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Ogilvie RP, Layton JB, Lloyd PC, Jiao Y, Djibo DA, Wong HL, Gruber JF, Parambi R, Deng J, Miller M, Song J, Weatherby LB, Peetluk L, Lo AC, Matuska K, Wernecke M, Bui CL, Clarke TC, Cho S, Bell EJ, Yang G, Amend KL, Forshee RA, Anderson SA, McMahill-Walraven CN, Chillarige Y, Anthony MS, Seeger JD, Shoaibi A. Effectiveness of BNT162b2 COVID-19 primary series vaccination in children aged 5-17 years in the United States: a cohort study. BMC Pediatr 2024; 24:276. [PMID: 38671379 PMCID: PMC11047006 DOI: 10.1186/s12887-024-04756-5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND COVID-19 vaccines are authorized for use in children in the United States; real-world assessment of vaccine effectiveness in children is needed. This study's objective was to estimate the effectiveness of receiving a complete primary series of monovalent BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine in US children. METHODS This cohort study identified children aged 5-17 years vaccinated with BNT162b2 matched with unvaccinated children. Participants and BNT162b2 vaccinations were identified in Optum and CVS Health insurance administrative claims databases linked with Immunization Information System (IIS) COVID-19 vaccination records from 16 US jurisdictions between December 11, 2020, and May 31, 2022 (end date varied by database and IIS). Vaccinated children were followed from their first BNT162b2 dose and matched to unvaccinated children on calendar date, US county of residence, and demographic and clinical factors. Censoring occurred if vaccinated children failed to receive a timely dose 2 or if unvaccinated children received any dose. Two COVID-19 outcome definitions were evaluated: COVID-19 diagnosis in any medical setting and COVID-19 diagnosis in hospitals/emergency departments (EDs). Propensity score-weighted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with Cox proportional hazards models, and vaccine effectiveness (VE) was estimated as 1 minus HR. VE was estimated overall, within age subgroups, and within variant-specific eras. Sensitivity, negative control, and quantitative bias analyses evaluated various potential biases. RESULTS There were 453,655 eligible vaccinated children one-to-one matched to unvaccinated comparators (mean age 12 years; 50% female). COVID-19 hospitalizations/ED visits were rare in children, regardless of vaccination status (Optum, 41.2 per 10,000 person-years; CVS Health, 44.1 per 10,000 person-years). Overall, vaccination was associated with reduced incidence of any medically diagnosed COVID-19 (meta-analyzed VE = 38% [95% CI, 36-40%]) and hospital/ED-diagnosed COVID-19 (meta-analyzed VE = 61% [95% CI, 56-65%]). VE estimates were lowest among children 5-11 years and during the Omicron-variant era. CONCLUSIONS Receipt of a complete BNT162b2 vaccine primary series was associated with overall reduced medically diagnosed COVID-19 and hospital/ED-diagnosed COVID-19 in children; observed VE estimates differed by age group and variant era. REGISTRATION The study protocol was publicly posted on the BEST Initiative website ( https://bestinitiative.org/wp-content/uploads/2022/03/C19-VX-Effectiveness-Protocol_2022_508.pdf ).
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Affiliation(s)
| | - J Bradley Layton
- RTI Health Solutions, 3040 East Cornwallis Rd, PO Box 12194, Research Triangle Park, NC, 27709, USA.
| | | | | | | | - Hui Lee Wong
- US Food and Drug Administration, Silver Spring, MD, USA
| | | | | | - Jie Deng
- Optum Epidemiology, Boston, MA, USA
| | | | | | | | | | | | | | | | - Christine L Bui
- RTI Health Solutions, 3040 East Cornwallis Rd, PO Box 12194, Research Triangle Park, NC, 27709, USA
| | | | - Sylvia Cho
- US Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | | | | | - Mary S Anthony
- RTI Health Solutions, 3040 East Cornwallis Rd, PO Box 12194, Research Triangle Park, NC, 27709, USA
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Layton JB, Peetluk L, Wong HL, Jiao Y, Djibo DA, Bui C, Lloyd PC, Gruber JF, Miller M, Ogilvie RP, Deng J, Parambi R, Song J, Weatherby LB, Lo AC, Matuska K, Wernecke M, Clarke TC, Cho S, Bell EJ, Seeger JD, Yang GW, Illei D, Forshee RA, Anderson SA, McMahill-Walraven CN, Chillarige Y, Amend KL, Anthony MS, Shoaibi A. Effectiveness of monovalent COVID-19 booster/additional vaccine doses in the United States. Vaccine X 2024; 16:100447. [PMID: 38318230 PMCID: PMC10840109 DOI: 10.1016/j.jvacx.2024.100447] [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: 11/13/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 02/07/2024] Open
Abstract
Background Monovalent booster/additional doses of COVID-19 vaccines were first authorized in August 2021 in the United States. We evaluated the real-world effectiveness of receipt of a monovalent booster/additional dose of COVID-19 vaccine compared with receiving a primary vaccine series without a booster/additional dose. Methods Cohorts of individuals receiving a COVID-19 booster/additional dose after receipt of a complete primary vaccine series were identified in 2 administrative insurance claims databases (Optum, CVS Health) supplemented with state immunization information system data between August 2021 and March 2022. Individuals with a complete primary series but without a booster/additional dose were one-to-one matched to boosted individuals on calendar date, geography, and clinical factors. COVID-19 diagnoses were identified in any medical setting, or specifically in hospitals/emergency departments (EDs). Propensity score-weighted hazards ratios (HRs) and 95% confidence intervals (CI) were estimated with Cox proportional hazards models; vaccine effectiveness (VE) was estimated as 1 minus the HR by vaccine brand overall and within subgroups of variant-specific eras, immunocompromised status, and homologous/heterologous booster status. Results Across both data sources, we identified 752,165 matched pairs for BNT162b2, 410,501 for mRNA-1273, and 11,398 for JNJ-7836735. For any medically diagnosed COVID-19, meta-analyzed VE estimates for BNT162b2, mRNA-1273, and JNJ-7836735, respectively, were: BNT162b2, 54% (95% CI, 53%-56%); mRNA-1273, 58% (95% CI, 56%-59%); JNJ-7836735, 34% (95% CI, 23%-44%). For hospital/ED-diagnosed COVID-19, VE estimates ranged from 70% to 76%. VE was generally lower during the Omicron era than the Delta era and for immunocompromised individuals. There was little difference observed by homologous or heterologous booster status. Conclusion The original, monovalent booster/additional doses were reasonably effective in real-world use among the populations for which they were indicated during the study period. Additional studies may be informative in the future as new variants emerge and new vaccines become available.Registration: The study protocol was publicly posted on the BEST Initiative website (https://bestinitiative.org/wp-content/uploads/2022/03/C19-VX-Effectiveness-Protocol_2022_508.pdf).
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Affiliation(s)
| | | | - Hui Lee Wong
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | | | | | - Christine Bui
- RTI Health Solutions, Research Triangle Park, NC, USA
| | - Patricia C. Lloyd
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | - Joann F. Gruber
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | | | | | - Jie Deng
- Optum Epidemiology, Boston, MA, USA
| | | | | | | | | | | | | | - Tainya C. Clarke
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | - Sylvia Cho
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | | | | | | | | | - Richard A. Forshee
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | - Steven A. Anderson
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | | | | | | | | | - Azadeh Shoaibi
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
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Northuis CA, Bell EJ, Lutsey PL, George KM, Gottesman RF, Mosley TH, Whitsel EA, Lakshminarayan K. Cumulative Use of Proton Pump Inhibitors and Risk of Dementia: The Atherosclerosis Risk in Communities Study. Neurology 2023; 101:e1771-e1778. [PMID: 37558503 PMCID: PMC10634644 DOI: 10.1212/wnl.0000000000207747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/20/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Studies on the association between proton pump inhibitor (PPI) use and dementia report mixed results and do not examine the impact of cumulative PPI use. We evaluated the associations between current and cumulative PPI use and risk of incident dementia in the Atherosclerosis Risk in Communities (ARIC) Study. METHODS These analyses used participants from a community-based cohort (ARIC) from the time of enrollment (1987-1989) through 2017. PPI use was assessed through visual medication inventory at clinic visits 1 (1987-1989) to 5 (2011-2013) and reported annually in study phone calls (2006-2011). This study uses ARIC visit 5 as baseline because this was the first visit in which PPI use was common. PPI use was examined 2 ways: current use at visit 5 and duration of use before visit 5 (from visit 1 to 2011, exposure categories: 0 day, 1 day-2.8 years, 2.8-4.4 years, >4.4 years). The outcome was incident dementia after visit 5. Cox proportional hazard models were used, adjusted for demographics, comorbid conditions, and other medication use. RESULTS A total of 5,712 dementia-free participants at visit 5 (mean age 75.4 ± 5.1 years; 22% Black race; 58% female) were included in our analysis. The median follow-up was 5.5 years. The minimum cumulative PPI use was 112 days, and the maximum use was 20.3 years. There were 585 cases of incident dementia identified during follow-up. Participants using PPIs at visit 5 were not at a significantly higher risk of developing dementia during subsequent follow-up than those not using PPIs (hazard ratio (HR): 1.1 [95% confidence interval (CI) 0.9-1.3]). Those who used PPIs for >4.4 cumulative years before visit 5 were at 33% higher risk of developing dementia during follow-up (HR: 1.3 [95% CI 1.0-1.8]) than those reporting no use. Associations were not significant for lesser durations of PPI use. DISCUSSION Future studies are needed to understand possible pathways between cumulative PPI use and the development of dementia. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that the use of prescribed PPIs for >4.4 years by individuals aged 45 years and older is associated with a higher incidence of newly diagnosed dementia.
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Affiliation(s)
- Carin A Northuis
- From the University of Minnesota (C.A.N., P.L.L., K.L.), Minneapolis; Optum (E.J.B.), Minneapolis, MN; University of California, Davis (K.M.G.); National Institute of Neurological Disorders and Stroke (R.F.G.), Washington, DC; University of Mississippi Medical Center (T.H.M.), Jackson; and University of North Carolina (E.A.W.), Chapel Hill
| | - Elizabeth J Bell
- From the University of Minnesota (C.A.N., P.L.L., K.L.), Minneapolis; Optum (E.J.B.), Minneapolis, MN; University of California, Davis (K.M.G.); National Institute of Neurological Disorders and Stroke (R.F.G.), Washington, DC; University of Mississippi Medical Center (T.H.M.), Jackson; and University of North Carolina (E.A.W.), Chapel Hill
| | - Pamela L Lutsey
- From the University of Minnesota (C.A.N., P.L.L., K.L.), Minneapolis; Optum (E.J.B.), Minneapolis, MN; University of California, Davis (K.M.G.); National Institute of Neurological Disorders and Stroke (R.F.G.), Washington, DC; University of Mississippi Medical Center (T.H.M.), Jackson; and University of North Carolina (E.A.W.), Chapel Hill
| | - Kristen M George
- From the University of Minnesota (C.A.N., P.L.L., K.L.), Minneapolis; Optum (E.J.B.), Minneapolis, MN; University of California, Davis (K.M.G.); National Institute of Neurological Disorders and Stroke (R.F.G.), Washington, DC; University of Mississippi Medical Center (T.H.M.), Jackson; and University of North Carolina (E.A.W.), Chapel Hill
| | - Rebecca F Gottesman
- From the University of Minnesota (C.A.N., P.L.L., K.L.), Minneapolis; Optum (E.J.B.), Minneapolis, MN; University of California, Davis (K.M.G.); National Institute of Neurological Disorders and Stroke (R.F.G.), Washington, DC; University of Mississippi Medical Center (T.H.M.), Jackson; and University of North Carolina (E.A.W.), Chapel Hill
| | - Tom H Mosley
- From the University of Minnesota (C.A.N., P.L.L., K.L.), Minneapolis; Optum (E.J.B.), Minneapolis, MN; University of California, Davis (K.M.G.); National Institute of Neurological Disorders and Stroke (R.F.G.), Washington, DC; University of Mississippi Medical Center (T.H.M.), Jackson; and University of North Carolina (E.A.W.), Chapel Hill
| | - Eric A Whitsel
- From the University of Minnesota (C.A.N., P.L.L., K.L.), Minneapolis; Optum (E.J.B.), Minneapolis, MN; University of California, Davis (K.M.G.); National Institute of Neurological Disorders and Stroke (R.F.G.), Washington, DC; University of Mississippi Medical Center (T.H.M.), Jackson; and University of North Carolina (E.A.W.), Chapel Hill
| | - Kamakshi Lakshminarayan
- From the University of Minnesota (C.A.N., P.L.L., K.L.), Minneapolis; Optum (E.J.B.), Minneapolis, MN; University of California, Davis (K.M.G.); National Institute of Neurological Disorders and Stroke (R.F.G.), Washington, DC; University of Mississippi Medical Center (T.H.M.), Jackson; and University of North Carolina (E.A.W.), Chapel Hill.
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Schneider KL, Bell EJ, Zhou CK, Yang G, Lloyd P, Clarke TC, Wilkinson M, Myers EE, Amend KL, Seeger JD, Chillarige Y, Forshee RA, Shoaibi A, Anderson SA, Wong HL. Use of Immunization Information Systems in Ascertainment of COVID-19 Vaccinations for Claims-Based Vaccine Safety and Effectiveness Studies. JAMA Netw Open 2023; 6:e2313512. [PMID: 37191962 DOI: 10.1001/jamanetworkopen.2023.13512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Importance Safety and effectiveness studies of COVID-19 vaccines are being conducted using clinical data, including administrative claims. However, claims data only partially capture administered COVID-19 vaccine doses for numerous reasons, such as vaccination at sites that do not generate claims for reimbursement. Objective To evaluate the extent to which Immunization Information Systems (IIS) data linked to claims data enhances claims-based COVID-19 vaccine capture for a commercially insured population and to estimate the magnitude of misclassification of vaccinated individuals as having unvaccinated status in the linked IIS and claims data. Design, Setting, and Participants This cohort study used claims data from a commercial health insurance database and obtained vaccination data from IIS repositories in 11 US states. Participants were individuals younger than 65 years who resided in 1 of 11 states of interest and who were insured in health plans from December 1, 2020, through December 31, 2021. Main Outcomes and Measures Estimated proportion of individuals with at least 1 dose of any COVID-19 vaccine and proportion of individuals with a completed vaccine series based on general population guidelines. Vaccination status estimates were calculated and compared using claims data alone and linked IIS and claims data. Remaining misclassification of vaccination status was assessed by comparing linked IIS and claims data estimates with estimates from external surveillance data sources (Centers for Disease Control and Prevention [CDC] and state Department of Health [DOH]) and capture-recapture analysis. Results This cohort study included 5 112 722 individuals (mean [SD] age, 33.5 [17.6] years; 2 618 098 females [51.2%]) from 11 states. Characteristics of those who received at least 1 vaccine dose and those who completed a vaccine series were similar to the overall study population. The proportion with at least 1 vaccine dose increased from 32.8% using claims data alone to 48.1% when the data were supplemented with IIS vaccination records. Vaccination estimates using linked IIS and claims data varied widely by state. The percentage of individuals who completed a vaccine series increased from 24.4% to 41.9% after the addition of IIS vaccine records and varied across states. The percentages of underrecording using linked IIS and claims data were 12.1% to 47.1% lower than those using CDC data, 9.1% to 46.9% lower than the state DOH, and 9.2% to 50.9% lower than capture-recapture analysis. Conclusion and Relevance Results of this study suggested that supplementing COVID-19 claims records with IIS vaccination records substantially increased the number of individuals who were identified as vaccinated, yet potential underrecording remained. Improvements in reporting vaccination data to IIS infrastructures could allow frequent updates of vaccination status for all individuals and all vaccines.
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Affiliation(s)
| | | | - C K Zhou
- Clinical Safety and Risk Management, Moderna, Cambridge, Massachusetts
| | - Grace Yang
- OptumServe Consulting, Falls Church, Virginia
| | - Patricia Lloyd
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Tainya C Clarke
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | | | | | | | - Richard A Forshee
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Azadeh Shoaibi
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Steven A Anderson
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Hui-Lee Wong
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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Chiorean MV, Allegretti JR, Sharma PP, Chastek B, Salese L, Bell EJ, Peterson-Brandt J, Cappelleri JC, Guo X, Khan N. Correction to: Real-world characteristics, treatment experiences and corticosteroid utilisation of patients treated with tofacitinib for moderate to severe ulcerative colitis. BMC Gastroenterol 2022; 22:356. [PMID: 35883049 PMCID: PMC9327372 DOI: 10.1186/s12876-022-02298-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | | | - Benjamin Chastek
- Optum Life Sciences, HEOR, 11000 Optum Circle, Eden Prairie, MN, 55344, USA.
| | | | - Elizabeth J Bell
- Optum Life Sciences, HEOR, 11000 Optum Circle, Eden Prairie, MN, 55344, USA
| | | | | | | | - Nabeel Khan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Chiorean MV, Allegretti JR, Sharma PP, Chastek B, Salese L, Bell EJ, Peterson-Brandt J, Cappelleri JC, Guo X, Khan N. Real-world characteristics, treatment experiences and corticosteroid utilisation of patients treated with tofacitinib for moderate to severe ulcerative colitis. BMC Gastroenterol 2022; 22:177. [PMID: 35397501 PMCID: PMC8994921 DOI: 10.1186/s12876-022-02215-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/08/2022] [Indexed: 12/22/2022] Open
Abstract
Background Tofacitinib is an oral, small molecule JAK inhibitor for the treatment of UC. We aimed to describe the real-world treatment experience and corticosteroid utilisation of patients treated with tofacitinib in a US claims database. Methods Patients with a UC diagnosis who initiated tofacitinib, vedolizumab or tumour necrosis factor inhibitor (TNFi) treatment between May 2018 and July 2019 were identified from the Optum Research Database. Demographic and clinical characteristics of patients who initiated tofacitinib, vedolizumab or TNFi were described. Oral corticosteroid use prior to and following tofacitinib initiation was evaluated. Tofacitinib adherence (proportion of days covered) and continuation was assessed for 6 months following initiation. Analyses were descriptive and stratified by prior biologic use (naïve, 1 or ≥ 2; minimum of 12 months prior to tofacitinib initiation). Results Among patients initiating tofacitinib (N = 225), mean age was 45.6 (SD 16.5) years and 50.2% were female. Of these, 43 (19.1%) patients were biologic-naïve and 182 (80.9%) had prior biologic use (92 [40.9%], 1 prior biologic; 90 [40.0%], ≥ 2 prior biologics). Among patients with 1 prior biologic, 82.6% were previously treated with a TNFi. Among patients with ≥ 2 prior biologics, 54.4% were previously treated with vedolizumab and a TNFi, 16.7% with two TNFi and 28.9% with ≥ 3 prior biologics. In the 6 months prior to tofacitinib initiation, 65.8% of patients had received oral corticosteroids (74.4%, 60.9% and 66.7% for biologic-naïve, 1 and ≥ 2 prior biologics, respectively). The proportion of patients with ongoing oral corticosteroid use 3–6 months after tofacitinib initiation decreased to 13.3% (9.3%, 18.5% and 10.0% for biologic-naïve, 1 and ≥ 2 prior biologics, respectively), and 19.6% of patients discontinued oral corticosteroid use during the 6 months after tofacitinib initiation. Overall, tofacitinib adherence, as determined by the mean proportion of days covered during the 6-month follow-up, was 0.7 (median 0.8). During the 6-month follow-up, 84.9% of patients continued tofacitinib. Conclusions Among patients with UC initiating tofacitinib, the majority had prior biologic use. Tofacitinib adherence was high, discontinuation was low and oral corticosteroid utilisation decreased irrespective of prior biologic use. Further research with longer follow-up and a larger sample size is required. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02215-y.
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Bell EJ, Yu J, Bhatt V, Bunner SH, Lal LS, Galvin J, Weisdorf D. Healthcare Resource Utilization and Costs of Steroid-Associated Complications in Patients With Graft-Versus-Host Disease. Transplant Cell Ther 2022; 28:707.e1-707.e7. [DOI: 10.1016/j.jtct.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/31/2022] [Accepted: 04/14/2022] [Indexed: 11/28/2022]
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Bell EJ, Bielinski SJ, St Sauver JL, Chen LY, Rooney MR, Larson NB, Takahashi PY, Folsom AR. Association of Proton Pump Inhibitors With Higher Risk of Cardiovascular Disease and Heart Failure. Mayo Clin Proc 2021; 96:2540-2549. [PMID: 34607633 PMCID: PMC8631442 DOI: 10.1016/j.mayocp.2021.02.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine associations of cumulative exposure to proton pump inhibitors (PPIs) with total cardiovascular disease (CVD; composed of stroke, coronary heart disease, and heart failure [HF]) and HF alone in a cohort study of White and African American participants of the Atherosclerosis Risk in Communities (ARIC) study. METHODS Use of PPIs was assessed by pill bottle inspection at visit 1 (January 1, 1987 to 1989) and up to 10 additional times before baseline (visit 5; 2011 to 2013). We calculated cumulative exposure to PPIs as days of use from visit 1 to baseline. Participants (n=4346 free of total CVD at visit 5; mean age, 75 years) were observed for incident total CVD and HF events through December 31, 2016. We used Cox regression to measure associations of PPIs with total CVD and HF. RESULTS After adjustment for potential confounding variables, participants with a cumulative exposure to PPIs of more than 5.1 years had a 2.02-fold higher risk of total CVD (95% CI, 1.50 to 2.72) and a 2.21-fold higher risk of HF (95% CI, 1.51 to 3.23) than nonusers. CONCLUSION Long-term PPI use was associated with twice the risk of total CVD and HF compared with nonusers. Our findings are in concordance with other research and suggest another reason to be cautious of PPI overuse.
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Affiliation(s)
| | - Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Jennifer L St Sauver
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Lin Y Chen
- Cardiovascular Division, University of Minnesota Medical School, Minneapolis
| | - Mary R Rooney
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD
| | - Nicholas B Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Paul Y Takahashi
- Division of Community Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Aaron R Folsom
- Division of Epidemiology and Community Health, University of Minnesota's School of Public Health, Minneapolis
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Mendez IJ, Manemann SM, Bell EJ, Larson NB, Decker PA, Guerrero MA, Hanson NQ, Heckbert SR, Pankow JS, Tsai MY, Bielinski SJ. Adhesion pathway proteins and risk of atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis. BMC Cardiovasc Disord 2021; 21:436. [PMID: 34521347 PMCID: PMC8442417 DOI: 10.1186/s12872-021-02241-w] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/01/2021] [Indexed: 11/12/2022] Open
Abstract
Background The cellular adhesion pathway has been suggested as playing an important role in the pathogenesis of atrial fibrillation (AF). However, prior studies that have investigated the role of adhesion pathway proteins in risk of AF have been limited in the number of proteins that were studied and in the ethnic and racial diversity of the study population. Therefore we aimed to study the associations of fifteen adhesion pathway proteins with incident AF in a large, diverse population. Methods Multi-Ethnic Study of Atherosclerosis participants from four races/ethnicities (n = 2504) with protein levels measured were followed for incident AF (n = 253). HGF protein was measured on Exam 1 samples (N = 6669; AF n = 851). Cox proportional hazards regression was used to assess the association of AF with 15 adhesion pathway proteins. Bonferroni correction was applied to account for multiple comparisons. Results After adjusting for potential confounding variables (age, sex, race/ethnicity, height, body mass index, systolic blood pressure, antihypertension therapy, diabetes status, current smoker, current alcohol use, and total and HDL cholesterol), and accounting for multiple testing (P < 0.05/15 = 0.0033), circulating levels of the following proteins were positively associated with a higher risk of AF: MMP-2 (HR per standard deviation increment, 1.27; 95% CI 1.11‒1.45), TIMP-2 (HR 1.28; 95% CI 1.12‒1.46), VCAM-1 (HR 1.32; 95% CI 1.16‒1.50), and SLPI (HR 1.22; 95% CI 1.07‒1.38). The association between proteins and AF did not differ by race/ethnicity. Conclusions Circulating levels of MMP-2, TIMP-2, VCAM-1, and SLPI were positively associated with an increased risk of incident AF in a diverse population. Our findings suggest that adhesion pathway proteins may be important risk predictors of AF. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02241-w.
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Affiliation(s)
- Israel J Mendez
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA.,University of Puerto Rico-School of Medicine, San Juan, PR, USA
| | - Sheila M Manemann
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Elizabeth J Bell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,Optum, Life Sciences, Eden Prairie, MN, USA
| | - Nicholas B Larson
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Paul A Decker
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | | | - Naomi Q Hanson
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Susan R Heckbert
- Cardiovascular Health Research Unit and Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Michael Y Tsai
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Suzette J Bielinski
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA.
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10
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Rooney MR, Bell EJ, Alonso A, Pankow JS, Demmer RT, Rudser KD, Chen LY, Lutsey PL. Proton Pump Inhibitor Use, Hypomagnesemia and Risk of Cardiovascular Diseases: The Atherosclerosis Risk in Communities (ARIC) Study. J Clin Gastroenterol 2021; 55:677-683. [PMID: 33471493 PMCID: PMC7921206 DOI: 10.1097/mcg.0000000000001420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/01/2020] [Indexed: 12/10/2022]
Abstract
GOALS The goal of this study was to evaluate whether proton pump inhibitor (PPI) use is cross-sectionally associated with hypomagnesemia and whether hypomagnesemia mediates the prospective association between PPIs and cardiovascular disease (CVD) risk. BACKGROUND Use of PPIs has been associated with hypomagnesemia, primarily in case reports or within insurance databases. Both PPI use and low serum magnesium (Mg) have been associated with modestly higher CVD risk. Yet, the interrelation between PPI use and Mg in relation to CVD risk is unclear. STUDY The 4436 Atherosclerosis Risk in Communities participants without prevalent CVD at visit 5 (baseline, 2011-2013) were included. Multivariable relative risk regression was used for cross-sectional analyses between PPI and hypomagnesemia prevalence (≤0.75 mmol/L). Incident CVD (defined by atrial fibrillation, coronary heart disease, CVD mortality, heart failure, stroke) was identified through 2017. Multivariable Cox regression was used to examine the PPI-CVD association. RESULTS Participants were mean±SD aged 75±5 years; 63% were women, 23% Black, and 24% were PPI users. PPI users had 1.24-fold (95% confidence interval: 1.08-1.44) higher prevalence of hypomagnesemia than nonusers. Over a median 5 years of follow-up, 684 incident CVD events occurred. PPI users had higher CVD risk [hazard ratio (95% confidence interval) 1.31 (1.10-1.57)] than nonusers. The effect estimate was largely unchanged when hypomagnesemia was added to the model as a potential mediator. CONCLUSIONS In this elderly community-based study, PPI users had a higher prevalence of hypomagnesemia than in nonusers. PPI users also had higher CVD risk than nonusers; however, it appears unlikely that hypomagnesemia explains associations of PPIs with CVD risk.
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Affiliation(s)
- Mary R Rooney
- Division of Epidemiology and Community Health
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | | | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | | | - Kyle D Rudser
- Division of Biostatistics, School of Public Health, University of Minnesota
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN
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11
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George S, Bell EJ, Zheng Y, Kim R, White J, Devgan G, Smith J, Lal LS, Engel‐Nitz NM, Liu FX. The Impact of Adverse Events on Health Care Resource Utilization, Costs, and Mortality Among Patients Treated with Immune Checkpoint Inhibitors. Oncologist 2021; 26:e1205-e1215. [PMID: 33955118 PMCID: PMC8265346 DOI: 10.1002/onco.13812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/15/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We investigated the association between adverse events (AEs) suspected to be immune-related and health care resource utilization, costs, and mortality among patients receiving programmed cell death 1/programmed cell death ligand 1 immune checkpoint inhibitor (ICI) monotherapy for urothelial carcinoma, renal cell carcinoma, non-small cell lung cancer, or Merkel cell carcinoma. PATIENTS AND METHODS We conducted a retrospective cohort study using medical and pharmacy claims and enrollment information from U.S. commercial and Medicare Advantage with Part D enrollees in the Optum Research Database from March 1, 2014, through April 30, 2019. Claims were linked with mortality data from the Social Security Death Index and the National Death Index. Eligible patients had at least one ICI claim between September 1, 2014, and April 30, 2019. RESULTS After adjusting for potential confounding variables, we found patients with AEs had more than double the risk of an inpatient stay (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.9-2.5) and an 80% higher risk of an emergency visit (HR, 1.8; 95% CI, 1.6-2.1) than patients without AEs. Adjusted 6-month total costs were $24,301 higher among patients with an AE versus those without ($99,037 vs. $74,736; 95% CI, $18,828-29,774; p < .001). Mean ± SD AE-related medical costs averaged $2,359 ± $7,496 per patient per month, driven by inpatient visits, which accounted for 89.9% of AE-related costs. Adjusted risk of mortality was similar in patients with and without AEs. CONCLUSION Patients with AEs had higher risks of hospitalizations, emergency room visits, and higher health care costs, driven by inpatient stays, than patients without AEs. The adjusted risk of mortality was similar between the two cohorts. IMPLICATIONS FOR PRACTICE Patients taking immune checkpoint inhibitors (ICIs) who had adverse events (AEs) had significantly higher health care costs and utilization, driven by inpatient stays, compared with patients who did not. Given this high cost associated with AEs and the differences in the side effect profile of ICIs versus traditional chemotherapy, it is important for physicians to be cognizant of these differences when treating patients with ICIs. Ongoing evaluation, earlier recognition, and more effective, multidisciplinary management of AEs may improve patient outcomes and reduce the need for costly inpatient stays.
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Affiliation(s)
- Saby George
- Roswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
| | | | - Ying Zheng
- Emmanuel Merck, Darmstadt Serono, Inc.RocklandMassachusettsUSA
| | | | | | | | - Jodi Smith
- Emmanuel Merck, Darmstadt Serono, Inc.RocklandMassachusettsUSA
| | | | | | - Frank X. Liu
- Emmanuel Merck, Darmstadt Serono, Inc.RocklandMassachusettsUSA
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12
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Swami U, Hong A, El-Chaar NN, Nimke D, Ramaswamy K, Bell EJ, Sandin R, Agarwal N. Real-world first-line (1L) treatment patterns in patients (pts) with metastatic castration-sensitive prostate cancer (mCSPC) in a U.S. health insurance database. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.5072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5072 Background: Over the past 6 years, intensification of androgen deprivation therapy (ADT) with docetaxel (DOC) and novel hormonal therapies (NHT) [abiraterone, enzalutamide, and apalutamide], has been shown to improve survival outcomes in men with mCSPC. This study assessed the real-world utilization of effective combination therapies as 1L treatment in insured pts in the U.S. with mCSPC. Methods: This retrospective study used the Optum health insurance claims database, which includes pt claims data from both commercially insured and Medicare Advantage populations. Eligible pts were adult men with ≥1 claim with a metastatic International Classification of Diseases diagnostic code (first claim was index date) within 90 days (d) prior to, or any time after, a prostate cancer diagnosis between January 2014 and June 2019. Pts with evidence of systemic anticancer therapy during the 1-year pre-index baseline period were excluded, unless the first drug claim occurred within 90 d prior to the diagnosis of metastatic disease. The 1L treatments were identified as any treatment for mCSPC within 90 d pre-index, plus any other treatment received within 180 d of the first, and were grouped by regimen: ADT only; ADT + first-generation antiandrogens (AA); ADT + DOC; ADT + NHT; and ADT + NHT + DOC. Results: Of 4221 men with mCSPC, 2364 (56.0%) received ADT only; 892 (21.1%) ADT + AA; 577 (13.7%) ADT + NHT; 348 (8.2%) ADT + DOC; and 40 (0.9%) ADT + NHT + DOC. Pts who received ADT + DOC or ADT + DOC + NHT were generally younger than the other treatment groups (Table). By 2019, use of ADT only and ADT + AA had declined, while the use of ADT + NHT and ADT + NHT + DOC had increased (Table). However, in 2018 and 2019, the majority of men with mCSPC still received either ADT alone, or ADT + AA, including those with visceral metastases (Table). Survival analysis across treatment cohorts is ongoing. Conclusions: Despite level 1 evidence demonstrating improved survival with intensified treatment (ADT + DOC or NHT), this study shows its underutilization in pts with mCSPC. This is evident even in those with more aggressive disease (visceral metastases) as recently as 2019. These data highlight that a minority of pts with mCSPC received optimal life-prolonging therapies in a commercially insured and Medicare Advantage U.S. population. Further studies are needed to identify the reasons for this underutilization of intensified treatments.[Table: see text]
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Affiliation(s)
- Umang Swami
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | | | | | | | | | | | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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13
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Li EC, Bell EJ, Campbell KJ, Lal LS, Peterson-Brandt J, Lyman GH. Association of febrile neutropenia (FN) risk factors (RFs) with incident FN in U.S. commercial and Medicare advantage patients receiving intermediate-risk chemotherapy for non-myeloid cancers between 2009 and 2019. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18607 Background: FN after myelosuppressive chemotherapy may result in significant morbidity/mortality and increase healthcare costs due to interventions such as hospitalization. For patients receiving chemotherapy at intermediate-risk of FN, guidelines recommend assessing patient-specific FN RFs to decide whether to provide primary prophylaxis. However, there is a paucity of real-world data that quantifies the FN risk based on patient RFs when receiving intermediate-risk chemotherapy. Thus, we examined the association of FN RFs with incident FN in the first and subsequent cycles in patients at intermediate-risk of chemotherapy-induced FN within the real-world. Methods: This retrospective cohort study used the Optum Research Database to identify US commercial and Medicare Advantage patients with a non-myeloid malignancy who were treated between 01 Jan 2009 and 31 Dec 2019 with a first-line intermediate-risk chemotherapy regimen. The following FN RFs were identified based on ICD or procedure codes on claims during the 6 months prior to chemotherapy, unless otherwise stated: radiation, neutropenia, liver dysfunction, renal dysfunction, age > 65 years, metastases to the bone, and surgery during the 30 days prior. FN was defined as ICD codes for neutropenia and fever on a claim. Patients without previous FN were followed for FN from five days after index through the earliest of the following: 1) FN, 2) 31 Dec 2019, 3) death, 4) health plan disenrollment, or 5) end of chemotherapy line or cycle (depending on time frame of interest). Cox regression was used to calculate HRs for incident FN. Results: The study included 13,937 patients, and the most common RFs were 1) recent surgery (84%), 2) age > 65 (67%), and 3) liver dysfunction (31%). Compared to patients with no individual RFs, each additional RF was associated with a greater risk of FN during both the first and subsequent cycles, although confidence intervals were large (Table). Conclusions: Among patients at intermediate-risk of chemotherapy-induced FN, patients with more individual RFs for FN had a higher risk of FN during both the first and all cycles. These results underscore the importance of RF analysis in prophylaxis decisions for patients at intermediate-risk of chemotherapy-induced FN.[Table: see text]
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14
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Decker PA, Larson NB, Bell EJ, Pankow JS, Hanson NQ, Wassel CL, Tsai MY, Bielinski SJ. Erratum to "Increased hepatocyte growth factor levels over 2 years are associated with coronary heart disease: The Multi-Ethnic Study of Atherosclerosis (MESA)" [Am Heart J (2019) 30-34]. Am Heart J 2019; 216:151. [PMID: 31439267 DOI: 10.1016/j.ahj.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Paul A Decker
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Nicholas B Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Elizabeth J Bell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Naomi Q Hanson
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | | | - Michael Y Tsai
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
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15
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Decker PA, Larson NB, Bell EJ, Pankow JS, Hanson NQ, Wassel CL, Tsai MY, Bielinski SJ. Increased hepatocyte growth factor levels over 2 years are associated with coronary heart disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Am Heart J 2019; 213:30-34. [PMID: 31085382 DOI: 10.1016/j.ahj.2019.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/27/2019] [Indexed: 11/28/2022]
Abstract
Hepatocyte growth factor (HGF) is associated with subclinical and clinical atherosclerosis. However, the significance of change in HGF and development of atherosclerotic disease is unknown. In a large and diverse population-based cohort, we report that change in the biomarker HGF is an independent predictor of incident CHD.
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Affiliation(s)
- Paul A Decker
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Nicholas B Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Elizabeth J Bell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Naomi Q Hanson
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | | | - Michael Y Tsai
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
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16
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St Sauver JL, Olson JE, Roger VL, Nicholson WT, Black JL, Takahashi PY, Caraballo PJ, Bell EJ, Jacobson DJ, Larson NB, Bielinski SJ. CYP2D6 phenotypes are associated with adverse outcomes related to opioid medications. Pharmgenomics Pers Med 2017. [PMID: 28769582 DOI: 10.2147/pgpm.s136341.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Variation in the CYP2D6 gene may affect response to opioids in both poor and ultrarapid metabolizers, but data demonstrating such associations have been mixed, and the impact of variants on toxicity-related symptoms (e.g., nausea) is unclear. Therefore, we examined the association between CYP2D6 phenotype and poor pain control or other adverse symptoms related to the use of opioids in a sample of primary care patients. MATERIALS AND METHODS We identified all patients in the Mayo Clinic RIGHT Protocol who were prescribed an opioid medication between July 01, 2013 and June 30, 2015, and categorized patients into three phenotypes: poor, intermediate to extensive, or ultrarapid CYP2D6 metabolizers. We reviewed the electronic health record of these patients for indications of poor pain control or adverse symptoms related to medication use. Associations between phenotype and outcomes were assessed using Chi-square tests and logistic regression. RESULTS Overall, 257 (25% of RIGHT Protocol participants) patients received at least one opioid prescription; of these, 40 (15%) were poor metabolizers, 146 (57%) were intermediate to extensive metabolizers, and 71 (28%) were ultrarapid metabolizers. We removed patients that were prescribed a CYP2D6 inhibitor medication (n=38). After adjusting for age and sex, patients with a poor or ultrarapid phenotype were 2.7 times more likely to experience either poor pain control or an adverse symptom related to the prescription compared to patients with an intermediate to extensive phenotype (odds ratio: 2.68; 95% CI: 1.39, 5.17; p=0.003). CONCLUSION Our results suggest that >30% of patients with a poor or ultrarapid CYP2D6 phenotype may experience an adverse outcome after being prescribed codeine, tramadol, oxycodone, or hydrocodone. These medications are frequently prescribed for pain relief, and ~39% of the US population is expected to carry one of these phenotypes, suggesting that the population-level impact of these gene-drug interactions could be substantial.
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Affiliation(s)
- Jennifer L St Sauver
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
| | - Janet E Olson
- Department of Health Sciences Research.,Center for Individualized Medicine
| | - Veronique L Roger
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester.,Department of Cardiovascular Diseases
| | | | - John L Black
- Center for Individualized Medicine.,Department of Laboratory Medicine and Pathology
| | - Paul Y Takahashi
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro J Caraballo
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Bell
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
| | - Debra J Jacobson
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
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17
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St Sauver JL, Olson JE, Roger VL, Nicholson WT, Black JL, Takahashi PY, Caraballo PJ, Bell EJ, Jacobson DJ, Larson NB, Bielinski SJ. CYP2D6 phenotypes are associated with adverse outcomes related to opioid medications. Pharmgenomics Pers Med 2017; 10:217-227. [PMID: 28769582 PMCID: PMC5533497 DOI: 10.2147/pgpm.s136341] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Variation in the CYP2D6 gene may affect response to opioids in both poor and ultrarapid metabolizers, but data demonstrating such associations have been mixed, and the impact of variants on toxicity-related symptoms (e.g., nausea) is unclear. Therefore, we examined the association between CYP2D6 phenotype and poor pain control or other adverse symptoms related to the use of opioids in a sample of primary care patients. Materials and methods We identified all patients in the Mayo Clinic RIGHT Protocol who were prescribed an opioid medication between July 01, 2013 and June 30, 2015, and categorized patients into three phenotypes: poor, intermediate to extensive, or ultrarapid CYP2D6 metabolizers. We reviewed the electronic health record of these patients for indications of poor pain control or adverse symptoms related to medication use. Associations between phenotype and outcomes were assessed using Chi-square tests and logistic regression. Results Overall, 257 (25% of RIGHT Protocol participants) patients received at least one opioid prescription; of these, 40 (15%) were poor metabolizers, 146 (57%) were intermediate to extensive metabolizers, and 71 (28%) were ultrarapid metabolizers. We removed patients that were prescribed a CYP2D6 inhibitor medication (n=38). After adjusting for age and sex, patients with a poor or ultrarapid phenotype were 2.7 times more likely to experience either poor pain control or an adverse symptom related to the prescription compared to patients with an intermediate to extensive phenotype (odds ratio: 2.68; 95% CI: 1.39, 5.17; p=0.003). Conclusion Our results suggest that >30% of patients with a poor or ultrarapid CYP2D6 phenotype may experience an adverse outcome after being prescribed codeine, tramadol, oxycodone, or hydrocodone. These medications are frequently prescribed for pain relief, and ~39% of the US population is expected to carry one of these phenotypes, suggesting that the population-level impact of these gene–drug interactions could be substantial.
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Affiliation(s)
- Jennifer L St Sauver
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
| | - Janet E Olson
- Department of Health Sciences Research.,Center for Individualized Medicine
| | - Veronique L Roger
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester.,Department of Cardiovascular Diseases
| | | | - John L Black
- Center for Individualized Medicine.,Department of Laboratory Medicine and Pathology
| | - Paul Y Takahashi
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro J Caraballo
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Bell
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
| | - Debra J Jacobson
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
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18
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Bielinski SJ, Berardi C, Decker PA, Larson NB, Bell EJ, Pankow JS, Sale MM, Tang W, Hanson NQ, Wassel CL, de Andrade M, Budoff MJ, Polak JF, Sicotte H, Tsai MY. Hepatocyte growth factor demonstrates racial heterogeneity as a biomarker for coronary heart disease. Heart 2017; 103:1185-1193. [PMID: 28572400 DOI: 10.1136/heartjnl-2016-310450] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 08/11/2016] [Revised: 01/19/2017] [Accepted: 01/27/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine if hepatocyte growth factor (HGF), a promising biomarker of coronary heart disease (CHD) given its release into circulation in response to endothelial damage, is associated with subclinical and clinical CHD in a racial/ethnic diverse population. METHODS HGF was measured in 6738 participants of the Multi-Ethnic Study of Atherosclerosis (MESA). Highest mean HGF values (pg/mL) were observed in Hispanic, followed by African, non-Hispanic white, then Chinese Americans. RESULTS In all races/ethnicities, HGF levels were associated with older age, higher systolic blood pressure (SBP) and body mass index, lower high-density lipoprotein, diabetes and current smoking. In fully adjusted models, each SD higher HGF was associated with an average increase in coronary artery calcium (CAC) of 55 Agatston units for non-Hispanic whites (p<0.001) and 51 Agatston units for African-Americans (p=0.007) but was not in the other race/ethnic groups (interaction p=0.02). There were 529 incident CHD events, and CHD risk was 41% higher in African (p<0.001), 17% in non-Hispanic white (p=0.026) and Chinese (p=0.36), and 6% in Hispanic Americans (p=0.56) per SD increase in HGF. CONCLUSION In a large and diverse population-based cohort, we report that HGF is associated with subclinical and incident CHD. We demonstrate evidence of racial/ethnic heterogeneity within these associations, as the results are most compelling in African-Americans and non-Hispanic white Americans. We provide evidence that HGF is a biomarker of atherosclerotic disease that is independent of traditional risk factors.
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Affiliation(s)
- Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Cecilia Berardi
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Department of Internal Medicine, Albert Einstein College of Medicine, and Montefiore Medical Center, Bronx, New York, USA
| | - Paul A Decker
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas B Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth J Bell
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michele M Sale
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, USA
| | - Weihong Tang
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Naomi Q Hanson
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christina L Wassel
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Colchester, Vermont, USA
| | - Mariza de Andrade
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew J Budoff
- Los Angeles Biomedical Research Institute, Harbor-UCLA, Torrance, California, USA
| | - Joseph F Polak
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Hugues Sicotte
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Y Tsai
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
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19
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Bell EJ, Larson NB, Decker PA, Pankow JS, Tsai MY, Hanson NQ, Wassel CL, Longstreth WT, Bielinski SJ. Hepatocyte Growth Factor Is Positively Associated With Risk of Stroke: The MESA (Multi-Ethnic Study of Atherosclerosis). Stroke 2016; 47:2689-2694. [PMID: 27729582 DOI: 10.1161/strokeaha.116.014172] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/06/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Hepatocyte growth factor (HGF) is positively associated with ischemic and hemorrhagic stroke risk factors. However, understanding the relation between HGF and stroke is in its infancy. Therefore, we sought to examine the association of circulating HGF with incident stroke using data from the MESA (Multi-Ethnic Study of Atherosclerosis). We hypothesized that circulating HGF would be positively associated with an increased risk of stroke. METHODS Participants aged 45 to 84 years (n=6711) had HGF measured between 2000 and 2002 and were followed for incident stroke through 2013 (n=233). Cox proportional hazards regression was used to calculate hazard ratios and 95% confidence intervals for incident stroke. A secondary analysis stratified results by adjudicated stroke type (n=183 ischemic; n=39 hemorrhagic; n=11 other). RESULTS After adjustment for potential confounding variables, risk of stroke was 17% higher with each standard deviation increase in HGF (hazard ratio, 1.17; 95% confidence interval, 1.03-1.34). This association was mainly driven by ischemic stroke and did not change on exclusion of cardioembolic strokes, although the number of excluded cases was small. The few hemorrhagic and other types of stroke were not associated with HGF. CONCLUSIONS Circulating HGF was positively associated with the incidence of stroke in a diverse, population-based cohort of men and women from the United States. Our findings support the hypothesis that circulating HGF is a marker of endothelial damage and suggest that HGF may have utility as a prognostic marker of stroke risk.
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Affiliation(s)
- Elizabeth J Bell
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.)
| | - Nicholas B Larson
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.)
| | - Paul A Decker
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.)
| | - James S Pankow
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.)
| | - Michael Y Tsai
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.)
| | - Naomi Q Hanson
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.)
| | - Christina L Wassel
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.)
| | - W T Longstreth
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.)
| | - Suzette J Bielinski
- From the Division of Epidemiology (E.J.B., S.J.B.) and Division of Biomedical Statistics and Informatics (N.B.L., P.A.D.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Division of Epidemiology and Community Health (J.S.P.) and Laboratory of Medicine and Pathology (M.Y.T., N.Q.H.), University of Minnesota, Minneapolis; Department of Pathology and Laboratory Medicine, College of Medicine, University of Vermont, Colchester (C.L.W.); and Departments of Neurology and Epidemiology, University of Washington, Seattle, WA (W.T.L.).
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St Sauver JL, Bielinski SJ, Olson JE, Bell EJ, Mc Gree ME, Jacobson DJ, McCormick JB, Caraballo PJ, Takahashi PY, Roger VL, Rohrer Vitek CR. Integrating Pharmacogenomics into Clinical Practice: Promise vs Reality. Am J Med 2016; 129:1093-1099.e1. [PMID: 27155109 PMCID: PMC5600492 DOI: 10.1016/j.amjmed.2016.04.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [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: 02/25/2016] [Revised: 03/30/2016] [Accepted: 04/05/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Limited information is available regarding primary care clinicians' response to pharmacogenomic clinical decision support (PGx-CDS) alerts integrated in the electronic health record. METHODS In February 2015, 159 clinicians in the Mayo Clinic primary care practice were sent e-mail surveys to understand their perspectives on the implementation and use of pharmacogenomic testing in their clinical practice. Surveys assessed how the clinicians felt about pharmacogenomics and whether they thought electronic PGx-CDS alerts were useful. Information was abstracted on the number of CDS alerts the clinicians received between October 2013 and the date their survey was returned. CDS alerts were grouped into 2 categories: the alert recommended caution using the prescription, or the alert recommended an alternate prescription. Finally, data were abstracted regarding whether the clinician changed their prescription in response to the alert recommendation. RESULTS The survey response rate was 57% (n = 90). Overall, 52% of the clinicians did not expect to use or did not know whether they would use pharmacogenomic information in their future prescribing practices. Additionally, 53% of the clinicians felt that the alerts were confusing, irritating, frustrating, or that it was difficult to find additional information. Finally, only 30% of the clinicians that received a CDS alert changed their prescription to an alternative medication. CONCLUSIONS Our results suggest a lack of clinician comfort with integration of pharmacogenomic data into primary care. Further efforts to refine PGx-CDS alerts to make them as useful and user-friendly as possible are needed to improve clinician satisfaction with these new tools.
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Affiliation(s)
- Jennifer L St Sauver
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn.
| | - Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Janet E Olson
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Elizabeth J Bell
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Michaela E Mc Gree
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Debra J Jacobson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Jennifer B McCormick
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Pedro J Caraballo
- Department of General Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Paul Y Takahashi
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Veronique L Roger
- Division of Cardiovascular Diseases, Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
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21
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Larson NB, Bell EJ, Decker PA, Pike M, Wassel CL, Tsai MY, Pankow JS, Tang W, Hanson NQ, Alexander K, Zakai NA, Cushman M, Bielinski SJ. ABO blood group associations with markers of endothelial dysfunction in the Multi-Ethnic Study of Atherosclerosis. Atherosclerosis 2016; 251:422-429. [PMID: 27298014 DOI: 10.1016/j.atherosclerosis.2016.05.049] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 05/24/2016] [Accepted: 05/31/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIMS ABO blood type is associated with cardiovascular disease, although the underlying mechanisms are presumed to be complex. While the relationship between non-O blood types and von Willebrand Factor (vWF) is well-established, associations with cellular adhesion molecules (CAMs) across diverse populations are understudied. METHODS We genetically inferred ABO alleles for N = 6202 participants from the Multi-Ethnic Study of Atherosclerosis. Linear regression was used to evaluate associations between major ABO allele dosages and log-transformed measurements of vWF (N = 924), soluble E-selectin (sE-selectin, N = 925), soluble P-selectin (sP-selectin, N = 2392), and soluble ICAM-1 (sICAM-1, N = 2236) by race/ethnicity. RESULTS For the selectins, the A1 allele was associated with significantly lower levels for all races/ethnicities, with each additional allele resulting in a 28-39% decrease in sE-selectin and 10-18% decrease in sP-selectin relative to Type O subjects. However, the A2 allele demonstrated effect heterogeneity across race/ethnicity for sE-selectin, with lower levels for non-Hispanic whites (p = 0.0011) but higher levels for Hispanics (p = 0.0021). We also identified elevated sP-selectin levels for B-allele carriers solely in Hispanic participants (p = 1.0E-04). ABO-by-race/ethnicity interactions were significant for both selectins (p < 0.0125). More modest associations were observed between A1 allele dosage and levels of sICAM-1, with ABO alleles explaining 0.8-1.1% of the total phenotypic variation within race/ethnicity. ABO associations with vWF activity were consistent across race/ethnicity, with B allele carriers corresponding to the highest vWF activity levels. CONCLUSIONS ABO blood type demonstrates complex associations with endothelial markers that are largely generalizable across diverse populations.
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Affiliation(s)
- Nicholas B Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
| | - Elizabeth J Bell
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Paul A Decker
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Mindy Pike
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Christina L Wassel
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT, USA
| | - Michael Y Tsai
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Weihong Tang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Naomi Q Hanson
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Kristine Alexander
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT, USA; Department of Medicine, University of Vermont, Burlington, VT, USA
| | - Neil A Zakai
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT, USA; Department of Medicine, University of Vermont, Burlington, VT, USA
| | - Mary Cushman
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT, USA; Department of Medicine, University of Vermont, Burlington, VT, USA
| | - Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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22
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Bell EJ, Agarwal SK, Cushman M, Heckbert SR, Lutsey PL, Folsom AR. Orthostatic Hypotension and Risk of Venous Thromboembolism in 2 Cohort Studies. Am J Hypertens 2016; 29:634-40. [PMID: 26306405 DOI: 10.1093/ajh/hpv151] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/06/2015] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Although venous stasis is a risk factor for venous thromboembolism (VTE) and orthostatic hypotension (OH) can cause venous stasis, to our knowledge no study has examined the relationship between OH and VTE risk. We sought to quantify the association between OH and VTE (deep vein thrombosis or pulmonary embolism) using data from 2 large, prospective cohort studies: the Cardiovascular Health Study (CHS) and the Atherosclerosis Risk in Communities (ARIC) Study. We hypothesized that OH was positively associated with incident VTE. METHODS We measured OH-defined as a drop in systolic blood pressure (SBP) of at least 20 mm Hg or diastolic blood pressure (DBP) of at least 10 mm Hg within 3 minutes of standing-in participants aged 45-64 years in ARIC (n = 12,480) and ≥65 years in CHS (n = 5,027) at baseline visits (1987-1989 in ARIC; 1989-1990 and 1992-1993 in CHS), and followed participants for incident VTE (n = 568 in ARIC through 2011 and n = 148 in CHS through 2001). We calculated adjusted hazard ratios (HRs) and their 95% confidence intervals (CIs) for incident VTE in relation to OH status. RESULTS In CHS, there was a positive association between OH status and incident VTE (HR for VTE = 1.74 (95% CI: 1.20-2.51)). In contrast, there was no association between OH and VTE in the ARIC study (HR for VTE = 0.97 (95% CI: 0.70-1.33)). CONCLUSIONS Community-dwelling older adults with OH had a moderately increased risk of VTE. These results were not seen in a population-based middle-aged cohort.
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Affiliation(s)
- Elizabeth J Bell
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA;
| | - Sunil K Agarwal
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Cushman
- Department of Medicine, Division of Hematology/Oncology, University of Vermont, Burlington, Vermont, USA
| | - Susan R Heckbert
- Cardiovascular Health Research Unit and Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Pamela L Lutsey
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Aaron R Folsom
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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23
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Bell EJ, Folsom AR, Lutsey PL, Selvin E, Zakai NA, Cushman M, Alonso A. Diabetes mellitus and venous thromboembolism: A systematic review and meta-analysis. Diabetes Res Clin Pract 2016; 111:10-8. [PMID: 26612139 PMCID: PMC4752919 DOI: 10.1016/j.diabres.2015.10.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/21/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED Diabetes mellitus (DM) may be a risk factor for venous thromboembolism (VTE) but results are inconsistent. AIM We conducted a systematic review and meta-analysis of epidemiologic studies to quantify the association between DM and VTE. METHODS AND RESULTS We included studies identified in PubMed, Web of Science, and CINAHL through 07/31/2014. We identified 19 studies that met our selection criteria. We pooled RRs using a random-effects model: the pooled RR for the association of DM with VTE was 1.10 (95% CI: 0.94-1.29). Between-study heterogeneity was explored with a forest plot, funnel plot, meta-regression, and a stratified analysis. Between-study heterogeneity was observed and not explained by study design, method of DM assessment, or degree of adjustment for confounding. Sensitivity analyses omitted one study at a time to assess the influence of any single study on the pooled estimate. These analyses indicated that one large study was highly influential; when this study was excluded, the pooled estimate increased and just reached statistical significance: 1.16 (95% CI: 1.01-1.34). CONCLUSIONS This meta-analysis suggests either no association or a modest positive one between DM and VTE in the general population. DM is unlikely to play a major role in VTE development.
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Affiliation(s)
- Elizabeth J Bell
- Division of Epidemiology & Community Health, University of Minnesota, USA.
| | - Aaron R Folsom
- Division of Epidemiology & Community Health, University of Minnesota, USA
| | - Pamela L Lutsey
- Division of Epidemiology & Community Health, University of Minnesota, USA
| | - Elizabeth Selvin
- Division of Epidemiology, Johns Hopkins Bloomberg School of Public Health, USA
| | - Neil A Zakai
- Department of Medicine, Division of Hematology/Oncology, University of Vermont, USA
| | - Mary Cushman
- Department of Medicine, Division of Hematology/Oncology, University of Vermont, USA
| | - Alvaro Alonso
- Division of Epidemiology & Community Health, University of Minnesota, USA
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24
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Murray AM, Bell EJ, Tupper DE, Davey CS, Pederson SL, Amiot EM, Miley KM, McPherson L, Heubner BM, Gilbertson DT, Foley RN, Drawz PE, Slinin Y, Rossom RC, Lakshminarayan K, Vemuri P, Jack CR, Knopman DS. The Brain in Kidney Disease (BRINK) Cohort Study: Design and Baseline Cognitive Function. Am J Kidney Dis 2015; 67:593-600. [PMID: 26744128 DOI: 10.1053/j.ajkd.2015.11.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 11/12/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The Brain in Kidney Disease (BRINK) Study aims to identify mechanisms that contribute to increased risk for cognitive impairment in patients with chronic kidney disease (CKD). We describe the rationale, design, and methods of the study and report baseline recruitment and cognitive function results. STUDY DESIGN Longitudinal observational cohort study of the epidemiology of cognitive impairment in CKD. The primary aim is to characterize the association between (1) baseline and incident stroke, white matter disease, estimated glomerular filtration rate (eGFR), inflammation, microalbuminuria, and dialysis initiation and (2) cognitive decline over 3 years in a CKD cohort with a mean eGFR<45 mL/min/1.73 m(2). SETTING & PARTICIPANTS Community-dwelling participants 45 years or older recruited from 4 health systems into 2 groups: reduced eGFR, defined as eGFR<60 mL/min/1.73 m(2) (non-dialysis dependent), and control, defined as eGFR≥60 mL/min/1.73 m(2). PREDICTOR eGFR group. OUTCOMES Performance on cognitive function tests and structural brain magnetic resonance imaging. MEASUREMENTS Sequential cognitive and physical function testing, serum and urine biomarker measurement, and brain magnetic resonance images over 3 years. RESULTS Of 554 participants, mean age was 69.3 years; 333, 88, and 133 had eGFRs<45 (non-dialysis dependent, nontransplantation), 45 to <60, and ≥60 (controls) mL/min/1.73 m(2), respectively. Mean eGFR in reduced-eGFR participants was 34.3 mL/min/1.73 m(2). Baseline cognitive performance was significantly associated with eGFR in all domains except language. Participants with eGFRs<30 mL/min/1.73 m(2) performed significantly worse than those with eGFRs≥30 mL/min/1.73 m(2) on tests of memory, processing speed, and executive function. Participants with reduced eGFRs overall scored worst on the Immediate Brief Visual-Spatial Memory Test-Revised. LIMITATIONS Healthy cohort bias, competing risk for death versus cognitive decline. CONCLUSIONS Cognitive function was significantly worse in participants with eGFRs<30 mL/min/1.73 m(2). Future BRINK analyses will measure risk factors for cognitive decline using the longitudinal data.
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Affiliation(s)
- Anne M Murray
- Berman Center for Clinical Research, Minneapolis Medical Research Foundation, Minneapolis, MN; Geriatrics Division, Hennepin County Medical Center, Minneapolis, MN.
| | - Elizabeth J Bell
- Berman Center for Clinical Research, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - David E Tupper
- Department of Psychology and Neuropsychology, Hennepin County Medical Center, Minneapolis, MN
| | - Cynthia S Davey
- Biostatistical Design and Analysis Center, University of Minnesota Clinical and Translational Science Institute, Minneapolis, MN
| | - Sarah L Pederson
- Berman Center for Clinical Research, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Elizabeth M Amiot
- Berman Center for Clinical Research, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Kathleen M Miley
- Department of Psychiatry, Hennepin County Medical Center, Minneapolis, MN
| | | | - Brooke M Heubner
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Hennepin County Medical Center, Minneapolis, MN
| | - David T Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Hennepin County Medical Center, Minneapolis, MN
| | - Robert N Foley
- Nephrology Division, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Paul E Drawz
- Nephrology Division, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Yelena Slinin
- Nephrology Division, Department of Medicine, University of Minnesota, Minneapolis, MN; Veterans Affairs Medical Center, Minneapolis, MN
| | - Rebecca C Rossom
- HealthPartners Institute for Education and Research, Minneapolis, MN
| | - Kamakshi Lakshminarayan
- Neurology Department, University of Minnesota, Minneapolis, MN; Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis, MN
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25
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Bell EJ, Selvin E, Lutsey PL, Nambi V, Cushman M, Folsom AR. Glycemia (hemoglobin A1c) and incident venous thromboembolism in the Atherosclerosis Risk in Communities cohort study. Vasc Med 2014; 18:245-50. [PMID: 24165467 DOI: 10.1177/1358863x13506764] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diabetes has been inconsistently associated with increased risk of venous thromboembolism (VTE) and there is little direct evidence on the associations of glycemia levels with VTE. We used data from the Atherosclerosis Risk in Communities study to test the hypothesis that glycemia, as measured by hemoglobin A1c (A1c), is positively associated with VTE. Participants aged 45-64 years (n = 12,298) had A1c measured in 1990 and were followed for incident VTE (n = 345) through 2005. Because A1c is affected by diabetes treatment, analyses were stratified by history of diagnosed diabetes. Owing to evidence of non-linearity, we categorized A1c according to clinical cut-points: <5.7, 5.7-6.4, and ≥ 6.5% in those with no diagnosed diabetes; <7.0 and ≥ 7.0% in those with diagnosed diabetes. After adjustment for potential confounders, the hazard ratios (95% CIs) for VTE across increasing A1c categories were 1 (referent), 1.02 (0.77, 1.35) and 0.72 (0.41, 1.29) for those without diagnosed diabetes, and 1.30 (0.77, 2.17) and 1.41 (0.95, 2.09) for those with diagnosed diabetes. To explore the relation, we employed various models to adjust for potential confounding variables and modeled A1c as tertiles. We consistently found elevated hazard ratios in those with diagnosed diabetes, though the association was not statistically significant in every model. Hazard ratios in those without diagnosed diabetes were close to 1. In conclusion, our results are mildly suggestive that diagnosed diabetes and high levels of glucose, per se, may increase the risk of VTE. Elevated glucose was not related to VTE in those without diagnosed diabetes.
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Affiliation(s)
- Elizabeth J Bell
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA
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26
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Bell EJ, Lutsey PL, Windham BG, Folsom AR. Physical activity and cardiovascular disease in African Americans in Atherosclerosis Risk in Communities. Med Sci Sports Exerc 2014; 45:901-7. [PMID: 23247714 DOI: 10.1249/mss.0b013e31827d87ec] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Although there is substantial evidence that physical activity reduces a person's risk of cardiovascular disease (CVD), few of these studies have included African Americans. The studies that have included African Americans offer inconclusive evidence on the association, and none studied heart failure separately. We used data from the Atherosclerosis Risk in Communities study cohort to examine, in African Americans, the association of physical activity with the incidence of CVD and its major components-stroke, heart failure, and CHD. METHODS Participants age 45-64 yr (3707 African Americans and, for comparison, 10,018 Caucasians) had physical activity assessed via questionnaire in 1987 and were followed for incident CVD (n = 1039) through 2008. RESULTS After adjustment for potential confounders, physical activity was inversely related to CVD, heart failure, and CHD incidence in both races (P values for trend <0.0001), and with stroke in African Americans. Hazard ratios (95% confidence intervals) for CVD for each higher physical activity category were similar by race: 1.0, 0.65 (0.56-0.75), and 0.59 (0.49-0.71) for African Americans and 1.0, 0.74 (0.66-0.83), and 0.67 (0.59-0.75) for Caucasians (P value for interaction = 0.38). CONCLUSIONS Our findings reinforce recommendations that regular physical activity is important for CVD risk reduction in African Americans as well as Caucasians and support the idea that some physical activity is better than none.
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Affiliation(s)
- Elizabeth J Bell
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55454, USA.
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27
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Huxley RR, Bell EJ, Lutsey PL, Bushnell C, Shahar E, Rosamond W, Gottesman R, Folsom A. A comparative analysis of risk factors for stroke in blacks and whites: the Atherosclerosis Risk in Communities study. Ethn Health 2013; 19:601-616. [PMID: 24261746 PMCID: PMC4029919 DOI: 10.1080/13557858.2013.857765] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Previous studies have speculated that the higher stroke incidence rate (IR) in blacks compared with whites may be due, in part, to stroke risk factors exerting a more adverse effect among blacks than whites. To determine whether such racial differences exist we compared the prospective associations between novel, traditional, and emerging stroke risk factors in blacks and whites. DESIGN Baseline characteristics on risk factor levels were obtained on 15,407 participants from the Atherosclerosis Risk in Communities Study. Stroke incidence was ascertained from 1987 to 2008. Adjusted Cox proportional hazard models were used to compute hazard ratios (HRs) and their 95% confidence intervals (CIs) for stroke in relation to stroke risk factor levels stratified by race. RESULTS During follow-up, 988 stroke events occurred: blacks had higher stroke incident rates compared with whites with the greatest difference in those aged <60 years: 4.34, 3.24, 1.20, and 0.84 per 1000 person-years, in black men, black women, white men, and white women, respectively. Associations between risk factors with incident stroke were similar in blacks and whites excluding diabetes which was more strongly associated with the risk of stroke in blacks than in whites: HR 2.54 (95% CI: 2.03-3.18) versus 1.74 (1.37-2.21), respectively; p for race interaction=0.02. CONCLUSIONS At all ages, blacks are at a considerably higher risk of incident stroke compared with whites, although the effect is most marked in younger age groups. This is most likely due to blacks having a greater burden of stroke risk factors rather than there being any substantial race differences in the associations between risk factors and stroke outcomes.
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Affiliation(s)
- Rachel R Huxley
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
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Bell EJ, Takhar SS, Beloff JR, Schuur JD, Landman AB. Information technology improves Emergency Department patient discharge instructions completeness and performance on a national quality measure: a quasi-experimental study. Appl Clin Inform 2013; 4:499-514. [PMID: 24454578 DOI: 10.4338/aci-2013-07-ra-0046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 10/07/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19). METHODS We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated. RESULTS The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 - 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% - 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% - 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats. CONCLUSION With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure.
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Affiliation(s)
| | | | - J R Beloff
- Brigham and Women's Hospital , Boston, MA
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Folsom AR, Nambi V, Bell EJ, Oluleye OW, Gottesman RF, Lutsey PL, Huxley RR, Ballantyne CM. Troponin T, N-terminal pro-B-type natriuretic peptide, and incidence of stroke: the atherosclerosis risk in communities study. Stroke 2013; 44:961-7. [PMID: 23471272 DOI: 10.1161/strokeaha.111.000173] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Increased levels of plasma troponins and natriuretic peptides are associated with increased risk of cardiovascular disease, but only limited information exists on these biomarkers and stroke occurrence. In a prospective epidemiological study, we tested the hypothesis that high-sensitivity troponin T (TnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated positively with incidence of stroke. METHODS The Atherosclerosis Risk in Communities (ARIC) Study measured plasma TnT and NT-proBNP in 10 902 men or women initially free of stroke and followed them for a mean of 11.3 years for stroke occurrence (n=507). RESULTS Both biomarkers were associated positively with total stroke, nonlacunar ischemic, and especially cardioembolic stroke, but not with lacunar or hemorrhagic stroke. For example, after adjustment for prevalent risk factors and cardiac diseases, the hazard ratios (95% CIs) for jointly high values of TnT and NT-proBNP (versus neither biomarker high) were 2.70 (1.92-3.79) for total stroke and 6.26 (3.40-11.5) for cardioembolic stroke. Associations with stroke appeared somewhat stronger for NT-proBNP than TnT. Strikingly, ≈ 58% of cardioembolic strokes occurred in the highest quintile of prestroke NT-proBNP, and 32% of cardioembolic strokes occurred in participants who had both NT-proBNP in the highest quintile and were known by ARIC to have atrial fibrillation sometime before their cardioembolic stroke occurrence. CONCLUSIONS In the general population, elevated plasma TnT and NT-proBNP concentrations are associated with increased risk of cardioembolic and other nonlacunar ischemic strokes.
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Affiliation(s)
- Aaron R Folsom
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55454, USA.
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Folsom AR, Nambi V, Bell EJ, Oluleye OW, Gottesman RF, Lutsey PL, Huxley RR, Ballantyne CM. Abstract 79: Troponin T, NT-proBNP, and Incidence of Stroke: The Atherosclerosis Risk in Communities (ARIC) Study. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.a79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increased levels of plasma troponins and natriuretic peptides in the general population are associated with increased future risk of cardiovascular disease, but only limited information exists on these biomarkers and stroke occurrence. In a prospective epidemiological study, the Atherosclerosis Risk in Communities (ARIC) Study, we tested the hypothesis that high-sensitivity troponin T (TnT) and N-terminal pro B-type natriuretic peptide (NT-proBNP) are associated positively with incidence of stroke. We measured plasma high-sensitivity TnT and NT-proBNP in 10,902 men or women initially free of stroke and followed them for a mean of 11.3 years for stroke occurrence (n=507). Analyses were performed using proportional hazards modeling. Both biomarkers were associated positively with total stroke, nonlacunar ischemic, and especially, cardioembolic stroke, but not with lacunar or hemorrhagic stroke. After adjustment for other stroke risk factors, the hazard ratio (95% CI) per one SD greater increment of natural log-transformed TnT was 1.23 (1.13, 1.35) for total stroke, 1.27 (1.15, 1.40) for total ischemic stroke, and 1.36 (1.14, 1.62) for cardioembolic stroke. Likewise, the hazard ratio per one SD greater natural log-transformed NT-proBNP, was 1.37 (1.26, 1.49) for total stroke, 1.39 (1.27, 1.53) for total ischemic stroke, and 1.95 (1.67, 2.28) for cardioembolic stroke. The hazard ratios for jointly high values of TnT (≥0.013 ug/L) and NT-proBNP (≥155.2 pg/mL), versus neither biomarker high, were 2.70 (1.92, 3.79) for total stroke and 6.26 (3.40, 11.5) for cardioembolic stroke, and somewhat stronger for NT-proBNP than TnT. Strikingly, approximately 58% of cardioembolic strokes occurred in the highest quintile of pre-stroke NT-proBNP (versus 3% occurring in the lowest quintile), and 32% of cardioembolic strokes occurred in participants who had both NT-proBNP in the highest quintile and were known by ARIC to have atrial fibrillation sometime before their cardioembolic stroke occurrence. In conclusion, in the general population, elevated plasma TnT and NT-proBNP concentrations are associated with increased risk of cardioembolic and other nonlacunar ischemic strokes.
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Wattanakit K, Lutsey PL, Bell EJ, Gornik H, Cushman M, Heckbert SR, Rosamond WD, Folsom AR. Association between cardiovascular disease risk factors and occurrence of venous thromboembolism. A time-dependent analysis. Thromb Haemost 2012; 108:508-15. [PMID: 22782466 DOI: 10.1160/th11-10-0726] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Accepted: 05/19/2012] [Indexed: 01/10/2023]
Abstract
Apart from obesity, it remains controversial whether atherosclerosis and its cardiovascular risk disease (CVD) factors are associated with risk of venous thromboembolism (VTE). Using data from the Atherosclerosis Risk in Communities study (ARIC), we evaluated associations between CVD risk factors and incident VTE in a cohort of 15,340 participants who were free a history of VTE and/or anticoagulant use on enrolment. The CVD risk factors were updated during the follow-up period. Over a mean follow-up time of 15.5 years (237,375 person-years), 468 participants had VTE events. Adjusting for demographic variables and body mass index (BMI), current smokers were at greater risk [HR of 1.44 (95% CI: 1.12-1.86)] compared to non-smokers. There was a positive monotonic association between BMI and VTE risk. Individuals with a BMI ≥35 kg/m² had a HR for VTE of 3.09 (95%CI: 2.26-4.23) compared to those with normal BMI (<25 kg/m²). Greater physical activity was associated with lower VTE risk in a demographic adjusted model; however, this association became non-significant following adjustment for BMI. Alcohol intake, diabetes, hypertension, high-density lipoprotein and low-density lipoprotein cholesterol, and triglycerides were not associated with VTE risk. In conclusion, among the well-established CVD risk factors, only current smoking and obesity were independently associated with VTE risk in this large cohort where risk factors were updated serially during follow-up. This finding corroborates that the pathogenesis of venous disease differs from that of atherosclerotic disease.
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Wattanakit K, Lutsey P, Bell EJ, Gornik H, Cushman M, Heckbert S, Rosamond W, Folsom A, Midwest H. ASSOCIATION BETWEEN CARDIOVASCULAR DISEASE RISK FACTORS AND OCCURRENCE OF VENOUS THROMBOEMBOLISM: A TIME-DEPENDENT ANALYSIS. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)61612-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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English CF, Bell EJ, Berger AJ. Isolation of thermophiles from broadleaf tobacco and effect of pure culture inoculation on cigar aroma and mildness. Appl Microbiol 2010; 15:117-9. [PMID: 16349710 PMCID: PMC546854 DOI: 10.1128/am.15.1.117-119.1967] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Thermophilic members of the genus Bacillus isolated from fermented Connecticut broadleaf tobacco included eight strains of B. subtilis, five strains of B. coagulans, four strains of B. megaterium, and three strains of B. circulans. Some of these strains in pure single or mixed culture were employed to enrich the normal thermophile flora of "sweating" tobacco. Three strains of B. subtilis and one of B. circulans, either in single or multiple enrichment, caused the more rapid appearance of a pleasing aroma in Pennsylvania "Wrapper B" filler tobacco. These conclusions are based on subjective reactions of professional testers after numerous blindfold smoking tests.
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Affiliation(s)
- C F English
- Department of Biological Sciences, University of Cincinnati, Cincinnati, Ohio
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Affiliation(s)
- E J Bell
- Ruchill Hospital, Glasgow, Scotland
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Blake FG, Maxcy KF, Sadusk JF, Kohls GM, Bell EJ. Tsutsugamushi Disease (Scrub Typhus, Mite-borne Typhus) in New Guinea. Am J Public Health Nations Health 2008; 35:1121-30. [PMID: 18016251 DOI: 10.2105/ajph.35.11.1121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
BACKGROUND Several studies have described the impact that dental caries and periodontitis may have on the dentitions of individuals with Down syndrome, but there are few reports about the effects of tooth wear. This investigation aimed to compare the aetiology, prevalence and severity of tooth wear in 49 cytogenetically confirmed Down syndrome children with 49 non-Down syndrome controls. METHODS This study involved three aspects: an oral examination, including obtaining dental impressions; a dietary analysis spanning three days; and a questionnaire seeking information about habits, medical problems and medications. Tooth wear severity was scored on a 4-grade scale (none-to-little; moderate; severe; very severe), while aetiology was classified as being due to attrition mainly, erosion mainly, or a combination of both. Double determinations established scoring method reliability and chi-square tests assessed associations between samples. RESULTS Tooth wear was significantly more frequent (p<0.01) in the Down syndrome than the non-Down syndrome sample (67.4 per cent cf 34.7 per cent), with more of the Down syndrome children showing severe to very severe wear (59.2 per cent cf 8.2 per cent). Significantly more Down syndrome children (p<0.05) displayed a multifactorial aetiology of tooth wear, i.e., both attrition and erosion (46.7 per cent cf 28.6 per cent), although no particular dietary link was established. Gastric reflux and vomiting were reported in over 20 per cent of the Down syndrome sample. CONCLUSIONS Given the potential consequences of high levels of tooth wear, associated with tooth grinding and an acidic oral environment in Down syndrome children, educational programmes aimed at increasing awareness of carers and health professionals are needed urgently.
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Affiliation(s)
- E J Bell
- Dental School, The University of Adelaide, South Australia
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Christensen DB, Holmes G, Fassett WE, Neil N, Andrilla CH, Smith DH, Andrews A, Bell EJ, Hansen RW, Shafer R, Stergachis A. Influence of a financial incentive on cognitive services: CARE project design/implementation. J Am Pharm Assoc (Wash) 1999; 39:629-39. [PMID: 10533344 DOI: 10.1016/s1086-5802(15)30347-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the design and methods of the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project, a demonstration project in which community pharmacies were paid for cognitive services (CS) provided to Medicaid patients, its evaluation objectives, and the extent to which implementation objectives were achieved. DESIGN Prospective randomized trial. Community pharmacies were allocated to a documentation-and-payment group, documentation-only group, and "silent" control group. CS were reported using a problem-intervention-result classification system embedded within a pseudo-National Drug Code format. Management strategies included use of area coordinators. SETTING Pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term-care residents. PARTICIPANTS 200 community pharmacies (110 treatment; 90 control), with another 100 randomly selected pharmacies as a silent control group. INTERVENTIONS A modest monthly stipend. The treatment group billed Medicaid for each documented CS associated with a drug therapy-related problem. All participants received training in documentation methods. A unique coding scheme allowed documentation of CS within the constraints of the Medicaid program. Data edit checks and feedback were used to ensure data quality and completeness. Area coordinators were used to facilitate training, compliance with study procedures, and participation. MAIN OUTCOME MEASURES Participation rates, documentation rates, coding scheme revision, data quality and completeness rates, and effectiveness of area coordinators. RESULTS Pharmacists documented more than 20,240 CS records. Approximately 89% of records passed edit checks, and 94% did so after modification. Nearly 83% could be linked to a paid drug or CS claim. The coding system was sufficient, with minor modifications, to account for all interventions documented. Area coordinators did not function as expected. CONCLUSION A system for documentation and payment of pharmacists' CS to Medicaid recipients was implemented successfully and relatively easily in community pharmacies.
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Affiliation(s)
- D B Christensen
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, USA.
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Abstract
The aim of this study was to compare the shape of exposed dentinal surfaces caused by abrasion and erosion with a view to developing a diagnostic clinical test. The study material consisted of 80 natural teeth and 129 dental models obtained from Australian Aborigines known to display considerable dental abrasion due to their diet, and dental models of 37 Caucasians diagnosed with dental erosion through detailed history and dietary analysis. Polyvinyl siloxane impressions were obtained of all occlusal surfaces with dentinal scooping in both the 'abrasion' and 'erosion' groups. All impressions were sectioned buccolingually through the deepest point of the scooped dentine, and then the profiles were photocopied at x2 magnification. The breadth and depth of dentinal profiles were measured to an accuracy of 0.1 mm, enabling ratios of depth:breadth to be determined, and the position of the deepest part of each scooped surface was recorded. The mean depth:breadth ratio of scooped dentine was significantly greater in the Aboriginal natural teeth (0.19 +/- 0.06, mean +/- SE) than in the Aboriginal dental models (0.15 +/- 0.04). Both Aboriginal natural teeth and models with abrasion showed significantly smaller ratios (p < 0.05) than the Caucasian models showing erosion (0.33 +/- 0.07). Furthermore, in the abrasion samples, the deepest region of the scooped dentine tended to be lingually placed more often in maxillary teeth but buccally placed more often in mandibular teeth (p < 0.05). These results indicate that scooped dentine on abraded occlusal surfaces of teeth displays significant differences in shape compared with that caused mainly by erosion.
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Affiliation(s)
- E J Bell
- Department of Dentistry, University of Adelaide, Australia
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Christensen DB, Holmes G, Fassett WE, Neil N, Andrilla CH, Smith DH, Andrews A, Bell EJ, Hansen R, Shafer R, Stergachis A. Principal findings from the Washington State cognitive services demonstration project. Manag Care Interface 1998; 11:60-2, 64. [PMID: 10181572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
In addition to dispensing, pharmacists are ideally positioned to provide cognitive services that are targeted at optimizing drug therapy through identification and resolution of drug therapy problems. The Washington Cognitive Activities and Reimbursement Effectiveness project sought to determine: (1) if pharmacists would respond to a financial incentive by performing more cognitive services, and (2) the effect on drug cost of cognitive services they performed.
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Abstract
Replication-competent retroviral vectors based on Rous sarcoma virus (RSV) are becoming increasingly popular for expressing genes in both primary cell cultures and embryonic chick tissues in ovo. In this article, we review the features of RSV and its life cycle that make it suitable for use as a vector. We describe the design and use of the RCAS and RCAS (BP) series of vectors, which are currently the most widely used RSV-based vectors, illustrating both their strengths and weakness. Finally, we outline laboratory protocols suitable for the banding of these retroviral vectors.
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Affiliation(s)
- E J Bell
- Department of Developmental Neurobiology, UMDS, Guy's Hospital, London, UK
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Duprez D, Bell EJ, Richardson MK, Archer CW, Wolpert L, Brickell PM, Francis-West PH. Overexpression of BMP-2 and BMP-4 alters the size and shape of developing skeletal elements in the chick limb. Mech Dev 1996; 57:145-57. [PMID: 8843392 DOI: 10.1016/0925-4773(96)00540-0] [Citation(s) in RCA: 227] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Bone morphogenetic proteins are members of the transforming growth factor beta (TGF beta) superfamily which are involved in a range of developmental processes including modelling of the skeleton. We show here that Bmp-2 is expressed in mesenchyme surrounding early cartilage condensations in the developing chick limb, and that Bmp-4 is expressed in the perichondrium of developing cartilage elements. To investigate their roles during cartilage development, BMP-2 and BMP-4 were expressed ectopically in developing chick limbs using retroviral vectors. Over-expression of BMP-2 or BMP-4 led to a dramatic increase in the volume of cartilage elements, altered their shapes and led to joint fusions. This increase in volume appeared to result from an increase in the amount of matrix and in the number of chondrocytes. The latter did not appear to be due to increased proliferation of chondrocytes, suggesting that it may result from increased recruitment of precursors. BMP-2 and BMP-4 also delayed hypertrophy of chondrocytes and formation of the osteogenic periosteum. These data provide insights into how BMP-2 and BMP-4 may model and control the growth of skeletal elements during normal embryonic development, suggesting roles for both molecules in recruiting non-chondrogenic precursors to chondrogenic fate.
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Affiliation(s)
- D Duprez
- Department of Molecular Pathology, University College London Medical School, UK
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Miller NA, Carmichael HA, Calder BD, Behan PO, Bell EJ, McCartney RA, Hall FC. Antibody to Coxsackie B virus in diagnosing postviral fatigue syndrome. BMJ 1991; 302:140-3. [PMID: 1847316 PMCID: PMC1668819 DOI: 10.1136/bmj.302.6769.140] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To study the association between coxsackie B virus infection and the postviral fatigue syndrome and to assess the immunological abnormalities associated with the syndrome. DESIGN Case-control study of patients with the postviral fatigue syndrome referred by local general practitioners over one year. SETTING General practitioner referrals in Dunbartonshire, Scotland. PATIENTS 254 Patients referred with the postviral fatigue syndrome (exhaustion, myalgia, and other symptoms referable to postviral fatigue syndrome of fairly recent onset--that is, several months) and age and sex matched controls obtained from same general practitioner; 11 patients were rejected because of wrong diagnoses, resolution of symptoms, and refusal to participate, leaving 243 patients and matched controls. MAIN OUTCOME MEASURES Detailed questionnaire (patients and controls) and clinical examination (patients) and blind analysis of blood sample at entry and after six months for determination of coxsackie B virus IgM and IgG antibodies and other variables (including lymphocyte protein synthesis, lymphocyte subsets, and immune complexes). RESULTS Percentage positive rates for coxsackie B virus IgM at entry were 24.4% for patients and 22.6% for controls and for coxsackie B virus IgG 56.2% and 55.3% respectively; there were no significant differences between different categories of patients according to clinical likelihood of the syndrome nor any predictive value in a fourfold rise or fall in the coxsackie B virus IgG titre in patients between entry and review at six months. The rates of positive antibody test results in patients and controls showed a strong seasonal variation. Of the numerous immunological tests performed, only a few detected significant abnormalities; in particular the mean value for immune complex concentration was much higher in 35 patients and 35 controls compared with the normal range and mean value for total IgM was also raised in 227 patients and 35 controls compared with the normal range. CONCLUSIONS Serological tests available for detecting coxsackie B virus antibodies do not help diagnose the postviral fatigue syndrome. Percentage positive rates of the antibodies in patients simply reflect the background in the population as probably do the raised concentrations of total IgM and immune complexes.
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Cossar JH, Reid D, Fallon RJ, Bell EJ, Riding MH, Follett EA, Dow BC, Mitchell S, Grist NR. A cumulative review of studies on travellers, their experience of illness and the implications of these findings. J Infect 1990; 21:27-42. [PMID: 2166766 DOI: 10.1016/0163-4453(90)90600-d] [Citation(s) in RCA: 119] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A cumulative review of illness experienced by 13,816 travellers returning to Scotland since 1977, shows an overall attack rate of 36%. Alimentary complaints predominated; 18% of travellers had these alone and a further 10% had other symptoms as well as their gastro-intestinal disorder. Higher attack rates were noted in those taking package holidays. Inexperience of travel, smoking, more southerly travel and younger age (particularly those between 20- and 29-years-old) were other contributing factors. A similar pattern emerged from a I year study of hospital in-patients with travel related admissions. Serological studies of 470 travellers showed that 20% had incomplete immunity to poliomyelitis; 25% of those tested (312 travellers) had serological evidence of typhoid immunisation, I.9% (of 760 travellers) had antibodies to Legionella pneumophila, 64% (5II travellers tested) had antibodies to hepatitis A, 87% (288 tested) had adequate levels of tetanus antitoxin but only 40% of the 225 travellers tested had adequate levels of diphtheria antitoxin. Amongst a subgroup of 645 travellers the travel agent was the most frequently consulted source of pre-travel health advice. This carries particular significance for the dissemination of relevant advice in view of the inadequacies found from study of the health information in travel brochures. These findings, viewed against the perspective of the continuing growth in international travel, means that travellers, the medical profession, the travel trade, health educators, global health agencies and health authorities in those countries accepting and encouraging tourists, will be required to recognise the health implications of further tourism development if this problem of illness associated with travel is to be brought under control.
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Affiliation(s)
- J H Cossar
- Communicable Diseases (Scotland) Unit, U.K
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Abstract
Myalgic encephalomyelitis is a common disability but frequently misinterpreted. Amongst 6,000 patients referred for general microbiological diagnosis between 1975 and 1987, 420 cases were recognized. Coxsackie B neutralization tests, in 205 of these, demonstrated significant titres in 103/205 (50%), while of 124 additionally investigated for enteroviral IgM, 38/124 (31%) were positive. This illness is distinguished from a variety of other post-viral states by an unique clinical and epidemiological pattern characteristic of enteroviral infection. Prompt recognition and advice to avoid over-exertion is mandatory. Routine diagnosis, specific therapy and prevention, await further technical advances.
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Abstract
A retrospective study of the clinical features in 39 children who were investigated for evidence of Coxsackie B virus (CBV) infection is reported. Eighteen children were found to have serological evidence of infection. An extensive range of features was elicited in both seropositive and seronegative patients, most children complaining of abnormalities referable to muscle and, in particular, of weakness and easy fatiguability. Children with evidence of CBV infection were significantly more likely to belong to social classes I and II, to have relatives with serological evidence of CBV infection, and to show certain dysphoric features as well as to complain of sore throats. The relationship between CBV infection and 'myalgic encephalomyelitis' or 'post-viral syndrome' is discussed, and it is suggested that these descriptions are inappropriate given our current knowledge, and inadequately describe the clinical features seen in the children under study. An alternative description, 'fatigue-dysphoria syndrome' is proposed.
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Affiliation(s)
- P M Wilson
- Royal Hospital for Sick Children, Edinburgh, Scotland
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Abstract
A 9-month-old boy died of a disseminated echovirus 7 (E7) infection with virus being cultured from his liver and spleen. His hepatic failure was complicated by candidiasis and marrow hypoplasia and aggravated by a possible immune deficiency.
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Affiliation(s)
- D O Ho-Yen
- Regional Virus Laboratory, Ruchill Hospital, Glasgow, Scotland
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Bell EJ. A splint in time. Prof Nurse 1988; 3:464-5. [PMID: 3420124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
A six-month-old British female, living in Glasgow was admitted in June 1986 with a four-day history of fever and lower limb weakness following immunisation with oral polio and triple (DTP) vaccines. Examination revealed paralysis of all limbs, facial muscles and right diaphragm, scoliosis, opsoclonus and ocular flutter. Poliovirus types 1, 2 and 3, isolated from her stool specimens were all vaccine-like strains. Her serial serum IgA levels were persistently low and salivary IgA was undetectable. This appears to be the first fully authenticated case of poliovaccine damage in Scotland. It is unclear whether the selective IgA deficiency contributed to her vulnerability. It is essential to investigate elaborately and process viral isolates in every suspected case of acute poliomyelitis so as to determine the dimension and ramifications of poliovaccine damage in the UK population which is known to be rather apprehensive about vaccine dangers.
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Affiliation(s)
- A A Asindi
- Fraser of Allander Unit (Paediatric Neurology), Royal Hospital for Sick Children, Glasgow
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Archard LC, Bowles NE, Behan PO, Bell EJ, Doyle D. Postviral fatigue syndrome: persistence of enterovirus RNA in muscle and elevated creatine kinase. J R Soc Med 1988; 81:326-9. [PMID: 3404526 PMCID: PMC1291623 DOI: 10.1177/014107688808100608] [Citation(s) in RCA: 105] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Enterovirus-specific probes have been prepared by reverse transcription of conserved sequences in purified Coxsackie B2 virus genomic RNA and molecular cloning techniques. These probes were used in quantitative slot blot hybridizations to test for the presence of enterovirus-specific RNA in skeletal muscle biopsy specimens from 96 patients who had suffered from the postviral fatigue syndrome myalgic encephalomyelitis for up to 20 years. Biopsy specimens from 20 patients were positive for the presence of virus-specific RNA with hybridization signals more than three standard deviations greater than the mean of the normal muscle controls. Biopsies from the remaining 76 patients were indistinguishable from the controls. These data show that enterovirus RNA is present in skeletal muscle of some patients with postviral fatigue syndrome up to 20 years after onset of disease and suggest that a persistent virus infection has an aetiological role.
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Affiliation(s)
- L C Archard
- Department of Biochemistry, Charing Cross and Westminster Medical School, London
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Abstract
Data collected over the past 6 years suggest that Coxsackie B viruses (CBV) play an important role in myalgic encephalomyelitis (ME). Since psychological upset is a feature of this illness, 247 patients, recently admitted to a psychiatric hospital, were tested for neutralizing antibodies to CBV. A total of 12.5% had significantly raised CBV titres compared with 4-5% of 'well' control groups; the percentage positive was greatest (21%) in those aged 30-39 years. During 1985 and 1986 sera from 290 adults with ME were tested using the newly developed CBV IgM ELISA test; 37% were CBV IgM positive compared with 9% of 500 'well' adult controls. Forty-seven children, with ME were similarly tested during this period; 38% were positive, implying recent or active CBV infection. The combined use of this ELISA test and the virus probe techniques now available should further help to elucidate the exact role of CBV in this disabling illness.
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