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Kip KE, Diamond D, Mulukutla S, Marroquin OC. Is LDL cholesterol associated with long-term mortality among primary prevention adults? A retrospective cohort study from a large healthcare system. BMJ Open 2024; 14:e077949. [PMID: 38548371 PMCID: PMC10982736 DOI: 10.1136/bmjopen-2023-077949] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/18/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVES Among primary prevention-type adults not on lipid-lowering therapy, conflicting results exist on the relationship between low-density lipoprotein cholesterol (LDL-C) and long-term mortality. We evaluated this relationship in a real-world evidence population of adults. DESIGN Retrospective cohort study. SETTING Electronic medical record data for adults, from 4 January 2000 through 31 December 2022, were extracted from the University of Pittsburgh Medical Center healthcare system. PARTICIPANTS Adults without diabetes aged 50-89 years not on statin therapy at baseline or within 1 year and classified as primary prevention-type patients. To mitigate potential reverse causation, patients who died within 1 year or had baseline total cholesterol (T-C) ≤120 mg/dL or LDL-C <30 mg/dL were excluded. MAIN EXPOSURE MEASURE Baseline LDL-C categories of 30-79, 80-99, 100-129, 130-159, 160-189 or ≥190 mg/dL. MAIN OUTCOME MEASURE All-cause mortality with follow-up starting 365 days after baseline cholesterol measurement. RESULTS 177 860 patients with a mean (SD) age of 61.1 (8.8) years and mean (SD) LDL-C of 119 (31) mg/dL were evaluated over a mean of 6.1 years of follow-up. A U-shaped relationship was observed between the six LDL-C categories and mortality with crude 10-year mortality rates of 19.8%, 14.7%, 11.7%, 10.7%, 10.1% and 14.0%, respectively. Adjusted mortality HRs as compared with the referent group of LDL-C 80-99 mg/dL were: 30-79 mg/dL (HR 1.23, 95% CI 1.17 to 1.30), 100-129 mg/dL (0.87, 0.83-0.91), 130-159 mg/dL (0.88, 0.84-0.93), 160-189 mg/dL (0.91, 0.84-0.98) and ≥190 mg/dL (1.19, 1.06-1.34), respectively. Unlike LDL-C, both T-C/HDL cholesterol (high-density lipoprotein cholesterol) and triglycerides/HDL cholesterol ratios were independently associated with long-term mortality. CONCLUSIONS Among primary prevention-type patients aged 50-89 years without diabetes and not on statin therapy, the lowest risk for long-term mortality appears to exist in the wide LDL-C range of 100-189 mg/dL, which is much higher than current recommendations. For counselling these patients, minimal consideration should be given to LDL-C concentration.
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Affiliation(s)
- Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - David Diamond
- Department of Psychology, University of South Florida, Tampa, Florida, USA
| | - Suresh Mulukutla
- Clinical Analytics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Oscar C Marroquin
- Physician Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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2
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Panza E, Kip KE, Venkatakrishnan K, Marroquin OC, Wing RR. Changes in body weight and glycemic control in association with COVID-19 Shutdown among 23,000 adults with type 2 diabetes. Acta Diabetol 2023; 60:787-795. [PMID: 36894712 PMCID: PMC9998005 DOI: 10.1007/s00592-023-02056-5] [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: 12/05/2022] [Accepted: 02/19/2023] [Indexed: 03/11/2023]
Abstract
AIMS To examine the association between COVID-19 Shutdown and within-subjects changes in body weight, body mass index (BMI), and glycemic parameters using electronic health record (EHR) data from 23,000 adults with type 2 diabetes (T2DM). METHODS Patients with T2DM with outpatient visit data on body weight, BMI, hemoglobin A1c (HbA1c), and blood glucose (≥ 2 measures before and after 3/16/2020) recorded in the EHR at the University of Pittsburgh Medical Center were included. A within-subjects analysis compared average and clinically significant changes in weight, BMI, HbA1c, and blood glucose during the year POST-Shutdown (Time 2-3) compared to the same interval during the PRE-Shutdown year (Time 0-1) using paired samples t-tests and the McNemar-Bowker test. RESULTS We studied 23,697 adults with T2DM (51% female; 89% White; mean age = 66 ± 13 years; mean BMI = 34 ± 7 kg/m2; mean HbA1c = 7 ± 2% [53 ± 21.9 mmol/mol]). Weight and BMI decreased during both the PRE- and POST-Shutdown intervals, but the changes were statistically smaller during the year POST-Shutdown relative to PRE (0.32 kg and 0.11 units, p < 0.0001). HbA1c showed statistically greater improvements during the POST-Shutdown interval compared to PRE (- 0.18% [-2 mmol/mol], p < 0.0001), but changes in glucose did not differ for the two intervals. CONCLUSIONS Despite widespread discussion of weight gain in association with the COVID-19 Shutdown, study data showed no evidence of adverse effects of Shutdown on body weight, BMI, HbA1C, or blood glucose in a large sample of adults with T2DM. This information may help to inform future public health decision-making.
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Affiliation(s)
- Emily Panza
- Weight Control and Diabetes Research Center, The Miriam Hospital, 196 Richmond Street, Providence, RI, 02903, USA.
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA.
| | - Kevin E Kip
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kripa Venkatakrishnan
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rena R Wing
- Weight Control and Diabetes Research Center, The Miriam Hospital, 196 Richmond Street, Providence, RI, 02903, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
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Kip KE, McCreary EK, Collins K, Minnier TE, Snyder GM, Garrard W, McKibben JC, Yealy DM, Seymour CW, Huang DT, Bariola JR, Schmidhofer M, Wadas RJ, Angus DC, Kip PL, Marroquin OC. Evolving Real-World Effectiveness of Monoclonal Antibodies for Treatment of COVID-19 : A Cohort Study. Ann Intern Med 2023; 176:496-504. [PMID: 37011399 PMCID: PMC10074437 DOI: 10.7326/m22-1286] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [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: 04/05/2023] Open
Abstract
BACKGROUND Treatment guidelines and U.S. Food and Drug Administration emergency use authorizations (EUAs) of monoclonal antibodies (mAbs) for treatment of high-risk outpatients with mild to moderate COVID-19 changed frequently as different SARS-CoV-2 variants emerged. OBJECTIVE To evaluate whether early outpatient treatment with mAbs, overall and by mAb product, presumed SARS-CoV-2 variant, and immunocompromised status, is associated with reduced risk for hospitalization or death at 28 days. DESIGN Hypothetical pragmatic randomized trial from observational data comparing mAb-treated patients with a propensity score-matched, nontreated control group. SETTING Large U.S. health care system. PARTICIPANTS High-risk outpatients eligible for mAb treatment under any EUA with a positive SARS-CoV-2 test result from 8 December 2020 to 31 August 2022. INTERVENTION Single-dose intravenous mAb treatment with bamlanivimab, bamlanivimab-etesevimab, sotrovimab, bebtelovimab, or intravenous or subcutaneous casirivimab-imdevimab administered within 2 days of a positive SARS-CoV-2 test result. MEASUREMENTS The primary outcome was hospitalization or death at 28 days among treated patients versus a nontreated control group (no treatment or treatment ≥3 days after SARS-CoV-2 test date). RESULTS The risk for hospitalization or death at 28 days was 4.6% in 2571 treated patients and 7.6% in 5135 nontreated control patients (risk ratio [RR], 0.61 [95% CI, 0.50 to 0.74]). In sensitivity analyses, the corresponding RRs for 1- and 3-day treatment grace periods were 0.59 and 0.49, respectively. In subgroup analyses, those receiving mAbs when the Alpha and Delta variants were presumed to be predominant had estimated RRs of 0.55 and 0.53, respectively, compared with 0.71 for the Omicron variant period. Relative risk estimates for individual mAb products all suggested lower risk for hospitalization or death. Among immunocompromised patients, the RR was 0.45 (CI, 0.28 to 0.71). LIMITATIONS Observational study design, SARS-CoV-2 variant presumed by date rather than genotyping, no data on symptom severity, and partial data on vaccination status. CONCLUSION Early mAb treatment among outpatients with COVID-19 is associated with lower risk for hospitalization or death for various mAb products and SARS-CoV-2 variants. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Tami E Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (T.E.M., P.L.K.)
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - William Garrard
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Jeffrey C McKibben
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y., R.J.W.)
| | - Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (C.W.S., D.C.A.)
| | - David T Huang
- Department of Emergency Medicine and Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.T.H.)
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.K.M., G.M.S., J.R.B.)
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (M.S.)
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y., R.J.W.)
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (C.W.S., D.C.A.)
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (T.E.M., P.L.K.)
| | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (K.E.K., K.C., W.G., J.C.M., O.C.M.)
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Pang T, Murn L, Williams D, Lawental M, Abhayakumar A, Kip KE. Comparison of Accelerated Resolution Therapy for PTSD Between Veterans With and Without Prior PTSD Treatment. Mil Med 2023; 188:e621-e629. [PMID: 34383937 DOI: 10.1093/milmed/usab335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Post-traumatic stress disorder (PTSD) is a psychiatric disorder commonly caused by a traumatic event(s) and prevalent among service members and veterans. Accelerated Resolution Therapy (ART) is an emerging "mind-body" psychotherapy for PTSD that is generally briefer and less expensive than current first-line treatments, such as cognitive processing therapy (CPT) and prolonged exposure (PE) therapy. This study examined the results of ART for treatment of military-related PTSD, with stratification by prior PTSD treatment types, including service members/veterans with reported residual PTSD symptoms following receipt of first-line recommended psychotherapy. MATERIALS AND METHODS Four groups were constructed and compared based on self-reported prior PTSD treatment history: treatment-naïve (n = 33), pharmacotherapy only (n = 40), first-line psychotherapy (CPT and/or PE) (n = 33), and other psychotherapy (n = 42). Participants were assessed for PTSD symptoms at baseline, post-treatment, and 6-month follow-up using the 17-item Military PTSD Checklist (PCL-M), as well as assessment of depressive, anxiety, and sleep symptoms. The study was approved by the Institutional Review Board at University of South Florida. RESULTS Among 148 veterans/service members who enrolled and started treatment with ART, 106 (71.6%) completed treatment in a mean of 3.5 treatment sessions, and 55 (51.9%) provided 6-month follow-up data. Mean age was 43.8 years, 95% were male, and 84% were of white race. Within-group standardized effect sizes for pre-to-post changes in PTSD scores (PCL-M) were large at 1.48, 1.11, 1.88, and 1.03 for the treatment-naïve, pharmacotherapy only, first-line psychotherapy, and other psychotherapy groups, respectively. Among treatment completers, the clinically significant treatment response rate (reduction of ≥10 points on the PCL-M) was highest in the treatment-naïve (83%) and first-line psychotherapy (88%) groups. Similar significant symptom reductions were observed for measures of depression and anxiety, and favorable treatment effects were generally sustained at 6-month follow-up. CONCLUSION In a brief treatment period, ART appears to result in substantial reductions in symptoms of PTSD among veterans, including those with residual PTSD symptoms after prior treatment with first-line psychotherapies endorsed by the U.S. Department of Defense and Veterans Affairs. These results suggest that ART be considered as a potential first-line treatment modality for veterans with PTSD.
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Affiliation(s)
- Tiantian Pang
- College of Public Health, University of South Florida, Tampa, FL 33612, USA
| | - Lindsay Murn
- Minnesota State University-Mankato, Mankato, MN 56001, USA
| | - Dana Williams
- College of Behavioral and Community Sciences, University of South Florida
| | - Maayan Lawental
- College of Public Health, University of South Florida, Tampa, FL 33612, USA
| | | | - Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Park JY, Lengacher CA, Reich RR, Park HY, Whiting J, Nguyen AT, Rodríguez C, Meng H, Tinsley S, Chauca K, Gordillo-Casero L, Wittenberg T, Joshi A, Lin K, Ismail-Khan R, Kiluk JV, Kip KE. Translational Genomic Research: The Association between Genetic Profiles and Cognitive Functioning or Cardiac Function Among Breast Cancer Survivors Completing Chemotherapy. Biol Res Nurs 2022; 24:433-447. [PMID: 35499926 PMCID: PMC9630728 DOI: 10.1177/10998004221094386] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Emerging evidence suggests that Chemotherapy (CT) treated breast cancer survivors (BCS) who have "risk variants" in genes may be more susceptible to cognitive impairment (CI) and/or poor cardiac phenotypes. The objective of this preliminary study was to examine whether there is a relationship between genetic variants and objective/subjective cognitive or cardiac phenotypes. Methods and Analysis: BCS were recruited from Moffitt Cancer Center, Morsani College of Medicine, AdventHealth Tampa and Sarasota Memorial Hospital. Genomic DNA were collected at baseline for genotyping analysis. A total of 16 single nucleotide polymorphisms (SNPs) from 14 genes involved in cognitive or cardiac function were evaluated. Three genetic models (additive, dominant, and recessive) were used to test correlation coefficients between genetic variants and objective/subjective measures of cognitive functioning and cardiac outcomes (heart rate, diastolic blood pressure, systolic blood pressure, respiration rate, and oxygen saturation). Results: BCS (207 participants) with a mean age of 56 enrolled in this study. The majority were non-Hispanic white (73.7%), married (63.1%), and received both CT and radiation treatment (77.3%). Three SNPs in genes related to cognitive functioning (rs429358 in APOE, rs1800497 in ANKK1, rs10119 in TOMM40) emerged with the most consistent significant relationship with cognitive outcomes. Among five candidate SNPs related to cardiac functioning, rs8055236 in CDH13 and rs1801133 in MTHER emerged with potential significant relationships with cardiac phenotype. Conclusions: These preliminary results provide initial targets to further examine whether BCS with specific genetic profiles may preferentially benefit from interventions designed to improve cognitive and cardiac functioning following CT.
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Affiliation(s)
- Jong Y. Park
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Richard R. Reich
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Hyun Y. Park
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Junmin Whiting
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Anh Thy Nguyen
- Department of Epidemiology and
Biostatistics, USF College of Public Health, University of South
Florida, Tampa, FL, USA
| | | | - Hongdao Meng
- School of Aging Studies, College of
Behavioral and Community Sciences, University of South
Floridaa, Tampa, FL, USA
| | - Sara Tinsley
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | | | | | | | - Anisha Joshi
- University of South Florida College
of Nursing, Tampa, FL, USA
| | - Katherine Lin
- University of South Florida College
of Nursing, Tampa, FL, USA
| | - Roohi Ismail-Khan
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - John V. Kiluk
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kevin E. Kip
- UPMC Health Services
Division, Pittsburgh, PA, USA
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McCreary EK, Kip KE, Collins K, Minnier TE, Snyder GM, Steiner A, Meyers R, Borneman T, Adam M, Thurau L, Yealy DM, Huang DT, Bariola JR, Schmidhofer M, Wadas RJ, Angus DC, Kip PL, Marroquin OC. Evaluation of Bebtelovimab for Treatment of COVID-19 During the SARS-CoV-2 Omicron Variant Era. Open Forum Infect Dis 2022; 9:ofac517. [PMID: 36324319 PMCID: PMC9619560 DOI: 10.1093/ofid/ofac517] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 08/10/2022] [Accepted: 09/30/2022] [Indexed: 11/26/2022] Open
Abstract
Background Monoclonal antibody (mAb) treatment is associated with decreased risk of hospitalization and death in high-risk outpatients with mild to moderate coronavirus disease 2019 (COVID-19) caused by early severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants. Bebtelovimab exhibits in vitro activity against the Omicron variant and its sublineages; however, clinical data are lacking. Methods A retrospective cohort study was conducted comparing bebtelovimab-treated patients with propensity score–adjusted and matched nontreated control groups. Participants included high-risk outpatients eligible for bebtelovimab treatment under Emergency Use Authorization with a positive SARS-CoV-2 test from March 30 to May 28, 2022. Treated patients received single-dose intravenous treatment with bebtelovimab. The primary outcome was hospitalization or death over 28 days. Results Before matching/statistical adjustment, mAb-treated patients were, on average, 10 years older than nontreated patients (61.6 vs 51.3 years) and had higher prevalence of obstructive sleep apnea, hypertension, chronic kidney disease, cancer, organ or cell transplant, and immunocompromised status (standardized mean differences ≥0.20). The adjusted odds ratio (OR) of hospitalization or death comparing 1006 treated with 2023 nontreated patients was 0.50 (95% CI, 0.31–0.80). Among 930 treated and 930 propensity score–matched nontreated patients, the incidence of hospitalization or death was 3.1% vs 5.5%, respectively (conditional OR, 0.53; 95% CI, 0.32–0.86). The lower odds ratio of hospitalization or death associated with bebtelovimab treatment was most evident in older patients, those with immunocompromised status, and fully vaccinated patients. Conclusions Monoclonal antibody treatment with bebtelovimab among COVID-19 outpatients is associated with lower odds of hospitalization or death, particularly among immunocompromised and older patients.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Kevin E Kip
- Clinical Analytics , UPMC, Pittsburgh, PA , USA
| | | | | | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Ashley Steiner
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Tina Borneman
- UPMC Corporate Pharmacy Service Center , Pittsburgh, PA , USA
| | - Michelle Adam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Lauren Thurau
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA , USA
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
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Berkowitz J, Khetpal V, Echouffo-Tcheugui JB, Bambs CE, Aiyer A, Kip KE, Reis SE, Erqou S. Associations between cumulative social risk, psychosocial risk, and ideal cardiovascular health: Insights from the HeartSCORE study. Am J Prev Cardiol 2022; 11:100367. [PMID: 35923764 PMCID: PMC9340530 DOI: 10.1016/j.ajpc.2022.100367] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/16/2022] [Accepted: 07/16/2022] [Indexed: 11/21/2022] Open
Abstract
Higher social risk is associated with achievement of fewer ideal cardiovascular health factors. The association was modestly attenuated after adjusting for depression, stress, and perceived discrimination. Psychosocial factors may mediate part of the association between social risk and achievement of ideal cardiovascular health.
Background Limited studies have assessed the effects of psychosocial risk factors on achievement of ideal cardiovascular health (CVH). Methods Using the Heart Strategies Concentrating on Risk Evaluation (HeartSCORE) cohort, we examined the cross-sectional associations of cumulative social risk (CSR) and three psychosocial factors (depression, stress, perceived discrimination) with ideal CVH. CSR was calculated by assigning one point for each of: low family income, low education level, minority race (Black), and single-living status. Ideal CVH was calculated by assigning one point for ideal levels of each factor in American Heart Association's Life's Simple 7. Ideal CVH was dichotomized into fewer versus higher by combining participants achieving <3 versus ≥3 factors. Logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) of having fewer ideal CVH factors. Psychosocial factors were assessed as mediators of the association between CSR and ideal CVH. Results We included 2000 participants (mean age 59.1 [7.5] years, 34.6% male, 42.7% Black, and 29.1% with low income), among whom 60.6% had <3 ideal CVH factors. The odds of having fewer ideal CVH factors increased significantly with increasing CSR scores from 1 to 2, to ≥3 compared to individuals with CSR score of zero, after adjusting for age and sex (OR [95% CIs]: 1.77 [1.41 - 2.22]; 2.09 [1.62 - 2.69] 2.67 [1.97 - 3.62], respectively). Taking the components of ideal CVH separately, higher CSR was directly associated with odds of being in ‘non-ideal’ category for six of the seven factors, but was inversely associated with probability of being in ‘non-ideal’ category for cholesterol. The association was modestly attenuated after adjusting for depression, stress, and perceived discrimination (corresponding OR [95% CI]: 1.69 [1.34 - 2.12], 1.96 [1.51 - 2.55], 2.34 [1.71 - 3.20]). The psychosocial factors appeared to mediate between 10% and 20% of relationship between CSR and ideal CVH. Conclusions Increased CSR was associated with lower probability of achieving ideal CVH factors. A modest amount of the effect of CSR on ideal CVH appeared to be mediated by depression, stress and perceived discrimination. Public health strategies aimed at improving ideal cardiovascular health may benefit from including interventions targeting social and psychosocial risk factors.
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Affiliation(s)
- Julia Berkowitz
- Department of Medicine, the Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Vishal Khetpal
- Department of Medicine, the Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Justin B Echouffo-Tcheugui
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Claudia E Bambs
- Department of Public Health, and Advanced Center for Chronic Diseases-ACCDiS, School of Medicine, Pontificia Universidad Católica de Chile, United States
| | - Aryan Aiyer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kevin E. Kip
- UPMC Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Steven E. Reis
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sebhat Erqou
- Department of Medicine, the Warren Alpert Medical School of Brown University, Providence, RI, United States
- Division of Cardiology, Department of Medicine, Providence VA Medical Center, Providence, RI, United States
- Corresponding author at: Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, United States.
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8
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Huang DT, McCreary EK, Bariola JR, Minnier TE, Wadas RJ, Shovel JA, Albin D, Marroquin OC, Kip KE, Collins K, Schmidhofer M, Wisniewski MK, Nace DA, Sullivan C, Axe M, Meyers R, Weissman A, Garrard W, Peck-Palmer OM, Wells A, Bart RD, Yang A, Berry LR, Berry S, Crawford AM, McGlothlin A, Khadem T, Linstrum K, Montgomery SK, Ricketts D, Kennedy JN, Pidro CJ, Nakayama A, Zapf RL, Kip PL, Haidar G, Snyder GM, McVerry BJ, Yealy DM, Angus DC, Seymour CW. Effectiveness of Casirivimab-Imdevimab and Sotrovimab During a SARS-CoV-2 Delta Variant Surge: A Cohort Study and Randomized Comparative Effectiveness Trial. JAMA Netw Open 2022; 5:e2220957. [PMID: 35834252 PMCID: PMC10881222 DOI: 10.1001/jamanetworkopen.2022.20957] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Importance The effectiveness of monoclonal antibodies (mAbs), casirivimab-imdevimab and sotrovimab, is unknown in patients with mild to moderate COVID-19 caused by the SARS-CoV-2 Delta variant. Objective To evaluate the effectiveness of mAb against the Delta variant compared with no mAb treatment and to ascertain the comparative effectiveness of casirivimab-imdevimab and sotrovimab. Design, Setting, and Participants This study comprised 2 parallel studies: (1) a propensity score-matched cohort study of mAb treatment vs no mAb treatment and (2) a randomized comparative effectiveness trial of casirivimab-imdevimab and sotrovimab. The cohort consisted of patients who received mAb treatment at the University of Pittsburgh Medical Center outpatient infusion centers and emergency departments from July 14 to September 29, 2021. Participants were patients with a positive SARS-CoV-2 test result who were eligible to receive mAbs according to emergency use authorization criteria. Exposure For the trial, patients were randomized to either intravenous casirivimab-imdevimab or sotrovimab according to a system therapeutic interchange policy. Main Outcomes and Measures For the cohort study, risk ratio (RR) estimates for the primary outcome of hospitalization or death by 28 days were compared between mAb treatment and no mAb treatment using propensity score-matched models. For the comparative effectiveness trial, the primary outcome was hospital-free days (days alive and free of hospitalization) within 28 days after mAb treatment, where patients who died were assigned -1 day in a bayesian cumulative logistic model adjusted for treatment location, age, sex, and time. Inferiority was defined as a 99% posterior probability of an odds ratio (OR) less than 1. Equivalence was defined as a 95% posterior probability that the OR was within a given bound. Results A total of 3069 patients (1023 received mAb treatment: mean [SD] age, 53.2 [16.4] years; 569 women [56%]; 2046 had no mAb treatment: mean [SD] age, 52.8 [19.5] years; 1157 women [57%]) were included in the prospective cohort study, and 3558 patients (mean [SD] age, 54 [18] years; 1919 women [54%]) were included in the randomized comparative effectiveness trial. In propensity score-matched models, mAb treatment was associated with reduced risk of hospitalization or death (RR, 0.40; 95% CI, 0.28-0.57) compared with no treatment. Both casirivimab-imdevimab (RR, 0.31; 95% CI, 0.20-0.50) and sotrovimab (RR, 0.60; 95% CI, 0.37-1.00) were associated with reduced hospitalization or death compared with no mAb treatment. In the clinical trial, 2454 patients were randomized to receive casirivimab-imdevimab and 1104 patients were randomized to receive sotrovimab. The median (IQR) hospital-free days were 28 (28-28) for both mAb treatments, the 28-day mortality rate was less than 1% (n = 12) for casirivimab-imdevimab and less than 1% (n = 7) for sotrovimab, and the hospitalization rate by day 28 was 12% (n = 291) for casirivimab-imdevimab and 13% (n = 140) for sotrovimab. Compared with patients who received casirivimab-imdevimab, those who received sotrovimab had a median adjusted OR for hospital-free days of 0.88 (95% credible interval, 0.70-1.11). This OR yielded 86% probability of inferiority for sotrovimab vs casirivimab-imdevimab and 79% probability of equivalence. Conclusions and Relevance In this propensity score-matched cohort study and randomized comparative effectiveness trial, the effectiveness of casirivimab-imdevimab and sotrovimab against the Delta variant was similar, although the prespecified criteria for statistical inferiority or equivalence were not met. Both mAb treatments were associated with a reduced risk of hospitalization or death in nonhospitalized patients with mild to moderate COVID-19 caused by the Delta variant. Trial Registration ClinicalTrials.gov Identifier: NCT04790786.
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Affiliation(s)
- David T. Huang
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tami E. Minnier
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Richard J. Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith A. Shovel
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, UPMC, Pittsburgh, Pennsylvania
| | | | - Kevin E. Kip
- Clinical Analytics, UPMC, Pittsburgh, Pennsylvania
| | | | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - David A. Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Colleen Sullivan
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Octavia M. Peck-Palmer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert D. Bart
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health Services Division, UPMC, Pittsburgh, Pennsylvania
| | - Anne Yang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | - Tina Khadem
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Stephanie K. Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Daniel Ricketts
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jason N. Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Caroline J. Pidro
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anna Nakayama
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Rachel L. Zapf
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Paula L. Kip
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Graham M. Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health System Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
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9
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McCreary EK, Bariola JR, Minnier TE, Wadas RJ, Shovel JA, Albin D, Marroquin OC, Kip KE, Collins K, Schmidhofer M, Wisniewski MK, Nace DA, Sullivan C, Axe M, Meyers R, Weissman A, Garrard W, Peck-Palmer OM, Wells A, Bart RD, Yang A, Berry LR, Berry S, Crawford AM, McGlothlin A, Khadem T, Linstrum K, Montgomery SK, Ricketts D, Kennedy JN, Pidro CJ, Haidar G, Snyder GM, McVerry BJ, Yealy DM, Angus DC, Nakayama A, Zapf RL, Kip PL, Seymour CW, Huang DT. The comparative effectiveness of COVID-19 monoclonal antibodies: A learning health system randomized clinical trial. Contemp Clin Trials 2022; 119:106822. [PMID: 35697146 PMCID: PMC9187853 DOI: 10.1016/j.cct.2022.106822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 02/24/2022] [Revised: 05/09/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
Background Monoclonal antibodies (mAb) that neutralize SARS-CoV-2 decrease hospitalization and death compared to placebo in patients with mild to moderate COVID-19; however, comparative effectiveness is unknown. We report the comparative effectiveness of bamlanivimab, bamlanivimab-etesevimab, and casirivimab-imdevimab. Methods A learning health system platform trial in a U.S. health system enrolled patients meeting mAb Emergency Use Authorization criteria. An electronic health record-embedded application linked local mAb inventory to patient encounters and provided random mAb allocation. Primary outcome was hospital-free days to day 28. Primary analysis was a Bayesian model adjusting for treatment location, age, sex, and time. Inferiority was defined as 99% posterior probability of an odds ratio < 1. Equivalence was defined as 95% posterior probability the odds ratio is within a given bound. Findings Between March 10 and June 25, 2021, 1935 patients received treatment. Median hospital-free days were 28 (IQR 28, 28) for each mAb. Mortality was 0.8% (1/128), 0.8% (7/885), and 0.7% (6/922) for bamlanivimab, bamlanivimab-etesevimab, and casirivimab-imdevimab, respectively. Relative to casirivimab-imdevimab (n = 922), median adjusted odds ratios were 0.58 (95% credible interval [CI] 0.30–1.16) and 0.94 (95% CI 0.72–1.24) for bamlanivimab (n = 128) and bamlanivimab-etesevimab (n = 885), respectively. These odds ratios yielded 91% and 94% probabilities of inferiority of bamlanivimab versus bamlanivimab-etesevimab and casirivimab-imdevimab, and an 86% probability of equivalence between bamlanivimab-etesevimab and casirivimab-imdevimab. Interpretation Among patients with mild to moderate COVID-19, bamlanivimab-etesevimab or casirivimab-imdevimab treatment resulted in 86% probability of equivalence. No treatment met prespecified criteria for statistical equivalence. Median hospital-free days to day 28 were 28 (IQR 28, 28) for each mAb. Funding and registration This work received no external funding. The U.S. government provided the reported mAb. This trial is registered at ClinicalTrials.gov, NCT04790786.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tami E Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Judith A Shovel
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Colleen Sullivan
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - William Garrard
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Octavia M Peck-Palmer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert D Bart
- Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anne Yang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | | | - Tina Khadem
- Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephanie K Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel Ricketts
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jason N Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Caroline J Pidro
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna Nakayama
- Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rachel L Zapf
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Health System Office of Healthcare Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Wing RR, Venkatakrishnan K, Panza E, Marroquin OC, Kip KE. Association of COVID-19 Stay-at-Home Orders With 1-Year Weight Changes. JAMA Netw Open 2022; 5:e2217313. [PMID: 35708692 PMCID: PMC9204539 DOI: 10.1001/jamanetworkopen.2022.17313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Rena R. Wing
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kripa Venkatakrishnan
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Emily Panza
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Oscar C. Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kevin E. Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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11
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McCreary EK, Bariola JR, Wadas RJ, Shovel JA, Wisniewski MK, Adam M, Albin D, Minnier T, Schmidhofer M, Meyers R, Marroquin OC, Collins K, Garrard W, Berry LR, Berry S, Crawford AM, McGlothlin A, Linstrum K, Nakayama A, Montgomery SK, Snyder GM, Yealy DM, Angus DC, Kip PL, Seymour CW, Huang DT, Kip KE. Association of Subcutaneous or Intravenous Administration of Casirivimab and Imdevimab Monoclonal Antibodies With Clinical Outcomes in Adults With COVID-19. JAMA Netw Open 2022; 5:e226920. [PMID: 35412625 PMCID: PMC9006104 DOI: 10.1001/jamanetworkopen.2022.6920] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Monoclonal antibody (mAb) treatment decreases hospitalization and death in high-risk outpatients with mild to moderate COVID-19; however, only intravenous administration has been evaluated in randomized clinical trials of treatment. Subcutaneous administration may expand outpatient treatment capacity and qualified staff available to administer treatment, but the association with patient outcomes is understudied. OBJECTIVES To evaluate whether subcutaneous casirivimab and imdevimab treatment is associated with reduced 28-day hospitalization and death compared with nontreatment among mAb-eligible patients and whether subcutaneous casirivimab and imdevimab treatment is clinically and statistically similar to intravenous casirivimab and imdevimab treatment. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study evaluated high-risk outpatients in a learning health system in the US with mild to moderate COVID-19 symptoms from July 14 to October 26, 2021, who were eligible for mAb treatment under emergency use authorization. A nontreated control group of eligible patients was also studied. EXPOSURES Subcutaneous injection or intravenous administration of the combined single dose of 600 mg of casirivimab and 600 mg of imdevimab. MAIN OUTCOMES AND MEASURES The primary outcome was the 28-day adjusted risk ratio or adjusted risk difference for hospitalization or death. Secondary outcomes included 28-day adjusted risk ratios and differences in hospitalization, death, a composite end point of emergency department admission and hospitalization, and rates of adverse events. Among 1959 matched adults with mild to moderate COVID-19, 969 patients (mean [SD] age, 53.8 [16.7] years; 547 women [56.4%]) who received casirivimab and imdevimab subcutaneously had a 28-day rate of hospitalization or death of 3.4% (22 of 653 patients) compared with 7.0% (92 of 1306 patients) in nontreated controls (risk ratio, 0.48; 95% CI, 0.30-0.80; P = .002). Among 2185 patients treated with subcutaneous (n = 969) or intravenous (n = 1216; mean [SD] age, 54.3 [16.6] years; 672 women [54.4%]) casirivimab and imdevimab, the 28-day rate of hospitalization or death was 2.8% vs 1.7%, which resulted in an adjusted risk difference of 1.5% (95% CI, -0.6% to 3.5%; P = .16). Among all infusion patients, there was no difference in intensive care unit admission (adjusted risk difference, 0.7%; 95% CI, -3.5% to 5.0%) or need for mechanical ventilation (adjusted risk difference, 0.2%; 95% CI, -5.8% to 5.5%). CONCLUSIONS AND RELEVANCE In this cohort study of high-risk outpatients with mild to moderate COVID-19 symptoms, subcutaneously administered casirivimab and imdevimab was associated with reduced hospitalization and death when compared with no treatment. These results provide preliminary evidence of potential expanded use of subcutaneous mAb treatment, particularly in areas that are facing treatment capacity and/or staffing shortages.
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Affiliation(s)
- Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard J. Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith A. Shovel
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Michelle Adam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Debbie Albin
- Supply Chain Management/HC Pharmacy, UPMC, Pittsburgh, Pennsylvania
| | - Tami Minnier
- Wolff Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Kelsey Linstrum
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Anna Nakayama
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | | | - Graham M. Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula L. Kip
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David T. Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Office of Healthcare Innovation, UPMC, Pittsburgh, Pennsylvania
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kevin E. Kip
- Clinical Analytics, UPMC, Pittsburgh, Pennsylvania
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Berkowitz J, Khetpal V, Tcheugui JE, Aiyer AN, Kip KE, Reis SE, Erqou S. ASSOCIATIONS BETWEEN CUMULATIVE SOCIAL RISK, PSYCHOSOCIAL RISK, AND IDEAL CARDIOVASCULAR HEALTH: INSIGHTS FROM THE HEARTSCORE STUDY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02482-2] [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: 10/18/2022]
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13
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Nasrazadani A, Marti JLG, Kip KE, Marroquin OC, Lemon L, Shapiro SD, Brufsky AM. Breast cancer mortality as a function of age. Aging (Albany NY) 2022; 14:1186-1199. [PMID: 35134749 PMCID: PMC8876898 DOI: 10.18632/aging.203881] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/28/2022] [Indexed: 11/25/2022]
Abstract
Background: Incidence of breast cancer (BC) in US women continues to increase with age as the strongest risk factor. We aimed to compare clinical, pathological and sociological variables associated to BC diagnosis, as well as the relative mortality rates of BC patients compared to the general US population. Methods: We performed a retrospective, single-institution study evaluating 52,509 patients diagnosed with unilateral BC at the University of Pittsburgh Medical Center (UPMC) between 1990–2020. Primary outcome was death from any cause with cancer recurrence as a secondary outcome, evaluated for 4 age groups: 20–44, 45–55, 56–69, and 70–90. A dataset of expected mortality for women in the general population over a 10-year period was constructed using the Surveillance, Epidemiology, and End Results (SEER) Program. Observed vs. expected mortality and standardized mortality ratios (SMR) for each age group were calculated. Results: Youngest patients with BC demonstrated the highest SMR at 10-year follow-up from time of diagnosis compared to the general US population (SMR 9.68, 95% CI: 8.99to 10.42), and remained highest compared to other age groups when analysis was limited to Stage 0/1 disease (10-year SMR 3.11, 95% CI: 2.54 to 3.76). SMRs decreased with increasing age at diagnosis with an SMR <1.0 in patients diagnosed with stage 0/1 at ages 70–90 at 5-year follow-up. Conclusions: Younger BC patients have the highest SMR which declines gradually with age. In the elderly, lower stage 0/1 SMR’s are found compared to the general population, suggesting the possibility of an associated protective effect.
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Affiliation(s)
- Azadeh Nasrazadani
- Division of Medical Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Juan Luis Gomez Marti
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Kevin E. Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Oscar C. Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Lara Lemon
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Steve D. Shapiro
- Keck Medicine of USC, University of Southern California, Los Angeles, CA 90007, USA
| | - Adam M. Brufsky
- Division of Medical Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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14
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McCreary EK, Kip KE, Bariola JR, Schmidhofer M, Minnier T, Mayak K, Albin D, Daley J, Linstrum K, Hernandez E, Sackrowitz R, Hughes K, Horvat C, Snyder GM, McVerry BJ, Yealy DM, Huang DT, Angus DC, Marroquin OC. A learning health system approach to the
COVID
‐19 pandemic:
System‐wide
changes in clinical practice and
30‐day
mortality among hospitalized patients. Learn Health Syst 2022; 6:e10304. [PMID: 35860323 PMCID: PMC9284933 DOI: 10.1002/lrh2.10304] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 08/25/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Rapid, continuous implementation of credible scientific findings and regulatory approvals is often slow in large, diverse health systems. The coronavirus disease 2019 (COVID‐19) pandemic created a new threat to this common “slow to learn and adapt” model in healthcare. We describe how the University of Pittsburgh Medical Center (UPMC) committed to a rapid learning health system (LHS) model to respond to the COVID‐19 pandemic. Methods A treatment cohort study was conducted among 11 429 hospitalized patients (pediatric/adult) from 22 hospitals (PA, NY) with a primary diagnosis of COVID‐19 infection (March 19, 2020 ‐ June 6, 2021). Sociodemographic and clinical data were captured from UPMC electronic medical record (EMR) systems. Patients were grouped into four time‐defined patient “waves” based on nadir of daily hospital admissions, with wave 3 (September 20, 2020 ‐ March 10, 2021) split at its zenith due to high volume with steep acceleration and deceleration. Outcomes included changes in clinical practice (eg, use of corticosteroids, antivirals, and other therapies) in relation to timing of internal system analyses, scientific publications, and regulatory approvals, along with 30‐day rate of mortality over time. Results The mean (SD) daily number of admissions across hospitals was 26 (29) with a maximum 7‐day moving average of 107 patients. System‐wide implementation of the use of dexamethasone, remdesivir, and tocilizumab occurred within days of release of corresponding seminal publications and regulatory actions. After adjustment for differences in patient clinical profiles over time, each month of hospital admission was associated with an estimated 5% lower odds of 30‐day mortality (adjusted odds ratio [OR] = 0.95, 95% confidence interval: 0.93‐0.97, P < .001). Conclusions In our large LHS, near real‐time changes in clinical management of COVID‐19 patients happened promptly as scientific publications and regulatory approvals occurred throughout the pandemic. Alongside these changes, patients with COVID‐19 experienced lower adjusted 30‐day mortality following hospital admission over time.
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Affiliation(s)
- Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Kevin E. Kip
- Health Services Division Clinical Analytics, UPMC Pittsburgh Pennsylvania USA
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Mark Schmidhofer
- Division of Cardiology, Dept of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Tami Minnier
- Health Services Division UPMC Wolff Center and Quality Offices, UPMC Pittsburgh Pennsylvania USA
| | - Katelyn Mayak
- Media Relations Department UPMC Communications, UPMC Pittsburgh Pennsylvania USA
| | - Debbie Albin
- UPMC Enterprises UPMC Supply Chain Management/HC Pharmacy, UPMC Pittsburgh Pennsylvania USA
| | - Jessica Daley
- UPMC Enterprises UPMC Supply Chain Management/HC Pharmacy, UPMC Pittsburgh Pennsylvania USA
| | - Kelsey Linstrum
- UPMC Health System UPMC Office of Healthcare Innovation Pittsburgh Pennsylvania USA
| | - Erik Hernandez
- Department of Pharmacy UPMC Pinnacle, UPMC Pittsburgh Pennsylvania USA
| | - Rachel Sackrowitz
- Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Kailey Hughes
- Division of Infectious Diseases, Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Christopher Horvat
- Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
- Department of Critical Care Medicine UPMC Children’s Hospital of Pittsburgh Pittsburgh Pennsylvania USA
| | - Graham M. Snyder
- Division of Infectious Diseases, Department of Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Bryan J. McVerry
- Department of Medicine, Division of Pulmonary Allergy, and Critical Care Medicine Pittsburgh Pennsylvania USA
| | - Donald M. Yealy
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - David T. Huang
- Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Derek C. Angus
- UPMC Health System UPMC Office of Healthcare Innovation Pittsburgh Pennsylvania USA
- Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Oscar C. Marroquin
- Health Services Division Clinical Analytics, UPMC Pittsburgh Pennsylvania USA
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15
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Korabathina R, Porcadas J, Kip KE, Korabathina PR, Rosenthal AD, Wassmer P. Left Ventricular Ballooning Patterns in Recurrent Takotsubo Cardiomyopathy: A Systematic Review and Meta-analysis of Reported Cases. Tex Heart Inst J 2021; 48:475127. [PMID: 34902024 DOI: 10.14503/thij-20-7223] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Recurrent takotsubo cardiomyopathy (TTC) and the clinical profiles and outcomes of patients have not been fully evaluated, nor has the effect of left ventricular ballooning pattern. After searching the medical literature for reports of patients with recurrent TTC, we identified 84 articles with 101 case descriptions. We divided the cases into those with only apical left ventricular ballooning patterns at recurrence (typical, n=60), and those with at least one midventricular or basal ballooning pattern (atypical, n=41). We then compared their clinical profiles and outcomes. The groups were similar in terms of baseline demographic characteristics, presence and types of triggers, use of heart failure medications at TTC recurrence, electrocardiographic changes at presentation, initial left ventricular ejection fractions, timespans between recurrent TTC episodes, and recovery times after each event. However, patients in the atypical group had significantly fewer severe adverse events (cardiogenic shock and cardiac arrest) than did those in the typical group, with an estimated 63% lower odds (adjusted odds ratio=0.37; 95% CI, 0.14-0.97; P=0.039). Survival to hospital discharge was statistically similar but lower in the typical group (n=53; 88.3%) than in the atypical group (n=24; 96%). Our results suggest that left ventricular ballooning patterns influence clinical outcomes, and that outcomes are more favorable in patients with recurrent TTC who have atypical left ventricular ballooning patterns.
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Affiliation(s)
- Ravi Korabathina
- Department of Cardiovascular Medicine, Bayfront Health, St. Petersburg, Florida.,Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Jamie Porcadas
- Department of Family Medicine, Bayfront Health, St. Petersburg, Florida
| | - Kevin E Kip
- Department of Epidemiology and Biostatistics, University of South Florida College of Public Health, Tampa, Florida
| | - Puja R Korabathina
- Department of Internal Medicine, Bayfront Health, St. Petersburg, Florida
| | - Andrew D Rosenthal
- Department of Cardiovascular Medicine, Bayfront Health, St. Petersburg, Florida
| | - Peter Wassmer
- Department of Cardiovascular Medicine, Bayfront Health, St. Petersburg, Florida
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16
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Bariola JR, McCreary EK, Wadas RJ, Kip KE, Marroquin OC, Minnier T, Koscumb S, Collins K, Schmidhofer M, Shovel JA, Wisniewski MK, Sullivan C, Yealy DM, Nace DA, Huang DT, Haidar G, Khadem T, Linstrum K, Seymour CW, Montgomery SK, Angus DC, Snyder GM. Impact of Bamlanivimab Monoclonal Antibody Treatment on Hospitalization and Mortality Among Nonhospitalized Adults With Severe Acute Respiratory Syndrome Coronavirus 2 Infection. Open Forum Infect Dis 2021; 8:ofab254. [PMID: 34250192 PMCID: PMC8241472 DOI: 10.1093/ofid/ofab254] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/12/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Monoclonal antibody treatment may prevent complications of coronavirus disease 2019 (COVID-19). We sought to quantify the impact of bamlanivimab monoclonal antibody monotherapy on hospitalization and mortality among outpatients at high risk of COVID-19 complications. METHODS In this observational study we compared outpatients who received bamlanivimab monoclonal antibody from December 9, 2020 to March 3, 2021 to nontreated patients with a positive polymerase chain reaction or antigen test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the same period who were eligible for monoclonal antibody treatment. The primary outcome was 28-day hospitalization or all-cause mortality, and the secondary outcome was hospitalization or emergency department visit without hospitalization. The risk-adjusted odds of study outcomes comparing bamlanivimab treated and untreated patients was determined using 1:5 propensity matching and multivariable logistic regression. RESULTS Among 232 patients receiving bamlanivimab matched with 1160 comparator patients, the mean age was 67 years, 56% were female, and 196 (14%) of patients experienced hospitalization or mortality. After adjustment for propensity to receive treatment, bamlanivimab treatment was associated with a significantly reduced risk-adjusted odds of hospitalization or mortality within 28 days (odds ratio [OR], 0.40; 95% confidence interval [95% CI], 0.24-0.69; P < .001). Bamlanivimab treatment was also associated with a significantly lower risk adjusted odds of hospitalization or emergency department visit without hospitalization (OR, 0.54; 95% CI, 0.35-0.82; P = .004). The results were most strongly associated with patients age 65 years and older. CONCLUSIONS Bamlanivimab monoclonal antibody monotherapy was associated with reduced hospitalizations and mortality within 28 days among outpatients with mild to moderate COVID-19.Use of bamlanivimab monotherapy for outpatients with mild to moderate COVID-19 infection was associated with reductions in hospitalizations and mortality within 28 days. Benefit was strongest in those age 65 years or older.
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Affiliation(s)
- J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tami Minnier
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stephen Koscumb
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kevin Collins
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark Schmidhofer
- Division of Cardiology, Dept of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith A Shovel
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mary Kay Wisniewski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Colleen Sullivan
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tina Khadem
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kelsey Linstrum
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christopher W Seymour
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stephanie K Montgomery
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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17
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Nace DA, Kip KE, Mellors JW, Peck Palmer OM, Shurin MR, Mulvey K, Crandall M, Sobolewski MD, Enick PN, McCormick KD, Jacobs JL, Kane AL, Lukanski A, Kip PL, Wells A. Antibody Responses After mRNA-Based COVID-19 Vaccination in Residential Older Adults: Implications for Reopening. J Am Med Dir Assoc 2021; 22:1593-1598. [PMID: 34129831 PMCID: PMC8196346 DOI: 10.1016/j.jamda.2021.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 05/05/2021] [Revised: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 01/13/2023]
Abstract
Objective COVID-19 disproportionately impacts residents in long-term care facilities. Our objective was to quantify the presence and magnitude of antibody response in vaccinated, older adult residents at assisted living, personal care, and independent living communities. Design A cross-sectional quality improvement study was conducted March 15 – April 1, 2021 in the greater Pittsburgh region. Setting and Population Participants were older adult residents at assisted living, personal care, and independent living communities, who received mRNA-based COVID-19 vaccine. Conditions that impair immune responses were exclusionary criteria. Methods Sera were collected to measure IgG anti-SARS-CoV-2 antibody level with reflex to total anti-SARS-CoV-2 immunoglobulin levels, and blinded evaluation of SARS-CoV-2 pseudovirus neutralization titers. Descriptive statistics, Pearson correlation coefficients, and multiple linear regression analysis evaluated relationships between factors potentially associated with antibody levels. Spearman correlations were calculated between antibody levels and neutralization titers. Results All participants (N = 70) had received two rounds of vaccination and were found to have antibodies with wide variation in relative levels. Antibody levels trended lower in males, advanced age, current use of steroids, and longer length of time from vaccination. Pseudovirus neutralization titer levels were strongly correlated (P < .001) with Beckman Coulter antibody levels [D614 G NT50, rs = 0.91; B.1.1.7 (UK) NT50, rs = 0.91]. Conclusions and Implications Higher functioning, healthier, residential older adults mounted detectable antibody responses when vaccinated with mRNA-based COVID-19 vaccines. Data suggests some degree of immunity is present during the immediate period following vaccination. However, protective effects remain to be determined in larger studies as clinical protection is afforded by ongoing adaptive immunity, which is known to be decreased in older adults. This study provides important preliminary results on level of population risk in older adult residents at assisted living, personal care, and independent living communities to inform reopening strategies, but are not likely to be translatable for residents in nursing homes.
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Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Kevin E Kip
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John W Mellors
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Michael R Shurin
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katie Mulvey
- Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa Crandall
- Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michele D Sobolewski
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - P Nathan Enick
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin D McCormick
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jana L Jacobs
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - April L Kane
- Senior Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amy Lukanski
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paula L Kip
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA; Clinical Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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18
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Huang DT, McCreary EK, Bariola JR, Wadas RJ, Kip KE, Marroquin OC, Koscumb S, Collins K, Shovel JA, Schmidhofer M, Wisniewski MK, Sullivan C, Yealy DM, Axe M, Nace DA, Haidar G, Khadem T, Linstrum K, Snyder GM, Seymour CW, Montgomery SK, McVerry BJ, Berry L, Berry S, Meyers R, Weissman A, Peck-Palmer OM, Wells A, Bart R, Albin DL, Minnier T, Angus DC. The UPMC OPTIMISE-C19 (OPtimizing Treatment and Impact of Monoclonal antIbodieS through Evaluation for COVID-19) trial: a structured summary of a study protocol for an open-label, pragmatic, comparative effectiveness platform trial with response-adaptive randomization. Trials 2021; 22:363. [PMID: 34034784 PMCID: PMC8144687 DOI: 10.1186/s13063-021-05316-3] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022] Open
Abstract
Objectives The primary objective is to evaluate the comparative effectiveness of COVID-19 specific monoclonal antibodies (mABs) with US Food and Drug Administration (FDA) Emergency Use Authorization (EUA), alongside UPMC Health System efforts to increase patient access to these mABs. Trial design Open-label, pragmatic, comparative effectiveness platform trial with response-adaptive randomization Participants We will evaluate patients who meet the eligibility criteria stipulated by the COVID-19 mAB EUAs who receive mABs within the UPMC Health System, including infusion centers and emergency departments. EUA eligibility criteria include patients with mild to moderate COVID-19, <10 days of symptoms, and who are at high risk for progressing to severe COVID-19 and/or hospitalization (elderly, obese, and/or with specific comorbidities). The EUA criteria exclude patients who require oxygen for the treatment of COVID-19 and patients already hospitalized for the treatment of COVID-19. We will use data collected for routine clinical care, including data entered into the electronic medical record and from follow-up calls. Intervention and comparator The interventions are the COVID-19 specific mABs authorized by the EUAs. All aspects of mAB treatment, including eligibility criteria, dosing, and post-infusion monitoring, are as per the EUAs. As a comparative effectiveness trial, all patients receive mAB treatment, and the interventions are compared against each other. When U.S. government mAB policies change (e.g., FDA grants or revokes EUAs), UPMC Health System policies and the evaluated mAB interventions will accordingly change. From November 2020 to February 2021, FDA issued EUAs for three mAB treatments (bamlanivimab; bamlanivimab and etesevimab; and casirivimab and imdevimab), and at trial launch on March 10, 2021 we evaluated all three. Due to a sustained increase in SARS-CoV-2 variants in the United States resistant to bamlanivimab administered alone, on March 24, 2021 the U.S. Government halted distribution of bamlanivimab alone, and UPMC accordingly halted bamlanivimab monotherapy on March 31, 2021. On April 16, 2021, FDA revoked the EUA for bamlanivimab monotherapy. At the time of manuscript submission, we are therefore evaluating the two mAB treatments authorized by EUAs (bamlanivimab and etesevimab; and casirivimab and imdevimab). Main outcomes The primary outcome is total hospital free days (HFD) at 28 days after mAB administration, calculated as 28 minus the number of days during the index stay (if applicable – e.g., for patients admitted to hospital after mAB administration in the emergency department) minus the number of days readmitted during the 28 days after treatment. This composite endpoint captures the number of days from the day of mAB administration to the 28 days thereafter, during which the patient is alive and free of hospitalization. Death within 28 days is recorded as -1 HFD, as the worst outcome. Randomisation We will start with equal allocation. Due to uncertainty in sample size, we will use a Bayesian adaptive design and response adaptive randomization to ensure ability to provide statistical inference despite variable sample size. When mABs are ordered by UPMC physicians as a generic referral order, the order is filled by UPMC pharmacy via therapeutic interchange. OPTIMISE-C19 provides the therapeutic interchange via random allocation. Infusion center operations teams and pharmacists use a mAB assignment application embedded in the electronic medical record to determine the random allocation. Blinding (masking) This trial is open-label. However, outcome assessors conducting follow-up calls at day 28 are blinded to mAB assignment, and investigators are blinded to by-mAB aggregate outcome data until a statistical platform trial conclusion is reached. Numbers to be randomised (sample size) Sample size will be determined by case volume throughout the course of the pandemic, supply of FDA authorized mABs, and by that needed to reach a platform trial conclusion of inferiority, superiority, or futility of a given mAB. The trial will continue as long as more than one mAB type is available under EUA, and their comparative effectiveness is uncertain. Trial Status Protocol Version 1.0, February 24, 2021. Recruitment began March 10, 2021 and is ongoing at the time of manuscript submission. The estimated recruitment end date is February 22, 2022, though the final end date is dependent on how the pandemic evolves, mAB availability, and when final platform trial conclusions are reached. As noted above, due to U.S. Government decisions, UPMC Health System halted bamlanivimab monotherapy on March 31, 2021. Trial registration ClinicalTrials.gov Identifier: NCT04790786. Registered March 10, 2021 Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05316-3.
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Affiliation(s)
- David T Huang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA. .,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard J Wadas
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - Kevin E Kip
- Clinical Analytics, UPMC, Pittsburgh, PA, USA
| | | | | | | | | | - Mark Schmidhofer
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Colleen Sullivan
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ghady Haidar
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tina Khadem
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kelsey Linstrum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Graham M Snyder
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Stephanie K Montgomery
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - Russell Meyers
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 606B Scaife Hall, Pittsburgh, PA, 15213, USA
| | - Octavia M Peck-Palmer
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert Bart
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health Services Division, Pittsburgh, PA, USA
| | - Debbie L Albin
- UPMC Supply Chain Management/HC Pharmacy, Pittsburgh, PA, USA
| | | | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,UPMC Health System Office of Healthcare Innovation, Pittsburgh, PA, USA
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19
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Lengacher CA, Gruss LF, Kip KE, Reich RR, Chauca KG, Moscoso MS, Joshi A, Tinsley S, Shani B, Cousin L, Khan CP, Goodman M, Park JY. Mindfulness-based stress reduction for breast cancer survivors (MBSR(BC)): evaluating mediators of psychological and physical outcomes in a large randomized controlled trial. J Behav Med 2021; 44:591-604. [PMID: 33963420 DOI: 10.1007/s10865-021-00214-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 03/11/2021] [Indexed: 12/13/2022]
Abstract
MBSR(BC) is known to have a positive impact on psychological and physical symptoms among breast cancer survivors (BCS). The cognitive mechanisms of "how" MBSR(BC) works was addressed in a recent study that found that there was strong consistent evidence that reduced emotional reactivity is a mediator and moderate consistent evidence that mindfulness, rumination, and worry were mediators. The purpose of this study, as part of a larger R01 trial, was to test whether positive effects achieved from the MBSR(BC) program were mediated through changes in increased mindfulness, decreased fear of breast cancer recurrence, and perceived stress. Female BCS > 21 years diagnosed with Stage 0-III breast cancer were randomly assigned to a 6-week MBSR(BC) or a Usual Care (UC)regimen. Potential mediators of 6- and 12-week outcomes were identified by analysis of covariance (ANCOVA), followed by formal mediational analyses of main effects of MBSR(BC) on 6- and 12-week outcomes, including percentage of total effects explained. Among 322 BCS (167 MBSR(BC) and 155 UC), fear of recurrence and perceived stress, but not mindfulness, mediated reductions in anxiety and fatigue at weeks 6 and 12, partially supporting our hypothesis of cognitive mechanisms of MBSR(BC). TRIAL REGISTRATION: Registration Number: NCT01177124 http://www.ClinicalTrials.gov.
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Affiliation(s)
- Cecile A Lengacher
- University of South Florida College of Nursing, MDC 22, 12901 Bruce B. Downs Blvd., Tampa, FL, 33612-4476, USA.
| | - L Forest Gruss
- University of South Florida College of Nursing, MDC 22, 12901 Bruce B. Downs Blvd., Tampa, FL, 33612-4476, USA
| | - Kevin E Kip
- University of Pittsburgh Medical Center, Pittsburgh, PA, 15261, USA
| | | | - Katterine G Chauca
- University of South Florida College of Nursing, MDC 22, 12901 Bruce B. Downs Blvd., Tampa, FL, 33612-4476, USA
| | - Manolete S Moscoso
- University of South Florida College of Nursing, MDC 22, 12901 Bruce B. Downs Blvd., Tampa, FL, 33612-4476, USA
| | - Anisha Joshi
- University of South Florida College of Nursing, MDC 22, 12901 Bruce B. Downs Blvd., Tampa, FL, 33612-4476, USA
| | | | | | | | | | | | - Jong Y Park
- Moffitt Cancer Center, Tampa, FL, 33612, USA
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20
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Hernandez D, Kip KE, Long CJ, Redman JL. Accelerated resolution therapy and a thematic approach to military experiences in US Special Operations Veterans. BMJ Mil Health 2021; 168:224-228. [PMID: 33911011 DOI: 10.1136/bmjmilitary-2020-001729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/22/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 11/04/2022]
Abstract
Accelerated Resolution Therapy (ART) is an emerging therapeutic intervention that has demonstrated effectiveness in treating post-traumatic stress, anxiety and depression. The ART protocol aligns with first-line trauma-focused psychotherapies and clinical guides in the USA and UK. This review addresses previous ART research that includes members of US Special Operations Forces. Observations from that research has led to a thematic conceptualisation of trauma through ART interventions. These include three clusters of traumatic memories and several themes relevant to individual distress but not necessarily symptoms that meet diagnostic criteria for PTSD. ART represents a movement in treatment away from the symptoms, to the individuals' story. Not only the story of an event, but how that experience becomes incorporated into one's sense of identity. The themes identified (and treated with ART) appear to have broader application to the entirety of one's military experience, not just PTSD. These themes may be helpful in directing treatment and may help to focus on significant aspects of service not traditionally associated with PTSD. Theoretically, some of these areas may have protective implications in suicide.
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Affiliation(s)
- Diego Hernandez
- Balanced Living Psychology, Tampa, Florida, USA .,College Public Health, University of South Florida, Tampa, Florida, USA
| | - K E Kip
- College Public Health, University of South Florida, Tampa, Florida, USA.,Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - C J Long
- College Public Health, University of South Florida, Tampa, Florida, USA
| | - J L Redman
- Division of Counseling and Family Therapy, Regis University, Denver, Colorado, USA
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21
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Fradley MG, Damrongwatanasuk R, Chandrasekhar S, Alomar M, Kip KE, Sarnaik AA. Cardiovascular Toxicity and Mortality Associated With Adoptive Cell Therapy and Tumor-infiltrating Lymphocytes for Advanced Stage Melanoma. J Immunother 2021; 44:86-89. [PMID: 33044384 DOI: 10.1097/cji.0000000000000341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/25/2020] [Indexed: 11/26/2022]
Abstract
Adoptive cellular therapy (ACT) with tumor-infiltrating lymphocytes (TILs) has emerged as an effective treatment option for unresectable stage III/IV metastatic melanoma. Acute toxicities, particularly cardiovascular (CV), can have a significant effect on the completion of therapy. We abstracted information on 43 patients who received ACT-TIL treatment for melanoma at the Moffitt Cancer Center between 2010 and 2016. The Student t tests and χ2 tests were used to compare patient characteristics by presence versus absence of specific CV complications. In this cohort, 32.6% developed hypotension requiring treatment with intravenous fluids and pressors, 14% atrial fibrillation, and 2.3% troponin elevations suggestive of myocardial damage. No patients developed clinical heart failure, and among the patients that underwent echocardiography, there was no significant difference in mean left ventricular ejection fraction before or after therapy (62.9% vs. 63.5%, respectively, P=0.79). There was also no statistically significant difference in survival between those with and without CV complications (overall survival=61.9%, mean: 26.0 mo and progression-free survival=45.2%, mean: 18.1 mo). CV toxicities are common in ACT-TIL protocols; however, survival does not appear to be significantly affected. Further research is needed to define mechanisms and potential prevention strategies to help clinicians manage these complications and mitigate risk.
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Affiliation(s)
- Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, University of Pennsylvania, Philadelphia, PA
| | - Rongras Damrongwatanasuk
- Cardio-Oncology Program, Division of Cardiology, University of South Florida and Moffitt Cancer Center
| | - Sanjay Chandrasekhar
- Cardio-Oncology Program, Division of Cardiology, University of South Florida and Moffitt Cancer Center
| | - Mohammed Alomar
- Cardio-Oncology Program, Division of Cardiology, University of South Florida and Moffitt Cancer Center
| | - Kevin E Kip
- Department of Biostatistics, University of South Florida
| | - Amod A Sarnaik
- Cutaneous Oncology Program, Moffitt Cancer Center, Tampa, FL
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22
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Loux T, Mansuri F, Brooks SE, Slye N, Lewis B, Lu Y, Chen H, Kip KE. Factors associated with pediatric drowning admissions and outcomes at a trauma center, 2010–2017. Am J Emerg Med 2021; 39:86-91. [DOI: 10.1016/j.ajem.2020.01.025] [Citation(s) in RCA: 1] [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] [Received: 10/28/2019] [Revised: 01/08/2020] [Accepted: 01/11/2020] [Indexed: 10/25/2022] Open
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23
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Nguyen ATH, Saeed A, Bambs CE, Swanson J, Emechebe N, Mansuri F, Talreja K, Reis SE, Kip KE. Usefulness of the American Heart Association's Ideal Cardiovascular Health Measure to Predict Long-term Major Adverse Cardiovascular Events (From the Heart SCORE Study). Am J Cardiol 2021; 138:20-25. [PMID: 33065086 DOI: 10.1016/j.amjcard.2020.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023]
Abstract
To further reduce the burden of cardiovascular disease (CVD) and expand prevention efforts, the American Heart Association (AHA) introduced in 2010 the concept of Ideal Cardiovascular Health (ICH), which includes 7 metrics (smoking status, body mass index, physical activity, diet, total cholesterol, blood pressure, and fasting plasma glucose). Limited data exist on the relation between ICH and long-term CVD risk. The Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study cohort was used to examine the relation between ICH and incident major adverse cardiovascular events (MACE: first occurrence of death, myocardial infarction, stroke, acute ischemic syndrome, or coronary revascularization). The 7 factors of the ICH were scored at study entry on a 0 to 2 scale, resulting in possible range of 0 to 14, with higher scores representing "better" health. Cox regression analyses were used to estimate hazard ratios (HR) of MACE, along with 95% confidence intervals. Over a median follow-up of 12 years, the study population (n = 1,863, 67% women, 42% Black race, mean age 59 years [range 45 to 75]) had 218 MACE. In unadjusted analysis, the ICH score (per 1 unit) was associated with an estimated 12% lower risk of MACE (HR [95% Confidence Interval]: 0.88 [0.82, 0.93]). Adjusting for demographics, education, and quality of life, ICH score was associated with a 10% lower risk of MACE (HR 0.90 [0.84, 0.96]). In a community-based sample of adults, the AHA ICH construct, which includes 7 modifiable CVD risk factors, appears to be a valid measure for predicting long-term risk of MACE.
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24
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Fradley MG, Ellenberg K, Alomar M, Swanson J, Kharod A, Nguyen ATH, Khodor S, Mishra S, Duong LM, Shah N, Armanious M, Rhea IB, Schabath MB, Kip KE. Patterns of Anticoagulation Use in Patients With Cancer With Atrial Fibrillation and/or Atrial Flutter. JACC CardioOncol 2020; 2:747-754. [PMID: 34396290 PMCID: PMC8352174 DOI: 10.1016/j.jaccao.2020.09.008] [Citation(s) in RCA: 20] [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] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
Background Atrial fibrillation (AF) is a common cardiovascular complication affecting patients with cancer, but management strategies are not well established. Objectives The purpose of this retrospective cohort study was to evaluate cross-sectional patterns of anticoagulation (AC) use in patients with cancer with AF or atrial flutter (AFL) on the basis of their risk for stroke and bleeding. Methods Patients with cancer and electrocardiograms showing AF or AFL performed at Moffitt Cancer Center in either the inpatient or outpatient setting were included in this retrospective analysis. We described percentages of AC prescription by stroke and bleeding risk, as determined by individual CHA2DS2-VASc and HAS-BLED scores, respectively. Multivariable logistic regression evaluated clinical variables independently associated with anticoagulant prescription. Results The prevalence of electrocardiography-documented AF or AFL was 4.8% (n = 472). The mean CHA2DS2-VASc score was 2.8 ± 1.4. Among patients with CHA2DS2-VASc scores ≥2 and HAS-BLED scores <3, 44.3% did not receive AC, and of these, only 18.3% had platelet values <50,000/μl. In multivariable analysis, older age, hypertension, prior stroke, and history of venous thromboembolism were each directly associated with AC use, while current chemotherapy use, prior bleeding, renal disease, and thrombocytopenia were each inversely associated with AC use. Conclusions Nearly one-half of patients with cancer, the majority with normal platelet counts, had an elevated risk for stroke but did not receive AC. In addition to known predictors, current chemotherapy use was independently associated with a lower odds of AC use. This study highlights the need to improve the application of AF treatment algorithms to cancer populations.
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Affiliation(s)
- Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kerry Ellenberg
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Mohammed Alomar
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Justin Swanson
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Anant Kharod
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Anh Thy H Nguyen
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Sara Khodor
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Shreya Mishra
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Linh M Duong
- University of South Florida College of Public Health, Tampa, Florida, USA
| | - Nirav Shah
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Merna Armanious
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Isaac B Rhea
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Matthew B Schabath
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Kevin E Kip
- University of South Florida College of Public Health, Tampa, Florida, USA
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25
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Bell JM, Mason TM, Buck HG, Tofthagen CS, Duffy AR, Groër MW, McHale JP, Kip KE. Challenges in Obtaining and Assessing Salivary Cortisol and α-Amylase in an Over 60 Population Undergoing Psychotherapeutic Treatment for Complicated Grief: Lessons Learned. Clin Nurs Res 2020; 30:680-689. [PMID: 33218253 DOI: 10.1177/1054773820973274] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Biomarkers may serve as objective measures in complicated grief (CG) potentially capturing responses to stress reduction treatment. This paper reports challenges in obtaining and assessing salivary cortisol and α-amylase (sAA) for a recent randomized clinical trial. Within-session changes in salivary cortisol and sAA for 54 older adults with CG who received Accelerated Resolution Therapy were compared with perceived stress measured by Subjective Units of Distress Scale. Bivariate correlations and multiple regressions examined changes in biomarkers. Protocols, study logs, and audit reports identified challenges. Challenges included obtaining unstimulated passive drool salivary samples and their analyses. Our sample of older females on multiple medications may have resulted in a perfect storm of moderating and intervening variables which affected the stress response. This paper contributes to the discussion on designing clinical trials for older adults which must account for physiologic changes, multimorbidity, and polypharmacy common in this population and makes recommendations moving forward.
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Affiliation(s)
- Jesse M Bell
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Tina M Mason
- College of Nursing, University of South Florida, and Department of Nursing Research, Moffitt Cancer Center, Tampa, FL, USA
| | - Harleah G Buck
- College of Nursing, University of South Florida, Tampa, FL, USA
| | | | - Allyson R Duffy
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Maureen W Groër
- College of Nursing and Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - James P McHale
- Department of Psychology, USF St. Petersburg Family Study Center, University of South Florida, Tampa, FL, USA
| | - Kevin E Kip
- Health Services Division, Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
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26
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Tofthagen C, Hernandez DF, Mason TM, Buck HG, Kip KE. Complicated Grief With Post-Traumatic Stress Disorder Addressed With Accelerated Resolution Therapy: Case Discussions. Omega (Westport) 2020; 85:455-464. [PMID: 32757692 DOI: 10.1177/0030222820947241] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Complicated grief is a significant health concern for older adults, resulting in significant psychological and physical morbidity. Elements of post traumatic stress disorder (PTSD) are often present in individuals with complicated grief. Accelerated Resolution Therapy (ART) is a brief form of psychotherapy that utilizes the techniques of imaginal exposure, rescripting of events, and lateral eye movements that may be useful in complicated grief with PTSD symptoms. Two cases where ART was used for complicated grief with PTSD are presented. Both individuals had attempted to come to terms with their loss through traditional grief therapy with an inadequate response and substantial residual grief symptoms. These cases illustrate how ART can be used to address CG and PTSD and describe situations where it may be appropriate. Clinical and research implications are also discussed.
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Affiliation(s)
- Cindy Tofthagen
- Department of Nursing, Nursing Research Division, Mayo Clinic, Florida, USA
| | | | - Tina M Mason
- College of Public Health, University of South Florida, USA
| | - Harleah G Buck
- College of Public Health, University of South Florida, USA
| | - Kevin E Kip
- College of Public Health, University of South Florida, USA
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Buck HG, Cairns P, Emechebe N, Hernandez DF, Mason TM, Bell J, Kip KE, Barrison P, Tofthagen C. Accelerated Resolution Therapy: Randomized Controlled Trial of a Complicated Grief Intervention. Am J Hosp Palliat Care 2020; 37:791-799. [PMID: 31960705 DOI: 10.1177/1049909119900641] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Complicated grief (CG) is severe, prolonged (>12 months) grieving. Complicated grief disproportionately affects older adults and is associated with negative physical/psychological effects. Although treatment options exist, those which do are time-intensive. We report on a randomized clinical trial (RCT) which examined whether accelerated resolution therapy (ART), a novel mind-body therapy, is effective in treating CG, post-traumatic stress disorder (PTSD), and depression among hospice informal caregivers. RESEARCH DESIGN AND METHODS Prospective 2 group, wait-listed RCT. All participants were scheduled to receive 4 ART sessions. INCLUSION ≥60 years, inventory of CG >25, and PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition >33 or Psychiatric Diagnostic Screen Questionnaire PTSD subscale >5. EXCLUSION Major psychiatric disorder, other current psychotherapy treatment. Depression was measured by the Center for Epidemiologic Studies Depression. RESULTS Mean (standard deviation [SD]) age of 54 participants was 68.7 (7.2) years, 85% female, and 93% white. Participants assigned to ART reported significantly greater mean (SD) CG reduction (-22.8 [10.3]) versus Wait-list participants (-4.3 [6.0]). Within-participant effect sizes (ESs) for change from baseline to 8-week post-treatment were CG (ES = 1.96 (95% confidence interval [CI]: 1.45-2.47; P < .0001), PTSD (ES = 2.40 [95% CI: 1.79-3.00]; P < .0001), depression (ES = 1.63 [95% CI: 1.18-2.08; P < .0001). Treatment effects did not substantially differ by baseline symptom levels. DISCUSSION AND IMPLICATIONS Results suggests that ART presents an effective and less time-intensive intervention for CG in older adults. However, it should undergo further effectiveness testing in a larger, more diverse clinical trial with a focus on determining physiological or behavioral mechanisms of action.
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Affiliation(s)
| | | | | | | | | | - Jesse Bell
- University of South Florida, Tampa, FL, USA
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28
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Fowler CA, Ballistrea LM, Mazzone KE, Martin AM, Kaplan H, Kip KE, Murphy JL, Winkler SL. A virtual reality intervention for fear of movement for Veterans with chronic pain: protocol for a feasibility study. Pilot Feasibility Stud 2019; 5:146. [PMID: 31890259 PMCID: PMC6907328 DOI: 10.1186/s40814-019-0501-y] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A key concern for people with chronic pain is experiencing increased pain and/or re-injury. Consequently, individuals with chronic pain can develop a maladaptive fear of movement that leads to adverse functional consequences. A primary goal of chronic pain rehabilitation is re-engagement in feared movements through exposure. This is often challenging since safe movement can be uncomfortable. Virtual environments provide a promising opportunity to safely and gradually expose Veterans to movements that are avoided in the real world. The current study will utilize multiple virtual reality (VR) applications (APPs) of varying the intensity levels ranging from passive distraction from pain to active exposure to feared movement. The primary aims of this pilot are to examine VR as an adjunctive nonpharmacological intervention to assist with the adoption and implementation of skills to decrease fear of movement and increase overall functioning among Veterans with chronic pain. Second, to build a hierarchy of VR APPs to assist in gradual exposure to feared movements. METHODS This study will be conducted in the Chronic Pain Rehabilitation Program (CPRP) at the James A. Haley Veterans Hospital, a unique inpatient program within the VA system. Participants will include up to 20 Veterans who receive a VR intervention as part of their physical therapy. A rating form containing qualitative and quantitative experiences will be administered following each VR session to assess feasibility and to provide descriptive information for the proposed hierarchy. Effect sizes will be calculated from intake and discharge measures for the primary outcome fear of movement and secondary pain and functional outcomes. DISCUSSION This study will inform the feasibility of a randomized controlled trial examining the clinical utility of using VR to reduce fear of movement and increase function among Veterans with chronic pain. VR has the advantage of being easily implemented both within VA healthcare settings as well as in Veterans' own residences, where engagement in ongoing self-management approaches is often most challenging. Presumably, VR that is matched to patient needs, progresses in intensity, immerses Veterans in the applications, and is perceived positively by Veterans, will result in positive functional outcomes.
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Affiliation(s)
- Christopher A. Fowler
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
| | - Lisa M. Ballistrea
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
| | - Kerry E. Mazzone
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Aaron M. Martin
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Howard Kaplan
- Advanced Visualization Center, University of South Florida – Information Technology, 4202 E. Fowler Avenue, CMC147, Tampa, FL 33620 USA
| | - Kevin E. Kip
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL 33612 USA
| | - Jennifer L. Murphy
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
- Department of Neurology, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Sandra L. Winkler
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
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Willing AE, Girling SA, Deichert R, Wood-Deichert R, Gonzalez J, Hernandez D, Foran E, Sanberg PR, Kip KE. Brazilian Jiu Jitsu Training for US Service Members and Veterans with Symptoms of PTSD. Mil Med 2019; 184:e626-e631. [PMID: 31004163 PMCID: PMC6910885 DOI: 10.1093/milmed/usz074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 02/26/2019] [Accepted: 03/15/2019] [Indexed: 11/14/2022] Open
Abstract
Introduction The United States has been actively involved in major armed conflicts over the last 15 years. As a result, a significant proportion of active duty service personnel and returning veterans have endured combat, putting them at risk for developing post-traumatic stress disorder (PTSD), a disabling disorder that may occur after exposure to a traumatic event. Current therapies often require long-term, time-intensive and costly commitment from the patient and have variable degrees of success. There remains an ongoing need for better therapies, including complementary medicine approaches that can effectively reduce PTSD symptoms. While anecdotal evidence suggests that routine practice of Brazilian Jiu Jitsu (BJJ) can reduce symptoms of PTSD, there have been no formal studies to address this. Materials and Methods This study was approved by the University of South Florida Institutional Review Board (#PRO00019430). Male US active duty service members and veterans from the Tampa area participated in a 5-month (40 sessions) BJJ training program. Before beginning and again midway through and upon completion of training the participants completed several validated self-report measures that addressed symptoms of PTSD and other co-morbid conditions. Effect size and 95% confidence intervals were determined using a within-person single-group pretest–posttest design. Results Study participants demonstrated clinically meaningful improvements in their PTSD symptoms as well as decreased symptoms of major depressive disorder, generalized anxiety and decreased alcohol use; effect sizes varied from 0.80 to 1.85. Conclusions The results from this first-of-kind pilot study suggest that including BJJ as a complementary treatment to standard therapy for PTSD may be of value. It will be necessary to validate these promising results with a larger subject cohort and a more rigorous experimental design before routinely recommending this complementary therapy.
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Affiliation(s)
- Alison E Willing
- Center for Excellence in Aging and Brain Repair, Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 3515 E. Fletcher, Tampa, FL 33613
| | - Sue Ann Girling
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612
| | - Ryan Deichert
- Tampa Jiu Jitsu, LLC, 4210 Carnal Ave, Tampa, FL 33618
| | | | - Jason Gonzalez
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612
| | - Diego Hernandez
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612
| | - Elspeth Foran
- Center for Excellence in Aging and Brain Repair, Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 3515 E. Fletcher, Tampa, FL 33613
| | - Paul R Sanberg
- Center for Excellence in Aging and Brain Repair, Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 3515 E. Fletcher, Tampa, FL 33613.,Office of Research, Innovation & Knowledge Enterprise, University of South Florida, 3702 Spectrum Blvd. Ste. 165, Tampa, FL 33612
| | - Kevin E Kip
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, Tampa, FL 33612
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Buck HG, Hernandez DF, Mason T, Tofthagen C, Kip KE. A TALE OF TWO CASE STUDIES: ACCELERATED RESOLUTION THERAPY FOR COMPLICATED GRIEF IN OLDER ADULTS. Innov Aging 2019. [PMCID: PMC6840051 DOI: 10.1093/geroni/igz038.1010] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Complicated grief (CG) is characterized by lengthy, intense, and functionally impairing grief which disproportionately affects older adults. Accelerated Resolution Therapy (ART) is a brief, protocol driven, exposure/imagery rescripting therapy which uses lateral left-right eye movements. ART, unlike traditional psychotherapy, directs the person to perform two tasks simultaneously (e.g. re-experiencing the grief experience and performing eye movements), taxing limited working memory capacity. Importantly, this may force memory traces representing events, emotions, and sensations to compete for permanence, as well as reduce the vividness and emotional intensity of the original grief. Two CG case studies are presented (expected; unexpected death) with their response to ART. Stake’s instrumental case study methodology was used to identify and study cases which reflect a range of CG. Additionally, CG was measured by the Inventory of Complicated Grief (ICF). ICF’s range is 0-76 with scores > 24 indicating CG. Case 1 was a spousal caregiver with a single, expected death where helplessness, guilt, shame, and a life alone had resulted in CG (baseline ICF 33). Her ICF at 8 weeks post-ART was 10. Case 2 was an adult child caregiver with multiple (parent, sibling), unexpected deaths in quick succession where loss, guilt, anger, and helplessness had resulted in CG (baseline ICF 25). Her ICF at 8 weeks post-ART was 9. Both participants were able to process the distressing sensations that emerged during the imaginal exposure component facilitated with the use of eye movements. This suggests that ART may be a powerful new mind-body treatment for CG.
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Affiliation(s)
- Harleah G Buck
- University of South Florida, Tampa, Florida, United States
| | | | - Tina Mason
- H.L. Moffitt Cancer Center, Tampa, Florida, United States
| | | | - Kevin E Kip
- University of South Florida, Tampa, Florida, United States
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31
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Cairns PL, Buck HG, Kip KE, Rodriguez CS, Liang Z, Munro CL. Stress Management Intervention to Prevent Post-Intensive Care Syndrome-Family in Patients' Spouses. Am J Crit Care 2019; 28:471-476. [PMID: 31676522 DOI: 10.4037/ajcc2019668] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Post-intensive care syndrome-family (PICS-F) refers to acute and chronic psychological effects of critical care on family members of patients in intensive care units (ICUs). Evidence suggests that increased distress during the ICU stay increases risk of PICS-F. Sensation Awareness Focused Training (SĀF-T) is a new, promising stress management intervention, but the feasibility of such training during the ICU stay for family caregivers who are acting as the surrogate decision-maker for patients who are undergoing mechanical ventilation is unknown. OBJECTIVES To assess feasibility and acceptability of SĀF-T to inform a future larger randomized controlled trial. METHODS This randomized controlled trial of SĀF-T (n = 5) versus a control (n = 5) group was conducted at a level 1 trauma center. Participants assigned to SĀF-T completed 1 session daily for 3 days. Measures included enrollment rate, data completion rate, acceptability of SĀF-T, and symptoms of PICS-F. Scales used included Perceived Stress, Hospital Anxiety and Depression, Impact of Event, and National Institutes of Health Toolbox Emotion Battery. RESULTS Mean age was 58 (SD, 12) years; 70% of participants were female. Predetermined feasibility criteria were met in enrollment rate (67%), outcome measures completion rate (> 90%), and SĀF-T acceptability (100% of doses completed during the ICU stay) without adverse events. Stress scores after SĀF-T were significantly lower than scores before SĀF-T (z = -3.5, P = .01). CONCLUSIONS SĀF-T intervention during the ICU stay is feasible, acceptable, and may improve family caregivers' post-ICU outcomes. Larger clinical trial to assess the effectiveness of SĀF-T in preventing PICS-F seem warranted.
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Affiliation(s)
- Paula L. Cairns
- Paula L. Cairns is an assistant professor, Kevin E. Kip is a distinguished professor, and Harleah G. Buck and Carmen S. Rodriguez are associate professors, University of South Florida, Tampa, Florida. Zhan Liang is an assistant professor and Cindy L. Munro is a professor and dean, University of Miami, Coral Gables, Florida
| | - Harleah G. Buck
- Paula L. Cairns is an assistant professor, Kevin E. Kip is a distinguished professor, and Harleah G. Buck and Carmen S. Rodriguez are associate professors, University of South Florida, Tampa, Florida. Zhan Liang is an assistant professor and Cindy L. Munro is a professor and dean, University of Miami, Coral Gables, Florida
| | - Kevin E. Kip
- Paula L. Cairns is an assistant professor, Kevin E. Kip is a distinguished professor, and Harleah G. Buck and Carmen S. Rodriguez are associate professors, University of South Florida, Tampa, Florida. Zhan Liang is an assistant professor and Cindy L. Munro is a professor and dean, University of Miami, Coral Gables, Florida
| | - Carmen S. Rodriguez
- Paula L. Cairns is an assistant professor, Kevin E. Kip is a distinguished professor, and Harleah G. Buck and Carmen S. Rodriguez are associate professors, University of South Florida, Tampa, Florida. Zhan Liang is an assistant professor and Cindy L. Munro is a professor and dean, University of Miami, Coral Gables, Florida
| | - Zhan Liang
- Paula L. Cairns is an assistant professor, Kevin E. Kip is a distinguished professor, and Harleah G. Buck and Carmen S. Rodriguez are associate professors, University of South Florida, Tampa, Florida. Zhan Liang is an assistant professor and Cindy L. Munro is a professor and dean, University of Miami, Coral Gables, Florida
| | - Cindy L. Munro
- Paula L. Cairns is an assistant professor, Kevin E. Kip is a distinguished professor, and Harleah G. Buck and Carmen S. Rodriguez are associate professors, University of South Florida, Tampa, Florida. Zhan Liang is an assistant professor and Cindy L. Munro is a professor and dean, University of Miami, Coral Gables, Florida
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Fowler CA, Ballistrea LM, Mazzone KE, Martin AM, Kaplan H, Kip KE, Ralston K, Murphy JL, Winkler SL. Virtual Reality as a Therapy Adjunct for Fear of Movement in Veterans With Chronic Pain: Single-Arm Feasibility Study. JMIR Form Res 2019; 3:e11266. [PMID: 31670696 PMCID: PMC6914277 DOI: 10.2196/11266] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 06/13/2018] [Revised: 09/13/2019] [Accepted: 09/26/2019] [Indexed: 12/15/2022] Open
Abstract
Background Virtual reality (VR) has demonstrated efficacy for distraction from pain-related thoughts and exposure to feared movements. Little empirical VR research has focused on chronic pain management. Objective The purpose of this study was to examine the feasibility of VR as an adjunctive intervention for Veterans with chronic pain. We designed a hierarchy ranging from low-intensity pain distraction to high-intensity movement-based exposure for this purpose. VR apps were mapped onto the hierarchy. Methods Sixteen Veterans receiving inpatient chronic pain rehabilitation participated in daily VR sessions over a 3-week period. Trajectories across the distraction-to-exposure hierarchy and Veteran-reported intensity ratings were described and evaluated over time. Minimum clinically important differences (MCIDs), pre-post effect sizes, and 95% confidence intervals were examined for fear of movement using the Fear of Daily Activities Questionnaire (FDAQ) and Pain Outcomes Questionnaire-VA (POQ-VA; fear scale). This approach was applied to secondary outcomes: POQ-VA (pain intensity, interference, negative affect), Pain Catastrophizing Scale, and Patient-Specific Functioning Scale (PSFS). Session attendance, completion, and VR experiences were described. Results Ten of 14 Veterans (71%) who participated in three or more VR sessions completed the distraction-to-exposure hierarchy. Only three trajectories emerged more than once. Due to high completion rates, Veterans that completed the hierarchy could self-select nonhierarchy apps. Veterans rated all hierarchy levels (low, medium, high) near medium intensity. Self-selected activities were rated as high intensity. For kinesiophobia, six Veterans (38%) exceeded the MCID on the FDAQ and a small effect size improvement was observed (Cohen d=−0.35). The confidence interval (95% CI −0.71 to 0.01) indicated the possibility of a null effect. The POQ-VA fear scale yielded no effect (Cohen d=0.06, 95% CI −0.43 to 0.54). For secondary outcomes, Veterans exceeding MCID were calculated with complete data: pain intensity (1/15, 7%), pain catastrophizing (5/14, 36%), and patient-specific functioning (10/15, 67%). Effect sizes were large for patient-specific functioning (Cohen d=1.14, 95% CI 0.50-1.78), medium for mobility interference (Cohen d=−0.56, 95% CI −0.96 to −0.16), and small for pain intensity (Cohen d=−0.40, 95% CI −0.69 to −0.12) and catastrophizing (Cohen d=−0.41, 95% CI −0.79 to −0.02). No effects were observed for interference in daily activities (Cohen d=0.10, 95% CI −0.27 to 0.47) and negative affect (Cohen d=0.07, 95% CI −0.26 to 0.40). Veterans attended 85.2% (98/108) of VR sessions and completed 95% (93/96) of sessions attended. Twenty-minute sessions were rated as too short. No significant adverse events were reported. Conclusions Findings support the feasibility of VR as an adjunct for Veterans with chronic pain. However, the hierarchy will require modification, as evidenced by homogeneous intensity ratings. Veteran-selected activities presented the highest intensity ratings, largest outcome effect size (PSFS), and MCID. This highlights the important role of utilizing Veteran stakeholders in hierarchy modification, design of VR interventions, and outcome selection.
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Affiliation(s)
- Christopher A Fowler
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Lisa M Ballistrea
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Kerry E Mazzone
- Chronic Pain Rehabilitation Program, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Aaron M Martin
- Chronic Pain Rehabilitation Program, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Howard Kaplan
- Advanced Visualization Center, Information Technology, University of South Florida, Tampa, FL, United States
| | - Kevin E Kip
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States.,College of Public Health, University of South Florida, Tampa, FL, United States
| | - Katherine Ralston
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Jennifer L Murphy
- Chronic Pain Rehabilitation Program, James A Haley Veterans Hospital, Tampa, FL, United States.,Department of Neurology, College of Medicine, University of South Florida, Tampa, FL, United States
| | - Sandra L Winkler
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States
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Park JY, Lengacher CA, Reich RR, Alinat CB, Ramesar S, Le A, Paterson CL, Pleasant ML, Park HY, Kiluk J, Han H, Ismail-Khan R, Kip KE. Translational genomic research: the role of genetic polymorphisms in MBSR program among breast cancer survivors (MBSR[BC]). Transl Behav Med 2019; 9:693-702. [PMID: 30137607 DOI: 10.1093/tbm/iby061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Genetic variations of breast cancer survivors (BCS) may contribute to level of residual symptoms, such as depression, stress, fatigue, and cognitive impairment. The objective of this study was to investigate whether particular single-nucleotide polymorphisms (SNPs) moderated symptom improvement resulting from the Mindfulness-Based Stress Reduction for Breast Cancer (MBSR[BC]) program. An overarching goal of personalized medicine is to identify individuals as risk for disease and tailor interventions based on genetic profiles of patients with diseases including cancer. BCS were recruited from Moffitt Cancer Center and University of South Florida's Breast Health Program and were randomized to either the 6-week MBSR(BC) program (n = 92) or Usual Care (n = 93). Measures of symptoms, demographic, and clinical history data were attained at baseline, 6 weeks, and 12 weeks. A total of 10 SNPs from eight genes known to be related to these symptoms were studied using genomic DNA extracted from blood. Our results were examined for effect sizes, consistency, and statistical significance (p < .05). Three SNPs (rs4680 in COMT, rs6314 in HTR2A, and rs429358 in APOE) emerged as having the strongest (though relatively weak) and most consistent effects in moderating the impact of the MBSR program on symptom outcomes. Although effects were generally weak, with only one effect withstanding multiple comparisons correction for statistical significance, this translational behavioral research may help start the identification of genetic profiles that moderate the impact of MBSR(BC). The ultimate goal of this study is the development of personalized treatment programs tailored to the genetic profile of each patient.
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Affiliation(s)
- Jong Y Park
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Richard R Reich
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Sophia Ramesar
- University of South Florida College of Nursing, Tampa, FL, USA
| | - Alice Le
- University of South Florida College of Nursing, Tampa, FL, USA
| | - Carly L Paterson
- National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | | | - Hyun Y Park
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - John Kiluk
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Hyo Han
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Roohi Ismail-Khan
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kevin E Kip
- Department of Epidemiology and Biostatistics, University of South Florida, College of Public Health, Tampa, FL, USA
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Bubu OM, Pirraglia E, Andrade AG, Sharma RA, Gimenez-Badia S, Umasabor-Bubu OQ, Hogan MM, Shim AM, Mukhtar F, Sharma N, Mbah AK, Seixas AA, Kam K, Zizi F, Borenstein AR, Mortimer JA, Kip KE, Morgan D, Rosenzweig I, Ayappa I, Rapoport DM, Jean-Louis G, Varga AW, Osorio RS. Obstructive sleep apnea and longitudinal Alzheimer's disease biomarker changes. Sleep 2019; 42:zsz048. [PMID: 30794315 PMCID: PMC6765111 DOI: 10.1093/sleep/zsz048] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [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: 10/12/2018] [Revised: 01/11/2019] [Accepted: 02/19/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES To determine the effect of self-reported clinical diagnosis of obstructive sleep apnea (OSA) on longitudinal changes in brain amyloid PET and CSF biomarkers (Aβ42, T-tau, and P-tau) in cognitively normal (NL), mild cognitive impairment (MCI), and Alzheimer's disease (AD) elderly. METHODS Longitudinal study with mean follow-up time of 2.52 ± 0.51 years. Data were obtained from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. Participants included 516 NL, 798 MCI, and 325 AD elderly. Main outcomes were annual rate of change in brain amyloid burden (i.e. longitudinal increases in florbetapir PET uptake or decreases in CSF Aβ42 levels); and tau protein aggregation (i.e. longitudinal increases in CSF total tau [T-tau] and phosphorylated tau [P-tau]). Adjusted multilevel mixed effects linear regression models with randomly varying intercepts and slopes was used to test whether the rate of biomarker change differed between participants with and without OSA. RESULTS In NL and MCI groups, OSA+ subjects experienced faster annual increase in florbetapir uptake (B = .06, 95% CI = .02, .11 and B = .08, 95% CI = .05, .12, respectively) and decrease in CSF Aβ42 levels (B = -2.71, 95% CI = -3.11, -2.35 and B = -2.62, 95% CI = -3.23, -2.03, respectively); as well as increases in CSF T-tau (B = 3.68, 95% CI = 3.31, 4.07 and B = 2.21, 95% CI = 1.58, 2.86, respectively) and P-tau (B = 1.221, 95% CI = 1.02, 1.42 and B = 1.74, 95% CI = 1.22, 2.27, respectively); compared with OSA- participants. No significant variations in the biomarker changes over time were seen in the AD group. CONCLUSIONS In both NL and MCI, elderly, clinical interventions aimed to treat OSA are needed to test if OSA treatment may affect the progression of cognitive impairment due to AD.
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Affiliation(s)
- Omonigho M Bubu
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
- Center for Brain Health, Department of Psychiatry, NYU Langone Medical Center, New York, NY
- Department of Applied Health Sciences, Wheaton College, Wheaton, IL
- Department of Population Health, New York University School of Medicine, Center for Healthful Behavior Change, New York, NY
| | - Elizabeth Pirraglia
- Center for Brain Health, Department of Psychiatry, NYU Langone Medical Center, New York, NY
| | - Andreia G Andrade
- Center for Brain Health, Department of Psychiatry, NYU Langone Medical Center, New York, NY
| | - Ram A Sharma
- Center for Brain Health, Department of Psychiatry, NYU Langone Medical Center, New York, NY
| | - Sandra Gimenez-Badia
- Multidisciplinary Sleep Unit - Respiratory Department, Hospital de la Santa Creu i Sant Pau. IIB Sant Pau Department of Clinical Psychobiology, University of Barcelona, Barcelona, Spain
| | | | - Megan M Hogan
- Department of Applied Health Sciences, Wheaton College, Wheaton, IL
| | - Amanda M Shim
- Department of Applied Health Sciences, Wheaton College, Wheaton, IL
| | - Fahad Mukhtar
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
| | - Nidhi Sharma
- Dipartmento Di Scienze Biochimica A. Rossi Fanelli, University of Rome, Rome, Italy
| | - Alfred K Mbah
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
| | - Azizi A Seixas
- Department of Population Health, New York University School of Medicine, Center for Healthful Behavior Change, New York, NY
| | - Korey Kam
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ferdinand Zizi
- Department of Population Health, New York University School of Medicine, Center for Healthful Behavior Change, New York, NY
| | - Amy R Borenstein
- Department of Family Medicine and Public Health, University of California—San Diego, San Diego, CA
| | - James A Mortimer
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
| | - Kevin E Kip
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
| | - David Morgan
- Department of Molecular Science and Translational Medicine, Michigan State University, Grand Rapids, MI
- Byrd Alzheimer’s Disease Institute, College of Medicine, Psychiatry and Behavioral Neurosciences, University of South Florida Health, Tampa, FL
| | - Ivana Rosenzweig
- Sleep Disorders Centre, Guy’s Hospital, Great Maze Pond, London, UK
- Sleep and Brain Plasticity Centre, Department of Neuroimaging, IoPPN, King’s College London, London, UK
| | - Indu Ayappa
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY
| | - David M Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Girardin Jean-Louis
- Department of Population Health, New York University School of Medicine, Center for Healthful Behavior Change, New York, NY
| | - Andrew W Varga
- Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ricardo S Osorio
- Center for Brain Health, Department of Psychiatry, NYU Langone Medical Center, New York, NY
- Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY
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Nash MC, Kip KE, Wang W, Custer M, O'Rourke K. Post-traumatic stress disorder and hypertensive disorders of pregnancy among military women. Paediatr Perinat Epidemiol 2019; 33:238-247. [PMID: 31006884 DOI: 10.1111/ppe.12546] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 10/31/2018] [Revised: 01/29/2019] [Accepted: 02/03/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Women are more likely to develop post-traumatic stress disorder (PTSD) than men. Limited research exists evaluating the risk of hypertensive disorders of pregnancy (HDP) among military women with PTSD. METHODS We conducted a retrospective cohort study using US Department of Defense (DoD) data comprised of all active-duty women giving birth to their first, liveborn singleton infant using DoD-sponsored health insurance from 1 January 2004 to 31 December 2008 (n = 34 176). Birth hospitalisation records, maternal mental health visits, and Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) screenings were included. The HDP outcome (yes vs no) was defined using ICD-9-CM codes in the maternal birth hospitalisation record. Women fit into one of four PTSD exposure categories (confirmed, probable, possible, none). Confirmed cases had a PTSD ICD-9-CM diagnosis code. Probable/possible cases were classified using PDHA screening items. We used multiple log-linear regression to assess PTSD (confirmed, any vs none) and the risk of HDP overall, and then explored effect modification by military service and demographic variables. We assessed the risk of HDP among deployed mothers with PTSD (confirmed, probable/possible vs none) who completed a PDHA, and explored effect modification by race/ethnicity. We also assessed risk of HDP with differing PTSD lead times. RESULTS Overall, PTSD was not associated with HDP except among mothers whose PTSD was diagnosed ≥1 year prior to conception (RR 1.42, 95% CI 1.06, 1.90). CONCLUSIONS Post-traumatic stress disorder preceding conception by at least a year appeared to confer an increased risk of HDP, but further research is needed using more thorough PTSD assessment.
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Affiliation(s)
| | - Kevin E Kip
- College of Public Health, University of South Florida, Tampa, Florida
| | - Wei Wang
- College of Public Health, University of South Florida, Tampa, Florida
| | - Michael Custer
- College of Public Health, University of South Florida, Tampa, Florida
| | - Kathleen O'Rourke
- College of Public Health, University of South Florida, Tampa, Florida
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Kip KE, Berumen J, Zeidan AR, Hernandez DF, Finnegan AP. The emergence of accelerated resolution therapy for treatment of post‐traumatic stress disorder: A review and new subgroup analyses. Couns Psychother Res 2019. [DOI: 10.1002/capr.12210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kevin E. Kip
- College of Public HealthUniversity of South Florida Tampa Florida
| | - Jessica Berumen
- College of Public HealthUniversity of South Florida Tampa Florida
| | - Amina R. Zeidan
- University of Texas Health Sciences Center San Antonio Texas
| | | | - Alan P. Finnegan
- Westminster Centre for Research & Innovation in Veterans WellbeingUniversity of Chester Chester UK
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Okoli ML, Alao S, Ojukwu S, Emechebe NC, Ikhuoria A, Kip KE. Predictive and spatial analysis for estimating the impact of sociodemographic factors on contraceptive use among women living with HIV/AIDS (WLWHA) in Kenya: Implications for policies and practice. BMJ Open 2019; 9:e022221. [PMID: 30617098 PMCID: PMC6326424 DOI: 10.1136/bmjopen-2018-022221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the availability and knowledge of various contraceptive methods, consistent utilisation in women living with HIV/AIDS (WLWHA) within the reproductive age group remains below the Sustainable Development Goals (SDGs) and Family Planning 2020 goals. This study examines the association between sociodemographic factors and contraceptive use including the effect of clustering tendencies of these factors on contraceptive usage among WLWHA in Kenya. METHODS Weighted multivariate logistic regression models were conducted to determine the association of sociodemographic factors on contraception use among WLWHA using the 2008-2009 Kenya Demographic Health Survey. Spatial autocorrelation techniques were used to explore clustering tendencies of these factors on contraception utilisation. Our study population included 304 HIV positive women, aged 15-49 years. RESULTS Among 304 HIV-positive women in our study population, 92 (30.3%) reported using one method of contraception. Contraceptive use was significantly associated with wealth and education after adjustment for other sociodemographic variables. Women classified as having low and middle wealth index were less likely to use contraceptives (OR=0.17, 95% CI 0.07 to 0.43; OR=0.33, 95% CI 0.11 to 0.98, respectively) compared with women classified as having high wealth index. Similarly, women with primary education only were less likely to use contraceptives compared with women with secondary or higher education (OR=0.42, 95% CI 0.18 to 0.98). Spatial autocorrelation revealed significant positive clusters with weak clustering tendencies of non-contraceptive use among different levels of wealth index and education within different regions of Kenya. CONCLUSION These findings underscores the need for intervention programmes to further target socially disadvantaged WLWHA, which is necessary for achieving the SDGs.
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Affiliation(s)
- Menkeoma Laura Okoli
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Samuel Alao
- Department of Global Health, College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Somtochukwu Ojukwu
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Nnadozie C Emechebe
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Kevin E Kip
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida, USA
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Kip KE, Diamond DM. Clinical, Empirical, and Theoretical Rationale for Selection of Accelerated Resolution Therapy for Treatment of Post-traumatic Stress Disorder in VA and DoD Facilities. Mil Med 2018; 183:e314-e321. [DOI: 10.1093/milmed/usy027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/06/2017] [Accepted: 02/06/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kevin E Kip
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
| | - David M Diamond
- Departments of Psychology and Molecular Pharmacology and Physiology, Center for Preclinical/Clinical Research on PTSD, University of South Florida, Tampa, FL
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Erqou S, Clougherty JE, Olafiranye O, Magnani JW, Aiyer A, Tripathy S, Kinnee E, Kip KE, Reis SE. Particulate Matter Air Pollution and Racial Differences in Cardiovascular Disease Risk. Arterioscler Thromb Vasc Biol 2018; 38:935-942. [PMID: 29545240 DOI: 10.1161/atvbaha.117.310305] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [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: 09/22/2017] [Accepted: 02/06/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aimed to assess racial differences in air pollution exposures to ambient fine particulate matter (particles with median aerodynamic diameter <2.5 µm [PM2.5]) and black carbon (BC) and their association with cardiovascular disease (CVD) risk factors, arterial endothelial function, incident CVD events, and all-cause mortality. APPROACH AND RESULTS Data from the HeartSCORE study (Heart Strategies Concentrating on Risk Evaluation) were used to estimate 1-year average air pollution exposure to PM2.5 and BC using land use regression models. Correlates of PM2.5 and BC were assessed using linear regression models. Associations with clinical outcomes were determined using Cox proportional hazards models, adjusting for traditional CVD risk factors. Data were available on 1717 participants (66% women; 45% blacks; 59±8 years). Blacks had significantly higher exposure to PM2.5 (mean 16.1±0.75 versus 15.7±0.73µg/m3; P=0.001) and BC (1.19±0.11 versus 1.16±0.13abs; P=0.001) compared with whites. Exposure to PM2.5, but not BC, was independently associated with higher blood glucose and worse arterial endothelial function. PM2.5 was associated with a higher risk of incident CVD events and all-cause mortality combined for median follow-up of 8.3 years. Blacks had 1.45 (95% CI, 1.00-2.09) higher risk of combined CVD events and all-cause mortality than whites in models adjusted for relevant covariates. This association was modestly attenuated with adjustment for PM2.5. CONCLUSIONS PM2.5 exposure was associated with elevated blood glucose, worse endothelial function, and incident CVD events and all-cause mortality. Blacks had a higher rate of incident CVD events and all-cause mortality than whites that was only partly explained by higher exposure to PM2.5.
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Affiliation(s)
- Sebhat Erqou
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.).
| | - Jane E Clougherty
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.)
| | - Oladipupo Olafiranye
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.)
| | - Jared W Magnani
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.)
| | - Aryan Aiyer
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.)
| | - Sheila Tripathy
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.)
| | - Ellen Kinnee
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.)
| | - Kevin E Kip
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.)
| | - Steven E Reis
- From the Department of Medicine, University of Pittsburgh, PA (S.E., O.O., J.W.M., A.A., S.E.R.); Department of Environmental Health, University of Pittsburgh Graduate School of Public Health, PA (J.E.C., S.T.); Department of Environmental Health, Drexel University Dornsife School of Public Health, Philadelphia, PA (J.E.C., S.T.); and College of Public Health, University of South Florida, Tampa (K.E.P.)
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Shpilsky D, Erqou S, Patel SR, Kip KE, Ajala O, Aiyer A, Strollo PJ, Reis SE, Olafiranye O. Association of obstructive sleep apnea with microvascular endothelial dysfunction and subclinical coronary artery disease in a community-based population. Vasc Med 2018. [PMID: 29537350 DOI: 10.1177/1358863x18755003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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: 11/17/2022]
Abstract
Studies have reported an association between obstructive sleep apnea (OSA) and cardiovascular disease (CVD) morbidity and mortality. Proposed mechanisms include endothelial dysfunction and atherosclerosis. We aimed to investigate the associations of OSA with endothelial dysfunction and subclinical atherosclerotic coronary artery disease (CAD), and assess the impact of race on these associations. We used data from the Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study, a community-based prospective cohort with approximately equal representation of black and white participants. OSA severity was measured in 765 individuals using the apnea-hypopnea index (AHI). Endothelial dysfunction was measured using the Endo-PAT device, expressed as Framingham reactive hyperemia index (F_RHI). Coronary artery calcium (CAC), a marker of subclinical CAD, was quantified by electron beam computed tomography. There were 498 (65%) female participants, 282 (37%) black individuals, and 204 (26%) participants with moderate/severe OSA (AHI ≥15). In univariate models, moderate/severe OSA was associated with lower F_RHI and higher CAC, as well as several traditional CVD risk factors including older age, male sex, hypertension, diabetes, higher body mass index, and lower high-density lipoprotein cholesterol levels. In a multivariable model, individuals with moderate/severe OSA had 10% lower F_RHI and 35% higher CAC, which did not reach statistical significance ( p=0.08 for both comparisons). There was no significant interaction of race on the association of OSA with F_RHI or CAC ( p-value >0.1 for all comparisons). In a community-based cohort comprised of black and white participants, moderate/severe OSA was modestly associated with endothelial dysfunction and subclinical atherosclerotic CAD. These associations did not vary by race.
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Affiliation(s)
- Daniel Shpilsky
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sebhat Erqou
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sanjay R Patel
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin E Kip
- 2 College of Public Health, University of South Florida, Tampa, FL, USA
| | - Oluremi Ajala
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aryan Aiyer
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Strollo
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven E Reis
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Lengacher CA, Reich RR, Ramesar S, Alinat CB, Moscoso M, Cousin L, Marino VR, Elias MN, Paterson CL, Pleasant ML, Rodriguez CS, Wang HL, Kip KE, Meng H, Park JY. Feasibility of the mobile mindfulness-based stress reduction for breast cancer (mMBSR(BC)) program for symptom improvement among breast cancer survivors. Psychooncology 2017; 27:524-531. [PMID: 28665541 DOI: 10.1002/pon.4491] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [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: 10/04/2016] [Revised: 05/19/2017] [Accepted: 06/26/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of this pilot study was to test the feasibility of delivering the mobile mindfulness-based stress reduction for breast cancer (mMBSR(BC)) program using an iPad and to evaluate its impact on symptom improvement. METHODS A single group, pre-posttest design was implemented among female stages 0-III breast cancer survivors (BCS) who completed treatment. Data were collected at baseline and week 6 on measures of psychological and physical symptoms and quality of life. The mMBSR(BC) program is a standardized, stress-reducing intervention that combines sitting and walking meditation, body scan, and yoga and is designed to deliver weekly 2-hour sessions for 6 weeks using an iPad. RESULTS The mean age of the 15 enrolled BCS was 57 years; one participant was non-Hispanic black, and 14 were non-Hispanic white. Of the 13 who completed the study, there were significant improvements from baseline to 6 weeks post-mMBSR(BC) in psychological and physical symptoms of depression, state anxiety, stress, fear of recurrence, sleep quality, fatigue, and quality of life (P's < .05). Effect sizes for improvements of multiple symptoms ranged from medium to large. CONCLUSIONS These results provide preliminary support that the mMBSR(BC) program may be feasible and acceptable, showing a clinical impact on decreasing psychological and physical symptoms. This mobile-based program offers a delivery of a standardized MBSR(BC) intervention to BCS that is convenient for their own schedule while decreasing symptom burden in the survivorship phase after treatment for breast cancer.
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Affiliation(s)
| | - Richard R Reich
- Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sophia Ramesar
- College of Nursing, University of South Florida, Tampa, FL, USA
| | | | | | - Lakeshia Cousin
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Victoria R Marino
- School of Aging Studies, University of South Florida, Tampa, FL, USA
| | - Maya N Elias
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Carly L Paterson
- National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | | | | | - Hsiao-Lan Wang
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Kevin E Kip
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Hongdao Meng
- School of Aging Studies, University of South Florida, Tampa, FL, USA
| | - Jong Y Park
- Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Chandra D, Gupta A, Strollo PJ, Fuhrman CR, Leader JK, Bon J, Slivka WA, Shoushtari AH, Avolio J, Kip KE, Reis S, Sciurba FC. Airflow Limitation and Endothelial Dysfunction. Unrelated and Independent Predictors of Atherosclerosis. Am J Respir Crit Care Med 2017; 194:38-47. [PMID: 26771278 DOI: 10.1164/rccm.201510-2093oc] [Citation(s) in RCA: 35] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Lower FEV1 is associated with increased prevalence of atherosclerosis; however, causal mechanisms remain elusive. OBJECTIVES To determine if systemic endothelial dysfunction mediates the association between reduced FEV1 and increased atherosclerosis. METHODS Brachial artery endothelial function, pulmonary function, coronary artery calcium, and carotid plaque were assessed in 231 Pittsburgh SCCOR (Specialized Centers for Clinically Oriented Research) study participants; peripheral arterial endothelial function, pulmonary function, and coronary artery calcium were assessed in 328 HeartSCORE (Heart Strategies Concentrating on Risk Evaluation) study participants. MEASUREMENTS AND MAIN RESULTS Lower FEV1 was independently associated with increased atherosclerosis in both cohorts (per 25% lower % predicted FEV1: odds ratio [OR], 1.76; 95% confidence interval [CI], 1.30-2.40; P < 0.001 for carotid plaque in SCCOR participants) (per 25% lower % predicted FEV1: OR, 1.35; 95% CI, 1.02-1.77; P = 0.03 for coronary artery calcium in HeartSCORE participants). Similarly, reduced endothelial function was independently associated with increased atherosclerosis in both cohorts (per SD lower endothelial function: OR, 1.30; 95% CI, 1.01-1.67; P = 0.04 for carotid plaque in SCCOR participants) (per SD lower endothelial function: OR, 1.38; 95% CI, 1.09-1.76; P = 0.008 and OR, 1.41; 95% CI, 1.07-1.86; P = 0.01 for coronary artery calcium in SCCOR and HeartSCORE participants, respectively). However, there was no association between endothelial dysfunction and FEV1, FEV1/FVC, low-attenuation area/visual emphysema, and diffusing capacity in SCCOR participants, and between endothelial dysfunction and FEV1 or FEV1/FVC in HeartSCORE participants (all P > 0.05). Adjusting the association between FEV1 and atherosclerosis for endothelial dysfunction had no impact. CONCLUSIONS Endothelial dysfunction does not mediate the association between airflow limitation and atherosclerosis. Instead, airflow limitation and endothelial dysfunction seem to be unrelated and mutually independent predictors of atherosclerosis.
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Affiliation(s)
| | | | | | | | | | | | | | - Ali Hakim Shoushtari
- 3 Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Jennifer Avolio
- 3 Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Kevin E Kip
- 4 College of Nursing, University of South Florida, Tampa, Florida
| | - Steven Reis
- 1 Department of Medicine.,3 Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania; and
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Erqou S, Echouffo-Tcheugui JB, Kip KE, Aiyer A, Reis SE. Association of cumulative social risk with mortality and adverse cardiovascular disease outcomes. BMC Cardiovasc Disord 2017; 17:110. [PMID: 28482797 PMCID: PMC5422978 DOI: 10.1186/s12872-017-0539-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 04/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quantifying the cumulative effect of social risk factors on cardiovascular disease (CVD) risk can help to better understand the sources of disparities in health outcomes. METHOD AND RESULTS Data from the Heart Strategies Concentrating on Risk Evaluation (HeartSCORE) study were used to create an index of cumulative social risk (CSR) and quantify its association with incident CVD and all-cause mortality. CSR was defined by assigning a score of 1 for the presence of each of 4 social factors: i) racial minority status (Black race), ii) single living status, iii) low income, and iv) low educational level. Hazard ratios (HRs) were computed using Cox-regression models, adjusted for CVD risk factors. Over a median follow-up period of 8.3 years, 127 incident events were observed. The incidence of the primary outcome for subgroups of participants with 0, 1, and ≥2 CSR scores was 5.31 (95% CI, 3.40-7.22), 10.32 (7.16-13.49) and 17.80 (12.94-22.67) per 1000 person-years, respectively. Individuals with CSR score of 1 had an adjusted HR of 1.85 (1.15-2.97) for incident primary outcomes, compared to those with score of 0. The corresponding HR for individuals with CSR score of 2 or more was 2.58 (1.60-4.17). CONCLUSION An accumulation of social risk factors independently increased the likelihood of CVD events and deaths in a cohort of White and Black individuals.
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Affiliation(s)
- Sebhat Erqou
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | | | - Kevin E. Kip
- College of Nursing, University of South Florida, Tampa, FL USA
| | - Aryan Aiyer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Steven E. Reis
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
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Reich RR, Lengacher CA, Klein TW, Newton C, Shivers S, Ramesar S, Alinat CB, Paterson C, Le A, Park JY, Johnson-Mallard V, Elias M, Moscoso M, Goodman M, Kip KE. A Randomized Controlled Trial of the Effects of Mindfulness-Based Stress Reduction (MBSR[BC]) on Levels of Inflammatory Biomarkers Among Recovering Breast Cancer Survivors. Biol Res Nurs 2017; 19:456-464. [PMID: 28460534 DOI: 10.1177/1099800417707268] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE The purpose of this substudy of a large randomized controlled trial was to evaluate the efficacy of the Mindfulness-Based Stress Reduction (Breast Cancer) (MBSR[BC]) program compared to usual care (UC) in normalizing blood levels of pro-inflammatory cytokines among breast cancer survivors (BCS). METHOD A total of 322 BCS were randomized to either a 6-week MBSR(BC) program or a UC. At baseline and 6 and 12 weeks, 10 ml of venous blood and demographic and clinical data were collected and/or updated. Plasma cytokines (interleukin [IL]-1β, IL-6, IL-10, tumor necrosis factor [TNF] α, transforming growth factor [TGF] β1, soluble tumor necrosis factor receptor [sTNFR] 1) were assayed. Linear mixed models were used to assess cytokine levels across three time points (baseline and 6 and 12 weeks) by group (MBSR[BC] vs. UC). RESULTS Of the six measured cytokines, three were nondetectable at rates greater than 50% (IL-10, IL-1β, TGF-β1) and, because of overall low prevalence, were not analyzed further. For the remaining cytokines (TNFα, IL-6, sTNFR1), results showed that TNFα and IL-6 increased during the follow-up period (between 6 and 12 weeks) rather than during the MBSR(BC) training period (between baseline and 6 weeks), while sTNFR1 levels did not change significantly across the 12-week period. CONCLUSIONS Study results suggest that MBSR(BC) affects cytokine levels in BCS, mainly with increases in TNFα and IL-6. The data further suggest that B-cell modulation may be a part of immune recovery during breast cancer management and that increases in TNFα and IL-6 may be markers for MBSR(BC)-related recovery.
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Affiliation(s)
- Richard R Reich
- 1 Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Thomas W Klein
- 3 Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Cathy Newton
- 3 Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Steve Shivers
- 4 Breast Health Clinical and Research Integrated Strategic Program, University of South Florida, Tampa, FL, USA
| | - Sophia Ramesar
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Carissa B Alinat
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | | | - Alice Le
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Jong Y Park
- 1 Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Maya Elias
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Manolete Moscoso
- 2 College of Nursing, University of South Florida, Tampa, FL, USA
| | - Matthew Goodman
- 7 Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Kevin E Kip
- 8 Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL, USA
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Reich RR, Lengacher CA, Alinat CB, Kip KE, Paterson C, Ramesar S, Han HS, Ismail-Khan R, Johnson-Mallard V, Moscoso M, Budhrani-Shani P, Shivers S, Cox CE, Goodman M, Park J. Mindfulness-Based Stress Reduction in Post-treatment Breast Cancer Patients: Immediate and Sustained Effects Across Multiple Symptom Clusters. J Pain Symptom Manage 2017; 53:85-95. [PMID: 27720794 PMCID: PMC7771358 DOI: 10.1016/j.jpainsymman.2016.08.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [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: 04/20/2016] [Revised: 07/05/2016] [Accepted: 08/03/2016] [Indexed: 01/04/2023]
Abstract
CONTEXT Breast cancer survivors (BCS) face adverse physical and psychological symptoms, often co-occurring. Biologic and psychological factors may link symptoms within clusters, distinguishable by prevalence and/or severity. Few studies have examined the effects of behavioral interventions or treatment of symptom clusters. OBJECTIVES The aim of this study was to identify symptom clusters among post-treatment BCS and determine symptom cluster improvement following the Mindfulness-Based Stress Reduction for Breast Cancer (MBSR(BC)) program. METHODS Three hundred twenty-two Stage 0-III post-treatment BCS were randomly assigned to either a six-week MBSR(BC) program or usual care. Psychological (depression, anxiety, stress, and fear of recurrence), physical (fatigue, pain, sleep, and drowsiness), and cognitive symptoms and quality of life were assessed at baseline, six, and 12 weeks, along with demographic and clinical history data at baseline. A three-step analytic process included the error-accounting models of factor analysis and structural equation modeling. RESULTS Four symptom clusters emerged at baseline: pain, psychological, fatigue, and cognitive. From baseline to six weeks, the model demonstrated evidence of MBSR(BC) effectiveness in both the psychological (anxiety, depression, perceived stress and QOL, emotional well-being) (P = 0.007) and fatigue (fatigue, sleep, and drowsiness) (P < 0.001) clusters. Results between six and 12 weeks showed sustained effects, but further improvement was not observed. CONCLUSION Our results provide clinical effectiveness evidence that MBSR(BC) works to improve symptom clusters, particularly for psychological and fatigue symptom clusters, with the greatest improvement occurring during the six-week program with sustained effects for several weeks after MBSR(BC) training. TRIAL REGISTRATION Name and URL of Registry: ClinicalTrials.gov. Registration number: NCT01177124.
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Affiliation(s)
- Richard R Reich
- Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.
| | | | - Carissa B Alinat
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Kevin E Kip
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Carly Paterson
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Sophia Ramesar
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Heather S Han
- Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | | | | | - Manolete Moscoso
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Pinky Budhrani-Shani
- Nelda C. Stark College of Nursing, Texas Woman's University, Houston, Texas, USA
| | - Steve Shivers
- University of South Florida Breast Health Clinical and Research Integrated Strategic Program, Tampa, Florida, USA
| | - Charles E Cox
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Matthew Goodman
- Department of Internal Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jong Park
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida, USA
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Belanger HG, Barwick F, Silva MA, Kretzmer T, Kip KE, Vanderploeg RD. Web-based psychoeducational intervention for postconcussion symptoms: a randomized trial. Mil Med 2016; 180:192-200. [PMID: 25643387 DOI: 10.7205/milmed-d-14-00388] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The objective of this study was to investigate the effectiveness of a web-based educational intervention for reducing postconcussion symptoms. 158 participants with self-reported symptomatic mild traumatic brain injury were randomized to intervention versus control. There was no effect of intervention on symptom severity or attributions. Subgroup analyses suggested benefit of the web-based intervention in those receiving concurrent mental health treatment and in those participants with the greatest time since injury (>1 year after mild traumatic brain injury). Web-based educational intervention was not effective overall in this sample. However, there is some suggestion of promise in those receiving concurrent mental health treatment and with more chronic symptoms. Findings also suggest potential benefit of interventions targeting self-efficacy.
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Affiliation(s)
- Heather G Belanger
- Department of Mental Health and Behavioral Sciences, James A. Haley VA, 13000 Bruce B. Downs Boulevard, Tampa, FL 33612
| | - Fiona Barwick
- Department of Mental/Behavioral Health, VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073
| | - Marc A Silva
- Department of Mental Health and Behavioral Sciences, James A. Haley VA, 13000 Bruce B. Downs Boulevard, Tampa, FL 33612
| | - Tracy Kretzmer
- Department of Mental Health and Behavioral Sciences, James A. Haley VA, 13000 Bruce B. Downs Boulevard, Tampa, FL 33612
| | - Kevin E Kip
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Boulevard, Tampa, FL
| | - Rodney D Vanderploeg
- Department of Mental Health and Behavioral Sciences, James A. Haley VA, 13000 Bruce B. Downs Boulevard, Tampa, FL 33612
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Kip KE, D'Aoust RF, Hernandez DF, Girling SA, Cuttino B, Long MK, Rojas P, Wittenberg T, Abhayakumar A, Rosenzweig L. Evaluation of brief treatment of symptoms of psychological trauma among veterans residing in a homeless shelter by use of Accelerated Resolution Therapy. Nurs Outlook 2016; 64:411-23. [DOI: 10.1016/j.outlook.2016.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 04/08/2016] [Accepted: 04/30/2016] [Indexed: 10/21/2022]
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Lengacher CA, Reich RR, Paterson CL, Ramesar S, Park JY, Alinat C, Johnson-Mallard V, Moscoso M, Budhrani-Shani P, Miladinovic B, Jacobsen PB, Cox CE, Goodman M, Kip KE. Examination of Broad Symptom Improvement Resulting From Mindfulness-Based Stress Reduction in Breast Cancer Survivors: A Randomized Controlled Trial. J Clin Oncol 2016; 34:2827-34. [PMID: 27247219 PMCID: PMC5012660 DOI: 10.1200/jco.2015.65.7874] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [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: 12/22/2022] Open
Abstract
PURPOSE The purpose of this randomized trial was to evaluate the efficacy of the Mindfulness-Based Stress Reduction for Breast Cancer (MBSR[BC]) program in improving psychological and physical symptoms and quality of life among breast cancer survivors (BCSs) who completed treatment. Outcomes were assessed immediately after 6 weeks of MBSR(BC) training and 6 weeks later to test efficacy over an extended timeframe. PATIENTS AND METHODS A total of 322 BCSs were randomly assigned to either a 6-week MBSR(BC) program (n = 155) or a usual care group (n = 167). Psychological (depression, anxiety, stress, and fear of recurrence) and physical symptoms (fatigue and pain) and quality of life (as related to health) were assessed at baseline and at 6 and 12 weeks. Linear mixed models were used to assess MBSR(BC) effects over time, and participant characteristics at baseline were also tested as moderators of MBSR(BC) effects. RESULTS Results demonstrated extended improvement for the MBSR(BC) group compared with usual care in both psychological symptoms of anxiety, fear of recurrence overall, and fear of recurrence problems and physical symptoms of fatigue severity and fatigue interference (P < .01). Overall effect sizes were largest for fear of recurrence problems (d = 0.35) and fatigue severity (d = 0.27). Moderation effects showed BCSs with the highest levels of stress at baseline experienced the greatest benefit from MBSR(BC). CONCLUSION The MBSR(BC) program significantly improved a broad range of symptoms among BCSs up to 6 weeks after MBSR(BC) training, with generally small to moderate overall effect sizes.
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Affiliation(s)
- Cecile A Lengacher
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA.
| | - Richard R Reich
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Carly L Paterson
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Sophia Ramesar
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Jong Y Park
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Carissa Alinat
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Versie Johnson-Mallard
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Manolete Moscoso
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Pinky Budhrani-Shani
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Branko Miladinovic
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Paul B Jacobsen
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Charles E Cox
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Matthew Goodman
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
| | - Kevin E Kip
- Cecile A. Lengacher, Sophia Ramesar, Carissa Alinat, Manolete Moscoso, and Kevin E. Kip, University of South Florida College of Nursing; Jong Y. Park and Paul B. Jacobsen, H. Lee Moffitt Cancer Center and Research Institute; Branko Miladinovic and Charles E. Cox, University of South Florida Morsani College of Medicine, Tampa; Richard R. Reich, University of South Florida Sarasota-Manatee, Manatee; Versie Johnson-Mallard, University of Florida, College of Nursing, Gainesville, FL; Carly L. Paterson, National Cancer Institute, Rockville, MD; Pinky Budhrani-Shani, Texas Woman's University, Nelda C. Stark College of Nursing, Houston, TX; and Matthew Goodman, University of Virginia, Charlottesville, VA
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49
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Merz CNB, Shaw LJ, Azziz R, Stanczyk FZ, Sopko G, Braunstein GD, Kelsey SF, Kip KE, Cooper-DeHoff RM, Johnson BD, Vaccarino V, Reis SE, Bittner V, Hodgson TK, Rogers W, Pepine CJ. Cardiovascular Disease and 10-Year Mortality in Postmenopausal Women with Clinical Features of Polycystic Ovary Syndrome. J Womens Health (Larchmt) 2016; 25:875-81. [PMID: 27267867 DOI: 10.1089/jwh.2015.5441] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Women with polycystic ovary syndrome (PCOS) have greater cardiac risk factor clustering but the link with mortality is incompletely described. OBJECTIVE To evaluate outcomes in 295 postmenopausal women enrolled in the National Institutes of Health-National Heart, Lung, and Blood Institute (NIH-NHLBI) sponsored Women's Ischemia Syndrome Evaluation (WISE) study according to clinical features of PCOS. MATERIALS AND METHODS A total of 25/295 (8%) women had clinical features of PCOS defined by a premenopausal history of irregular menses and current biochemical evidence of hyperandrogenemia, defined as the top quartile of androstenedione (≥701 pg/mL), testosterone (≥30.9 ng/dL), or free testosterone (≥4.5 pg/mL). Cox proportional hazard model estimated death (n = 80). RESULTS Women with clinical features of PCOS had an earlier menopause (p = 0.01), were more often smokers (p < 0.04), and trended toward more angiographic coronary artery disease (CAD) (p = 0.07) than women without these features. Cumulative 10-year mortality was 28% for women with (n = 25) versus 27% without clinical features of PCOS (n = 270) (p = 0.85). PCOS was not a significant predictor (p = NS) in prognostic models including diabetes, waist circumference, hypertension, and angiographic CAD. CONCLUSION From this longer-term follow up of a relatively small cohort of postmenopausal women with suspected ischemia, the prevalence of PCOS is similar to the general population, and clinical features of PCOS are not associated with CAD or mortality. These findings question whether identification of clinical features of PCOS in postmenopausal women who already have known cardiovascular disease provides any additional opportunity for risk factor intervention.
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Affiliation(s)
- C Noel Bairey Merz
- 1 Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute , Cedars-Sinai Medical Center, Los Angeles, California
| | - Leslee J Shaw
- 2 Clinical Cardiovascular Research Institute, Emory University , Atlanta, Georgia
| | | | | | - George Sopko
- 5 National Heart, Lung, and Blood Institute , NIH, Bethesda, Maryland
| | - Glenn D Braunstein
- 6 Department of Medicine, Cedars-Sinai Medical Center , Los Angeles, California
| | - Sheryl F Kelsey
- 7 Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Kevin E Kip
- 7 Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Rhonda M Cooper-DeHoff
- 8 Division of Cardiology, Department of Medicine, University of Florida , Gainesville, Florida
| | - B Delia Johnson
- 7 Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Viola Vaccarino
- 8 Division of Cardiology, Department of Medicine, University of Florida , Gainesville, Florida
| | - Steven E Reis
- 9 Cardiovascular Institute, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Vera Bittner
- 10 Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - T Keta Hodgson
- 6 Department of Medicine, Cedars-Sinai Medical Center , Los Angeles, California
| | - William Rogers
- 10 Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Carl J Pepine
- 8 Division of Cardiology, Department of Medicine, University of Florida , Gainesville, Florida
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50
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Erqou S, Kip KE, Mulukutla SR, Aiyer AN, Reis SE. Endothelial Dysfunction and Racial Disparities in Mortality and Adverse Cardiovascular Disease Outcomes. Clin Cardiol 2016; 39:338-44. [PMID: 27028406 DOI: 10.1002/clc.22534] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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] [Received: 07/01/2015] [Accepted: 02/04/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The contribution of arterial endothelial dysfunction (ED) to increased cardiovascular disease (CVD) risk among Blacks is not known. HYPOTHESIS We investigated whether peripheral arterial ED explains racial disparity in CVD events. METHODS Data from the Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study was used. Endothelial dysfunction was assessed by the Framingham reactive hyperemia index (fRHI), measured using pulse amplitude tonometry (PAT). Lower values of fRHI indicate more severe ED. The primary outcome of interest was combined CVD events and all-cause mortality. RESULTS 1454 individuals (62% female, 40% Black, mean age 59 ± 8 years) had available data on fRHI (mean [SD]: 0.74 [0.46]). Over a mean follow-up period of 8.0 ± 2.4 years (11,186 person-years), 116 events were observed. Black race, male sex, smoking, diabetes, blood pressure, triglycerides, C-reactive protein, and interleukin-6 were inversely correlated with fRHI in univariate models. In an unadjusted Cox regression model, fRHI was associated with 20% lower risk of the primary outcome events (hazard ratio [HR] per 1-SD higher fRHI: 0.80, 95% confidence interval [CI]: 0.66-0.97). However, this association was no longer significant after adjustment for CVD risk factors (HR: 0.90, 95% CI: 0.74-1.11). In an age- and sex-adjusted model, Blacks had 1.68 (95% CI: 1.16-2.43) higher risk of primary outcome compared with Whites. This association was not significantly attenuated by addition of fRHI to the multivariable models. CONCLUSION Black race is associated with increased risk of CVD events and mortality independent of its associations with ED, as measured by PAT.
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Affiliation(s)
- Sebhat Erqou
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevin E Kip
- College of Nursing, University of South Florida, Tampa, Florida
| | - Suresh R Mulukutla
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aryan N Aiyer
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven E Reis
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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