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Huang DQ, Ajmera V, Tomaszewski C, LaFree A, Bettencourt R, Thompson WK, Smith DM, Malhotra A, Mehta RL, Tolia V, Yin J, Insel PA, Leachman S, Jung J, Collier S, Richards L, Woods K, Amangurbanova M, Bhatt A, Zhang X, Penciu OM, Zarich S, Retta T, Harkins MS, Teixeira JP, Chinnock B, Utay NS, Lake JE, Loomba R. Ramipril for the Treatment of COVID-19: RAMIC, a Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Adv Ther 2023; 40:4805-4816. [PMID: 37615850 PMCID: PMC10709987 DOI: 10.1007/s12325-023-02618-7] [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] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/14/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Retrospective studies report that angiotensin-converting enzyme inhibitors (ACEIs) may reduce the severity of COVID-19, but prospective data on de novo treatment with ACEIs are limited. The RAMIC trial was a randomized, multicenter, placebo-controlled, double-blind, allocation-concealed clinical trial to examine the efficacy of de novo ramipril versus placebo for the treatment of COVID-19. METHODS Eligible participants were aged 18 years and older with a confirmed diagnosis of SARS-CoV-2 infection, recruited from urgent care clinics, emergency departments, and hospital inpatient wards at eight sites in the USA. Participants were randomly assigned to daily ramipril 2.5 mg or placebo orally in a 2:1 ratio, using permuted block randomization. Analyses were conducted on an intention-to-treat basis. The primary outcome was a composite of mortality, intensive care unit (ICU) admission, or invasive mechanical ventilation by day 14. RESULTS Between 27 May 2020 and 19 April 2021, a total of 114 participants (51% female) were randomized to ramipril (n = 79) or placebo (n = 35). The overall mean (± SD) age and BMI were 45 (± 15) years and 33 (± 8) kg/m2. Two participants in the ramipril group required ICU admission and one died, compared with none in the placebo group. There were no significant differences between ramipril and placebo in the primary endpoint (ICU admission, mechanical ventilation, or death) (3% versus 0%, p = 1.00) or adverse events (27% versus 29%, p = 0.82). The study was terminated early because of a low event rate and subsequent Emergency Use Authorization of therapies for COVID-19. CONCLUSION De novo ramipril was not different compared with placebo in improving or worsening clinical outcomes from COVID-19 but appeared safe in non-critically ill patients with COVID-19. TRIAL REGISTRATION Clinicaltrials.gov NCT04366050.
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Affiliation(s)
- Daniel Q Huang
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Veeral Ajmera
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Christian Tomaszewski
- Department of Emergency Medicine, University of California, San Diego and the El Centro Regional Medical Center, San Diego, CA, USA
| | - Andrew LaFree
- Department of Emergency Medicine, University of California, San Diego and the El Centro Regional Medical Center, San Diego, CA, USA
| | - Ricki Bettencourt
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Wesley K Thompson
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - Davey M Smith
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Veteran Affairs Medical Center, San Diego, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Ravindra L Mehta
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Vaishal Tolia
- Department of Emergency Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jeffrey Yin
- Department of Pharmacy, University of California San Diego, La Jolla, CA, USA
| | - Paul A Insel
- Department of Pharmacology, University of California San Diego, La Jolla, CA, USA
- Division of Endocrinology and Metabolism, University of California San Diego, La Jolla, CA, USA
| | - Stone Leachman
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Jinho Jung
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Summer Collier
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Lisa Richards
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Kristin Woods
- Clinical & Translational Research Institute, University of California, San Diego, La Jolla, CA, USA
| | - Maral Amangurbanova
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA
| | - Archana Bhatt
- Clinical & Translational Research Institute, University of California, San Diego, La Jolla, CA, USA
| | - Xinlian Zhang
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California San Diego, San Diego, CA, USA
| | | | - Stuart Zarich
- Section of Cardiovascular Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Tamrat Retta
- Department of Internal Medicine, Howard University, Washington, DC, USA
| | - Michelle S Harkins
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - J Pedro Teixeira
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Brian Chinnock
- Department of Emergency Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA, USA
| | - Netanya S Utay
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jordan E Lake
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, CA, USA.
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
- Division of Epidemiology, Department of Family Medicine and Public Health, University of California at San Diego, San Diego, CA, USA.
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Horwitz LI, Thaweethai T, Brosnahan SB, Cicek MS, Fitzgerald ML, Goldman JD, Hess R, Hodder SL, Jacoby VL, Jordan MR, Krishnan JA, Laiyemo AO, Metz TD, Nichols L, Patzer RE, Sekar A, Singer NG, Stiles LE, Taylor BS, Ahmed S, Algren HA, Anglin K, Aponte-Soto L, Ashktorab H, Bassett IV, Bedi B, Bhadelia N, Bime C, Bind MAC, Black LJ, Blomkalns AL, Brim H, Castro M, Chan J, Charney AW, Chen BK, Chen LQ, Chen P, Chestek D, Chibnik LB, Chow DC, Chu HY, Clifton RG, Collins S, Costantine MM, Cribbs SK, Deeks SG, Dickinson JD, Donohue SE, Durstenfeld MS, Emery IF, Erlandson KM, Facelli JC, Farah-Abraham R, Finn AV, Fischer MS, Flaherman VJ, Fleurimont J, Fonseca V, Gallagher EJ, Gander JC, Gennaro ML, Gibson KS, Go M, Goodman SN, Granger JP, Greenway FL, Hafner JW, Han JE, Harkins MS, Hauser KSP, Heath JR, Hernandez CR, Ho O, Hoffman MK, Hoover SE, Horowitz CR, Hsu H, Hsue PY, Hughes BL, Jagannathan P, James JA, John J, Jolley S, Judd SE, Juskowich JJ, Kanjilal DG, Karlson EW, Katz SD, Kelly JD, Kelly SW, Kim AY, Kirwan JP, Knox KS, Kumar A, Lamendola-Essel MF, Lanca M, Lee-lannotti JK, Lefebvre RC, Levy BD, Lin JY, Logarbo BP, Logue JK, Longo MT, Luciano CA, Lutrick K, Malakooti SK, Mallett G, Maranga G, Marathe JG, Marconi VC, Marshall GD, Martin CF, Martin JN, May HT, McComsey GA, McDonald D, Mendez-Figueroa H, Miele L, Mittleman MA, Mohandas S, Mouchati C, Mullington JM, Nadkarni GN, Nahin ER, Neuman RB, Newman LT, Nguyen A, Nikolich JZ, Ofotokun I, Ogbogu PU, Palatnik A, Palomares KTS, Parimon T, Parry S, Parthasarathy S, Patterson TF, Pearman A, Peluso MJ, Pemu P, Pettker CM, Plunkett BA, Pogreba-Brown K, Poppas A, Porterfield JZ, Quigley JG, Quinn DK, Raissy H, Rebello CJ, Reddy UM, Reece R, Reeder HT, Rischard FP, Rosas JM, Rosen CJ, Rouphael NG, Rouse DJ, Ruff AM, Saint Jean C, Sandoval GJ, Santana JL, Schlater SM, Sciurba FC, Selvaggi C, Seshadri S, Sesso HD, Shah DP, Shemesh E, Sherif ZA, Shinnick DJ, Simhan HN, Singh U, Sowles A, Subbian V, Sun J, Suthar MS, Teunis LJ, Thorp JM, Ticotsky A, Tita ATN, Tragus R, Tuttle KR, Urdaneta AE, Utz PJ, VanWagoner TM, Vasey A, Vernon SD, Vidal C, Walker T, Ward HD, Warren DE, Weeks RM, Weiner SJ, Weyer JC, Wheeler JL, Whiteheart SW, Wiley Z, Williams NJ, Wisnivesky JP, Wood JC, Yee LM, Young NM, Zisis SN, Foulkes AS. Researching COVID to Enhance Recovery (RECOVER) adult study protocol: Rationale, objectives, and design. PLoS One 2023; 18:e0286297. [PMID: 37352211 PMCID: PMC10289397 DOI: 10.1371/journal.pone.0286297] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/12/2023] [Indexed: 06/25/2023] Open
Abstract
IMPORTANCE SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis. METHODS RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms. DISCUSSION RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options. REGISTRATION NCT05172024.
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Affiliation(s)
- Leora I. Horwitz
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Tanayott Thaweethai
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Shari B. Brosnahan
- Division of Pulmonary Critical Care and Sleep Medicine, NYU Langone Health, New York, New York, United States of America
| | - Mine S. Cicek
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Megan L. Fitzgerald
- Patient Led Research Collaboration on COVID-19, Washington, DC, United States of America
| | - Jason D. Goldman
- Division of Infectious Diseases, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Rachel Hess
- Department of Population Health Sciences and Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - S. L. Hodder
- Department of Medicine, West Virginia University, Morgantown, West Virginia, United States of America
| | - Vanessa L. Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Michael R. Jordan
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Medford, Massachusetts, United States of America
| | - Jerry A. Krishnan
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Adeyinka O. Laiyemo
- Department of Medicine, Howard University, Washington, DC, United States of America
| | - Torri D. Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, United States of America
| | - Lauren Nichols
- Body Politic COVID-19 Support Group, Boston, Massachusetts, United States of America
| | - Rachel E. Patzer
- Department of Medicine and Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Anisha Sekar
- Patient Led Research Collaboration on COVID-19, Washington, DC, United States of America
| | - Nora G. Singer
- Department of Medicine and Rheumatology, The MetroHealth Medical Center, Cleveland, Ohio, United States of America
| | - Lauren E. Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Barbara S. Taylor
- Department of Medicine, Division of Infectious Diseases and Infectious Diseases, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Shifa Ahmed
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Heather A. Algren
- Swedish Center for Research and Innovation, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Khamal Anglin
- Department of Epidemiology and Biostatistics, University of California at San Francisco Institute of Global Health Sciences, San Francisco, San Francisco, California, United States of America
| | - Lisa Aponte-Soto
- College of Science and Health, Department of Health Sciences, DePaul University, Chicago, Illinois, United States of America
| | - Hassan Ashktorab
- Department of Medicine, Howard University, Washington, DC, United States of America
| | - Ingrid V. Bassett
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brahmchetna Bedi
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Nahid Bhadelia
- Center for Emerging Infectious Diseases Policy and Research, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Christian Bime
- Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Marie-Abele C. Bind
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lora J. Black
- Department of Clinical Research, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Andra L. Blomkalns
- Department of Emergency Medicine, Stanford University, Stanford, California, United States of America
| | - Hassan Brim
- Department of Pathology, Howard University, Washington, DC, United States of America
| | - Mario Castro
- Division of Pulmonary and Critical Care, University of Kansas Medical Center, Kansas City, Kansas City, United States of America
| | - James Chan
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Alexander W. Charney
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Benjamin K. Chen
- Division of Infectious Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Li Qing Chen
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - David Chestek
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Lori B. Chibnik
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Dominic C. Chow
- Department of Medicine, University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii, United States of America
| | - Helen Y. Chu
- Department of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Rebecca G. Clifton
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Shelby Collins
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, The Ohio State University Hospital, Columbus, Ohio, United States of America
| | - Sushma K. Cribbs
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Steven G. Deeks
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - John D. Dickinson
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Sarah E. Donohue
- Department of Research Services, University of Illinois College of Medicine, Peoria, Illinois, United States of America
| | - Matthew S. Durstenfeld
- Department of Medicine, Division of Cardiology at Zuckerberg San Francisco General, University of California San Francisco, San Francisco, California, United States of America
| | - Ivette F. Emery
- MaineHealth Institute for Research, MaineHealth, Scarborough, Maine, United States of America
| | - Kristine M. Erlandson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Julio C. Facelli
- Department of Biomedical Informatics and Clinical and Translational Science Institute, University of Utah, Salt Lake City, Utah, United States of America
| | - Rachael Farah-Abraham
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Aloke V. Finn
- Department of Pathology, CVPath Institute, Gaithersburg, Maryland, United States of America
| | - Melinda S. Fischer
- Department of Medicine, Division of Infectious Diseases and Infectious Diseases, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Valerie J. Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Judes Fleurimont
- Mile Square Health Center, University of Illinois Chicago, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Vivian Fonseca
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Emily J. Gallagher
- Department of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente of Georgia, Atlanta, Georgia, United States of America
| | - Maria Laura Gennaro
- Public Health Research Institute and Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, United States of America
| | - Kelly S. Gibson
- Department of Obstetrics and Gynecology, MetroHealth System, Cleveland, Ohio, United States of America
| | - Minjoung Go
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Steven N. Goodman
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Joey P. Granger
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Frank L. Greenway
- Clinical Trials, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - John W. Hafner
- Department of Emergency Medicine, OSF Saint Francis Medical Center, Peoria, Illinois, United States of America
| | - Jenny E. Han
- Department of Pulmonary and Critical Care, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Michelle S. Harkins
- Department of Internal Medicine University of New Mexico, Health Science Center, Albuquerque, New Mexico, United States of America
| | - Kristine S. P. Hauser
- Clinical Research Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - James R. Heath
- Department of Bioengineering, Institute for Systems Biology, Seattle, Washington, United States of America
| | - Carla R. Hernandez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - On Ho
- Seattle Children’s Therapeutics, Seattle, Washington, United States of America
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health Services, Newark, Delaware, United States of America
| | - Susan E. Hoover
- Department of Clinical Research, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Carol R. Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Harvey Hsu
- Department of Internal Medicine, University of Arizona, Phoenix, Arizona, United States of America
| | - Priscilla Y. Hsue
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Brenna L. Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, United States of America
| | - Prasanna Jagannathan
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Judith A. James
- Department of Arthritis & Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, United States of America
| | - Janice John
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
| | - Sarah Jolley
- Department of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - S. E. Judd
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Joy J. Juskowich
- Department of Medicine, Division of Infectious Diseases, West Virginia School of Medicine, Morgantown, West Virginia, United States of America
| | - Diane G. Kanjilal
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Elizabeth W. Karlson
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stuart D. Katz
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - J. Daniel Kelly
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Sara W. Kelly
- Department of Pediatrics & Department of Research Services, University of Illinois College of Medicine, Peoria, Illinois, United States of America
| | - Arthur Y. Kim
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - John P. Kirwan
- Department Integrated Physiology and Molecular Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - Kenneth S. Knox
- Department of Internal Medicine, University of Arizona, Phoenix, Arizona, United States of America
| | - Andre Kumar
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | | | - Margaret Lanca
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Joyce K. Lee-lannotti
- Department of Internal Medicine and Neurology, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, United States of America
| | - R. Craig Lefebvre
- Communications Practice Area, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Bruce D. Levy
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Janet Y. Lin
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Brian P. Logarbo
- Tulane Center for Clinical Research, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Jennifer K. Logue
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Michele T. Longo
- Tulane Center for Clinical Neurosciences, Tulane School of Medicine, New Orleans, Louisiana, United States of America
| | - Carlos A. Luciano
- Department of Neurology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico, United States of America
| | - Karen Lutrick
- Department of Family & Community Medicine, University of Arizona, College of Medicine – Tucson, Tucson, Arizona, United States of America
| | - Shahdi K. Malakooti
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Gail Mallett
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, United States of America
| | - Gabrielle Maranga
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Jai G. Marathe
- Department of Medicine, Section of Infectious Diseases, Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Vincent C. Marconi
- Department of Medicine, Infectious Diseases and Department of Global Health, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Gailen D. Marshall
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Christopher F. Martin
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jeffrey N. Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Heidi T. May
- Department of Cardiology, Intermountain Medical Center, Salt Lake City, Utah, United States of America
| | - Grace A. McComsey
- Department of Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Dylan McDonald
- Department of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Lucio Miele
- Department of Genetics, Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sindhu Mohandas
- Department of Infectious Diseases, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California, United States of America
| | - Christian Mouchati
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Janet M. Mullington
- Department of Neurology and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Girish N. Nadkarni
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Erica R. Nahin
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - Robert B. Neuman
- Division of Cardiology, Kaiser Permanente of Georgia, Atlanta, Georgia, United States of America
| | - Lisa T. Newman
- Department of Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Amber Nguyen
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Janko Z. Nikolich
- Department of Immunobiology, University of Arizona College of Medicine, Tucson, Arizona, United States of America
| | - Igho Ofotokun
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Princess U. Ogbogu
- Division of Pediatric Allergy, Immunology, and Rheumatology, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, United States of America
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Kristy T. S. Palomares
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Peter’s University Hospital, New Brunswick, New Jersey, United States of America
| | - Tanyalak Parimon
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Sairam Parthasarathy
- Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Thomas F. Patterson
- Department of Medicine, Department of Infectious Disease, University of Texas Health, San Antonio, Texas, United States of America
| | - Ann Pearman
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Michael J. Peluso
- Division of HIV, Infectious Disease, and Global Medicine, University of California, San Francisco, California, United States of America
| | - Priscilla Pemu
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Christian M. Pettker
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Beth A. Plunkett
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois, United States of America
| | - Kristen Pogreba-Brown
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, United States of America
| | - Athena Poppas
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - J. Zachary Porterfield
- Department of Internal Medicine, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky, United States of America
| | - John G. Quigley
- Department of Medicine, Division of Hematology/Oncology, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Davin K. Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Hengameh Raissy
- Department of Pediatrics, University of New Mexico, Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Candida J. Rebello
- Department of Nutrition and Chronic Disease, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - Uma M. Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, United States of America
| | - Rebecca Reece
- Department of Medicine, Division of Infectious Diseases, West Virginia School of Medicine, Morgantown, West Virginia, United States of America
| | - Harrison T. Reeder
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Franz P. Rischard
- Department of Pulmonary and Critical Care, University of Arizona, Tucson, Arizona, United States of America
| | - Johana M. Rosas
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - Clifford J. Rosen
- MaineHealth Institute for Research, MaineHealth, Scarborough, Maine, United States of America
| | - Nadine G. Rouphael
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island, United States of America
| | - Adam M. Ruff
- Division of Pulmonary and Critical Care, University of Kansas Medical Center, Kansas City, Kansas City, United States of America
| | - Christina Saint Jean
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Grecio J. Sandoval
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Jorge L. Santana
- Department of Medicine, University of Puerto Rico, San Juan, Puerto Rico, United States of America
| | - Shannon M. Schlater
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Frank C. Sciurba
- Department of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Caitlin Selvaggi
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Sciences Center San Antonio, San Antonio, Texas, United States of America
| | - Howard D. Sesso
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Dimpy P. Shah
- Department of Population Health Sciences, Mays Cancer Center, University of Texas Health, San Antonio, Texas, United States of America
| | - Eyal Shemesh
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Zaki A. Sherif
- Department of Biochemistry & Molecular Biology, Howard University College of Medicine, Washington, DC, United States of America
| | - Daniel J. Shinnick
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Hyagriv N. Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Upinder Singh
- Department of Internal Medicine, Stanford University, Stanford, California, United States of America
| | - Amber Sowles
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, United States of America
| | - Vignesh Subbian
- Department of Biomedical Engineering, Department of Systems and Industrial Engineering, University of Arizona College of Engineering, Tucson, Arizona, United States of America
| | - Jun Sun
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Mehul S. Suthar
- Department of Pediatrics, Emory Vaccine Center, Emory University, Atlanta, Georgia, United States of America
| | - Larissa J. Teunis
- Health Services Research Center, Emory University, Atlanta, Georgia, United States of America
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Amberly Ticotsky
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology and Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Robin Tragus
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas, United States of America
| | - Katherine R. Tuttle
- Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Spokane, Washington, United States of America
| | - Alfredo E. Urdaneta
- Department of Emergency Medicine, Stanford University, Stanford, California, United States of America
| | - P. J. Utz
- Department of Internal Medicine, Stanford University, Stanford, California, United States of America
| | - Timothy M. VanWagoner
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Andrew Vasey
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Suzanne D. Vernon
- Department of Research, Bateman Horne Center, Salt Lake City, Utah, United States of America
| | - Crystal Vidal
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Tiffany Walker
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Honorine D. Ward
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - David E. Warren
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Ryan M. Weeks
- Department of Microbiology, Immunology, and Molecular Genetics, University of Kentucky, Lexington, Kentucky, United States of America
| | - Steven J. Weiner
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Jordan C. Weyer
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jennifer L. Wheeler
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sidney W. Whiteheart
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, Kentucky, United States of America
| | - Zanthia Wiley
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Natasha J. Williams
- Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - John C. Wood
- Department of Pediatrics and Radiology, Children’s Hospital of Los Angeles, Los Angeles, California, United States of America
| | - Lynn M. Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Natalie M. Young
- Swedish Center for Research and Innovation, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Sokratis N. Zisis
- Department of Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Andrea S. Foulkes
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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3
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Ortega-Villa AM, Hynes NA, Levine CB, Yang K, Wiley Z, Jilg N, Wang J, Whitaker JA, Colombo CJ, Nayak SU, Kim HJ, Iovine NM, Ince D, Cohen SH, Langer AJ, Wortham JM, Atmar RL, El Sahly HM, Jain MK, Mehta AK, Wolfe CR, Gomez CA, Beresnev T, Mularski RA, Paules CI, Kalil AC, Branche AR, Luetkemeyer A, Zingman BS, Voell J, Whitaker M, Harkins MS, Davey RT, Grossberg R, George SL, Tapson V, Short WR, Ghazaryan V, Benson CA, Dodd LE, Sweeney DA, Tomashek KM. Evaluating Demographic Representation in Clinical Trials: Use of the Adaptive Coronavirus Disease 2019 Treatment Trial (ACTT) as a Test Case. Open Forum Infect Dis 2023; 10:ofad290. [PMID: 37383244 PMCID: PMC10296069 DOI: 10.1093/ofid/ofad290] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/25/2023] [Indexed: 06/30/2023] Open
Abstract
Background Clinical trials initiated during emerging infectious disease outbreaks must quickly enroll participants to identify treatments to reduce morbidity and mortality. This may be at odds with enrolling a representative study population, especially when the population affected is undefined. Methods We evaluated the utility of the Centers for Disease Control and Prevention's COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), the COVID-19 Case Surveillance System (CCSS), and 2020 United States (US) Census data to determine demographic representation in the 4 stages of the Adaptive COVID-19 Treatment Trial (ACTT). We compared the cumulative proportion of participants by sex, race, ethnicity, and age enrolled at US ACTT sites, with respective 95% confidence intervals, to the reference data in forest plots. Results US ACTT sites enrolled 3509 adults hospitalized with COVID-19. When compared with COVID-NET, ACTT enrolled a similar or higher proportion of Hispanic/Latino and White participants depending on the stage, and a similar proportion of African American participants in all stages. In contrast, ACTT enrolled a higher proportion of these groups when compared with US Census and CCSS. The proportion of participants aged ≥65 years was either similar or lower than COVID-NET and higher than CCSS and the US Census. The proportion of females enrolled in ACTT was lower than the proportion of females in the reference datasets. Conclusions Although surveillance data of hospitalized cases may not be available early in an outbreak, they are a better comparator than US Census data and surveillance of all cases, which may not reflect the population affected and at higher risk of severe disease.
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Affiliation(s)
- Ana M Ortega-Villa
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Noreen A Hynes
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Corri B Levine
- Division of Infectious Disease, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Katherine Yang
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
| | - Zanthia Wiley
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nikolaus Jilg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Jennifer A Whitaker
- Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Christopher J Colombo
- Department of Virtual Health and Department of Medicine, Madigan Army Medical Center, Tacoma, Washington, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Seema U Nayak
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Hannah Jang Kim
- Department of Community Health Systems, School of Nursing, University of California, San Francisco,San Francisco, California, USA
- National Patient Care Services, Kaiser Permanente, Oakland, California, USA
| | - Nicole M Iovine
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Dilek Ince
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Stuart H Cohen
- Division of Infectious Diseases, University of California, Davis, Sacramento, California, USA
| | - Adam J Langer
- COVID-19 Emergency Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonathan M Wortham
- COVID-19–Associated Hospitalization Surveillance Network, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Robert L Atmar
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hana M El Sahly
- Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mamta K Jain
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aneesh K Mehta
- Division of Infection Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- National Emerging Special Pathogens Treatment and Education Center, Atlanta, Georgia, USA
| | - Cameron R Wolfe
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Carlos A Gomez
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Tatiana Beresnev
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Richard A Mularski
- Department of Pulmonary and Critical Care Medicine, Northwest Permanente, Kaiser Permanente Northwest, Portland, Oregon, USA
- The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Catharine I Paules
- Division of Infectious Diseases, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Angela R Branche
- Division of Infectious Diseases, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Annie Luetkemeyer
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Barry S Zingman
- Department of Medicine, Montefiore Medical Center, University Hospital for Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jocelyn Voell
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael Whitaker
- COVID-19–Associated Hospitalization Surveillance Network, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michelle S Harkins
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Richard T Davey
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Robert Grossberg
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sarah L George
- Department of Internal Medicine, Saint Louis University and St Louis Veterans Affairs Medical Center, St Louis, Missouri, USA
| | - Victor Tapson
- Division of Pulmonary and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - William R Short
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Varduhi Ghazaryan
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Constance A Benson
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, San Diego, California, USA
| | - Lori E Dodd
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, San Diego, California, USA
| | - Kay M Tomashek
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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4
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Burns KEA, Moss M, Lorens E, Jose EKA, Martin CM, Viglianti EM, Fox-Robichaud A, Mathews KS, Akgun K, Jain S, Gershengorn H, Mehta S, Han JE, Martin GS, Liebler JM, Stapleton RD, Trachuk P, Vranas KC, Chua A, Herridge MS, Tsang JLY, Biehl M, Burnham EL, Chen JT, Attia EF, Mohamed A, Harkins MS, Soriano SM, Maddux A, West JC, Badke AR, Bagshaw SM, Binnie A, Carlos WG, Çoruh B, Crothers K, D'Aragon F, Denson JL, Drover JW, Eschun G, Geagea A, Griesdale D, Hadler R, Hancock J, Hasmatali J, Kaul B, Kerlin MP, Kohn R, Kutsogiannis DJ, Matson SM, Morris PE, Paunovic B, Peltan ID, Piquette D, Pirzadeh M, Pulchan K, Schnapp LM, Sessler CN, Smith H, Sy E, Thirugnanam S, McDonald RK, McPherson KA, Kraft M, Spiegel M, Dodek PM. Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey. Crit Care Med 2022; 50:1689-1700. [PMID: 36300945 PMCID: PMC9668381 DOI: 10.1097/ccm.0000000000005674] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN Cross-sectional survey using four validated instruments. SETTING Sixty-two sites in Canada and the United States. SUBJECTS Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.
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Affiliation(s)
- Karen E A Burns
- Unity Health Toronto - St. Michaels Hospital, Toronto, ON, Canada
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Marc Moss
- University of Colorado - Anschutz Medical Campus and Children's Hospital of Colorado, Aurora, CO
| | - Edmund Lorens
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Claudio M Martin
- Division of Critical Care, London Health Sciences, London Health Sciences Centre, London, ON, Canada
| | - Elizabeth M Viglianti
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Alison Fox-Robichaud
- Division of Critical Care, McMaster University, Department of Medicine, Hamilton, ON, Canada
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kathleen Akgun
- Section of Pulmonary, Critical Care & Sleep Medicine, VA Connecticut Healthcare System, West Haven, CT
| | - Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Hayley Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Sangeeta Mehta
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Sinai Health, Toronto, ON, Canada
| | - Jenny E Han
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA
| | - Gregory S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA
| | - Janice M Liebler
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Polina Trachuk
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, New York University Langone Health, New York, NY
| | - Kelly C Vranas
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR
| | | | - Margaret S Herridge
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, ON, Canada
| | | | - Michelle Biehl
- Departments of Critical Care Medicine and Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Bronx, NY
| | - Jen-Ting Chen
- Harborview Medical Center, University of Washington, Seattle, WA
| | - Engi F Attia
- Division of Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Amira Mohamed
- Division of Pulmonary, Critical Care and Sleep, Department of Internal Medicine, Montefiore Medical Center, Bronx, NY
| | - Michelle S Harkins
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of New Mexico, Albuquerque, NM
| | - Sheryll M Soriano
- OSF Medical Group Pulmonary and Critical Care Division, Order of St Francis (OSF) Healthcare, Peoria, IL
| | - Aline Maddux
- University of Colorado - Anschutz Medical Campus and Children's Hospital of Colorado, Aurora, CO
| | - Julia C West
- Department of Pediatrics, Section of Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Andrew R Badke
- Pulmonary and Critical Care, LDS Hospital, Intermountain Healthcare, Salt Lake City, UT
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alexandra Binnie
- Department of Critical Care Medicine at William Osler Health System, William Osler Health System, Toronto, ON, Canada
| | - W Graham Carlos
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Başak Çoruh
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Kristina Crothers
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Veterans Affairs Puget Sound Health Care, Seattle, WA
| | - Frederick D'Aragon
- Department of Anesthesia, University de Sherbrooke, Sherbrooke, QC, Canada
| | - Joshua Lee Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
| | - John W Drover
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Gregg Eschun
- Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada
| | - Anna Geagea
- Division of Critical Care, Department of Medicine, North York General Hospital, Toronto, ON, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia. Vancouver, BC, Canada
| | - Rachel Hadler
- Department of Anesthesia, University of Iowa Hospital and Clinics, Iowa City, IA
| | | | - Jovan Hasmatali
- Department of Critical Care, Health Sciences Centre, Winnipeg, MB, Canada
| | - Bhavika Kaul
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Meeta Prasad Kerlin
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Rachel Kohn
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D James Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Scott M Matson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Peter E Morris
- University of Kentucky College of Medicine, Lexington, KY
| | - Bojan Paunovic
- Department of Internal Medicine, Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ithan D Peltan
- Division of Pulmonary/Critical Care Medicine, Department of Medicine, Intermountain Healthcare, Salt Lake City, UT
| | - Dominique Piquette
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mina Pirzadeh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Krishna Pulchan
- Division of Critical Care Medicine, Horizon Health Network, Fredericton, NB, Canada
| | - Lynn M Schnapp
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Curtis N Sessler
- Department of Medicine, Section of Critical Care, Virginia Commonwealth University Health System, Richmond, VA
| | | | - Eric Sy
- Regina General Hospital, Regina, SK, Canada
| | | | | | - Katie A McPherson
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Monica Kraft
- University of Arizona College of Medicine, Tucson, AZ
| | - Michelle Spiegel
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, SC
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Wolfe CR, Tomashek KM, Patterson TF, Gomez CA, Marconi VC, Jain MK, Yang OO, Paules CI, Palacios GMR, Grossberg R, Harkins MS, Mularski RA, Erdmann N, Sandkovsky U, Almasri E, Pineda JR, Dretler AW, de Castilla DL, Branche AR, Park PK, Mehta AK, Short WR, McLellan SLF, Kline S, Iovine NM, El Sahly HM, Doernberg SB, Oh MD, Huprikar N, Hohmann E, Kelley CF, Holodniy M, Kim ES, Sweeney DA, Finberg RW, Grimes KA, Maves RC, Ko ER, Engemann JJ, Taylor BS, Ponce PO, Larson L, Melendez DP, Seibert AM, Rouphael NG, Strebe J, Clark JL, Julian KG, de Leon AP, Cardoso A, de Bono S, Atmar RL, Ganesan A, Ferreira JL, Green M, Makowski M, Bonnett T, Beresnev T, Ghazaryan V, Dempsey W, Nayak SU, Dodd LE, Beigel JH, Kalil AC. Baricitinib versus dexamethasone for adults hospitalised with COVID-19 (ACTT-4): a randomised, double-blind, double placebo-controlled trial. Lancet Respir Med 2022; 10:888-899. [PMID: 35617986 PMCID: PMC9126560 DOI: 10.1016/s2213-2600(22)00088-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Baricitinib and dexamethasone have randomised trials supporting their use for the treatment of patients with COVID-19. We assessed the combination of baricitinib plus remdesivir versus dexamethasone plus remdesivir in preventing progression to mechanical ventilation or death in hospitalised patients with COVID-19. METHODS In this randomised, double-blind, double placebo-controlled trial, patients were enrolled at 67 trial sites in the USA (60 sites), South Korea (two sites), Mexico (two sites), Singapore (two sites), and Japan (one site). Hospitalised adults (≥18 years) with COVID-19 who required supplemental oxygen administered by low-flow (≤15 L/min), high-flow (>15 L/min), or non-invasive mechanical ventilation modalities who met the study eligibility criteria (male or non-pregnant female adults ≥18 years old with laboratory-confirmed SARS-CoV-2 infection) were enrolled in the study. Patients were randomly assigned (1:1) to receive either baricitinib, remdesivir, and placebo, or dexamethasone, remdesivir, and placebo using a permuted block design. Randomisation was stratified by study site and baseline ordinal score at enrolment. All patients received remdesivir (≤10 days) and either baricitinib (or matching oral placebo) for a maximum of 14 days or dexamethasone (or matching intravenous placebo) for a maximum of 10 days. The primary outcome was the difference in mechanical ventilation-free survival by day 29 between the two treatment groups in the modified intention-to-treat population. Safety analyses were done in the as-treated population, comprising all participants who received one dose of the study drug. The trial is registered with ClinicalTrials.gov, NCT04640168. FINDINGS Between Dec 1, 2020, and April 13, 2021, 1047 patients were assessed for eligibility. 1010 patients were enrolled and randomly assigned, 516 (51%) to baricitinib plus remdesivir plus placebo and 494 (49%) to dexamethasone plus remdesivir plus placebo. The mean age of the patients was 58·3 years (SD 14·0) and 590 (58%) of 1010 patients were male. 588 (58%) of 1010 patients were White, 188 (19%) were Black, 70 (7%) were Asian, and 18 (2%) were American Indian or Alaska Native. 347 (34%) of 1010 patients were Hispanic or Latino. Mechanical ventilation-free survival by day 29 was similar between the study groups (Kaplan-Meier estimates of 87·0% [95% CI 83·7 to 89·6] in the baricitinib plus remdesivir plus placebo group and 87·6% [84·2 to 90·3] in the dexamethasone plus remdesivir plus placebo group; risk difference 0·6 [95% CI -3·6 to 4·8]; p=0·91). The odds ratio for improved status in the dexamethasone plus remdesivir plus placebo group compared with the baricitinib plus remdesivir plus placebo group was 1·01 (95% CI 0·80 to 1·27). At least one adverse event occurred in 149 (30%) of 503 patients in the baricitinib plus remdesivir plus placebo group and 179 (37%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 7·5% [1·6 to 13·3]; p=0·014). 21 (4%) of 503 patients in the baricitinib plus remdesivir plus placebo group had at least one treatment-related adverse event versus 49 (10%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 6·0% [2·8 to 9·3]; p=0·00041). Severe or life-threatening grade 3 or 4 adverse events occurred in 143 (28%) of 503 patients in the baricitinib plus remdesivir plus placebo group and 174 (36%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 7·7% [1·8 to 13·4]; p=0·012). INTERPRETATION In hospitalised patients with COVID-19 requiring supplemental oxygen by low-flow, high-flow, or non-invasive ventilation, baricitinib plus remdesivir and dexamethasone plus remdesivir resulted in similar mechanical ventilation-free survival by day 29, but dexamethasone was associated with significantly more adverse events, treatment-related adverse events, and severe or life-threatening adverse events. A more individually tailored choice of immunomodulation now appears possible, where side-effect profile, ease of administration, cost, and patient comorbidities can all be considered. FUNDING National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
| | - Kay M Tomashek
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Thomas F Patterson
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | | | - Mamta K Jain
- University of Texas Southwestern and Parkland Health and Hospital System, Dallas, TX, USA
| | - Otto O Yang
- University of California, Los Angeles, CA, USA
| | - Catharine I Paules
- Pennsylvania State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | | | - Robert Grossberg
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | | | | | - Eyad Almasri
- University of California, San Francisco, CA, USA
| | | | - Alexandra W Dretler
- Infectious Disease Specialists of Atlanta and Emory Decatur Hospital, Decatur, GA, USA
| | | | | | | | | | | | | | - Susan Kline
- The University of Minnesota Medical School, Minneapolis, MN, USA
| | - Nicole M Iovine
- University of Florida Health, Shands Hospital, Gainesville, FL, USA
| | | | | | - Myoung-Don Oh
- Seoul National University Hospital, Seoul, South Korea
| | - Nikhil Huprikar
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | | | | | - Eu Suk Kim
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | | | | | | | | | | | | | - Barbara S Taylor
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Philip O Ponce
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - LuAnn Larson
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | - Joslyn Strebe
- University of Texas Southwestern and Parkland Health and Hospital System, Dallas, TX, USA
| | | | - Kathleen G Julian
- Pennsylvania State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Alfredo Ponce de Leon
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | | | | | - Tyler Bonnett
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory, Frederick, MD, USA
| | - Tatiana Beresnev
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Varduhi Ghazaryan
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Walla Dempsey
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Seema U Nayak
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Lori E Dodd
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John H Beigel
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Andre C Kalil
- University of Nebraska Medical Center, Omaha, NE, USA.
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Kalil AC, Mehta AK, Patterson TF, Erdmann N, Gomez CA, Jain MK, Wolfe CR, Ruiz-Palacios GM, Kline S, Regalado Pineda J, Luetkemeyer AF, Harkins MS, Jackson PEH, Iovine NM, Tapson VF, Oh MD, Whitaker JA, Mularski RA, Paules CI, Ince D, Takasaki J, Sweeney DA, Sandkovsky U, Wyles DL, Hohmann E, Grimes KA, Grossberg R, Laguio-Vila M, Lambert AA, Lopez de Castilla D, Kim E, Larson L, Wan CR, Traenkner JJ, Ponce PO, Patterson JE, Goepfert PA, Sofarelli TA, Mocherla S, Ko ER, Ponce de Leon A, Doernberg SB, Atmar RL, Maves RC, Dangond F, Ferreira J, Green M, Makowski M, Bonnett T, Beresnev T, Ghazaryan V, Dempsey W, Nayak SU, Dodd L, Tomashek KM, Beigel JH. Efficacy of interferon beta-1a plus remdesivir compared with remdesivir alone in hospitalised adults with COVID-19: a double-bind, randomised, placebo-controlled, phase 3 trial. Lancet Respir Med 2021; 9:1365-1376. [PMID: 34672949 PMCID: PMC8523116 DOI: 10.1016/s2213-2600(21)00384-2] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Functional impairment of interferon, a natural antiviral component of the immune system, is associated with the pathogenesis and severity of COVID-19. We aimed to compare the efficacy of interferon beta-1a in combination with remdesivir compared with remdesivir alone in hospitalised patients with COVID-19. METHODS We did a double-blind, randomised, placebo-controlled trial at 63 hospitals across five countries (Japan, Mexico, Singapore, South Korea, and the USA). Eligible patients were hospitalised adults (aged ≥18 years) with SARS-CoV-2 infection, as confirmed by a positive RT-PCR test, and who met one of the following criteria suggestive of lower respiratory tract infection: the presence of radiographic infiltrates on imaging, a peripheral oxygen saturation on room air of 94% or less, or requiring supplemental oxygen. Patients were excluded if they had either an alanine aminotransferase or an aspartate aminotransferase concentration more than five times the upper limit of normal; had impaired renal function; were allergic to the study product; were pregnant or breast feeding; were already on mechanical ventilation; or were anticipating discharge from the hospital or transfer to another hospital within 72 h of enrolment. Patients were randomly assigned (1:1) to receive intravenous remdesivir as a 200 mg loading dose on day 1 followed by a 100 mg maintenance dose administered daily for up to 9 days and up to four doses of either 44 μg interferon beta-1a (interferon beta-1a group plus remdesivir group) or placebo (placebo plus remdesivir group) administered subcutaneously every other day. Randomisation was stratified by study site and disease severity at enrolment. Patients, investigators, and site staff were masked to interferon beta-1a and placebo treatment; remdesivir treatment was given to all patients without masking. The primary outcome was time to recovery, defined as the first day that a patient attained a category 1, 2, or 3 score on the eight-category ordinal scale within 28 days, assessed in the modified intention-to-treat population, defined as all randomised patients who were classified according to actual clinical severity. Safety was assessed in the as-treated population, defined as all patients who received at least one dose of the assigned treatment. This trial is registered with ClinicalTrials.gov, NCT04492475. FINDINGS Between Aug 5, 2020, and Nov 11, 2020, 969 patients were enrolled and randomly assigned to the interferon beta-1a plus remdesivir group (n=487) or to the placebo plus remdesivir group (n=482). The mean duration of symptoms before enrolment was 8·7 days (SD 4·4) in the interferon beta-1a plus remdesivir group and 8·5 days (SD 4·3) days in the placebo plus remdesivir group. Patients in both groups had a time to recovery of 5 days (95% CI not estimable) (rate ratio of interferon beta-1a plus remdesivir group vs placebo plus remdesivir 0·99 [95% CI 0·87-1·13]; p=0·88). The Kaplan-Meier estimate of mortality at 28 days was 5% (95% CI 3-7%) in the interferon beta-1a plus remdesivir group and 3% (2-6%) in the placebo plus remdesivir group (hazard ratio 1·33 [95% CI 0·69-2·55]; p=0·39). Patients who did not require high-flow oxygen at baseline were more likely to have at least one related adverse event in the interferon beta-1a plus remdesivir group (33 [7%] of 442 patients) than in the placebo plus remdesivir group (15 [3%] of 435). In patients who required high-flow oxygen at baseline, 24 (69%) of 35 had an adverse event and 21 (60%) had a serious adverse event in the interferon beta-1a plus remdesivir group compared with 13 (39%) of 33 who had an adverse event and eight (24%) who had a serious adverse event in the placebo plus remdesivir group. INTERPRETATION Interferon beta-1a plus remdesivir was not superior to remdesivir alone in hospitalised patients with COVID-19 pneumonia. Patients who required high-flow oxygen at baseline had worse outcomes after treatment with interferon beta-1a compared with those given placebo. FUNDING The National Institute of Allergy and Infectious Diseases (USA).
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Affiliation(s)
- Andre C Kalil
- University of Nebraska Medical Center, Omaha, NE, USA.
| | | | - Thomas F Patterson
- University of Texas Health San Antonio, University Health System, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | | | - Mamta K Jain
- University of Texas Southwestern Medical Center, Parkland Health & Hospital System, Dallas, TX, USA; UT Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | | | | | - Susan Kline
- University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | | | | | | | | | | | | | | | - Catharine I Paules
- Pennsylvania State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Dilek Ince
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Jin Takasaki
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | | | - David L Wyles
- Denver Health and Hospital Authority, Denver, CO, USA
| | | | | | - Robert Grossberg
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | | | - EuSuk Kim
- Seoul National University Bundang Hospital, Seongnam, Korea
| | - LuAnn Larson
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Philip O Ponce
- University of Texas Health San Antonio, University Health System, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Jan E Patterson
- University of Texas Health San Antonio, University Health System, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | | | - Satish Mocherla
- University of Texas Southwestern Medical Center, Parkland Health & Hospital System, Dallas, TX, USA; UT Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | | | - Alfredo Ponce de Leon
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Ryan C Maves
- Naval Medical Center, San Diego, CA, USA; Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | | | | | | | - Tyler Bonnett
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Tatiana Beresnev
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Varduhi Ghazaryan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Walla Dempsey
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Seema U Nayak
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Lori Dodd
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Kay M Tomashek
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - John H Beigel
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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Moghimi N, Di Napoli M, Biller J, Siegler JE, Shekhar R, McCullough LD, Harkins MS, Hong E, Alaouieh DA, Mansueto G, Divani AA. The Neurological Manifestations of Post-Acute Sequelae of SARS-CoV-2 infection. Curr Neurol Neurosci Rep 2021; 21:44. [PMID: 34181102 PMCID: PMC8237541 DOI: 10.1007/s11910-021-01130-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [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] [Accepted: 06/11/2021] [Indexed: 02/06/2023]
Abstract
Purpose of Review Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global health challenge. This review aims to summarize the incidence, risk factors, possible pathophysiology, and proposed management of neurological manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC) or neuro-PASC based on the published literature. Recent Findings The National Institutes of Health has noted that PASC is a multi-organ disorder ranging from mild symptoms to an incapacitating state that can last for weeks or longer following recovery from initial infection with SARS-CoV-2. Various pathophysiological mechanisms have been proposed as the culprit for the development of PASC. These include, but are not limited to, direct or indirect invasion of the virus into the brain, immune dysregulation, hormonal disturbances, elevated cytokine levels due to immune reaction leading to chronic inflammation, direct tissue damage to other organs, and persistent low-grade infection. A multidisciplinary approach for the treatment of neuro-PASC will be required to diagnose and address these symptoms. Tailored rehabilitation and novel cognitive therapy protocols are as important as pharmacological treatments to treat neuro-PASC effectively. Summary With recognizing the growing numbers of COVID-19 patients suffering from neuro-PASC, there is an urgent need to identify affected individuals early to provide the most appropriate and efficient treatments. Awareness among the general population and health care professionals about PASC is rising, and more efforts are needed to understand and treat this new emerging challenge. In this review, we summarize the relevant scientific literature about neuro-PASC.
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Affiliation(s)
- Narges Moghimi
- Department of Neurology, School of Medicine, 1 University of New Mexico, MSC10-5620, Albuquerque, NM 87131 USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L’Aquila, Italy
| | - José Biller
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL USA
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Health Care, Camden, NJ 08103 USA
| | - Rahul Shekhar
- Department of Medicine, School of Medicine, University of New Mexico, Albuquerque, NM USA
| | - Louise D. McCullough
- Department of Neurology, McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas USA
| | - Michelle S. Harkins
- Department of Medicine, School of Medicine, University of New Mexico, Albuquerque, NM USA
| | - Emily Hong
- Department of Neurology, School of Medicine, 1 University of New Mexico, MSC10-5620, Albuquerque, NM 87131 USA
| | - Danielle A. Alaouieh
- Department of Neurology, School of Medicine, 1 University of New Mexico, MSC10-5620, Albuquerque, NM 87131 USA
| | - Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences, University of Campania, Naples, Italy
| | - Afshin A. Divani
- Department of Neurology, School of Medicine, 1 University of New Mexico, MSC10-5620, Albuquerque, NM 87131 USA
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Self WH, Stewart TG, Wheeler AP, El Atrouni W, Bistran-Hall AJ, Casey JD, Cataldo VD, Chappell JD, Cohn CS, Collins JB, Denison MR, de Wit M, Dixon SL, Duggal A, Edwards TL, Fontaine MJ, Ginde AA, Harkins MS, Harrington T, Harris ES, Hoda D, Ipe TS, Jaiswal SJ, Johnson NJ, Jones AE, Laguio-Vila M, Lindsell CJ, Mallada J, Mammen MJ, Metcalf RA, Middleton EA, Mucha S, O'Neal HR, Pannu SR, Pulley JM, Qiao X, Raval JS, Rhoads JP, Schrager H, Shanholtz C, Shapiro NI, Schrantz SJ, Thomsen I, Vermillion KK, Bernard GR, Rice TW. Passive Immunity Trial for Our Nation (PassITON): study protocol for a randomized placebo-control clinical trial evaluating COVID-19 convalescent plasma in hospitalized adults. Trials 2021; 22:221. [PMID: 33743799 PMCID: PMC7980732 DOI: 10.1186/s13063-021-05171-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 02/09/2021] [Accepted: 03/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Convalescent plasma is being used widely as a treatment for coronavirus disease 2019 (COVID-19). However, the clinical efficacy of COVID-19 convalescent plasma is unclear. METHODS The Passive Immunity Trial for Our Nation (PassITON) is a multicenter, placebo-controlled, blinded, randomized clinical trial being conducted in the USA to provide high-quality evidence on the efficacy of COVID-19 convalescent plasma as a treatment for adults hospitalized with symptomatic disease. Adults hospitalized with COVID-19 with respiratory symptoms for less than 14 days are eligible. Enrolled patients are randomized in a 1:1 ratio to 1 unit (200-399 mL) of COVID-19 convalescent plasma that has demonstrated neutralizing function using a SARS-CoV-2 chimeric virus neutralization assay. Study treatments are administered in a blinded fashion and patients are followed for 28 days. The primary outcome is clinical status 14 days after study treatment as measured on a 7-category ordinal scale assessing mortality, respiratory support, and return to normal activities of daily living. Key secondary outcomes include mortality and oxygen-free days. The trial is projected to enroll 1000 patients and is designed to detect an odds ratio ≤ 0.73 for the primary outcome. DISCUSSION This trial will provide the most robust data available to date on the efficacy of COVID-19 convalescent plasma for the treatment of adults hospitalized with acute moderate to severe COVID-19. These data will be useful to guide the treatment of COVID-19 patients in the current pandemic and for informing decisions about whether developing a standardized infrastructure for collecting and disseminating convalescent plasma to prepare for future viral pandemics is indicated. TRIAL REGISTRATION ClinicalTrials.gov NCT04362176 . Registered on 24 April 2020.
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Affiliation(s)
- Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA.
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA.
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Allison P Wheeler
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, USA
| | - Wissam El Atrouni
- Division of Infectious Diseases, Department of Internal Medicine, The University of Kansas School of Medicine, Kasas, USA
| | - Amanda J Bistran-Hall
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Vince D Cataldo
- Division of Hematology and Oncology, Louisiana State University Health-Sciences Center, New Orleans, USA
| | - James D Chappell
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, USA
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, USA
| | - Jessica B Collins
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Mark R Denison
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, USA
| | - Marjolein de Wit
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, USA
| | - Sheri L Dixon
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinical Healthcare System, Cleveland, USA
| | - Terri L Edwards
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Magali J Fontaine
- Division of Transfusion Services, Department of Pathology, University of Maryland School of Medicine, Baltimore, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Boulder, USA
| | - Michelle S Harkins
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Thelma Harrington
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, College Park, USA
| | - Estelle S Harris
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, USA
| | | | - Tina S Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Fayetteville, USA
| | - Stuti J Jaiswal
- Division of Hospital Medicine, Scripps Clinic, Scripps Research Translational Institute, The Scripps Research Institute, San Diego, USA
| | - Nicholas J Johnson
- Department of Emergency and Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, USA
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Oxford, USA
| | - Maryrose Laguio-Vila
- Department of Internal Medicine, Division of Infectious Disease, Rochester General Hospital, Rochester, USA
| | | | - Jason Mallada
- Department of Pharmacy, Newton-Wellesley Hospital, Massachusetts College of Pharmacy and Health Sciences, Boston, USA
| | - Manoj J Mammen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, State University of New York at Buffalo, Buffalo, USA
| | - Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City, USA
| | - Elizabeth A Middleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, USA
| | - Simon Mucha
- Department of Critical Care, Respiratory Institute, Cleveland Clinical Healthcare System, Cleveland, USA
| | - Hollis R O'Neal
- Division of Pulmonary and Critical Care, Louisiana State University Health-Sciences Center, New Orleans, USA
| | - Sonal R Pannu
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, USA
| | - Jill M Pulley
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Xian Qiao
- Sentara Pulmonary, Critical Care, and Sleep Specialists, Sentara Health, Eastern Virginia Medical School, Norfolk, USA
| | - Jay S Raval
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Jillian P Rhoads
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Harry Schrager
- Newton-Wellesley Hospital, Department of Medicine, Tufts School of Medicine, Boston, USA
| | - Carl Shanholtz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, College Park, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | | | - Isaac Thomsen
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, USA
| | - Krista K Vermillion
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Todd W Rice
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
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Self WH, Stewart TG, Wheeler AP, El Atrouni W, Bistran-Hall AJ, Casey JD, Cataldo VD, Chappell JD, Cohn CS, Collins JB, Denison MR, de Wit M, Dixon SL, Duggal A, Edwards TL, Fontaine MJ, Ginde AA, Harkins MS, Harrington T, Harris ES, Hoda D, Ipe TS, Jaiswal SJ, Johnson NJ, Jones AE, Laguio-Vila M, Lindsell CJ, Mallada J, Mammen MJ, Metcalf RA, Middleton EA, Mucha S, O'Neal HR, Pannu SR, Pulley JM, Qiao X, Raval JS, Rhoads JP, Schrager H, Shanholtz C, Shapiro NI, Schrantz SJ, Thomsen I, Vermillion KK, Bernard GR, Rice TW. Passive Immunity Trial for Our Nation (PassITON): study protocol for a randomized placebo-control clinical trial evaluating COVID-19 convalescent plasma in hospitalized adults. Res Sq 2021:rs.3.rs-227796. [PMID: 33688640 PMCID: PMC7941637 DOI: 10.21203/rs.3.rs-227796/v1] [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] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Background: Convalescent plasma is being used widely as a treatment for coronavirus disease 2019 (COVID-19). However, the clinical efficacy of COVID-19 convalescent plasma is unclear. Methods: The Pass ive I mmunity T rial for O ur N ation (PassITON), is a multicenter, placebo-controlled, blinded, randomized clinical trial being conducted in the United States to provide high-quality evidence on the efficacy of COVID-19 convalescent plasma as a treatment for adults hospitalized with symptomatic disease. Adults hospitalized with COVID-19 with respiratory symptoms for less than 14 days are eligible. Enrolled patients are randomized in a 1:1 ratio to 1 unit (200-399 mL) of COVID-19 convalescent plasma that has demonstrated neutralizing function using a SARS-CoV-2 chimeric virus neutralization assay. Study treatments are administered in a blinded fashion and patients are followed for 28 days. The primary outcome is clinical status 14 days after study treatment as measured on a 7-category ordinal scale assessing mortality, respiratory support, and return to normal activities of daily living. Key secondary outcomes include mortality and oxygen-free days. The trial is projected to enroll 1000 patients and is designed to detect an odds ratio ≤ 0.73 for the primary outcome. Discussion: This trial will provide the most robust data available to date on the efficacy of COVID-19 convalescent plasma for the treatment of adults hospitalized with acute moderate to severe COVID-19. These data will be useful to guide the treatment of COVID-19 patients in the current pandemic and for informing decisions about whether developing a standardized infrastructure for collecting and disseminating convalescent plasma to prepare for future viral pandemics is indicated. Trial Registration: ClinicalTrials.gov: NCT04362176. Date of trial registration: April 24, 2020, https://clinicaltrials.gov/ct2/show/NCT04362176.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adit A Ginde
- University of Colorado Denver School of Medicine
| | | | | | | | | | - Tina S Ipe
- University of Arkansas for Medical Sciences
| | | | | | | | | | | | | | - Manoj J Mammen
- State University of New York at Buffalo: University at Buffalo
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10
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Bradfute SB, Hurwitz I, Yingling AV, Ye C, Cheng Q, Noonan TP, Raval JS, Sosa NR, Mertz GJ, Perkins DJ, Harkins MS. Severe Acute Respiratory Syndrome Coronavirus 2 Neutralizing Antibody Titers in Convalescent Plasma and Recipients in New Mexico: An Open Treatment Study in Patients With Coronavirus Disease 2019. J Infect Dis 2020; 222:1620-1628. [PMID: 32779705 PMCID: PMC7454720 DOI: 10.1093/infdis/jiaa505] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/04/2020] [Indexed: 12/28/2022] Open
Abstract
Background Convalescent plasma (CP) is a potentially important therapy for coronavirus disease 2019 (COVID-19). However, knowledge regarding neutralizing antibody (NAb) titers in donor plasma and their impact in acute COVID-19 patients remains largely undetermined. We measured NAb titers in CP and in acute COVID-19 patients before and after transfusion through the traditional FDA IND pathway. Methods We performed a single-arm interventional trial measuring NAb and total antibody titers before and after CP transfusion over a 14-day period in hospitalized patients with laboratory-confirmed severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection. Trial Registration: Clinicaltrials.gov identifier: NCT04434131 (https://clinicaltrials.gov/ct2/show/NCT04434131) Results NAb titers in the donor CP units were low (<1:40 to 1:160) and had no effect on recipient neutralizing activity one day after transfusion. NAb titers were detected in 6/12 patients upon enrollment and in 11/12 patients during at least two timepoints. Average titers peaked on day 7 and declined towards day 14 (P=0.004). NAb and IgG titers were correlated in donor plasma units (ρ=0.938, P<0.0001) and in the cumulative patient measures (ρ=0.781, P<0.0001). Conclusions CP infusion did not alter recipient NAb titers. Pre-screening of CP may be necessary for selecting donors with high levels of neutralizing activity for infusion into patients with COVID-19.
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Affiliation(s)
- Steven B Bradfute
- Center for Global Health, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Ivy Hurwitz
- Center for Global Health, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Alexandra V Yingling
- Center for Global Health, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Chunyan Ye
- Center for Global Health, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Qiuying Cheng
- Center for Global Health, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Timothy P Noonan
- Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Jay S Raval
- Department of Pathology, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Nestor R Sosa
- Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Gregory J Mertz
- Center for Global Health, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Douglas J Perkins
- Center for Global Health, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Michelle S Harkins
- Division of Pulmonary, Critical Care and Sleep, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
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11
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Raval JS, Burnett AE, Rollins-Raval MA, Griggs JR, Rosenbaum L, Nielsen ND, Harkins MS. Viscoelastic testing in COVID-19: a possible screening tool for severe disease? Transfusion 2020; 60:1131-1132. [PMID: 32374920 PMCID: PMC7267656 DOI: 10.1111/trf.15847] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Allison E Burnett
- Department of Pharmacy, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Joseph R Griggs
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Lizabeth Rosenbaum
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA.,Vitalant, Albuquerque, New Mexico, USA
| | - Nathan D Nielsen
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Michelle S Harkins
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
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12
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Haselkorn T, Szefler SJ, Chipps BE, Bleecker ER, Harkins MS, Paknis B, Kianifard F, Ortiz B, Zeiger RS. Disease Burden and Long-Term Risk of Persistent Very Poorly Controlled Asthma: TENOR II. J Allergy Clin Immunol Pract 2020; 8:2243-2253. [PMID: 32173511 DOI: 10.1016/j.jaip.2020.02.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 01/30/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe/difficult-to-treat disease occurs in 5% to 10% of patients with asthma, but accounts for more than 50% of related economic costs. Understanding factors associated with persistent very poorly controlled (VPC) asthma may improve outcomes. OBJECTIVE To characterize persistent VPC asthma after more than 10 years of standard of care. METHODS The Epidemiology and Natural history of asthma: Outcomes and treatment Regimens (TENOR) II (N = 341) was a multicenter, observational study of patients with severe/difficult-to-treat asthma with a single, cross-sectional visit more than 10 years after TENOR I. Persistent VPC asthma was defined as VPC asthma at TENOR I and TENOR II enrollment; without VPC asthma was defined as well- or not well-controlled asthma at either or both visits. Multivariable logistic regression assessed long-term predictors of persistent VPC asthma using TENOR I baseline variables. RESULTS Of 327 patients, nearly half (48.0%, n = 157) had persistent VPC asthma. Comorbidities and asthma triggers were more frequent in patients with persistent VPC asthma than in patients without VPC asthma. Total geometric mean IgE was higher in patients with persistent VPC asthma (89.3 IU/mL vs 55.7 IU/mL); there was no difference in eosinophil levels. Lung function was lower in patients with persistent VPC asthma (mean % predicted pre- and postbronchodilator FEV1, 63.0% vs 82.8% and 69.6% vs 87.2%, respectively). Exacerbations in the previous year were more likely in patients with persistent VPC asthma (29.7% vs 9.0%, respectively). Predictors of persistent VPC asthma were black versus white race/ethnicity, allergic trigger count (4 vs 0), systemic corticosteroid use, and postbronchodilator FEV1 (per 10% decrease). CONCLUSIONS The burden of persistent VPC asthma is high in severe/difficult-to-treat disease; management of modifiable risk factors, maximization of lung function, and trigger avoidance may improve outcomes.
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Affiliation(s)
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colo
| | - Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Eugene R Bleecker
- Department of Medicine, Division of Pharmacogenomics, Center for Applied Genetics and Genomics Medicine, University of Arizona Health Sciences, Tucson, Ariz
| | - Michelle S Harkins
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico, Albuquerque, NM
| | | | | | | | - Robert S Zeiger
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif
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13
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Bondu V, Bitting C, Poland VL, Hanson JA, Harkins MS, Lathrop S, Nolte KB, Lawrence DA, Buranda T. Upregulation of P2Y 2R, Active uPA, and PAI-1 Are Essential Components of Hantavirus Cardiopulmonary Syndrome. Front Cell Infect Microbiol 2018; 8:169. [PMID: 29930915 PMCID: PMC6001748 DOI: 10.3389/fcimb.2018.00169] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 12/19/2017] [Accepted: 05/03/2018] [Indexed: 12/13/2022] Open
Abstract
Sin Nombre virus (SNV) causes hantavirus cardiopulmonary pulmonary syndrome (HCPS) with the loss of pulmonary vascular endothelial integrity, and pulmonary edema without causing cytopathic effects on the vascular endothelium. HCPS is associated primarily with a dysregulated immune response. We previously found occult signs of hemostatic imbalance in the form of a sharp >30-100 fold increase in the expression of plasminogen activator inhibitor type 1 (PAI-1), in serial blood plasma draws of terminal stage-patients. However, the mechanism of the increase in PAI-1 remains unclear. PAI-1 is a primary inhibitor of fibrinolysis caused by tissue plasminogen activator (tPA) and urokinase plasminogen activator plasma (uPA). Here, we investigate factors that contribute to PAI-1 upregulation during HCPS. Using zymography, we found evidence of PAI-1-refractory uPA activity and no tPA activity in plasma samples drawn from HCPS patients. The sole prevalence of uPA activity suggested that severe inflammation drove PAI-1 activity. We have recently reported that the P2Y2 receptor (P2Y2R) mediates SNV infectivity by interacting in cis with β3 integrins, which activates the latter during infection. P2Y2R is a known effector for several biological processes relevant to HCPS pathogenesis, such as upregulation of tissue factor (TF), a primary initiator of the coagulation cascade, stimulating vascular permeability and leukocyte homing to sites of infection. As P2Y2R is prone to upregulation under conditions of inflammation, we compared the expression level of P2Y2R in formalin fixed tissues of HCPS decedents using a TaqMan assay and immunohistochemistry. Our TaqMan results show that the expression of P2Y2R is upregulated significantly in HCPS cases compared to non- HCPS controls (P < 0.001). Immunohistochemistry showed that lung macrophages were the primary reservoir of high and coincident localization of P2Y2R, uPA, PAI-1, and TF antigens. We also observed increased staining for SNV antigens in the same tissue segments where P2Y2R expression was upregulated. Conversely, sections of low P2Y2R expression showed weak manifestations of macrophages, SNV, PAI-1, and TF. Coincident localization of P2Y2R and PAI-1 on macrophage deposits suggests an inflammation-dependent mechanism of increasing pro-coagulant activity in HCPS in the absence of tissue injury.
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Affiliation(s)
- Virginie Bondu
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Casey Bitting
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Valerie L Poland
- Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Joshua A Hanson
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Michelle S Harkins
- Division of Infectious Disease, Pulmonary, Critical Care, and Sleep, Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, United States
| | - Sarah Lathrop
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, United States.,Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Kurt B Nolte
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, United States.,Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Daniel A Lawrence
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Tione Buranda
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, United States
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Abstract
OBJECTIVES There is growing evidence indicating a connection between vitamin D deficiency and the severity of asthma exacerbations. This study seeks to assess the relationship between vitamin D deficiency and the number and severity of asthma exacerbation in adults. METHODS A retrospective analysis was conducted in 92 patients being treated for asthma at the University of New Mexico Adult Asthma Clinic. Serum 25-hydroxyvitamin D3 levels were analyzed in adults with mild to severe persistent asthma. Using multi-variant modeling, the relationship was examined between serum vitamin D levels and the odds of asthma exacerbations ranging in severity from moderate to severe over the span of five years. RESULTS This study demonstrates that vitamin D sufficiency was significantly associated with a decreased total number of asthma exacerbations (incidence rate ratio [IRR]: 0.61, 95% confidence interval [CI]: 0.44-0.84, p = 0.002), decreased total severe asthma exacerbations (IRR: 0.41, 95% CI: 0.24-0.72, p = 0.002) and decreased emergency room visits (IRR: 0.42, 95% CI: 0.20-0.88, p = 0.023). CONCLUSION Vitamin D deficiency may be linked to the risk of severe asthma exacerbations in adults.
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Affiliation(s)
- Natalie Mariam Salas
- Department of Internal Medicine, University of New Mexico Health Sciences Center , Albuquerque, NM , USA
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15
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Fiato KL, Iwamoto GK, Harkins MS, Morelos J. Monitoring flow rates and retention of inhalation techniques using the in-check dial device in adult asthmatics. J Asthma 2007; 44:209-12. [PMID: 17454340 DOI: 10.1080/02770900701209798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The In-Check-Dial (Alliance Tech Medical, Granburg, TX) was used to determine adequacy of inhalation techniques and teaching of two different devices. Retention of adequate techniques, was assessed in 234 moderate to severe asthmatics. Inhalation techniques were assessed at periodic follow-ups divided into less than 1 month return visit, between 1 and 3 months, 3 to less than 6 months, and 6 months to less than 1 year. Proper inhalation techniques worsened at greater than 3 months after the last instruction. The use of the In-Check-Dial is a useful tool in teaching proper technique and monitoring the patient's ability to correctly use inhalation devices.
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Affiliation(s)
- Karen-Lynn Fiato
- Department of Internal Medicine, University of New Mexico. Albuquerque, NM 87131, USA
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16
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Kelly HW, Harkins MS, Boushey H. The role of inhaled long-acting beta-2 agonists in the management of asthma. J Natl Med Assoc 2006; 98:8-16. [PMID: 16532973 PMCID: PMC2594808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
The role of inhaled beta-2 agonists in the management of asthma has changed significantly over the last several years. This review outlines the most recent understanding of the pathophysiology of asthma and the studies that define the roles that both short- and long-acting beta-2 agonists play in therapy for this disease. A concentration on the clinical pharmacology and genetic implications for clinical use of this class of drugs in accordance with the national and international guidelines are described.
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Affiliation(s)
- H William Kelly
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA
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17
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Abstract
The fraction of exhaled nitric oxide (FeNO) is elevated in asthmatics compared to normal subjects. Many studies have demonstrated that FeNO correlates with other markers of airway inflammation. The purpose of this study was to assess the clinical utility of routine monitoring of FeNO in determining its ability to predict future asthma exacerbations compared with other standard clinical measures of spirometry, peak flows, quality of life score, medication usage, and symptoms. A convenience sample of 22 patients with moderate and severe-persistent asthma in the University of New Mexico Adult Asthma Clinic were evaluated during a routine clinic visit and then noted whether they had an exacerbation within 2 weeks of the initial appointment. Those with an exacerbation had a higher mean FeNO (29.67 ppb +/- 14.48) compared to those who did not (12.92 ppb +/- 5.17), p = 0.002. A nominal logistic regression model to determine those variables that predict asthma exacerbation found that FeNO was the only significant predictor, p = 0.03. Thus, FeNO appears to be a clinically useful tool to assess disease control in this population.
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Affiliation(s)
- Michelle S Harkins
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
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18
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Basehore MJ, Howard TD, Lange LA, Moore WC, Hawkins GA, Marshik PL, Harkins MS, Meyers DA, Bleecker ER. A comprehensive evaluation of IL4 variants in ethnically diverse populations: association of total serum IgE levels and asthma in white subjects. J Allergy Clin Immunol 2004; 114:80-7. [PMID: 15241348 DOI: 10.1016/j.jaci.2004.05.035] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The role of variation in the IL4 gene in asthma and allergy susceptibility is controversial. This cytokine is important in IgE isotype switching and the regulation of allergic inflammation; however, published studies have not delineated the specific role of variation in this gene in allergic disorders. OBJECTIVE We sought to identify single nucleotide polymorphisms (SNPs) in IL4 and to evaluate the association of SNPs and haplotypes with asthma and allergic phenotypes (total serum IgE) in white, African American, and Hispanic asthmatic populations. METHODS Sixteen individuals were resequenced, and 19 SNPs were identified; 2 novel and 17 SNPs were previously reported. Eleven of the SNPs were used to evaluate association in the 3 groups. RESULTS Nine polymorphisms were associated with total serum IgE levels in white subjects (.0012 < or = P < or =.034), and 5 of these were also associated with asthma in this population (.010 < or = P < or =.031). Three common haplotypes were observed, and all were associated with either high or low serum IgE levels in white subjects (.00008 < or = P < or =.004). Inspection of the haplotypes revealed that 3017 G/T in intron 2 was the only SNP concordant with serum IgE levels (G allele with lower levels and T allele with higher levels). CONCLUSIONS After a comprehensive genetic evaluation, our data suggest that the 3017 G/T variant or the haplotype it identifies influences IL4's ability to modulate total serum IgE levels. Inconsistencies with previously reported IL4 associations might be due to population differences in allele frequencies, the extent of linkage disequilibrium with this SNP or haplotype, or both.
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Affiliation(s)
- Monica J Basehore
- Center for Human Genomics, Section of Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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19
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VanderJagt DJ, Mcclung KD, Kassam HA, Harkins MS, Glew RH. Pulmonary function of herdsmen. J Natl Med Assoc 2004; 96:550-5. [PMID: 15101676 PMCID: PMC2595003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To determine whether the pulmonary function deficit documented previously in Fulani children is also present in adult Fulani herdsmen in northern Nigeria. SUBJECTS AND METHODS The subjects for this study consisted of adult Fulani men from the hamlet of Magama Gumau and adult non-Fulani men from the city of Jos. Age, height, weight, mid-arm circumference (MAC), triceps skin-fold thickness, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), forced expiratory flow during the middle half of the FVC maneuver (FEF25-75%), and peak expiratory flow rate (PEF) were measured. Body mass index (BMI) and FEV1/FVC were calculated for all subjects. Multiple regression analysis was performed to identify correlations between pulmonary function parameters and anthropometric variables. RESULTS The 44 Fulani subjects and 28 urban subjects were well-matched for age and height. The Fulani men weighed significantly less than the urban men (58.5+/-9.4 versus 67.4+/-11.3 kg, p <0.001) and consequently had significantly lower BMI, MAC, and triceps skin-fold thickness. The only significant difference in pulmonary function parameters between the two groups was in FEV1/FVC (0.93+/-0.1 versus 0.85+/-0.1, p <0.001). Small but significant correlations were found between pulmonary function parameters and anthropometric variables for both study populations. CONCLUSIONS The pulmonary function deficits documented previously in Fulani children and adolescents were not present in adult Fulani men. However, the observed elevation in FEV1/FVC in the rural Fulani men as compared to their urban counterparts, which is often seen in restrictive pulmonary patterns, deserves further study.
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Affiliation(s)
- Dorothy J VanderJagt
- Department of Biochemistry and Molecular Biology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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20
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Harkins MS, Moseley PL, Iwamoto GK. Regulation of CD23 in the chronic inflammatory response in asthma: a role for interferon-gamma and heat shock protein 70 in the TH2 environment. Ann Allergy Asthma Immunol 2004; 91:567-74. [PMID: 14700442 DOI: 10.1016/s1081-1206(10)61536-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Monocytic cells and alveolar macrophages (AMs) are activated in patients with asthma, producing inflammatory cytokines. This occurs despite a TH2 environment that consists of the cytokines interleukin (IL) 4, IL-10, and IL-13. The mechanism by which this occurs may involve cross-linking of the low-alphaffinity IgE receptor CD23. OBJECTIVE To determine the effect of the TH2 environment with interferon-gamma (IFN-gamma) and heat shock protein 70 (HSP 70) on CD23 receptor expression and tumor necrosis factor alpha (TNF-alpha) production. METHODS We examined the effect of IL-4 and IL-13 in culture with IFN-gamma and HSP 70 on CD23 expression in both THP-1 cells and AMs from healthy controls via flow cytometry. AMs from mild asthmatic patients and THP-1 cells were evaluated for TNF-alpha production after cross-linking CD23 with immune complexes. RESULTS Asthmatic AMs stimulated with anti-IgE exhibited a 5.7- +/- 1.9-fold increase in TNF-alpha protein. AMs from healthy controls increased the geometric mean +/- SD of CD23 2.00- +/- 0.50-fold in IL-4 and 2.14- +/- 0.50-fold in IL-13. THP-1 cells cultured with IL-4 and IL-13 then stimulated with IFN-gamma or HSP 70 increased CD23 expression above baseline as follows: IL-4, 2.16- +/- 0.31-fold; IL-13, 2.66- +/- 0.43-fold; IFN-gamma, 2.03- +/- 0.34-fold; IL-4/IFN-gamma, 9.14- to 4.02-fold; IL-13/IFN-gamma, 11.51- +/- 5.51-fold; IL-4/HSP, 5.20- +/- 0.61-fold; and IL-13/HSP, 5.60- +/- 0.79-fold. Stimulating the CD23 receptor with immune complexes significantly increased TNF-alpha production by THP-1 cells stimulated with IFN-gamma, IL-4, IL-13, or a combination of these. CONCLUSIONS Both IFN-gamma and HSP 70, in the TH2 environment, up-regulate CD23 expression and thus may play an important role in maintaining the chronic inflammatory state in asthma.
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Affiliation(s)
- Michelle S Harkins
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Pulmonary, Allergy & Critical Care Division, Albuquerque Veterans Affairs Medical Center, Albuquerque, New Mexico 87131, USA.
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21
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Glew RH, Brock HS, VanderVoort J, Agaba P, Harkins MS, VanderJagt DJ. Lung function and nutritional status of semi-nomadic Fulani children and adolescents in northern Nigeria. J Trop Pediatr 2004; 50:20-5. [PMID: 14984165 DOI: 10.1093/tropej/50.1.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [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] [Indexed: 11/14/2022]
Abstract
The Fulani are semi-nomadic pastoralists of the western Sahel whose culture and economy are centered on cattle. We have shown previously that Fulani children and adolescents (5-18 years old) are stunted and underweight. Nutritional status and lung function were studied in Fulani children and adolescents (n = 70), aged 6-18, and compared with a non-Fulani, rural Nigerian control group (n = 153) of the same age. Participants were restricted to healthy individuals with no prior history of respiratory disease and no symptoms of an upper respiratory tract infection within the past 6 weeks. Significant deficits in forced vital capacity (FVC; Fulani males, 1.51 l; non-Fulani males, 1.86 l, p = 0.009; Fulani females, 1.36 l; non-Fulani females, 1.79 l, p < 0.001), forced expiratory volume in one second (FEV1; Fulani males, 1.44 l; non-Fulani males, 1.76 l, p = 0.02; Fulani females, 1.24 l; non-Fulani females, 1.69 l, p < 0.001), and peak expiratory flow rate (PEFR; Fulani males, 2.69 l/s; non-Fulani males, 3.48 l/s, p = 0.002; Fulani females, 2.29 l/s; non-Fulani females, 3.35 l/s, p < 0.001) were found in both the Fulani boys and girls compared with the non-Fulani controls. The diminished lung function in the Fulani group could be attributed to respiratory muscle weakness or an overall deficit in energy.
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Affiliation(s)
- R H Glew
- Department of Biochemistry and Molecular Biology, School of Medicine, University of New Mexico, Albuquerque, New Mexico 87131, USA
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