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Mainous AG, Orlando FA, Yin L, Sharma P, Wu V, Saguil A. Inflammation and poverty as individual and combined predictors of 15-year mortality risk in middle aged and older adults in the US. Front Med (Lausanne) 2024; 10:1261083. [PMID: 38293298 PMCID: PMC10824842 DOI: 10.3389/fmed.2023.1261083] [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: 07/18/2023] [Accepted: 10/27/2023] [Indexed: 02/01/2024] Open
Abstract
Background Chronic systemic inflammation and poverty are both linked to an increased mortality risk. The goal of this study was to determine if there is a synergistic effect of the presence of inflammation and poverty on the 15-year risk of all-cause, heart disease and cancer mortality among US adults. Methods We analyzed the nationally representative National Health and Nutrition Examination Survey (NHANES) 1999 to 2002 with linked records to the National Death Index through the date December 31, 2019. Among adults aged 40 and older, 15-year mortality risk associated with inflammation, C-reactive protein (CRP), and poverty was assessed in Cox regressions. All-cause, heart disease and cancer mortality were the outcomes. Results Individuals with elevated CRP at 1.0 mg/dL and poverty were at greater risk of 15-year adjusted, all-cause mortality (HR = 2.45; 95% CI 1.64, 3.67) than individuals with low CRP and were above poverty. For individuals with just one at risk characteristic, low inflammation/poverty (HR = 1.58; 95% CI 1.30, 1.93), inflammation/above poverty (HR = 1.59; 95% CI 1.31, 1.93) the mortality risk was essentially the same and substantially lower than the risk for adults with both. Individuals with both elevated inflammation and living in poverty experience a 15-year heart disease mortality risk elevated by 127% and 15-year cancer mortality elevated by 196%. Discussion This study extends the past research showing an increased mortality risk for poverty and systemic inflammation to indicate that there is a potential synergistic effect for increased mortality risk when an adult has both increased inflammation and is living in poverty.
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Affiliation(s)
- Arch G. Mainous
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
- Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL, United States
| | - Frank A. Orlando
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
| | - Lu Yin
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
| | - Pooja Sharma
- Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL, United States
| | - Velyn Wu
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
| | - Aaron Saguil
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
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Amaris MA, Kallas HE, Gonzalo DH, Orlando FA. Gastric and colonic metastases of malignant melanoma diagnosed during endoscopic evaluation of symptomatic anemia presenting as angina: a case report. Front Med (Lausanne) 2023; 10:1268973. [PMID: 38020144 PMCID: PMC10652385 DOI: 10.3389/fmed.2023.1268973] [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: 07/28/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023] Open
Abstract
A 72-year-old man visited cardiology for exertional chest pain, lightheadedness, and fatigue. Six years prior, he was surgically treated for cutaneous malignant melanoma of the lower back. After a negative cardiac work-up, primary care diagnosed severe iron deficiency anemia. Emergent upper and lower gastrointestinal (GI) endoscopy revealed simultaneous melanoma metastases to the stomach and colon with discrete macroscopic features. Metastatic disease, including brain, lung, and bone, was discovered on imaging. Treatment included immunotherapy with nivolumab and stereotactic radiosurgery of the brain metastases, and our patient has remained in continued remission even after 2 years. Melanoma with GI tract (GIT) metastasis has a poor prognosis and rarely presents symptomatically or with synchronous gastric and colonic lesions. This case illustrates the importance of early primary care involvement to expedite work-up for multifocal GI metastases in patients with a remote melanoma history presenting with symptoms related to iron deficiency anemia (IDA).
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Affiliation(s)
- Manuel A. Amaris
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Henrique E. Kallas
- Division of Geriatrics, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - David H. Gonzalo
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Frank A. Orlando
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
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3
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Raviprasad AG, Malaty J, Wynne B, Orlando FA. Incidental seromucinous hamartoma of the anterior nasal cavity presenting after episode of vestibular neuritis. BMJ Case Rep 2023; 16:e254889. [PMID: 37914165 PMCID: PMC10626906 DOI: 10.1136/bcr-2023-254889] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
A woman in her 70s presented to primary care clinic complaining of acute onset dizziness for 1 day that was initially diagnosed as vestibular neuritis and treated with steroids. The next day, she presented to the emergency department with worsening symptoms. Imaging revealed no intracranial process; however, non-contrast CT imaging revealed a soft-tissue mass in the posterior ethmoid sinus. The vertigo completely resolved before an otolaryngologist surgically removed the nasal mass, which actually originated from the right cribriform plate and extended to the anterior middle turbinate head. The final pathology was consistent with seromucinous hamartoma.
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Affiliation(s)
| | - John Malaty
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Brianna Wynne
- Division of Geriatrics, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Frank A Orlando
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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Wang Y, Wilson DL, Fernandes D, Adkins LE, Bantad A, Copacia C, Dharma N, Huang PL, Joseph A, Park TW, Budd J, Meenrajan S, Orlando FA, Pennington J, Schmidt S, Shorr R, Uphold CR, Lo-Ciganic WH. Deprescribing Strategies for Opioids and Benzodiazepines with Emphasis on Concurrent Use: A Scoping Review. J Clin Med 2023; 12:jcm12051788. [PMID: 36902574 PMCID: PMC10002935 DOI: 10.3390/jcm12051788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023] Open
Abstract
While the Food and Drug Administration's black-box warnings caution against concurrent opioid and benzodiazepine (OPI-BZD) use, there is little guidance on how to deprescribe these medications. This scoping review analyzes the available opioid and/or benzodiazepine deprescribing strategies from the PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases (01/1995-08/2020) and the gray literature. We identified 39 original research studies (opioids: n = 5, benzodiazepines: n = 31, concurrent use: n = 3) and 26 guidelines (opioids: n = 16, benzodiazepines: n = 11, concurrent use: n = 0). Among the three studies deprescribing concurrent use (success rates of 21-100%), two evaluated a 3-week rehabilitation program, and one assessed a 24-week primary care intervention for veterans. Initial opioid dose deprescribing rates ranged from (1) 10-20%/weekday followed by 2.5-10%/weekday over three weeks to (2) 10-25%/1-4 weeks. Initial benzodiazepine dose deprescribing rates ranged from (1) patient-specific reductions over three weeks to (2) 50% dose reduction for 2-4 weeks, followed by 2-8 weeks of dose maintenance and then a 25% reduction biweekly. Among the 26 guidelines identified, 22 highlighted the risks of co-prescribing OPI-BZD, and 4 provided conflicting recommendations on the OPI-BZD deprescribing sequence. Thirty-five states' websites provided resources for opioid deprescription and three states' websites had benzodiazepine deprescribing recommendations. Further studies are needed to better guide OPI-BZD deprescription.
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Affiliation(s)
- Yanning Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Department of Health Outcome and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Deanna Fernandes
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
| | - Lauren E. Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL 32610, USA
| | - Ashley Bantad
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Clint Copacia
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Nilay Dharma
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Amanda Joseph
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Tae Woo Park
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jeffrey Budd
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Senthil Meenrajan
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Frank A. Orlando
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - John Pennington
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Siegfried Schmidt
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Ronald Shorr
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Constance R. Uphold
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
- Department of Physiology and Aging, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Correspondence:
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Orlando FA, Governale KM, Estores IM. Appraising Important Medical Literature Biases: Uncorrected Statistical Mistakes and Conflicts of Interest. Front Med (Lausanne) 2022; 9:925643. [PMID: 35935772 PMCID: PMC9352946 DOI: 10.3389/fmed.2022.925643] [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] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/17/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Frank A. Orlando
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL, United States
- *Correspondence: Frank A. Orlando
| | - Karyn M. Governale
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL, United States
| | - Irene M. Estores
- Department of Physical Medicine and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, United States
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Mainous AG, Rooks BJ, Orlando FA. The Impact of Initial COVID-19 Episode Inflammation Among Adults on Mortality Within 12 Months Post-hospital Discharge. Front Med (Lausanne) 2022; 9:891375. [PMID: 35646997 PMCID: PMC9135460 DOI: 10.3389/fmed.2022.891375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 12/29/2022] Open
Abstract
Background Inflammation in the initial COVID-19 episode may be associated with post-recovery mortality. The goal of this study was to determine the relationship between systemic inflammation in COVID-19 hospitalized adults and mortality after recovery from COVID-19. Methods An analysis of electronic health records (EHR) for patients from 1 January, 2020 through 31 December, 2021 was performed for a cohort of COVID-19 positive hospitalized adult patients. 1,207 patients were followed for 12 months post COVID-19 episode at one health system. 12-month risk of mortality associated with inflammation, C-reactive protein (CRP), was assessed in Cox regressions adjusted for age, sex, race and comorbidities. Analyses evaluated whether steroids prescribed upon discharge were associated with later mortality. Results Elevated CRP was associated other indicators of severity of the COVID-19 hospitalization including, supplemental oxygen and intravenous dexamethasone. Elevated CRP was associated with an increased mortality risk after recovery from COVID-19. This effect was present for both unadjusted (HR = 1.60; 95% CI 1.18, 2.17) and adjusted analyses (HR = 1.61; 95% CI 1.19, 2.20) when CRP was split into high and low groups at the median. Oral steroid prescriptions at discharge were found to be associated with a lower risk of death post-discharge (adjusted HR = 0.49; 95% CI 0.33, 0.74). Discussion Hyperinflammation present with severe COVID-19 is associated with an increased mortality risk after hospital discharge. Although suggestive, treatment with anti-inflammatory medications like steroids upon hospital discharge is associated with a decreased post-acute COVID-19 mortality risk.
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Affiliation(s)
- Arch G. Mainous
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
- Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL, United States
- *Correspondence: Arch G. Mainous III
| | - Benjamin J. Rooks
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
| | - Frank A. Orlando
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
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7
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Mainous AG, Rooks BJ, Wu V, Orlando FA. COVID-19 Post-acute Sequelae Among Adults: 12 Month Mortality Risk. Front Med (Lausanne) 2021; 8:778434. [PMID: 34926521 PMCID: PMC8671141 DOI: 10.3389/fmed.2021.778434] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background: There are concerns regarding post-acute sequelae of COVID-19, but it is unclear whether COVID-19 poses a significant downstream mortality risk. The objective was to determine the relationship between COVID-19 infection and 12-month mortality after recovery from the initial episode of COVID-19 in adult patients. Methods: An analysis of electronic health records (EHR) was performed for a cohort of 13,638 patients, including COVID-19 positive and a comparison group of COVID-19 negative patients, who were followed for 12 months post COVID-19 episode at one health system. Both COVID-19 positive patients and COVID-19 negative patients were PCR validated. COVID-19 positive patients were classified as severe if they were hospitalized within the first 30 days of the date of their initial positive test. The 12-month risk of mortality was assessed in unadjusted Cox regressions and those adjusted for age, sex, race and comorbidities. Separate subgroup analyses were conducted for (a) patients aged 65 and older and (b) those <65 years. Results: Of the 13,638 patients included in this cohort, 178 had severe COVID-19, 246 had mild/moderate COVID-19, and 13,214 were COVID-19 negative. In the cohort, 2,686 died in the 12-month period. The 12-month adjusted all-cause mortality risk was significantly higher for patients with severe COVID-19 compared to both COVID-19 negative patients (HR 2.50; 95% CI 2.02, 3.09) and mild COVID-19 patients (HR 1.87; 95% CI 1.28, 2.74). The vast majority of deaths (79.5%) were for causes other than respiratory or cardiovascular conditions. Among patients aged <65 years, the pattern was similar but the mortality risk for patients with severe COVID-19 was increased compared to both COVID-19 negative patients (HR 3.33; 95% CI 2.35, 4.73) and mild COVID-19 patients (HR 2.83; 95% CI 1.59, 5.04). Patients aged 65 and older with severe COVID-19 were also at increased 12-month mortality risk compared to COVID-19 negative patients (HR 2.17; 95% CI 1.66, 2.84) but not mild COVID-19 patients (HR 1.41; 95% CI 0.84, 2.34). Discussion: Patients with a COVID-19 hospitalization were at significantly increased risk for future mortality. In a time when nearly all COVID-19 hospitalizations are preventable this study points to an important and under-investigated sequela of COVID-19 and the corresponding need for prevention.
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Affiliation(s)
- Arch G Mainous
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States.,Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL, United States
| | - Benjamin J Rooks
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
| | - Velyn Wu
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
| | - Frank A Orlando
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
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Mainous AG, Rooks BJ, Orlando FA. Is There Limited Utility for Lifestyle Recommendations for Diabetes Prevention Among Overweight or Obese Depressed Patients? Front Med (Lausanne) 2021; 8:757250. [PMID: 34869458 PMCID: PMC8639493 DOI: 10.3389/fmed.2021.757250] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Lifestyle interventions like diet and exercise are commonly recommended for diabetes prevention, but it is unclear if depression modifies the likelihood of adherence. We evaluated the relationship between high depressive symptomatology and adherence to lifestyle interventions among patients with pre-diabetes. Methods: We conducted an analysis of the nationally representative National Health and Nutrition Examination Survey (NHANES) 2017-2018. Adults, aged ≥18 years old who were overweight or obese (BMI ≥25) and had diagnosed or undiagnosed pre-diabetes (HbA1c 5.7-6.4) were included. Depressive symptomatology was classified by the Patient Health Questionniare-9 (PHQ-9). We used self-reported adherence to physician suggested lifestyle changes of diet and exercise. Results: In this nationally representative survey of overweight or obese adults with pre-diabetes, 14.8% also have high depressive symptomatology. In unadjusted analyses, an interaction was observed with high depressive symptomatology acting as an effect modifier for adherence to exercise oriented interventions among patients with diagnosed pre-diabetes (p = 0.027). In logistic regressions, adjusting for age, sex, race, outpatient medical care in the past 12 months, and obesity, among patients with diagnosed pre-diabetes, depressed patients were less likely to attempt to exercise more (OR = 0.31; 95% CI: 0.10, 0.94) and no association between high depressive symptomatology and attempting to lose weight was observed (OR = 0.45; 95% CI: 0.14, 1.42). Conclusions: The findings of this nationally representative study of US adults, high depressive symptomatology decreases the likelihood of adherence to exercise based lifestyle recommendations among patients with diagnosed pre-diabetes.
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Affiliation(s)
- Arch G Mainous
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, United States.,Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
| | - Benjamin J Rooks
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
| | - Frank A Orlando
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, United States
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Abstract
This medical field surveys details of assimilation, defense and repair, energy, biotransformation and elimination, transport, communication, and structural integrity, and addresses 5 lifestyle factors.
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Affiliation(s)
- Frank A Orlando
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville
| | - Ku-Lang Chang
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville
| | - Irene M Estores
- Department of Physical Medicine and Rehabilitation, University of Florida College of Medicine, Gainesville
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Orlando FA, Rahmanian KP, Byrd CE, Chang KL, Yang Y, Carek PJ, Lupi ME. Daily self-regulation with biofeedback to improve stress and job satisfaction in a primary care clinic. J Family Med Prim Care 2021; 10:968-973. [PMID: 34041106 PMCID: PMC8138359 DOI: 10.4103/jfmpc.jfmpc_1820_20] [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: 09/04/2020] [Revised: 10/25/2020] [Accepted: 10/31/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Burnout in healthcare professions is higher than other careers. An undesirable work-life balance has resulted in declining job satisfaction among primary care physicians. Biofeedback devices teach self-regulation techniques, which reduce stress and increase resilience. OBJECTIVES We assessed whether self-regulation with biofeedback is effective at decreasing stress and improving job satisfaction among primary care clinicians and nurses. METHODS Two naturally occurring cohorts of clinicians and nurses were followed over 12 weeks. The treatment group (N = 9) completed 12 weeks of self-regulation with optional clinic-based biofeedback and received peer support for the first half. The control group (N = 9) started a delayed intervention after 6 weeks without peer support. Descriptive and bivariate analyses were conducted. RESULTS The treatment group averaged one biofeedback session weekly for 6 min and the control group two sessions for 11 min. Adherence differed by age. Subjects also reported using self-regulation techniques without biofeedback. Perceived stress initially increased in both groups with intervention implementation, more so in the treatment group (P = 0.03) whose stress then decreased but was not significant. Overall and extrinsic job satisfaction similarly increased but were not significance. CONCLUSION The initial increase in perceived stress was related to daily biofeedback adherence and clinic responsibilities. Treatment group stress then decreased with self-regulation but was difficult to quantify in a small cohort. Larger studies could increase daily self-regulation adherence by improving biofeedback accessibility for leisurely use. Using self-regulation with biofeedback may be an innovative approach to reduce stress and improve job satisfaction in primary care.
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Affiliation(s)
- Frank A. Orlando
- Department of Community Health & Family Medicine, University of Florida College of Medicine, USA
| | | | - Charles E. Byrd
- Department of Community Health & Family Medicine, University of Florida College of Medicine, USA
| | - Ku-Lang Chang
- Department of Community Health & Family Medicine, University of Florida College of Medicine, USA
| | - Yang Yang
- Department of Biostatistics, University of Florida College of Public Health & Health Professions, USA
| | - Peter J. Carek
- Department of Community Health & Family Medicine, University of Florida College of Medicine, USA
| | - Maria Elisa Lupi
- Department of Community Health & Family Medicine, University of Florida College of Medicine, USA
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11
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Chang KL, Orlando FA, Donahoo WT. How to Manage a Patient with Weight Regain. Am Fam Physician 2020; 102:567-570. [PMID: 33118796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Ku-Lang Chang
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Frank A Orlando
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - W Troy Donahoo
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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12
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Cicali EJ, Weitzel KW, Elsey AR, Orlando FA, Vinson M, Mosley S, Smith DM, Davis R, Drum L, Estores D, Franciosi JP, Hagen MG, Jerkins GJ, Mercado ES, Nainaparampil J, Padron A, Rosenberg EI, Wright A, Schmidt SO, Mathews CA, Cavallari LH, Johnson JA. Challenges and lessons learned from clinical pharmacogenetic implementation of multiple gene-drug pairs across ambulatory care settings. Genet Med 2019; 21:2264-2274. [PMID: 30926959 DOI: 10.1038/s41436-019-0500-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [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: 01/10/2019] [Accepted: 03/14/2019] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Incorporating a patient's genotype into the clinical decision-making process is one approach to precision medicine. The University of Florida (UF) Health Precision Medicine Program is a pharmacist-led multidisciplinary effort that has led the clinical implementation of six gene-drug(s) pairs to date. This study focuses on the challenges encountered and lessons learned with implementing pharmacogenetic testing for three of these: CYP2D6-opioids, CYP2D6/CYP2C19-selective serotonin reuptake inhibitors, and CYP2C19-proton pump inhibitors within six pragmatic clinical trials at UF Health and partners. METHODS We compared common measures collected within each of the pharmacogenetic implementations as well as solicited feedback from stakeholders to identify challenges, successes, and lessons learned. RESULTS We identified several challenges related to trial design and implementation, and learned valuable lessons. Most notably, case discussions are effective for prescriber education, prescribers need clear concise guidance on genotype-based actions, having genotype results available at the time of the patient-prescriber encounter helps optimize the ability to act on them, children prefer noninvasive sample collection, and study participants are willing to answer patient-reported outcomes questionnaires if they are not overly burdensome, among others. CONCLUSION The lessons learned from implementing three gene-drug pairs in ambulatory care settings will help shape future pharmacogenetic clinical trials and clinical implementations.
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Affiliation(s)
- Emily J Cicali
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Kristin Wiisanen Weitzel
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Frank A Orlando
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michelle Vinson
- Florida State University College of Medicine, Orlando, FL, USA
| | - Scott Mosley
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - D Max Smith
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Richard Davis
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lori Drum
- Florida State University College of Medicine, Orlando, FL, USA
| | - David Estores
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, Gainesville, FL, USA
| | - James P Franciosi
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Hospital, Orlando, FL, USA.,University of Central Florida College of Medicine, Orlando, FL, USA
| | - Melanie Gross Hagen
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Gabriel J Jerkins
- Department of Psychiatry, University of Florida Genetics Institute, Gainesville, FL, USA
| | - Elvira S Mercado
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jaison Nainaparampil
- Department of Psychiatry, University of Florida Genetics Institute, Gainesville, FL, USA
| | - Adaixa Padron
- Department of Psychiatry, University of Florida Genetics Institute, Gainesville, FL, USA
| | - Eric I Rosenberg
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Ashleigh Wright
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Siegfried O Schmidt
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Carol A Mathews
- Department of Psychiatry, University of Florida Genetics Institute, Gainesville, FL, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA.
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13
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Orlando FA, Brown KD. Unraveling breast cancer heterogeneity through transcriptomic and epigenomic analysis. Ann Surg Oncol 2009; 16:2270-9. [PMID: 19452229 DOI: 10.1245/s10434-009-0500-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 03/31/2009] [Accepted: 04/19/2009] [Indexed: 12/31/2022]
Abstract
Breast cancer diversity is histologically evident as various proliferative benign lesions, in situ carcinomas, and invasive carcinomas that may develop into distant metastases. Breast tumor molecular subtypes have been defined by genome-wide expression microarray technology and reveal associations between genetic alterations and the malignant phenotype. Early work has been conducted to use subtype-specific biomarkers to elucidate targeted treatment options early in the course of breast cancer progression. Additionally, DNA methylation is an epigenetic modification that contributes to breast cancer progression by transcriptionally silencing certain tumor suppressor genes. Among the genes characterized as targets for silencing are well-established tumor suppressors such as RASSF1A, RARB, SFN, and TGM2. Measuring elevated gene copy number and aberrant gene promoter methylation can further facilitate characterization of breast tumor molecular subtype; however, profiling of breast tumors based on epigenetic criteria has yet to be established. Epigenomic analysis has been investigated for clinical applicability, and it has great promise when used in combination with minimally invasive techniques for both diagnostic and prognostic purposes.
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Affiliation(s)
- Frank A Orlando
- Department of Surgery, University of Florida College of Medicine and UF Shands Cancer Center, Gainesville, FL, USA.
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14
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Hassid VJ, Orlando FA, Awad ZT, Tan D, Khoury T, Ahmed BH, Alrawi SJ. Genetic and molecular abnormalities in cholangiocarcinogenesis. Anticancer Res 2009; 29:1151-6. [PMID: 19414358 PMCID: PMC4011011] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Cholangiocarcinomas are biliary tree neoplasms of cholangiocyte origin. Several clinical risk factors are associated with cholangiocarcinogenesis. During the last decade, there has been an increasing interest in the causative molecular mechanisms of cholangiocarcinoma because of its poor prognosis and the lack of effective therapies. A better understanding of cholangiocarcinoma tumor initiation, promotion, and progression, as well as neurotransmitter, neuroendocrine, and endocrine growth effects, may elucidate molecular targets for diagnostic and therapeutic purposes.
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Affiliation(s)
- Victor J Hassid
- Surgical Oncology Specialties, Cancer Center of Jacksonville, Jacksonville, FL 32256, USA
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15
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Orlando FA, Tan D, Baltodano JD, Khoury T, Gibbs JF, Hassid VJ, Ahmed BH, Alrawi SJ. Aberrant crypt foci as precursors in colorectal cancer progression. J Surg Oncol 2008; 98:207-13. [PMID: 18623110 DOI: 10.1002/jso.21106] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [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] [Indexed: 12/11/2022]
Abstract
Colorectal cancer progression originates when accumulated genetic and epigenetic alterations cause genomic instability and a malignant phenotype. Subsequent molecular pathway deregulation leads to histopathologic changes that are clinically evident as aberrant crypt foci (ACF) and visualized by high-magnification chromoscopic colonoscopy. ACF are biomarkers of increased colorectal cancer risk, particularly those with dysplastic features. Genetic profiling using genomic instability, loss of heterozygosity, and methylation analysis has revealed a minority population of ACF genotypically analogous to cancer.
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Affiliation(s)
- Frank A Orlando
- Department of Surgery, University of Florida, Gainesville, Florida 32610, USA.
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16
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Ahmed BH, Ahmed A, Tan D, Awad ZT, Al-Aali AY, Kilkenny J, Orlando FA, Al-Chalabi A, Crass R, Alrawi SJ. Post-laparoscopic cholecystectomy pain: effects of intraperitoneal local anesthetics on pain control--a randomized prospective double-blinded placebo-controlled trial. Am Surg 2008; 74:201-209. [PMID: 18376682] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Postoperative pain after laparoscopic cholecystectomy (LC) is generally less than open cholecystectomy; however, the postoperative shoulder and abdominal pain experienced by patients still causes preventable distress. Intraperitoneal irrigation of the diaphragmatic surface and gallbladder fossa using normal saline, bupivacaine, or lignocaine may effectively control visceral abdominal pain after an LC. Two hundred patients with similar demographics undergoing elective LC were randomized to one of four groups of 50 patients each, including Group A placebo control, Group B with isotonic saline irrigation, Group C with bupivacaine irrigation, and Group D with lignocaine irrigation. All patients received preperitoneal abdominal wall infiltration with 0.25 per cent bupivacaine to control parietal (somatic) abdominal pain. The visual analogue and verbal rating pain scores at 0, 4, 8, 12 and 24 hours for both shoulder and abdominal pain were recorded in a prospective double-blind fashion at four points during the first 24 postoperative hours. Analgesia requirements, vital signs, blood glucose, and incidence of nausea and vomiting were also recorded. Patients in each group demonstrated a significant difference in visual analogue and verbal rating pain scores and analgesic consumption when compared with controls. Lignocaine controlled pain significantly better than saline or bupivacaine. Bowel function recovery was similar in all patients, and there were no significant complications. We conclude that intraperitoneal irrigation with either saline, bupivacaine, or lignocaine can significantly reduce visceral abdominal pain after LC. Lignocaine was the most efficacious local anesthetic in this trial and has a high safety profile when used at recommended doses.
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Affiliation(s)
- Bestoun H Ahmed
- Department of General Surgery, University of Florida, Jacksonville, Florida 32209, USA.
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17
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Ahmed BH, Ahmed A, Tan D, Awad ZT, Al-Aali AY, Kilkenny J, Orlando FA, Al-Chalabi A, Crass R, Alrawi SJ. Post-Laparoscopic Cholecystectomy Pain: Effects of Intraperitoneal Local Anesthetics on Pain Control–A Randomized Prospective Double-Blinded Placebo-Controlled Trial. Am Surg 2008. [DOI: 10.1177/000313480807400304] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [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
Postoperative pain after laparoscopic cholecystectomy (LC) is generally less than open cholecystectomy; however, the postoperative shoulder and abdominal pain experienced by patients still causes preventable distress. Intraperitoneal irrigation of the diaphragmatic surface and gallbladder fossa using normal saline, bupivacaine, or lignocaine may effectively control visceral abdominal pain after an LC. Two hundred patients with similar demographics undergoing elective LC were randomized to one of four groups of 50 patients each, including Group A placebo control, Group B with isotonic saline irrigation, Group C with bupivacaine irrigation, and Group D with lignocaine irrigation. All patients received preperitoneal abdominal wall infiltration with 0.25 per cent bupivacaine to control parietal (somatic) abdominal pain. The visual analogue and verbal rating pain scores at 0, 4, 8, 12 and 24 hours for both shoulder and abdominal pain were recorded in a prospective double-blind fashion at four points during the first 24 postoperative hours. Analgesia requirements, vital signs, blood glucose, and incidence of nausea and vomiting were also recorded. Patients in each group demonstrated a significant difference in visual analogue and verbal rating pain scores and analgesic consumption when compared with controls. Lignocaine controlled pain significantly better than saline or bupivacaine. Bowel function recovery was similar in all patients, and there were no significant complications. We conclude that intraperitoneal irrigation with either saline, bupivacaine, or lignocaine can significantly reduce visceral abdominal pain after LC. Lignocaine was the most efficacious local anesthetic in this trial and has a high safety profile when used at recommended doses.
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Affiliation(s)
- Bestoun H. Ahmed
- Department of General Surgery, University of Florida, Jacksonville, Florida
| | - Aryan Ahmed
- Department of General Surgery/Anesthesia/Biostatistics, Hamad General Hospital, Qatar; and the
| | - Dongfeng Tan
- Department of General Surgery/Anesthesia/Biostatistics, Hamad General Hospital, Qatar; and the
| | - Ziad T. Awad
- Department of General Surgery, University of Florida, Jacksonville, Florida
| | - Ali Yousef Al-Aali
- Department of General Surgery/Anesthesia/Biostatistics, Hamad General Hospital, Qatar; and the
| | - John Kilkenny
- Department of General Surgery, University of Florida, Jacksonville, Florida
| | - Frank A. Orlando
- Department of General Surgery, University of Florida, Jacksonville, Florida
| | - Abbas Al-Chalabi
- Department of General Surgery/Anesthesia/Biostatistics, Hamad General Hospital, Qatar; and the
| | - Richard Crass
- Department of General Surgery, University of Florida, Jacksonville, Florida
| | - Sadir J. Alrawi
- Department of General Surgery, University of Florida, Jacksonville, Florida
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18
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Orlando FA, Goncalves CG, George ZM, Halverson JD, Cunningham PR, Meguid MM. Neurohormonal pathways regulating food intake and changes after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005; 1:486-95. [PMID: 16925275 DOI: 10.1016/j.soard.2005.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2004] [Revised: 05/24/2005] [Accepted: 05/29/2005] [Indexed: 12/22/2022]
Affiliation(s)
- Frank A Orlando
- Surgical Metabolism and Nutrition Laboratory, Department of Surgery, Neuroscience Program, SUNY Upstate Medical University, Syracuse, New York 13210, USA
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