future research, and withdrawal prior to study completion. Results Overall, we observed higher levels of post-enrollment study participation among non-Hispanic White (NHW) participants as compared to Black or Hispanic participants: 95% of NHW participants completed follow-up versus 87% of Black participants and 91% of Hispanic participants, 73% of NHW participants provided bio samples versus 64% Black participants and 67% Hispanic participants, and 65% of NHW participants provided consent for future research versus 62% of Black participants and 52% of Hispanic participants. Conclusions Our findings demonstrate that the degree of study participation after enrollment in this decentralized study differed by race and ethnicity, indicating that attention to diversity, equity, and inclusion is needed not only in clinical research recruitment but also throughout study administration.
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Affiliation(s)
- Margie Boccieri
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Riley Craig
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Xian Zhang
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Ann M. Firestine
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Millie D. Long
- Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Michael D. Kappelman
- Pediatric Gastroenterology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Kappelman MD, Wohl DA, Herfarth HH, Firestine AM, Adler J, Ammoury RF, Aronow JE, Bass DM, Bass JA, Benkov K, Berenblum Tobi C, Boccieri ME, Boyle BM, Brinkman WB, Cabera JM, Chun K, Colletti RB, Dodds CM, Dorsey JM, Ebach DR, Entrena E, Forrest CB, Galanko JA, Grunow JE, Gulati AS, Ivanova A, Jester TW, Kaplan JL, Kugathasan S, Kusek ME, Leibowitz IH, Linville TM, Lipstein EA, Margolis PA, Minar P, Molle Rios Z, Moses J, Olano KK, Osaba L, Palomo PJ, Pappa H, Park KT, Pashankar DS, Pitch L, Robinson M, Samson CM, Sandberg KC, Schuchard JR, Seid M, Shelly KA, Steiner SJ, Strople JA, Sullivan JS, Tung J, Wali P, Zikry M, Weinberger M, Saeed SA, Bousvaros A. Comparative Effectiveness of Anti-TNF in Combination with Low Dose Methotrexate vs Anti-TNF Monotherapy in Pediatric Crohn's Disease: a Pragmatic Randomized Trial. Gastroenterology 2023:S0016-5085(23)00538-3. [PMID: 37004887 DOI: 10.1053/j.gastro.2023.03.224] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS Tumor Necrosis Factor inhibitors (TNFi), including infliximab and adalimumab, are a mainstay of pediatric Crohn's disease (PCD) therapy; however, non-response and loss of response is common. As combination therapy with methotrexate may improve response, we performed a multi-center, randomized, double-blind, placebo-controlled pragmatic trial to compare TNFi with oral methotrexate to TNFi monotherapy. METHODS PCD patients initiating infliximab or adalimumab were randomized in 1:1 allocation to methotrexate or placebo and followed for 12-36 months. The primary outcome was a composite indicator of treatment failure. Secondary outcomes included anti-drug antibodies (ADA) and patient reported outcomes (PROs) of pain interference and fatigue. Adverse events (AEs) and Serious AEs (SAEs) were collected. RESULTS Of 297 participants (mean age 13.9 years, 35% female), 156 were assigned to methotrexate (110 infliximab initiators and 46 adalimumab initiators) and 141 to placebo (102 infliximab initiators and 39 adalimumab initiators). In the overall population, time to treatment failure did not differ by study arm (HR 0.69, 95% CI 0.45-1.05). Among infliximab initiators, there were no differences between combination and monotherapy (HR 0.93, 95% CI 0.55-1.56). Among adalimumab initiators, combination therapy was associated with longer time to treatment failure (HR 0.40, 95% CI 0.19-0.81). A trend towards lower ADA development in the combination therapy arm was not significant. [(infliximab OR 0.72 (0.49-1.07); adalimumab OR 0.71 (0.24-2.07)]. No differences in PROs were observed. Combination therapy resulted in more AEs but fewer SAEs. CONCLUSIONS Among adalimumab but not infliximab initiators, PCD patients treated with methotrexate combination therapy experienced a 2-fold reduction in treatment failure with a tolerable safety profile.
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Affiliation(s)
- Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David A Wohl
- Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC
| | - Ann M Firestine
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jeremy Adler
- Susan B. Meister Child Health Evaluation and Research Center and Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Rana F Ammoury
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, VA
| | | | - Dorsey M Bass
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Julie A Bass
- Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, MO, Division of Gastroenterology, Children's Mercy Kansas City, Kansas City, MO
| | - Keith Benkov
- Division of Pediatric Gastroenterology, Icahn School of Medicine at Mt Sinai, New York City, NY
| | | | - Margie E Boccieri
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Brendan M Boyle
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - William B Brinkman
- Department of Pediatrics, University of Cincinnati College of Medicine; Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jose M Cabera
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Kelly Chun
- Esoterix Specialty Laboratory, Labcorp, Calabasas, CA
| | - Richard B Colletti
- Division of Gastroenterology, Department of Pediatrics, University of Vermont, Burlington, VT
| | - Cassandra M Dodds
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jill M Dorsey
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nemours Children's Health, Jacksonville, FL
| | - Dawn R Ebach
- Division of Pediatric Gastroenterology, Hepatology, Pancreatology, and Nutrition, University of Iowa, Iowa City, IA
| | - Edurne Entrena
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia Spain
| | | | - Joseph A Galanko
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - John E Grunow
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, OK
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Traci W Jester
- Department of Pediatrics, Division of Gastroenterology, University of Alabama at Birmingham, AL
| | - Jess L Kaplan
- Division of Pediatric Gastroenterology, Mass General for Children and Harvard Medical School, Boston, MA
| | | | - Mark E Kusek
- Division of Gastroenterology, University of Nebraska Medical Center, Omaha, NE
| | - Ian H Leibowitz
- Division of Gastroenterology, Hepatology and Nutrition, Children's National Medical Center, Department of Pediatrics, George Washington University, Washington, DC
| | - Tiffany M Linville
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Levine Children's Hospital, Charlotte, NC
| | - Ellen A Lipstein
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, and Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peter A Margolis
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence, and Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Zarela Molle Rios
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Wilmington, DE
| | - Jonathan Moses
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, UH Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Kelly K Olano
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lourdes Osaba
- Progenika Biopharma, a Grifols Company, Derio, Bizkaia Spain
| | - Pablo J Palomo
- Division of Pediatric Gastroenterology, Nemours Children's Hospital, Orlando, FL
| | - Helen Pappa
- Division of Pediatric Gastroenterology, Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, Saint Louis, MO
| | - K T Park
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Dinesh S Pashankar
- Section of Pediatric Gastroenterology & Hepatology, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, CT
| | | | - Michelle Robinson
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Charles M Samson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kelly C Sandberg
- Department of Gastroenterology, Dayton Children's Hospital, Boonshoft School of Medicine, Wright State University, Dayton, OH
| | - Julia R Schuchard
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michael Seid
- Department of Pediatrics, University of Cincinnati College of Medicine; Division Pulmonary Medicine and the James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kimberly A Shelly
- Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Steven J Steiner
- Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Jennifer A Strople
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Jillian S Sullivan
- The University of Vermont Children's Hospital and Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, VT
| | - Jeanne Tung
- University of Oklahoma Children's Physicians, Pediatric Gastroenterology, Oklahoma City, OK
| | - Prateek Wali
- Division of Gastroenterology, Hepatology, and Nutrition, State University of New York Upstate Medical University, Syracuse, NY
| | - Michael Zikry
- Esoterix Specialty Laboratory, Labcorp, Calabasas, CA
| | - Morris Weinberger
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Shehzad A Saeed
- Boonshoft School of Medicine, Wright State University, Associate Chief Medical Officer, Physician Lead, Patient and Family Experience, Dayton Children's Hospital, Dayton OH
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
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Fredrickson BL, Grewen KM, Algoe SB, Firestine AM, Arevalo JMG, Ma J, Cole SW. Psychological well-being and the human conserved transcriptional response to adversity. PLoS One 2015; 10:e0121839. [PMID: 25811656 PMCID: PMC4374902 DOI: 10.1371/journal.pone.0121839] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 02/16/2015] [Indexed: 01/02/2023] Open
Abstract
Research in human social genomics has identified a conserved transcriptional response to adversity (CTRA) characterized by up-regulated expression of pro-inflammatory genes and down-regulated expression of Type I interferon- and antibody-related genes. This report seeks to identify the specific aspects of positive psychological well-being that oppose such effects and predict reduced CTRA gene expression. In a new confirmation study of 122 healthy adults that replicated the approach of a previously reported discovery study, mixed effect linear model analyses identified a significant inverse association between expression of CTRA indicator genes and a summary measure of eudaimonic well-being from the Mental Health Continuum – Short Form. Analyses of a 2- representation of eudaimonia converged in finding correlated psychological and social subdomains of eudaimonic well-being to be the primary carriers of CTRA associations. Hedonic well-being showed no consistent CTRA association independent of eudaimonic well-being, and summary measures integrating hedonic and eudaimonic well-being showed less stable CTRA associations than did focal measures of eudaimonia (psychological and social well-being). Similar results emerged from analyses of pooled discovery and confirmation samples (n = 198). Similar results also emerged from analyses of a second new generalization study of 107 healthy adults that included the more detailed Ryff Scales of Psychological Well-being and found this more robust measure of eudaimonic well-being to also associate with reduced CTRA gene expression. Five of the 6 major sub-domains of psychological well-being predicted reduced CTRA gene expression when analyzed separately, and 3 remained distinctively prognostic in mutually adjusted analyses. All associations were independent of demographic characteristics, health-related confounders, and RNA indicators of leukocyte subset distribution. These results identify specific sub-dimensions of eudaimonic well-being as promising targets for future interventions to mitigate CTRA gene expression, and provide no support for any independent favorable contribution from hedonic well-being.
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Affiliation(s)
- Barbara L Fredrickson
- Department of Psychology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Karen M Grewen
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Sara B Algoe
- Department of Psychology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Ann M Firestine
- Department of Psychology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Jesusa M G Arevalo
- Department of Medicine, UCLA School of Medicine, Los Angeles, California, United States of America
| | - Jeffrey Ma
- Department of Medicine, UCLA School of Medicine, Los Angeles, California, United States of America
| | - Steve W Cole
- Department of Medicine, UCLA School of Medicine, Los Angeles, California, United States of America; Jonsson Comprehensive Cancer Center, UCLA School of Medicine, Los Angeles, California, United States of America; Norman Cousins Center, UCLA School of Medicine, Los Angeles, California, United States of America; UCLA AIDS Institute, Los Angeles, California, United States of America; UCLA Molecular Biology Institute, Los Angeles, California, United States of America
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