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Cox ZL, Collins SP, Hernandez GA, McRae AT, Davidson BT, Adams K, Aaron M, Cunningham L, Jenkins CA, Lindsell CJ, Harrell FE, Kampe C, Miller KF, Stubblefield WB, Lindenfeld J. Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure. J Am Coll Cardiol 2024; 83:1295-1306. [PMID: 38569758 DOI: 10.1016/j.jacc.2024.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals. OBJECTIVES The authors aimed to assess the diuretic efficacy and safety of early dapagliflozin initiation in AHF. METHODS In a multicenter, open-label study, 240 patients were randomized within 24 hours of hospital presentation for hypervolemic AHF to dapagliflozin 10 mg once daily or structured usual care with protocolized diuretic titration until day 5 or hospital discharge. The primary outcome, diuretic efficiency expressed as cumulative weight change per cumulative loop diuretic dose, was compared across treatment assignment using a proportional odds model adjusted for baseline weight. Secondary and safety outcomes were adjudicated by a blinded committee. RESULTS For diuretic efficiency, there was no difference between dapagliflozin and usual care (OR: 0.65; 95% CI: 0.41-1.02; P = 0.06). Dapagliflozin was associated with reduced loop diuretic doses (560 mg [Q1-Q3: 260-1,150 mg] vs 800 mg [Q1-Q3: 380-1,715 mg]; P = 0.006) and fewer intravenous diuretic up-titrations (P ≤ 0.05) to achieve equivalent weight loss as usual care. Early dapagliflozin initiation did not increase diabetic, renal, or cardiovascular safety events. Dapagliflozin was associated with improved median 24-hour natriuresis (P = 0.03) and urine output (P = 0.005), expediting hospital discharge over the study period. CONCLUSIONS Early dapagliflozin during AHF hospitalization is safe and fulfills a component of GDMT optimization. Dapagliflozin was not associated with a statistically significant reduction in weight-based diuretic efficiency but was associated with evidence for enhanced diuresis among patients with AHF. (Efficacy and Safety of Dapagliflozin in Acute Heart Failure [DICTATE-AHF]; NCT04298229).
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee, USA; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee, USA
| | - Gabriel A Hernandez
- Division of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - A Thomas McRae
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Beth T Davidson
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Kirkwood Adams
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mark Aaron
- Department of Cardiac Sciences, Saint Thomas West Hospital, Nashville, Tennessee, USA
| | - Luke Cunningham
- Department of Cardiology, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christina Kampe
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Mart MF, Semler MW, Jenkins CA, Wang G, Casey JD, Ely EW, Jackson JC, Kiehl AL, Bryant PT, Pugh SK, Wang L, DeMasi S, Rice TW, Bernard GR, Freundlich RE, Self WH, Han JH. Oxygen-Saturation Targets and Cognitive and Functional Outcomes in Mechanically Ventilated Adults. Am J Respir Crit Care Med 2024; 209:861-870. [PMID: 38285550 PMCID: PMC10995564 DOI: 10.1164/rccm.202310-1826oc] [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: 10/19/2023] [Accepted: 01/26/2024] [Indexed: 01/31/2024] Open
Abstract
Rationale: Among mechanically ventilated critically ill adults, the PILOT (Pragmatic Investigation of Optimal Oxygen Targets) trial demonstrated no difference in ventilator-free days among lower, intermediate, and higher oxygen-saturation targets. The effects on long-term cognition and related outcomes are unknown.Objectives: To compare the effects of lower (90% [range, 88-92%]), intermediate (94% [range, 92-96%]), and higher (98% [range, 96-100%]) oxygen-saturation targets on long-term outcomes.Methods: Twelve months after enrollment in the PILOT trial, blinded neuropsychological raters conducted assessments of cognition, disability, employment status, and quality of life. The primary outcome was global cognition as measured using the Telephone Montreal Cognitive Assessment. In a subset of patients, an expanded neuropsychological battery measured executive function, attention, immediate and delayed memory, verbal fluency, and abstraction.Measurements and Main Results: A total of 501 patients completed follow-up, including 142 in the lower, 186 in the intermediate, and 173 in the higher oxygen target groups. Median (interquartile range) peripheral oxygen saturation values in the lower, intermediate, and higher target groups were 94% (91-96%), 95% (93-97%), and 97% (95-99%), respectively. Telephone Montreal Cognitive Assessment score did not differ between lower and intermediate (adjusted odds ratio [OR], 1.36 [95% confidence interval (CI), 0.92-2.00]), intermediate and higher (adjusted OR, 0.90 [95% CI, 0.62-1.29]), or higher and lower (adjusted OR, 1.22 [95% CI, 0.83-1.79]) target groups. There was also no difference in individual cognitive domains, disability, employment, or quality of life.Conclusions: Among mechanically ventilated critically ill adults who completed follow-up at 12 months, oxygen-saturation targets were not associated with cognition or related outcomes.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine
- Critical Illness, Brain Dysfunction, and Survivorship
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Veterans Affairs Healthcare System, Nashville, Tennessee
| | | | | | | | | | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine
- Critical Illness, Brain Dysfunction, and Survivorship
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Veterans Affairs Healthcare System, Nashville, Tennessee
| | - James C. Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine
- Critical Illness, Brain Dysfunction, and Survivorship
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Veterans Affairs Healthcare System, Nashville, Tennessee
| | - Amy L. Kiehl
- Division of Allergy, Pulmonary, and Critical Care Medicine
- Critical Illness, Brain Dysfunction, and Survivorship
| | - Patsy T. Bryant
- Division of Allergy, Pulmonary, and Critical Care Medicine
- Critical Illness, Brain Dysfunction, and Survivorship
| | | | | | | | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine
| | | | | | - Wesley H. Self
- Department of Emergency Medicine
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jin H. Han
- Critical Illness, Brain Dysfunction, and Survivorship
- Department of Emergency Medicine
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Veterans Affairs Healthcare System, Nashville, Tennessee
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Cox ZL, Siddiqi HK, Stevenson LW, Bales B, Han JH, Hart K, Imhoff B, Ivey-Miranda JB, Jenkins CA, Lindenfeld J, Shotwell MS, Miller KF, Ooi H, Rao VS, Schlendorf K, Self WH, Siew ED, Storrow A, Walsh R, Wrenn JO, Testani JM, Collins SP. Randomized controlled trial of urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE): Rationale and design. Am Heart J 2023; 265:121-131. [PMID: 37544492 PMCID: PMC10592235 DOI: 10.1016/j.ahj.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple clinical trials have investigated initial diuretic strategies for a designated period of time, there is a paucity of evidence to guide diuretic titration strategies continued until decongestion is achieved. The use of urine chemistries (urine sodium and creatinine) in a natriuretic response prediction equation accurately estimates natriuresis in response to diuretic dosing, but a randomized clinical trial is needed to compare a urine chemistry-guided diuresis strategy with a strategy of usual care. The urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE) trial is designed to test the hypothesis that protocolized diuretic therapy guided by spot urine chemistry through completion of intravenous diuresis will be superior to usual care and improve outcomes over the 14 days following randomization. ESCALATE will randomize and obtain complete data on 450 patients with acute heart failure to a diuretic strategy guided by urine chemistry or a usual care strategy. Key inclusion criteria include an objective measure of hypervolemia with at least 10 pounds of estimated excess volume, and key exclusion criteria include significant valvular stenosis, hypotension, and a chronic need for dialysis. Our primary outcome is days of benefit over the 14 days after randomization. Days of benefit combines patient symptoms captured by global clinical status with clinical state quantifying the need for hospitalization and intravenous diuresis. CLINICAL TRIAL REGISTRATION: NCT04481919.
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN.
| | - Hasan K Siddiqi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lynne W Stevenson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, TN
| | - Kimberly Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Brant Imhoff
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Henry Ooi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, TN
| | - Veena S Rao
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Kelly Schlendorf
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Edward D Siew
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alan Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan Walsh
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jesse O Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey M Testani
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, TN
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Desai N, Jenkins CA, Zanoni B, Nmoh A, Patel N, Shepherd BE, Hussen S, Doraivelu K, Pierce L, Carlucci JG, Ahonkhai AA. High Rates of Viral Suppression and Care Retention Among Youth Born Outside of the United States with Perinatally Acquired HIV. Pediatr Infect Dis J 2022; 41:970-975. [PMID: 36102695 PMCID: PMC9669206 DOI: 10.1097/inf.0000000000003698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Youth born outside of the US with perinatally acquired HIV infection (YBoUS-PHIV) account for most children living with HIV in the US, but there are few data characterizing their care outcomes. METHODS We conducted a retrospective study of YBoUS-PHIV receiving care across 3 HIV clinics in the Southeastern US between October 2018 and 2019. Primary outcomes were retention in care and viral suppression defined as (1) proportion of suppressed viral loads (VLs) and (2) having all VLs suppressed (definition 1 presented in the abstract). Primary predictors were age, adoption and disclosure status (full, partial and none/unknown). Multivariable logistic regression and χ 2 tests were used to test for associations with care outcomes. Analysis of disclosure status was restricted to youth greater than or equal to 12 years. RESULTS The cohort included 111 YBoUS-PHIV. Median age was 14 years (interquartile range, 12-18), 59% were female, and 79% were international adoptees. Overall, 84% of patients were retained in care, and 88% were virally suppressed at each VL measurement. Adopted youth were more likely to be virally suppressed than nonadopted youth [odds ratio (OR), 7.08; P < 0.01] although the association was not statistically significant in adjusted analysis (adjusted OR, 4.26; P = 0.07). Neither age nor adoption status was significantly associated with retention. Among 89 patients greater than or equal to 12 years, 74% were fully disclosed of their HIV status, 12% were partially disclosed, and 13% had not started the disclosure process. There was no significant difference in retention or viral suppression by disclosure status. CONCLUSIONS YBoUS-PHIV achieved high rates of retention and viral suppression. Adopted youth may be more likely to achieve viral suppression which may reflect the need for tailored interventions for nonadopted youth.
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Affiliation(s)
- Neerav Desai
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Cathy A. Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Brian Zanoni
- Department of Pediatrics, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Ashley Nmoh
- Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nehali Patel
- Division of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Sophia Hussen
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Division of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Kamini Doraivelu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Leslie Pierce
- Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James G Carlucci
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aima A. Ahonkhai
- Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Chastain CA, Jenkins CA, Rose M, Moore D, Parker D, Cave B, Crowe J, Adams S, Rubio MG, Potter R, Quedado K, Jones ID, Han JH, Self WH. Non-targeted hepatitis C virus screening in acute care healthcare settings in the Southern Appalachian region. J Am Coll Emerg Physicians Open 2022; 3:e12819. [PMID: 36172306 PMCID: PMC9467969 DOI: 10.1002/emp2.12819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/26/2022] [Accepted: 08/19/2022] [Indexed: 12/09/2022] Open
Abstract
Objectives The objective of this study was to evaluate the performance of non-targeted hepatitis C virus (HCV) screening in emergency departments (EDs) and other healthcare settings in terms of patients identified with HCV infection and linked to HCV care. Methods In the Southern Appalachian region of the United States, we developed non-targeted HCV screening and linkage-to-care programs in 10 institutions at different healthcare settings, including EDs, outpatient clinics, and inpatient units. Serum samples were tested for HCV antibodies, and if positive, reflexed to HCV ribonucleic acid (RNA) testing as a confirmatory test for active infection. Patients with positive RNA tests were contacted to link them to HCV care. Results Between 2017 and 2019, among 195,152 patients screened for HCV infection, 16,529 (8.5%) were positive by antibody testing, 10,139 (5.2% of screened patients and 61.3% of patients positive by antibody test) were positive by RNA testing, and 5778 (3.0% of screened patients and 57.0% of patients positive by RNA test) were successfully linked to HCV care. Among 83,645 patients screened in EDs, 9060 (10.8%) were positive by HCV antibody, and 5243 (6.3%) were positive by RNA test. Among patients positive by RNA testing, linkage to care was lower for patients screened in the ED (44.1%) compared with outpatient clinics (67.6%) (P < 0.01) and inpatient units (50.9%) (P < 0.01). Conclusions Non-targeted HCV screening in acute care settings can identify large numbers of people with HCV infection. To optimize the utility of these screening programs, future work is needed to develop best practices that consistently link these patients to HCV care.
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Affiliation(s)
- Cody A. Chastain
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Cathy A. Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Michelle Rose
- Population HealthNorton HealthcareLouisvilleKentuckyUSA
| | - Daniel Moore
- Department of Emergency MedicineUniversity of KentuckyLexingtonKentuckyUSA
| | - Diana Parker
- Consultant and Program DirectorAppalachia Regional HealthcareHazardKentuckyUSA
| | - Barbra Cave
- Department of MedicineUniversity of LouisvilleLouisvilleKentuckyUSA
| | - Jane Crowe
- Knox County Health DepartmentKnoxvilleTennesseeUSA
| | - Sarah Adams
- Knox County Health DepartmentKnoxvilleTennesseeUSA
| | | | - Rachel Potter
- Madison County Health DepartmentMadison CountyNorth CarolinaUSA
| | - Kimberly Quedado
- Department of Emergency MedicineWest Virginia UniversityMorgantownWest VirginiaUSA
| | - Ian D. Jones
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jin H. Han
- Department of Emergency MedicineVanderbilt University Medical Center and the Geriatric Research, Education, and Clinical CenterTennessee Valley Healthcare CenterNashvilleTennesseeUSA
| | - Wesley H. Self
- Department of Emergency Medicine and Vanderbilt Institute for Clinical and Translational ResearchVanderbilt University Medical CenterNashvilleTennesseeUSA
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Ward MJ, Kripalani S, Muñoz D, Collins SP, Moser K, Jenkins CA, Liu D, Vogus TJ. Association of Physician Coordination With Interfacility Transfer Acceptance Timeliness. Am J Accountable Care 2022; 10:7-15. [PMID: 38617098 PMCID: PMC11014424 DOI: 10.37765/ajac.2022.89231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Objectives Interfacility transfer for time-sensitive emergencies involves rapid and complex care transitions between facilities. We sought to validate relational coordination, a 7-dimension measure of coordination in which a higher score reflects higher-quality coordination, to examine how the quality of coordination affects timeliness in an emergency care setting. Study Design Retrospective observational cohort design. Methods We used a novel method to examine how the quality of coordination between physicians at the time of transfer affects timeliness of physician acceptance. We recorded physician-to-physician conversations from the transfer of patients with ST-segment elevation myocardial infarction (STEMI), a time-sensitive emergency requiring immediate intervention to prevent morbidity and mortality. Results We identified 81 patients experiencing STEMI who were transferred between August 1, 2016, and March 31, 2018. Descriptive statistics, interrater reliability (Spearman correlation coefficients), and generalized linear models were used to examine the association between relational coordination and the physician time-to-acceptance duration. Median (IQR) relational coordination score was 445 (403-493) of a maximum of 700, and median (IQR) time to acceptance was 90.4 (60.2-140.8) seconds. Agreement between abstractors was high (ρ = 0.76). There was a significant, negative relationship between relational coordination and time to acceptance (ρ = -0.38; P < .001). Every 40-point increase in relational coordination was associated with a 25% reduction in time to acceptance. Conclusions Relational coordination not only demonstrated high interrater reliability, but we also found that higher-quality coordination was associated with faster physician acceptance during time-sensitive transfers. Use of such measures may provide a mechanism to improve the quality of care and outcomes for patients with STEMI who experience interfacility transfers.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Sunil Kripalani
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Daniel Muñoz
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Sean P Collins
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Kelly Moser
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Cathy A Jenkins
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Dandan Liu
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Timothy J Vogus
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
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Schember CO, Scott SE, Jenkins CA, Rebeiro PF, Turner M, Furukawa SS, Bofill C, Yan Z, Jackson GP, Pettit AC. Electronic Patient Portal Access, Retention in Care, and Viral Suppression Among People Living With HIV in Southeastern United States: Observational Study. JMIR Med Inform 2022; 10:e34712. [PMID: 35877160 PMCID: PMC9361138 DOI: 10.2196/34712] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/14/2022] [Accepted: 04/11/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Approximately 1.1 million people living with HIV live in the United States, and the incidence is highest in Southeastern United States. Electronic patient portal prevalence is increasing and can improve engagement in primary medical care. Retention in care and viral suppression-measures of engagement in HIV care-are associated with decreased HIV transmission, morbidity, and mortality. OBJECTIVE We aimed to determine if patient portal access among people living with HIV was associated with retention and viral suppression. METHODS We conducted an observational cohort study among people living with HIV in care at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2011-2016. Individual access was defined as patient portal account registration at any point in the year prior. Retention was defined as ≥2 kept appointments or HIV lab measurements ≥3 months apart within a 12-month period. Viral suppression was defined as the last viral load in the calendar year <200 copies/mL. We calculated adjusted prevalence ratios (aPRs) and 95% CIs using modified Poisson regression with generalized estimating equations to estimate the association of portal access with retention and viral suppression. RESULTS We included 4237 people living with HIV contributing 16,951 person-years of follow-up (median 5, IQR 3-5 person-years). The median age was 43 (IQR 33-50) years. Of the 4237 people living with HIV, 78.1% (n=4237) were male, 40.8% (n=1727) were Black non-Hispanic, and 56.5% (n=2395) had access. Access was independently associated with retention (aPR 1.13, 95% CI 1.10-1.17) and viral suppression (aPR 1.18, 95% CI 1.14-1.22). CONCLUSIONS In this population, patient portal access was associated with retention and viral suppression. Future prospective studies should assess the impact of increasing portal access among people living with HIV on these HIV outcomes.
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Affiliation(s)
- Cassandra Oliver Schember
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sarah E Scott
- Departments of Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Peter F Rebeiro
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Megan Turner
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sally S Furukawa
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Carmen Bofill
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Zhou Yan
- Department of Health Information Technology Web Development, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Gretchen P Jackson
- Departments of Surgery, Pediatrics and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - April C Pettit
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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Castilho JL, Bian A, Jenkins CA, Shepherd BE, Sigel K, Gill MJ, Kitahata MM, Silverberg MJ, Mayor AM, Coburn SB, Wiley D, Achenbach CJ, Marconi VC, Bosch RJ, Horberg MA, Rabkin CS, Napravnik S, Novak RM, Mathews WC, Thorne JE, Sun J, Althoff KN, Moore RD, Sterling TR, Sudenga SL. CD4/CD8 Ratio and Cancer Risk Among Adults With HIV. J Natl Cancer Inst 2022; 114:854-862. [PMID: 35292820 PMCID: PMC9194634 DOI: 10.1093/jnci/djac053] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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: 07/23/2021] [Revised: 12/10/2021] [Accepted: 03/07/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Independent of CD4 cell count, a low CD4/CD8 ratio in people with HIV (PWH) is associated with deleterious immune senescence, activation, and inflammation, which may contribute to carcinogenesis and excess cancer risk. We examined whether low CD4/CD8 ratios predicted cancer among PWH in the United States and Canada. METHODS We examined all cancer-free PWH with 1 or more CD4/CD8 values from North American AIDS Cohort Collaboration on Research and Design observational cohorts with validated cancer diagnoses between 1998 and 2016. We evaluated the association between time-lagged CD4/CD8 ratio and risk of specific cancers in multivariable, time-updated Cox proportional hazard models using restricted cubic spines. Models were adjusted for age, sex, race and ethnicity, hepatitis C virus, and time-updated CD4 cell count, HIV RNA, and history of AIDS-defining illness. RESULTS Among 83 893 PWH, there were 5628 incident cancers, including lung cancer (n = 755), Kaposi sarcoma (n = 501), non-Hodgkin lymphoma (n = 497), and anal cancer (n = 439). The median age at cohort entry was 43 years. The overall median 6-month lagged CD4/CD8 ratio was 0.52 (interquartile range = 0.30-0.82). Compared with a 6-month lagged CD4/CD8 of 0.80, a CD4/CD8 of 0.30 was associated with increased risk of any incident cancer (adjusted hazard ratio = 1.24 [95% confidence interval = 1.14 to 1.35]). The CD4/CD8 ratio was also inversely associated with non-Hodgkin lymphoma, Kaposi sarcoma, lung cancer, anal cancer, and colorectal cancer in adjusted analyses (all 2-sided P < .05). Results were similar using 12-, 18-, and 24-month lagged CD4/CD8 values. CONCLUSIONS A low CD4/CD8 ratio up to 24 months before cancer diagnosis was independently associated with increased cancer risk in PWH and may serve as a clinical biomarker.
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Affiliation(s)
- Jessica L Castilho
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Keith Sigel
- Division of Infectious Diseases, Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - M John Gill
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mari M Kitahata
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Angel M Mayor
- Retrovirus Research Center, Internal Medicine Department, Universidad Central del Caribe School of Medicine, Bayamón, PR, USA
| | - Sally B Coburn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dorothy Wiley
- School of Nursing, University of California Los Angeles, Los Angeles, CA, USA
| | - Chad J Achenbach
- Division of Infectious Diseases, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA, USA
| | - Ronald J Bosch
- Department of Biostatistics, T.H. Chan Harvard School of Public Health, Boston, MA, USA
| | - Michael A Horberg
- Kaiser Permanente Mid-Atlantic Medical Group and Research Institute, Washington, DC, USA
| | - Charles S Rabkin
- Division of Cancer Epidemiology and Genetics, Infections and Immunoepidemiology Branch, National Cancer Institute, Rockville, MD, USA
| | - Sonia Napravnik
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Richard M Novak
- Division of Infectious Diseases, Department of Medicine, University of Illinois Chicago School of Medicine, Chicago, IL, USA
| | - W Christopher Mathews
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jennifer E Thorne
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jing Sun
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Richard D Moore
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy R Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Staci L Sudenga
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Walker P, Jenkins CA, Hatcher J, Freeman C, Srica N, Rosell B, Hanna E, March C, Seamens C, Storrow A, McCoin N. Seamens' Sign: a novel electrocardiogram prediction tool for left ventricular hypertrophy. PeerJ 2022; 10:e13548. [PMID: 35669958 PMCID: PMC9165589 DOI: 10.7717/peerj.13548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/16/2022] [Indexed: 01/17/2023] Open
Abstract
Introduction Patients with left ventricular hypertrophy (LVH) diagnosed by electrocardiogram (ECG) have increased mortality and higher risk for life-threatening cardiovascular disease. ECGs offer an opportunity to identify patients with increased risk for potential risk-modifying therapy. We developed a novel, quick, easy to use ECG screening criterion (Seamens' Sign) for LVH. This new criterion was defined as the presence of QRS complexes touching or overlapping in two contiguous precordial leads. Methods This study was a retrospective chart review of 2,184 patient records of patients who had an ECG performed in the emergency department and a transthoracic echocardiogram performed within 90 days. The primary outcome was whether Seamens' Sign was noninferior in confirming LVH compared to other common diagnostic criteria. Test characteristics were calculated for each of the LVH criteria. Inter-rater agreement was assessed on a random sample using Cohen's Kappa. Results Median age was 63, 52% of patients were male and there was a 35% prevalence of LVH by transthoracic echocardiogram (TTE). Nine percent were positive for LVH on ECG based on Seamens' Sign. Seamens' Sign had a specificity of 0.92. Tests assessing noninferiority indicated Seamens' Sign was non-inferior to all criteria (p < 0.001) except for Cornell criterion for women (p = 0.98). Seamens' Sign had 90% (0.81-1.00) inter-rater agreement, the highest of all criteria in this study. Conclusion When compared to both the Sokolow-Lyon criteria and the Cornell criterion for men, Seamens' Sign is noninferior in ruling in LVH on ECG. Additionally, Seamens' Sign has higher inter-rater agreement compared to both Sokolow-Lyon criteria as well as the Cornell criteria for men and women, perhaps related to its ease of use.
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Affiliation(s)
- Philip Walker
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Cathy A. Jenkins
- Department of Biostatistics, Vanderbilt University, Nashville, TN, United States of America
| | - Jeremy Hatcher
- School of Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Clifford Freeman
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Nickolas Srica
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Bryant Rosell
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Eriny Hanna
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Cooper March
- School of Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Charles Seamens
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Alan Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America
| | - Nicole McCoin
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America
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10
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Fermann GJ, Schrock JW, Levy PD, Pang P, Butler J, Chang AM, Char D, Diercks D, Han JH, Hiestand B, Hogan C, Jenkins CA, Kampe C, Khan Y, Kumar VA, Lee S, Lindenfeld J, Liu D, Miller KF, Peacock WF, Reilly CM, Robichaux C, Rothman RL, Self WH, Singer AJ, Sterling SA, Storrow AB, Stubblefield WB, Walsh C, Wilburn J, Collins SP. Troponin is unrelated to outcomes in heart failure patients discharged from the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12695. [PMID: 35434709 PMCID: PMC8994616 DOI: 10.1002/emp2.12695] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management. Objective Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED. Methods This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED‐HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30‐day cardiovascular death and/or heart failure‐related events. Results Of the 491 subjects included in the GUIDED‐HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54‐70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval, 0.49–2.01, P = 0.994) Conclusion If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.
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Affiliation(s)
- Gregory J. Fermann
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Jon W. Schrock
- Department of Emergency Medicine Metro Health Cleveland Ohio USA
| | - Phillip D. Levy
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Peter Pang
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis Indiana USA
| | - Javed Butler
- Division of Cardiovascular Medicine Stony Brook University Stony Brook New York USA
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Douglas Char
- Division of Emergency Medicine Washington University St. Louis Missouri USA
| | - Deborah Diercks
- Department of Emergency Medicine University of Texas‐Southwestern Dallas Texas USA
| | - Jin H. Han
- Department of Emergency Medicine Metro Health Cleveland Ohio USA
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis Indiana USA
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Brian Hiestand
- Department of Emergency Medicine Wake Forest University Winston‐Salem North Carolina USA
| | - Chris Hogan
- Department of Emergency Medicine Virginia Commonwealth University Richmond Virginia USA
| | - Cathy A. Jenkins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Christy Kampe
- Department of Biostatistics Vanderbilt University Nashville Tennessee USA
| | - Yosef Khan
- American Heart Association/American Stroke Association Dallas Texas USA
| | - Vijaya A. Kumar
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Sangil Lee
- Department of Emergency Medicine University of Iowa Iowa City Iowa USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Disease Vanderbilt University Medical Center Nashville Tennessee USA
| | - Dandan Liu
- Department of Biostatistics Vanderbilt University Nashville Tennessee USA
| | - Karen F. Miller
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - W. Frank Peacock
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| | - Carolyn M. Reilly
- Department of Emergency Medicine Emory University Atlanta Georgia USA
| | - Chad Robichaux
- Department of Medicine Emory University School of Medicine Atlanta Georgia USA
| | - Russell L. Rothman
- Department of Internal Medicine Pediatrics & Health Policy Vanderbilt University Nashville Tennessee USA
| | - Wesley H. Self
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Adam J. Singer
- Department of Emergency Medicine Renaissance School of Medicine at Stony Brook University Stony Brook New York USA
| | - Sarah A. Sterling
- Department of Emergency Medicine University of Mississippi Medical Center Jackson Mississippi USA
| | - Alan B. Storrow
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - William B. Stubblefield
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Cheryl Walsh
- Geriatric Research Education and Clinical Center Tennessee Valley Healthcare System Nashville Tennessee USA
| | - John Wilburn
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
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11
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Crabtree-Ramirez B, Jenkins CA, Shepherd BE, Jayathilake K, Veloso VG, Carriquiry G, Gotuzzo E, Cortes CP, Padgett D, McGowan C, Sierra-Madero J, Koenig S, Pape JW, Sterling TR. Tuberculosis treatment intermittency in the continuation phase and mortality in HIV-positive persons receiving antiretroviral therapy. BMC Infect Dis 2022; 22:341. [PMID: 35382770 PMCID: PMC8985331 DOI: 10.1186/s12879-022-07330-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Some tuberculosis (TB) treatment guidelines recommend daily TB treatment in both the intensive and continuation phases of treatment in HIV-positive persons to decrease the risk of relapse and acquired drug resistance. However, guidelines vary across countries, and treatment is given 7, 5, 3, or 2 days/week. The effect of TB treatment intermittency in the continuation phase on mortality in HIV-positive persons on antiretroviral therapy (ART), is not well-described. METHODS We conducted an observational cohort study among HIV-positive adults treated for TB between 2000 and 2018 and after enrollment into the Caribbean, Central, and South America network for HIV epidemiology (CCASAnet; Brazil, Chile, Haiti, Honduras, Mexico and Peru). All received standard TB therapy (2-month initiation phase of daily isoniazid, rifampin or rifabutin, pyrazinamide ± ethambutol) and continuation phase of isoniazid and rifampin or rifabutin, administered concomitantly with ART. Known timing of ART and TB treatment were also inclusion criteria. Kaplan-Meier and Cox proportional hazards methods compared time to death between groups. Missing model covariates were imputed via multiple imputation. RESULTS 2303 patients met inclusion criteria: 2003(87%) received TB treatment 5-7 days/week and 300(13%) 2-3 days/week in the continuation phase. Intermittency varied by site: 100% of patients from Brazil and Haiti received continuation phase treatment 5-7 days/week, followed by Honduras (91%), Peru (42%), Mexico (7%), and Chile (0%). The crude risk of death was lower among those receiving treatment 5-7 vs. 2-3 days/week (HR = 0.68; 95% CI = 0.51-0.91; P = 0.008). After adjusting for age, sex, CD4, ART use at TB diagnosis, site of TB disease (pulmonary vs. extrapulmonary), and year of TB diagnosis, mortality risk was lower, but not significantly, among those treated 5-7 days/week vs. 2-3 days/week (HR 0.75, 95%CI 0.55-1.01; P = 0.06). After also stratifying by study site, there was no longer a protective effect (HR 1.42, 95%CI 0.83-2.45; P = 0.20). CONCLUSIONS TB treatment 5-7 days/week was associated with a marginally decreased risk of death compared to TB treatment 2-3 days/week in the continuation phase in multivariable, unstratified analyses. However, little variation in TB treatment intermittency within country meant the results could have been driven by other differences between study sites. Therefore, randomized trials are needed, especially in heterogenous regions such as Latin America.
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Affiliation(s)
- Brenda Crabtree-Ramirez
- Departamento de Infectología. Instituto Nacional de Ciencias Médicas Y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Cathy A Jenkins
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Bryan E Shepherd
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Karu Jayathilake
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Gabriela Carriquiry
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Dennis Padgett
- Hospital Escuela and Instituto Hondureño de Seguridad Social, Tegucigalpa, Honduras
| | - Catherine McGowan
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Juan Sierra-Madero
- Departamento de Infectología. Instituto Nacional de Ciencias Médicas Y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Serena Koenig
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
- Le Groupe Haïtien d'Etude du Sarcome de Kaposi Et Des Infections Opportunistes (GHESKIO), Port-au-Prince, Haiti
| | - Jean W Pape
- Le Groupe Haïtien d'Etude du Sarcome de Kaposi Et Des Infections Opportunistes (GHESKIO), Port-au-Prince, Haiti
| | - Timothy R Sterling
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA.
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12
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Coelho LE, Jenkins CA, Shepherd BE, Pape JW, Cordero FM, Padgett D, Ramirez BC, Grinsztejn B, Althoff KN, Koethe JR, Marconi VC, Tien PC, Willig AL, Moore RD, Castilho JL, Colasanti J, Crane HM, Gill MJ, Horberg MA, Mayor A, Silverberg MJ, McGowan C, Rebeiro PF. Weight gain post-ART in HIV+ Latinos/as differs in the USA, Haiti, and Latin America. Lancet Reg Health Am 2022; 8:100173. [PMID: 35528706 PMCID: PMC9070999 DOI: 10.1016/j.lana.2021.100173] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background An obesity epidemic has been documented among adult Latinos/as in Latin America and the United States (US); however, little is known about obesity among Latinos/as with HIV (PWH). Moreover, Latinos/as PWH in the US may have different weight trajectories than those in Latin America due to the cultural and environmental contexts. We assessed weight and body mass index (BMI) trajectories among PWH initiating antiretroviral therapy (ART) across 5 countries in Latin America and the Caribbean and the US. Methods ART-naÿve PWH ≥18 years old, enrolled in Brazil, Honduras, Mexico, Peru, and Haiti (sites within CCA-SAnet) and the US (NA-ACCORD) starting ART between 2000 and 2017, with at least one weight measured after ART initiation were included. Participants were classified according to site/ethnicity as: Latinos/as in US, non-Latinos/as in US, Haitians, and Latinos/as in Latin America. Generalized least squares models were used to assess trends in weight and BMI. Models estimating probabilities of becoming overweight/obese (BMI ≥25 kg/m2) and of becoming obese (BMI ≥30 kg/m2) post ART initiation for males and females were fit using generalized estimating equations with a logit link and an independence working correlation structure. Findings Among 59,207 PWH, 9% were Latinos/as from Latin America, 9% Latinos/as from the US, 68% non-Latinos/as from the US and 14% were Haitian. At ART initiation, 29% were overweight and 14% were obese. Post-ART weight and BMI increases were steeper for Latinos/as in Latin America compared with other sites/ethnicities; however, BMI at 3-years post ART remained lower compared to Latinos/as and non-Latinos/as in the US. Among females, at 3-years post ART initiation the greatest adjusted probability of obesity was found among non-Latinas in the US (15·2%) and lowest among Latinas in Latin America (8.6%). Among males, while starting with a lower BMI, Latinos in Latin America had the greatest adjusted probability of becoming overweight or obese 3-years post-ART initiation. Interpretation In the Americas, PWH gain substantial weight after ART initiation. Despite environmental and cultural differences, PWH in Latin America, Haiti and Latinos and non-Latinos in the US share similar BMI trajectories on ART and high probabilities of becoming overweight and obese over time. Multicohort studies are needed to better understand the burden of other metabolic syndrome components in PWH across different countries.
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Affiliation(s)
- Lara E. Coelho
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Cathy A. Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jean W. Pape
- Groupe Haitien d'Etudes du Sarcome de Kaposi et des Infections Opportunistes, Port-au-Prince, Haiti
| | - Fernando Mejia Cordero
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Denis Padgett
- Instituto Hondureño de Seguridad Social & Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Brenda Crabtree Ramirez
- Deparatmento de Infectologia, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán. Mexico City, Mexico
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - John R. Koethe
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vincent C. Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA, USA
| | - Phyllis C. Tien
- Department of Medicine, University of California, San Francisco (UCSF), and the Department of Veterans Affairs Medical Center. San Francisco, CA, USA
| | - Amanda L. Willig
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Jessica L. Castilho
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan Colasanti
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA, USA
| | | | | | - Michael A. Horberg
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD, US
| | - Angel Mayor
- Universidad Central del Caribe, Retrovirus Research Center, Bayamón, PR, US
| | | | - Catherine McGowan
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter F. Rebeiro
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - North American AIDS Collaboration on Research and Design (NA-ACCORD) and the Caribbean, Central and South America network for HIV epidemiology (CCASAnet) of the International epidemiology Databases to Evaluate AIDS (IeDEA)
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Groupe Haitien d'Etudes du Sarcome de Kaposi et des Infections Opportunistes, Port-au-Prince, Haiti
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Instituto Hondureño de Seguridad Social & Hospital Escuela Universitario, Tegucigalpa, Honduras
- Deparatmento de Infectologia, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán. Mexico City, Mexico
- Johns Hopkins University, Baltimore, MD, USA
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA, USA
- Department of Medicine, University of California, San Francisco (UCSF), and the Department of Veterans Affairs Medical Center. San Francisco, CA, USA
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- University of Washington, Seattle, WA, US
- The University of Calgary, Calgary, AB, Canada
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD, US
- Universidad Central del Caribe, Retrovirus Research Center, Bayamón, PR, US
- Kaiser Permanente Northern California, Oakland, CA, US
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Ahonkhai AA, Rebeiro PF, Jenkins CA, Rickles M, Cook M, Conserve DF, Pierce LJ, Shepherd BE, Brantley M, Wester C. Individual, community, and structural factors associated with linkage to HIV care among people diagnosed with HIV in Tennessee. PLoS One 2022; 17:e0264508. [PMID: 35239705 PMCID: PMC8893655 DOI: 10.1371/journal.pone.0264508] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 02/11/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE We assessed trends and identified individual- and county-level factors associated with individual linkage to HIV care in Tennessee (TN). METHODS TN residents diagnosed with HIV from 2012-2016 were included in the analysis (n = 3,751). Individuals were assigned county-level factors based on county of residence at the time of diagnosis. Linkage was defined by the first CD4 or HIV RNA test date after HIV diagnosis. We used modified Poisson regression to estimate probability of 30-day linkage to care at the individual-level and the contribution of individual and county-level factors to this outcome. RESULTS Both MSM (aRR 1.23, 95%CI 0.98-1.55) and women who reported heterosexual sex risk factors (aRR 1.39, 95%CI 1.18-1.65) were more likely to link to care within 30-days than heterosexual males. Non-Hispanic Black individuals had poorer linkage than White individuals (aRR 0.77, 95%CI 0.71-0.83). County-level mentally unhealthy days were negatively associated with linkage (aRR 0.63, 95%CI: 0.40-0.99). CONCLUSIONS Racial disparities in linkage to care persist at both individual and county levels, even when adjusting for county-level social determinants of health. These findings suggest a need for structural interventions to address both structural racism and mental health needs to improve linkage to care and minimize racial disparities in HIV outcomes.
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Affiliation(s)
- Aima A. Ahonkhai
- Department of Medicine, Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Peter F. Rebeiro
- Department of Medicine, Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Department of Medicine, Division of Epidemiology, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Cathy A. Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Michael Rickles
- Tennessee Department of Health, Nashville, TN, United States of America
| | - Mekeila Cook
- Division of Public Health Practice, Meharry Medical College, Nashville, TN, United States of America
| | - Donaldson F. Conserve
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, SC, United States of America
| | - Leslie J. Pierce
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Meredith Brantley
- Tennessee Department of Health, Nashville, TN, United States of America
| | - Carolyn Wester
- Tennessee Department of Health, Nashville, TN, United States of America
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14
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Stubblefield WB, Jenkins CA, Liu D, Storrow AB, Spertus JA, Pang PS, Levy PD, Butler J, Chang AM, Char D, Diercks DB, Fermann GJ, Han JH, Hiestand BC, Hogan CJ, Khan Y, Lee S, Lindenfeld JM, McNaughton CD, Miller K, Peacock WF, Schrock JW, Self WH, Singer AJ, Sterling SA, Collins SP. Improvement in Kansas City Cardiomyopathy Questionnaire Scores After a Self-Care Intervention in Patients With Acute Heart Failure Discharged From the Emergency Department. Circ Cardiovasc Qual Outcomes 2021; 14:e007956. [PMID: 34555929 PMCID: PMC8628372 DOI: 10.1161/circoutcomes.121.007956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We conducted a secondary analysis of changes in the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 over 30 days in a randomized trial of self-care coaching versus structured usual care in patients with acute heart failure who were discharged from the emergency department. METHODS Patients in 15 emergency departments completed the KCCQ-12 at emergency department discharge and at 30 days. We compared change in KCCQ-12 scores between the intervention and usual care arms, adjusted for enrollment KCCQ-12 and demographic characteristics. We used linear regression to describe changes in KCCQ-12 summary scores and logistic regression to characterize clinically meaningful KCCQ-12 subdomain changes at 30 days. RESULTS There were 350 patients with both enrollment and 30-day KCCQ summary scores available; 166 allocated to usual care and 184 to the intervention arm. Median age was 64 years (interquartile range, 55-70), 37% were female participants, 63% were Black, median KCCQ-12 summary score at enrollment was 47 (interquartile range, 33-64). Self-care coaching resulted in significantly greater improvement in health status compared with structured usual care (5.4-point greater improvement, 95% CI, 1.12-9.68; P=0.01). Improvements in health status in the intervention arm were driven by improvements within the symptom frequency (adjusted odds ratio, 1.62 [95% CI, 1.01-2.59]) and quality of life (adjusted odds ratio, 2.39 [95% CI, 1.46-3.90]) subdomains. CONCLUSIONS In this secondary analysis, patients with acute heart failure who received a tailored, self-care intervention after emergency department discharge had clinically significant improvements in health status at 30 days compared with structured usual care largely due to improvements within the symptom frequency and quality of life subdomains of the KCCQ-12. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02519283.
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Affiliation(s)
- William B Stubblefield
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Cathy A Jenkins
- Department of Biostatistics (C.A.J., D.L.), Vanderbilt University Medical Center, Nashville, TN
| | - Dandan Liu
- Department of Biostatistics (C.A.J., D.L.), Vanderbilt University Medical Center, Nashville, TN
| | - Alan B Storrow
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - John A Spertus
- Department of Biomedical and Health Informatics, University of Missouri, Kansas City and Saint Luke's Mid America Heart Institute, MO (J.A.S.)
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.)
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI (P.D.L.)
| | - Javed Butler
- Department of Medicine (J.B.), University of Mississippi Medical Center, Jackson
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University Hospital (A.M.C.)
| | - Douglas Char
- Division of Emergency Medicine, Department of Internal Medicine, Washington University, Seattle (D.C.)
| | - Deborah B Diercks
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX (D.B.D.)
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.)
| | - Jin H Han
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (B.C.H.)
| | - Christopher J Hogan
- Division of Trauma/Critical Care, Departments of Emergency Medicine and Surgery, Virginia Commonwealth University Medical Center, Richmond (C.J.H.)
| | - Yosef Khan
- Health Informatics and Analytics, Centers for Health Metrics and Evaluation, American Heart Association (Y.K.)
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine (S.L.)
| | - JoAnn M Lindenfeld
- Division of Cardiovascular Disease (J.M.L.), Vanderbilt University Medical Center, Nashville, TN
| | - Candace D McNaughton
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Karen Miller
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.)
| | - Jon W Schrock
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH (J.W.S.)
| | - Wesley H Self
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, NY (A.J.S.)
| | - Sarah A Sterling
- Department of Emergency Medicine (S.A.S.), University of Mississippi Medical Center, Jackson
| | - Sean P Collins
- Department of Emergency Medicine (W.B.S., A.B.S., J.H.H., C.D.M., K.M., W.H.S., S.P.C.), Vanderbilt University Medical Center, Nashville, TN
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15
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Somerville K, Jenkins CA, Carlucci JG, Person AK, Machado DM, Luque MT, Pinto JA, Rouzier V, Friedman RK, McGowan CC, Shepherd BE, Rebeiro PF. Outcomes After Second-Line Antiretroviral Therapy in Children Living With HIV in Latin America. J Acquir Immune Defic Syndr 2021; 87:993-1001. [PMID: 33675618 PMCID: PMC8192432 DOI: 10.1097/qai.0000000000002678] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 01/25/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about the long-term outcomes of children living with HIV in Latin America. Few studies have examined antiretroviral therapy (ART) regimen switches in the years after the introduction of ART in this population. This study aimed to assess clinical outcomes among children who started second-line ART in the Caribbean, Central and South America network for HIV epidemiology. METHODS Children (<18 years old) with HIV who switched to second-line ART at sites within Caribbean, Central and South America network for HIV epidemiology were included. The cumulative incidence and relative hazards of virologic failure while on second-line ART, loss to follow-up, additional major ART regimen changes, and all-cause mortality were evaluated using competing risks methods and Cox models. RESULTS A total of 672 children starting second-line ART were included. Three years after starting second-line ART, the cumulative incidence of death was 0.10 [95% confidence interval (CI) 0.08 to 0.13], loss to follow-up was 0.14 (95% CI: 0.11 to 0.17), and major regimen change was 0.19 (95% CI: 0.15 to 0.22). Of those changing regimens, 35% were due to failure and 11% due to toxicities/side effects. Among the 312 children with viral load data, the cumulative incidence of virologic failure at 3 years was 0.62 (95% CI: 0.56 to 0.68); time to virologic failure and regimen change were uncorrelated (rank correlation -0.001; 95% CI -0.18 to 0.17). CONCLUSIONS Poor outcomes after starting second-line ART in Latin America were common. The high incidence of virologic failure and its poor correlation with changing regimens was particularly worrisome. Additional efforts are needed to ensure children receive optimal ART regimens.
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Affiliation(s)
| | - Cathy A. Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - James G. Carlucci
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Anna K. Person
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Daisy Maria Machado
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marco T. Luque
- Instituto Hondureño de Seguridad Social and Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Jorge A. Pinto
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Ruth Khalili Friedman
- Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Catherine C. McGowan
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Peter F. Rebeiro
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Medicine, Division of Epidemiology, Vanderbilt University School of Medicine, Nashville, TN, USA
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16
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Yohannes NT, Jenkins CA, Clouse K, Cortés CP, Mejía Cordero F, Padgett D, Rouzier V, Friedman RK, McGowan CC, Shepherd BE, Rebeiro PF. Timing of HIV diagnosis relative to pregnancy and postpartum HIV care continuum outcomes among Latin American women, 2000 to 2017. J Int AIDS Soc 2021; 24:e25740. [PMID: 34021715 PMCID: PMC8140191 DOI: 10.1002/jia2.25740] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/05/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND HIV incidence among women of reproductive age and vertical HIV transmission rates remain high in Latin America. We, therefore, quantified HIV care continuum barriers and outcomes among pregnant women living with HIV (WLWH) in Latin America. METHODS WLWH (aged ≥16 years) enrolling at Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites from 2000 to 2017 who had HIV diagnosis, pregnancy and delivery dates contributed. Logistic regression produced adjusted odds ratios (aOR) and 95% confidence intervals (CI) for retention in care (≥2 visits ≥3 months apart) and virological suppression (viral load <200 copies/mL) 12 months after pregnancy outcome. Cumulative incidences of loss to follow-up (LTFU) postpartum were estimated using Cox regression. Evidence of HIV status at pregnancy confirmation was the exposure. Covariates included pregnancy outcome (born alive vs. others); AIDS diagnosis prior to delivery; CD4, age, HIV-1 RNA and cART regimen at first delivery and CCASAnet country. RESULTS Among 579 WLWH, median postpartum follow-up was 4.34 years (IQR 1.91, 7.35); 459 (79%) were HIV-diagnosed before pregnancy confirmation, 445 (77%) retained in care and 259 (45%) virologically suppressed at 12 months of postpartum. Cumulative incidence of LTFU was 21% by 12 months and 40% by five years postpartum. Those HIV-diagnosed during pregnancy had lower odds of retention (aOR = 0.58, 95% CI: 0.35 to 0.97) and virological suppression (aOR = 0.50, 95% CI: 0.31 to 0.82) versus those HIV-diagnosed before. CONCLUSION HIV diagnosis during pregnancy was associated with poorer 12-month retention and virological suppression. Young women should be tested and linked to HIV care earlier to narrow these disparities.
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Affiliation(s)
| | - Cathy A Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Kate Clouse
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt University School of NursingNashvilleTNUSA
| | | | - Fernando Mejía Cordero
- Instituto de Medicina Tropical Alexander von HumboldtUniversidad Peruana Cayetano HerediaLimaPeru
| | - Denis Padgett
- Instituto Hondureño de Seguridad Social & Hospital Escuela UniversitarioTegucigalpaHonduras
| | - Vanessa Rouzier
- Groupe Haitien d'Etudes du Sarcome de Kaposi et des Infections OpportunistesPort‐au‐PrinceHaiti
| | - Ruth K Friedman
- Instituto Nacional de Infectologia Evandro Chagas (INI)Fundação Oswaldo CruzRio de JaneiroBrazil
| | - Catherine C McGowan
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Bryan E Shepherd
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Peter F Rebeiro
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
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17
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Pierce LJ, Rebeiro P, Brantley M, Fields EL, Jenkins CA, Griffith DM, Conserve D, Shepherd B, Wester C, Ahonkhai AA. Who Is Not Linking to HIV Care in Tennessee - the Benefits of an Intersectional Approach. J Racial Ethn Health Disparities 2021; 9:849-855. [PMID: 33876409 PMCID: PMC8523577 DOI: 10.1007/s40615-021-01023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/17/2021] [Accepted: 03/14/2021] [Indexed: 11/21/2022]
Abstract
Introduction Guided by an intersectional approach, we assessed the association between social categories (individual and combined) on time to linkage to HIV care in Tennessee. Methods Tennessee residents diagnosed with HIV from 2012-2016 were included in the analysis (n=3750). Linkage was defined by the first CD4 or HIV RNA test date after HIV diagnosis. We used Cox proportional hazards models to assess the association of time to linkage with individual-level variables. We modeled interactions between race, age, gender, and HIV acquisition risk factor (RF), to understand how these variables jointly influence linkage to care. Results Age, race, and gender/RF weAima A. Ahonkhaire strong individual (p < 0.001 for each) and joint predictors of time to linkage to HIV care (p < 0.001 for interaction). Older individuals were more likely to link to care (aHR comparing 40 vs. 30 years, 1.20, 95%CI 1.11-1.29). Blacks were less likely to link to care than Whites (aHR= 0.73, 95% CI: 0.67-0.79). Men who have sex with men (MSM) (aHR = 1.18, 95%CI: 1.03-1.34) and heterosexually active females (females) (aHR = 1.32, 95%CI: 1.14-1.53) were more likely to link to care than heterosexually active males. The three-way interaction between age, race, and gender/RF showed that Black males overall and young, heterosexually active Black males in particular were least likely to establish care. Conclusions Racial disparities persist in establishing HIV care in Tennessee, but data highlighting the combined influence of age, race, gender, and sexual orientation suggest that heterosexually active Black males should be an important focus of targeted interventions for linkage to HIV care. Supplementary Information The online version contains supplementary material available at 10.1007/s40615-021-01023-6.
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Affiliation(s)
- Leslie J Pierce
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | - Peter Rebeiro
- Department of Medicine, Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Medicine, Division of Epidemiology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Errol L Fields
- Division of Adolescent/Young Adult Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Derek M Griffith
- Center for Research on Men's Health, Vanderbilt University, Nashville, TN, USA
| | - Donaldson Conserve
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, SC, USA
| | - Bryan Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Aima A Ahonkhai
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA. .,Department of Medicine, Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA.
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18
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Ward MJ, Vogus TJ, Muñoz D, Collins SP, Moser K, Jenkins CA, Liu D, Kripalani S. Examining the Timeliness of ST-elevation Myocardial Infarction Transfers. West J Emerg Med 2021; 22:319-325. [PMID: 33856318 PMCID: PMC7972365 DOI: 10.5811/westjem.2020.8.47770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Despite large-scale quality improvement initiatives, substantial proportions of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention centers do not receive percutaneous coronary intervention within the recommended 120 minutes. We sought to examine the contributory role of emergency medical services (EMS) activation relative to percutaneous coronary intervention center activation in the timeliness of care for patients transferred with STEMI. Methods We conducted a retrospective analysis of interfacility transfers from emergency departments (ED) to a single percutaneous coronary intervention center between 2011–2014. We included emergency department (ED) patients transferred to the percutaneous coronary intervention center and excluded scene transfers and those given fibrinolytics. We calculated descriptive statistics and used multivariable linear regression to model the association of variables with ED time intervals (arrival to electrocardiogram [ECG], ECG-to-EMS activation, and ECG-to-STEMI alert) adjusting for patient age, gender, mode of arrival, weekday hour presentation, facility transfers in the past year, and transferring facility distance. Results We identified 159 patients who met inclusion criteria. Subjects were a mean of 59 years old (standard deviation 13), 22% female, and 93% White; 59% arrived by private vehicle, and 24% presented after weekday hours. EDs transferred a median of 9 STEMIs (interquartile range [IQR] 3, 15) in the past year and a median of 65 miles (IQR 35, 90) from the percutaneous coronary intervention center. Median ED length of stay was 65 minutes (IQR 51, 85). Among component intervals, arrival to ECG was 6%, ECG-to-EMS activation 32%, and ECG-to-STEMI alert was 49% of overall ED length of stay. Only 18% of transfers had EMS activation earlier than STEMI alert. ECG-to-EMS activation was shorter in EDs achieving length of stay ≤60 minutes compared to those >60 minutes (12 vs 31 minutes, P<0.001). Multivariable modeling showed that after-hours presentation was associated with longer ECG-to-EMS activation (adjusted relative risk [RR] 1.05, P<0.001). Female gender (adjusted RR 0.81, P<0.001), prior facility transfers (adjusted RR 0.84, P<0.001), and initial ambulance presentation (adjusted RR 0.93, P = 0.02) were associated with shorter ECG-to-EMS activation. Conclusion In STEMI transfers, faster EMS activation was more likely to achieve a shorter ED length of stay than a rapid, percutaneous coronary intervention center STEMI alert. Large-scale quality improvement efforts such as the American Heart Association’s Mission Lifeline that were designed to regionalize STEMI have improved the timeliness of reperfusion, but major gaps, particularly in interfacility transfers, remain. While the transferring EDs are recognized as the primary source of delay during interfacility STEMI transfers, the contributions to delays at transferring EDs remain poorly understood.
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Affiliation(s)
- Michael J Ward
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee.,VA Tennessee Valley Healthcare System, Department of Emergency Medicine, Murfreesboro, Tennessee
| | - Timothy J Vogus
- Vanderbilt University, Owen Graduate School of Management, Nashville, Tennessee
| | - Daniel Muñoz
- Vanderbilt University School of Medicine, Division of Cardiology, Nashville, Tennessee
| | - Sean P Collins
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee.,VA Tennessee Valley Healthcare System, Department of Emergency Medicine, Murfreesboro, Tennessee
| | - Kelly Moser
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Cathy A Jenkins
- Vanderbilt University School of Medicine, Department of Biostatistics, Nashville, Tennessee
| | - Dandan Liu
- Vanderbilt University School of Medicine, Department of Biostatistics, Nashville, Tennessee
| | - Sunil Kripalani
- Vanderbilt University Medical Center, Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Center for Clinical Quality and Implementation Research, Nashville, Tennessee
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19
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Collins SP, Liu D, Jenkins CA, Storrow AB, Levy PD, Pang PS, Chang AM, Char D, Diercks DJ, Fermann GJ, Han JH, Hiestand B, Hogan C, Kampe CJ, Khan Y, Lee S, Lindenfeld J, Martindale J, McNaughton CD, Miller KF, Miller-Reilly C, Moser K, Peacock WF, Robichaux C, Rothman R, Schrock J, Self WH, Singer AJ, Sterling SA, Ward MJ, Walsh C, Butler J. Effect of a Self-care Intervention on 90-Day Outcomes in Patients With Acute Heart Failure Discharged From the Emergency Department: A Randomized Clinical Trial. JAMA Cardiol 2021; 6:200-208. [PMID: 33206126 DOI: 10.1001/jamacardio.2020.5763] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Up to 20% of patients who present to the emergency department (ED) with acute heart failure (AHF) are discharged without hospitalization. Compared with rates in hospitalized patients, readmission and mortality are worse for ED patients. Objective To assess the impact of a self-care intervention on 90-day outcomes in patients with AHF who are discharged from the ED. Design, Setting, and Participants Get With the Guidelines in Emergency Department Patients With Heart Failure was an unblinded, parallel-group, multicenter randomized trial. Patients were randomized 1:1 to usual care vs a tailored self-care intervention. Patients with AHF discharged after ED-based management at 15 geographically diverse EDs were included. The trial was conducted from October 28, 2015, to September 5, 2019. Interventions Home visit within 7 days of discharge and twice-monthly telephone-based self-care coaching for 3 months. Main Outcomes and Measures The primary outcome was a global rank of cardiovascular death, HF-related events (unscheduled clinic visit due to HF, ED revisit, or hospitalization), and changes in the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) summary score (SS) at 90 days. Key secondary outcomes included the global rank outcome at 30 days and changes in the KCCQ-12 SS score at 30 and 90 days. Intention-to-treat analysis was performed for the primary, secondary, and safety outcomes. Per-protocol analysis was conducted including patients who completed a home visit and had scheduled outpatient follow-up in the intervention arm. Results Owing to slow enrollment, 479 of a planned 700 patients were randomized: 235 to the intervention arm and 244 to the usual care arm. The median age was 63.0 years (interquartile range, 54.7-70.2), 302 patients (63%) were African American, 305 patients (64%) were men, and 178 patients (37%) had a previous ejection fraction greater than 50%. There was no significant difference in the primary outcome between patients in the intervention vs usual care arm (hazard ratio [HR], 0.89; 95% CI, 0.73-1.10; P = .28). At day 30, patients in the intervention arm had significantly better global rank (HR, 0.80; 95% CI, 0.64-0.99; P = .04) and a 5.5-point higher KCCQ-12 SS (95% CI, 1.3-9.7; P = .01), while at day 90, the KCCQ-12 SS was 2.7 points higher (95% CI, -1.9 to 7.2; P = .25). Conclusions and Relevance The self-care intervention did not improve the primary global rank outcome at 90 days in this trial. However, benefit was observed in the global rank and KCCQ-12 SS at 30 days, suggesting that an early benefit of a tailored self-care program initiated at an ED visit for AHF was not sustained through 90 days. Trial Registration ClinicalTrials.gov Identifier: NCT02519283.
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Affiliation(s)
- Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dandan Liu
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cathy A Jenkins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Phillip D Levy
- Department of Emergency Medicine, Detroit Medical Center, Detroit, Michigan
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University Medical Center, Indianapolis
| | - Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University Medical Center, Philadelphia, Pennsylvania
| | - Douglas Char
- Department of Emergency Medicine, Washington University Medical Center in St Louis, St Louis, Missouri
| | - Deborah J Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian Hiestand
- Department of Emergency Medicine, Wake Forest University Medical Center, Winston-Salem, North Carolina
| | - Christopher Hogan
- Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Christina J Kampe
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yosef Khan
- Department of Emergency Medicine, American Heart Association
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa Medical Center, Iowa City
| | - JoAnn Lindenfeld
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer Martindale
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Kelly Moser
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Russell Rothman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jon Schrock
- Department of Emergency Medicine, Metro Health Medical Center, Cleveland, Ohio
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Sarah A Sterling
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
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Cox ZL, Collins SP, Aaron M, Hernandez GA, III ATM, Davidson BT, Fowler M, Lindsell CJ, Jr FEH, Jenkins CA, Kampe C, Miller KF, Stubblefield WB, Lindenfeld J. Efficacy and safety of dapagliflozin in acute heart failure: Rationale and design of the DICTATE-AHF trial. Am Heart J 2021; 232:116-124. [PMID: 33144086 DOI: 10.1016/j.ahj.2020.10.071] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/27/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, reduces cardiovascular death and worsening heart failure in patients with chronic heart failure and reduced ejection fraction. Early initiation during an acute heart failure (AHF) hospitalization may facilitate decongestion, improve natriuresis, and facilitate safe transition to a beneficial outpatient therapy for both diabetes and heart failure. OBJECTIVE The objective is to assess the efficacy and safety of initiating dapagliflozin within the first 24 hours of hospitalization in patients with AHF compared to usual care. METHODS DICTATE-AHF is a prospective, multicenter, open-label, randomized trial enrolling a planned 240 patients in the United States. Patients with type 2 diabetes hospitalized with hypervolemic AHF and an estimated glomerular filtration rate of at least 30 mL/min/1.73m2 are eligible for participation. Patients are randomly assigned 1:1 to dapagliflozin 10 mg once daily or structured usual care until day 5 or hospital discharge. Both treatment arms receive protocolized diuretic and insulin therapies. The primary endpoint is diuretic response expressed as the cumulative change in weight per cumulative loop diuretic dose in 40 mg intravenous furosemide equivalents. Secondary and exploratory endpoints include inpatient worsening AHF, 30-day hospital readmission for AHF or diabetic reasons, change in NT-proBNP, and measures of natriuresis. Safety endpoints include the incidence of hyper/hypoglycemia, ketoacidosis, worsening kidney function, hypovolemic hypotension, and inpatient mortality. CONCLUSIONS The DICTATE-AHF trial will establish the efficacy and safety of early initiation of dapagliflozin during AHF across both AHF and diabetic outcomes in patients with diabetes.
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21
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Yiadom MYAB, Olubowale OO, Jenkins CA, Miller KF, West JL, Vogus TJ, Lehmann CU, Antonello VD, Bernard GR, Storrow AB, Lindsell CJ, Liu D. Understanding timely STEMI treatment performance: A 3-year retrospective cohort study using diagnosis-to-balloon-time and care subintervals. J Am Coll Emerg Physicians Open 2021; 2:e12379. [PMID: 33644777 PMCID: PMC7890036 DOI: 10.1002/emp2.12379] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE From the perspective of percutaneous coronary intervention (PCI) centers, locations of ST-segment elevation myocardial infarction (STEMI) diagnosis can include a referring facility, emergency medical services (EMS) transporting to a PCI center, or the PCI center's emergency department (ED). This challenges the use of door-to-balloon-time as the primary evaluative measure of STEMI treatment pathways. Our objective was to identify opportunities to improve care by quantifying differences in the timeliness of STEMI treatment mobilization based on the location of the diagnostic ECG. METHODS This 3-year, single-center, retrospective cohort study classified patients by diagnostic ECG location: referring facility, EMS, or PCI center ED. We quantified door-to-balloon-time and diagnosis-to-balloon-time with its care subintervals. RESULTS Of 207 ED STEMI patients, 180 (87%) received PCI. Median diagnosis-to-balloon-times were shortest among the ED-diagnosed (78 minutes [interquartile range (IQR), 61-92]), followed by EMS-identified patients (89 minutes [IQR, 78-122]), and longest among those referred (140 minutes [IQR, 119-160]), reflecting time for transport to the PCI center. Conversely, referred patients had the shortest median door-to-balloon-times (38 minutes [IQR, 34-43]), followed by the EMS-identified (64 minutes [IQR, 47-77]), whereas ED-diagnosed patients had the longest (89 minutes [IQR, 70-114]), reflecting diagnosis and catheterization lab activation frequently occurring before PCI center ED arrival for referred and EMS-identified patients. CONCLUSIONS Diagnosis-to-balloon-time and its care subintervals are complementary to the traditional door-to-balloon-times as measures of the STEMI treatment process. Together, they highlight opportunities to improve timely identification among ED-diagnosed patients, use of out-of-hospital cath lab activation for EMS-identified patients, and encourage pathways for referred patients to bypass PCI center EDs.
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Affiliation(s)
- Maame Yaa A. B. Yiadom
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Olayemi O. Olubowale
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Cathy A. Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Karen F. Miller
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jennifer L. West
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Timothy J. Vogus
- Owen Graduate School of ManagementVanderbilt UniversityNashvilleTennesseeUSA
| | - Christoph U. Lehmann
- Department of Biomedical Informatics & PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Victoria D. Antonello
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Gordon R. Bernard
- Department of Medicine, Division of Critical CareVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Alan B. Storrow
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Dandan Liu
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
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22
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Castilho JL, Kim A, Jenkins CA, Grinsztejn B, Gotuzzo E, Fink V, Padgett D, Belaunzaran‐Zamudio PF, Crabtree‐Ramírez B, Escuder MM, Souza RA, Tenore SB, Pimentel SR, Ikeda MLR, de Alencastro PR, Tupinanbas U, Brites C, Luz E, Netto J, Cortes CP, Grangeiro A, Shepherd BE, McGowan CC. Antiretroviral therapy and Kaposi's sarcoma trends and outcomes among adults with HIV in Latin America. J Int AIDS Soc 2021; 24:e25658. [PMID: 33405281 PMCID: PMC7787071 DOI: 10.1002/jia2.25658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Kaposi's sarcoma (KS) remains the most frequent malignancy in persons living with HIV (PWH) in Latin America. We examined KS trends and outcomes from Latin American clinical sites in the era of increased access to antiretroviral therapy (ART). METHODS Cohorts in Brazil, Peru, Mexico, Honduras, Argentina and Chile contributed clinical data of PWH ≥16 years old from 2000 to 2017, excluding patients with KS diagnosed before clinic enrolment. We compared KS incidence over time using multivariable incidence rate ratios. Predictors of KS before/at or after ART initiation and of mortality after KS were examined using Cox regression. RESULTS Of 25 981 PWH, 481 had incident KS, including 200 ART-naïve and 281 ART-treated patients. From 2000 to 2017, the incidence of KS decreased from 55.1 to 3.0 per 1000 person-years. In models adjusting for CD4 and other factors, the relative risk for KS decreased from 2000 to 2008. Since 2010, the adjusted risk of KS increased in the periods before and ≤90 days after ART initiation but decreased >90 days after ART. In addition to low CD4 and male-to-male sex, KS risk after ART was associated with age and history of other AIDS-defining illnesses. Mortality after KS (approximately 25% after five years) was not associated with either year of KS diagnosis nor timing of diagnosis relative to ART initiation. CONCLUSIONS KS incidence in Latin America has remained stable in recent years and risk is highest before and shortly after ART initiation. Early diagnosis of HIV and ART initiation remain critical priorities in the region.
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Affiliation(s)
- Jessica L Castilho
- Division of Infectious DiseasesVanderbilt University Medical CenterNashvilleTNUSA
| | - Ahra Kim
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Cathy A Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | | | - Eduardo Gotuzzo
- Universidad Peruana Cayetano HerediaInstituto de Medicina Tropical Alexander von HumboldtLimaPeru
| | - Valeria Fink
- Fundación HuéspedInvestigaciones ClínicasBuenos AiresArgentina
| | - Denis Padgett
- Instituto Hondureño de Seguridad Social and Hospital Escuela UniversitarioTegucigalpaHonduras
| | - Pablo F Belaunzaran‐Zamudio
- Deparatmento de InfectologiaInstituto Nacional de Ciencias Médicas y NutriciónSalvador Zubirán. Mexico CityMexico
| | - Brenda Crabtree‐Ramírez
- Deparatmento de InfectologiaInstituto Nacional de Ciencias Médicas y NutriciónSalvador Zubirán. Mexico CityMexico
| | | | - Rosa Alencar Souza
- São Paulo State Department of HealthAIDS Reference and Training CenterSão PauloBrazil
| | - Simone B Tenore
- São Paulo State Department of HealthAIDS Reference and Training CenterSão PauloBrazil
| | - Sidnei R Pimentel
- São Paulo State Department of HealthAIDS Reference and Training CenterSão PauloBrazil
| | - Maria Letícia Rodrigues Ikeda
- Care and Treatment Clinic of the Partenon SanatoriumRio Grande do Sul State Department of HealthPorto AlegreBrazil
- University of Vale do Rio dos SinosSão LeopoldoBrazil
| | - Paulo R de Alencastro
- Care and Treatment Clinic of the Partenon SanatoriumRio Grande do Sul State Department of HealthPorto AlegreBrazil
| | - Unai Tupinanbas
- Medical SchoolFederal University of Minas GeraisBelo HorizonteBrazil
| | - Carlos Brites
- Edgar Santos University Hospital ComplexFederal University of BahiaSalvadorBrazil
| | - Estela Luz
- Edgar Santos University Hospital ComplexFederal University of BahiaSalvadorBrazil
| | - Juliana Netto
- Instituto Nacional de Infectiologia Evandro ChagasFiocruzBrazil
| | - Claudia P Cortes
- Fundaciòn Arriaran and University of Chile School of MedicineSantiagoChile
| | - Alexandre Grangeiro
- Department of Preventive MedicineUniversity of São Paulo School of MedicineSão PauloBrazil
| | - Bryan E Shepherd
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Catherine C McGowan
- Division of Infectious DiseasesVanderbilt University Medical CenterNashvilleTNUSA
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23
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Self WH, Evans CS, Jenkins CA, Brown RM, Casey JD, Collins SP, Coston TD, Felbinger M, Flemmons LN, Hellervik SM, Lindsell CJ, Liu D, McCoin NS, Niswender KD, Slovis CM, Stollings JL, Wang L, Rice TW, Semler MW. Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA Netw Open 2020; 3:e2024596. [PMID: 33196806 PMCID: PMC7670314 DOI: 10.1001/jamanetworkopen.2020.24596] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Saline (0.9% sodium chloride), the fluid most commonly used to treat diabetic ketoacidosis (DKA), can cause hyperchloremic metabolic acidosis. Balanced crystalloids, an alternative class of fluids for volume expansion, do not cause acidosis and, therefore, may lead to faster resolution of DKA than saline. OBJECTIVE To compare the clinical effects of balanced crystalloids with the clinical effects of saline for the acute treatment of adults with DKA. DESIGN, SETTING, AND PARTICIPANTS This study was a subgroup analysis of adults with DKA in 2 previously reported companion trials-Saline Against Lactated Ringer's or Plasma-Lyte in the Emergency Department (SALT-ED) and the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). These trials, conducted between January 2016 and March 2017 in an academic medical center in the US, were pragmatic, multiple-crossover, cluster, randomized clinical trials comparing balanced crystalloids vs saline in emergency department (ED) and intensive care unit (ICU) patients. This study included adults who presented to the ED with DKA, defined as a clinical diagnosis of DKA, plasma glucose greater than 250 mg/dL, plasma bicarbonate less than or equal to 18 mmol/L, and anion gap greater than 10 mmol/L. Data analysis was performed from January to April 2020. INTERVENTIONS Balanced crystalloids (clinician's choice of Ringer lactate solution or Plasma-Lyte A solution) vs saline for fluid administration in the ED and ICU according to the same cluster-randomized multiple-crossover schedule. MAIN OUTCOMES AND MEASURES The primary outcome was time between ED presentation and DKA resolution, as defined by American Diabetes Association criteria. The secondary outcome was time between initiation and discontinuation of continuous insulin infusion. RESULTS Among 172 adults included in this secondary analysis of cluster trials, 94 were assigned to balanced crystalloids and 78 to saline. The median (interquartile range [IQR]) age was 29 (24-45) years, and 90 (52.3%) were women. The median (IQR) volume of isotonic fluid administered in the ED and ICU was 4478 (3000-6372) mL. Cumulative incidence analysis revealed shorter time to DKA resolution in the balanced crystalloids group (median time to resolution: 13.0 hours; IQR: 9.5-18.8 hours) than the saline group (median: 16.9 hours; IQR: 11.9-34.5 hours) (adjusted hazard ratio [aHR] = 1.68; 95% CI, 1.18-2.38; P = .004). Cumulative incidence analysis also revealed shorter time to insulin infusion discontinuation in the balanced crystalloids group (median: 9.8 hours; IQR: 5.1-17.0 hours) than the saline group (median: 13.4 hours; IQR: 11.0-17.9 hours) (aHR = 1.45; 95% CI, 1.03-2.03; P = .03). CONCLUSIONS AND RELEVANCE In this secondary analysis of 2 cluster randomized clinical trials, compared with saline, treatment with balanced crystalloids resulted in more rapid resolution of DKA, suggesting that balanced crystalloids may be preferred over saline for acute management of adults with DKA. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT02614040; NCT02444988.
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Affiliation(s)
- Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher S. Evans
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cathy A. Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ryan M. Brown
- Asheville Pulmonary and Critical Care Associates, Asheville, North Carolina
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Taylor D. Coston
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Felbinger
- Department of Pharmacy Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lisa N. Flemmons
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan M. Hellervik
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nicole S. McCoin
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin D. Niswender
- Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Nashville
| | - Corey M. Slovis
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joanna L. Stollings
- Department of Pharmacy Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Rebeiro PF, Jenkins CA, Bian A, Lake JE, Bourgi K, Moore RD, Horberg MA, Matthews WC, Silverberg MJ, Thorne J, Mayor AM, Lima VD, Palella FJ, Saag MS, Althoff KN, Gill MJ, Wong C, Klein MB, Crane HM, Marconi VC, Shepherd BE, Sterling TR, Koethe JR. Risk of Incident Diabetes Mellitus, Weight Gain, and their Relationships with Integrase Inhibitor-based Initial Antiretroviral Therapy Among Persons with HIV in the US and Canada. Clin Infect Dis 2020; 73:e2234-e2242. [PMID: 32936919 DOI: 10.1093/cid/ciaa1403] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Integrase strand transfer inhibitor (INSTI)-based combination antiretroviral therapy (cART) is associated with greater weight gain among persons with HIV, though the metabolic consequences, such as diabetes mellitus (DM), are unclear. We examined the impact of initial cART regimen and weight on incident DM in a large North American HIV cohort (NA-ACCORD). METHODS cART-naïve adults (≥18 years) initiating INSTI-, PI-, or NNRTI-based regimens from 01/2007-12/2017 who had weight measured 12 (±6) months after treatment initiation contributed time until clinical DM (HbA1c ≥6.5%, initiation of DM-specific medication, or new DM diagnosis plus DM-related medication), virologic failure, cART regimen switch, administrative close, death, or loss to follow-up. Multivariable Cox regression yielded adjusted hazard ratios (HR) and 95% confidence intervals ([-]) for incident DM by cART class. Mediation analyses, with 12-month weight as mediator, adjusted for all covariates from the primary analysis. RESULTS Among 22,884 eligible individuals, 47% started NNRTI-, 30% PI-, and 23% INSTI-based cART with median follow-up of 3.0, 2.3, and 1.6 years, respectively. Overall, 722 (3%) developed DM. Persons starting INSTIs vs. NNRTIs had incident DM risk (HR=1.17 [0.92-1.48]) similar to PI- vs. NNRTI-initiators (HR=1.27 [1.07-1.51]). This effect was most pronounced for raltegravir- (HR=1.42 [1.06-1.91]) vs. NNRTI-initiators. The INSTI-DM association was attenuated (HR=1.03 [0.71-1.49] vs. NNRTIs) when accounting for 12-month weight. CONCLUSIONS Initiating first cART regimens with INSTIs or PIs vs. NNRTIs may confer greater risk of DM, likely mediated through weight gain. Further characterization of metabolic changes after INSTI initiation and potential therapeutic interventions are needed.
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Affiliation(s)
- Peter F Rebeiro
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Cathy A Jenkins
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Aihua Bian
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jordan E Lake
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kassem Bourgi
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | | | | | - Angel M Mayor
- Retrovirus Research Center, Universidad Central del Caribe, Bayamón, PR, USA
| | | | - Frank J Palella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael S Saag
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | | | | | | | | | - John R Koethe
- Vanderbilt University School of Medicine, Nashville, TN, USA.,Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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25
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Bourgi K, Jenkins CA, Rebeiro PF, Palella F, Moore RD, Altoff KN, Gill J, Rabkin CS, Gange SJ, Horberg MA, Margolick J, Li J, Wong C, Willig A, Lima VD, Crane H, Thorne J, Silverberg M, Kirk G, Mathews WC, Sterling TR, Lake J, Koethe JR. Weight gain among treatment-naïve persons with HIV starting integrase inhibitors compared to non-nucleoside reverse transcriptase inhibitors or protease inhibitors in a large observational cohort in the United States and Canada. J Int AIDS Soc 2020; 23:e25484. [PMID: 32294337 PMCID: PMC7159248 DOI: 10.1002/jia2.25484] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/26/2020] [Accepted: 03/06/2020] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Weight gain following antiretroviral therapy (ART) initiation is common, potentially predisposing some persons with HIV (PWH) to cardio-metabolic disease. We assessed relationships between ART drug class and weight change among treatment-naïve PWH initiating ART in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). METHODS Adult, treatment-naïve PWH in NA-ACCORD initiating integrase strand transfer inhibitor (INSTI), protease inhibitor (PI) or non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based ART on/after 1 January 2007 were followed through 31 December 2016. Multivariate linear mixed effects models estimated weight up to five years after ART initiation, adjusting for age, sex, race, cohort site, HIV acquisition mode, treatment year, and baseline weight, plasma HIV-1 RNA level and CD4+ cell count. Due to shorter follow-up for PWH receiving newer INSTI drugs, weights for specific INSTIs were estimated at two years. Secondary analyses using logistic regression and all covariates from primary analyses assessed factors associated with >10% weight gain at two and five years. RESULTS Among 22,972 participants, 87% were male, and 41% were white. 49% started NNRTI-, 31% started PI- and 20% started INSTI-based regimens (1624 raltegravir (RAL), 2085 elvitegravir (EVG) and 929 dolutegravir (DTG)). PWH starting INSTI-based regimens had mean estimated five-year weight change of +5.9kg, compared to +3.7kg for NNRTI and +5.5kg for PI. Among PWH starting INSTI drugs, mean estimated two-year weight change was +7.2kg for DTG, +5.8kg for RAL and +4.1kg for EVG. Women, persons with lower baseline CD4+ cell counts, and those initiating INSTI-based regimens had higher odds of >10% body weight increase at two years (adjusted odds ratio = 1.37, 95% confidence interval: 1.20 to 1.56 vs. NNRTI). CONCLUSIONS PWH initiating INSTI-based regimens gained, on average, more weight compared to NNRTI-based regimens. This phenomenon may reflect heterogeneous effects of ART agents on body weight regulation that require further exploration.
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Affiliation(s)
- Kassem Bourgi
- Vanderbilt University Medical CenterNashvilleTNUSA
- Indiana University School of MedicineIndianapolisINUSA
| | | | | | - Frank Palella
- Northwestern University Feinberg School of MedicineChicagoILUSA
| | | | | | - John Gill
- University of CalgaryCalgaryABCanada
| | | | | | - Michael A Horberg
- Mid‐Atlantic Permanente Research InstituteKaiser Permanente Mid‐Atlantic StatesRockvilleMDUSA
| | | | - Jun Li
- Centers for Disease Control and PreventionAtlantaGAUSA
| | | | | | | | | | | | - Michael Silverberg
- Kaiser Permanente Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | | | | | | | - Jordan Lake
- University of Texas Health Science Center at HoustonHoustonTXUSA
| | - John R Koethe
- Vanderbilt University Medical CenterNashvilleTNUSA
- Veterans Affairs Tennessee Valley Healthcare SystemNashvilleTNUSA
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Hall T, Jenkins CA, Hulgan T, Furukawa S, Turner M, Pratap S, Sterling TR, Tabatabai M, Berthaud V. Hepatitis C Coinfection and Mortality in People Living with HIV in Middle Tennessee. AIDS Res Hum Retroviruses 2020; 36:193-199. [PMID: 31789047 PMCID: PMC7071089 DOI: 10.1089/aid.2019.0113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
HIV and hepatitis C virus (HCV) coinfection is associated with poor health outcomes. This study was designed to assess risk factors for and mortality with coinfection before direct-acting antiviral treatment availability in a state with an evolving opioid epidemic. HCV infection was determined from review of the medical record at two clinics serving the majority of people living with HIV (PLWH) in care in Middle Tennessee from 2004 to 2013. Association of potential risk factors with HCV-positivity was assessed using logistic regression. Association of HCV-positivity with mortality was assessed with a Cox proportional hazards model, adjusting for selected covariates. A total of 3,501 patients were included: 24% female; 51% men who have sex with men; 47% white; 44% African American/black; median age of 38 at their first visit; median most recent CD4 count 502 cells/μL (301-716); and HIV viral load 47 copies/mL (39-605); followed for a median of 3.0 (1-5) years. Prevalence of HCV was 13%. Those with a history of injection drug use (IDU) demonstrated the highest odds of HCV-positivity [odds ratio 12.94; 95% confidence interval (CI) 9.39-17.83]. There were 305 deaths; median age at death was 47 years (40-53). HCV coinfection was associated with greater mortality (hazard ratio 1.61; 95% CI 1.20-2.17; p < .001). Among PLWH, HCV coinfection was associated with IDU and an independent predictor of mortality. These results affirm the importance of HCV coinfection and inform interventions targeting the continuum of HCV care, uptake of HCV treatment, and the impact of drug use in this population.
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Affiliation(s)
- Toni Hall
- Department of Medicine, Meharry Medical College, Nashville, Tennessee
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Hulgan
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sally Furukawa
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Megan Turner
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Siddharth Pratap
- Department of Bioinformatics, Meharry Medical College, Nashville, Tennessee
| | - Timothy R Sterling
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mohammad Tabatabai
- Department of Biostatistics, Meharry Medical College, Nashville, Tennessee
| | - Vladimir Berthaud
- Department of Medicine, Meharry Medical College, Nashville, Tennessee
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Neil Holby S, Muñoz D, Collins SP, Vogus TJ, Jenkins CA, Liu D, Ward MJ. Quality of physician care coordination during inter-facility transfer for cardiac arrest patients. Am J Emerg Med 2019; 38:339-342. [PMID: 31785983 DOI: 10.1016/j.ajem.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/23/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022] Open
Abstract
AIM We sought to evaluate whether the quality of coordination between physicians transferring comatose cardiac arrest survivors to a high-volume cardiac arrest center for targeted temperature management (TTM) was associated with timeliness of care. METHODS We conducted a retrospective analysis of inter-facility transfers to Vanderbilt University Medical Center for TTM between October 2016 and October 2018. We examined the relationship between Relational Coordination (RC) - a measure of communication and relationship quality - during phone conversations between transferring physicians and time-to-acceptance. RESULTS We identified 18 patients meeting criteria. TTM was initiated or continued in 72%, and in-hospital mortality was 75%. Median time-to-acceptance was 2.77 (interquartile range [IQR] 2.0, 4.1) minutes, and duration of calls was 3.95 (IQR 2.7, 5.2) minutes. Interrater reliability for overall RC was high (rho = 0.87). The correlation between RC and the time-to-acceptance was significant in univariate analyses (adjusted relative risk = 0.96, 95%CI 0.93, 1.0, p = 0.05). Secondary analyses did not find a significant relationship between RC and timeliness measures. CONCLUSION In this sample of patients transferred for TTM, we found that RC as a measure of care coordination, was reliable. Higher quality care coordination for cardiac arrest survivors was associated with faster physician acceptance. Future work using a larger cohort should explore if higher RC among a broader set of stakeholders (physicians, EMS, families, etc.) is associated with timeliness measures after adjusting for other factors, to better understand how the quality of care coordination impacts timeliness of care and patient outcomes.
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Affiliation(s)
- S Neil Holby
- Department of Medicine, Vanderbilt University Medical Center, United States
| | - Daniel Muñoz
- Division of Cardiology, Vanderbilt University Medical Center, United States
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, VA Tennessee Valley Healthcare System, United States
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, United States
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, United States
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, United States
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, VA Tennessee Valley Healthcare System, United States.
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Pettit AC, Jenkins CA, Blevins Peratikos M, Yotebieng M, Diero L, Do CD, Ross J, Veloso VG, Hawerlander D, Marcy O, Shepherd BE, Fenner L, Sterling TR. Directly observed therapy and risk of unfavourable tuberculosis treatment outcomes among an international cohort of people living with HIV in low- and middle-income countries. J Int AIDS Soc 2019; 22:e25423. [PMID: 31814312 PMCID: PMC6900483 DOI: 10.1002/jia2.25423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/08/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Identification of persons living with human immunodeficiency virus (HIV)-associated tuberculosis (TB) at increased risk for unfavourable TB outcomes would inform efforts to improve such outcomes. We sought to identify factors associated with a decreased risk of unfavourable TB treatment outcomes among people living with HIV-infection (PLHIV) in low- and middle-income countries (LMIC), with a specific focus on directly observed therapy (DOT) compared with self-administered therapy (SAT) during the continuation phase of anti-TB therapy. METHODS We conducted a retrospective cohort study among adults diagnosed with HIV-associated TB in Africa, Asia and the Americas from 2012 to 2013; data were collected from 2012 to 2016. Unfavourable TB treatment outcomes (death during TB treatment, and TB treatment failure or recurrence) were defined according to World Health Organization criteria. Receipt of DOT was obtained at the site level and defined as ≥5 days of DOT per week. The person administering DOT and treatment location varied by site. Lack of receipt of DOT was defined as SAT. Multivariable logistic regression estimated the adjusted odds of unfavourable TB treatment outcomes. RESULTS Among 1862 adults with HIV-associated TB included, 252 (13.5%) had unfavourable TB outcomes (226 deaths, 26 recurrences/failures). Overall, 1825 (98%) received DOT in the intensive phase and 1617 (87%) received DOT in the continuation phase. DOT in the continuation phase was not significantly associated with unfavourable TB outcomes (aOR 1.43, 95% CI 0.86 to 2.38) compared to SAT. Body mass index (BMI) change during anti-TB treatment (per 2 units increase, aOR 0.74, 95% CI 0.68 to 0.82) and CD4+ count at TB diagnosis (200 vs. 50 cells/µL, aOR 0.54, 95% CI 0.39 to 0.73) were both independently associated with decreased odds of unfavourable TB treatment outcomes. CONCLUSIONS In this large, international cohort of people living with HIV-associated TB in LMIC who received intensive phase DOT, DOT during the continuation phase of anti-TB therapy was not associated with a decreased odds of unfavourable TB treatment outcomes compared to SAT. Randomized trials evaluating the effect of continuation-phase DOT on TB outcomes among PLHIV are needed.
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Affiliation(s)
- April C Pettit
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt Tuberculosis CenterNashvilleTNUSA
| | - Cathy A Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | | | | | - Lameck Diero
- Academic Model Providing Access To Healthcare (AMPATH)EldoretKenya
| | | | - Jeremy Ross
- TREAT Asia/amfAR – The Foundation for AIDS ResearchBangkokThailand
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro ChagasFundação Oswaldo CruzRio de JaneiroRJBrazil
| | - Denise Hawerlander
- Centre Intégré de Recherches Biocliniques d'Abidjan CIRBAAbidjanCôte d'Ivoire
| | - Olivier Marcy
- Centre INSERM U1219Bordeaux Population HealthUniversity of BordeauxBordeauxFrance
| | - Bryan E Shepherd
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Lukas Fenner
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - Timothy R Sterling
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt Tuberculosis CenterNashvilleTNUSA
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Collins SP, Jenkins CA, Baughman A, Miller KF, Storrow AB, Han JH, Brown NJ, Liu D, Luther JM, McNaughton CD, Self WH, Peng D, Testani JM, Lindenfeld J. Early urine electrolyte patterns in patients with acute heart failure. ESC Heart Fail 2018; 6:80-88. [PMID: 30295437 PMCID: PMC6351901 DOI: 10.1002/ehf2.12368] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [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: 06/22/2018] [Revised: 08/23/2018] [Accepted: 08/30/2018] [Indexed: 12/24/2022] Open
Abstract
Aims We conducted a prospective study of emergency department (ED) patients with acute heart failure (AHF) to determine if worsening HF (WHF) could be predicted based on urinary electrolytes during the first 1–2 h of ED care. Loop diuretics are standard therapy for AHF patients. A subset of patients hospitalized for AHF will develop a blunted natriuretic response to loop diuretics, termed diuretic resistance, which often leads to WHF. Early detection of diuretic resistance could facilitate escalation of therapy and prevention of WHF. Methods and results Patients were eligible if they had an ED AHF diagnosis, had not yet received intravenous diuretics, had a systolic blood pressure > 90 mmHg, and were not on dialysis. Urine electrolytes and urine output were collected at 1, 2, 4, and 6 h after diuretic administration. Worsening HF was defined as clinically persistent or WHF requiring escalation of diuretics or administration of intravenous vasoactives after the ED stay. Of the 61 patients who qualified in this pilot study, there were 10 (16.3%) patients who fulfilled our definition of WHF. At 1 h after diuretic administration, patients who developed WHF were more likely to have low urinary sodium (9.5 vs. 43.0 mmol; P < 0.001) and decreased urine sodium concentration (48 vs. 80 mmol/L; P = 0.004) than patients without WHF. All patients with WHF had a total urine sodium of <35.4 mmol at 1 h (100% sensitivity and 60% specificity). Conclusions One hour after diuretic administration, a urine sodium excretion of <35.4 mmol was highly suggestive of the development of WHF. These relationships require further testing to determine if early intervention with alternative agents can prevent WHF.
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Affiliation(s)
- Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adrienne Baughman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy J Brown
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James M Luther
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Internal Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Internal Medicine, Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dungeng Peng
- Department of Internal Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Division of Cardiology, Yale University, New Haven, CT, USA
| | - JoAnn Lindenfeld
- Department of Internal Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Ward MJ, Kc D, Jenkins CA, Liu D, Padaki A, Pines JM. Emergency department provider and facility variation in opioid prescriptions for discharged patients. Am J Emerg Med 2018; 37:851-858. [PMID: 30077493 DOI: 10.1016/j.ajem.2018.07.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/09/2018] [Accepted: 07/30/2018] [Indexed: 12/19/2022] Open
Abstract
STUDY OBJECTIVE To study the variation in opioid prescribing among emergency physicians and facilities for discharged adult ED patients. METHODS We conducted a retrospective analysis of ED visits from five U.S. hospitals between January and May 2014 using records from Data to Intelligence (D2i). We examined physician- and facility-level variation in opioid prescription rates for discharged ED patients. We calculated unadjusted opioid prescription rates at the physician and facility levels and used a multivariable mixed-effect logistic regression model to examine within-facility physician variation in opioid prescription adjusting for patient and situational factors including time of presentation, ED census, and physician workload. RESULTS In 47,304 visits across five EDs, median patient age was 40 years old (IQR 28,55), and 89% had some form of insurance. There were 17,098 (36%) ED discharges with at least one opioid prescription. The unadjusted facility-level opioid prescription rate ranged from 24%-46%. Among 253 ED physicians, the adjusted opioid prescription rate varied from 22%-76%. Increased physician workload is related to decreased odds of opioid prescription at ED discharge for the lowest (<3 patients) and moderate (6-9 patients) physician workload levels, while the association weakened with increasing levels of workload. CONCLUSION There was substantial physician and facility variation in opioid prescription for discharged adult ED patients. Emergency physicians were less likely to prescribe opioids when their workload was lower, and this effect diminished at high workload levels. Understanding situational and other factors that explain this variation is important given the rising U.S. opioid epidemic and the need for urgent intervention.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, United States of America.
| | - Diwas Kc
- Information Systems & Operations Management, Goizueta Business School, Emory University, United States of America
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, United States of America
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, United States of America
| | - Amit Padaki
- Department of Emergency Medicine, Christiana Care Health System, United States of America
| | - Jesse M Pines
- Department of Emergency Medicine, Department Health Policy & Management, George Washington University School of Medicine and Health Sciences, United States of America
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31
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Bailin SS, Jenkins CA, Petucci C, Culver JA, Shepherd BE, Fessel JP, Hulgan T, Koethe JR. Lower Concentrations of Circulating Medium and Long-Chain Acylcarnitines Characterize Insulin Resistance in Persons with HIV. AIDS Res Hum Retroviruses 2018; 34:536-543. [PMID: 29607651 DOI: 10.1089/aid.2017.0314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In human immunodeficiency virus (HIV)-negative individuals, a plasma metabolite profile, characterized by higher levels of branched-chain amino acids (BCAA), aromatic amino acids, and C3/C5 acylcarnitines, is associated with insulin resistance and increased risk of diabetes. We sought to characterize the metabolite profile accompanying insulin resistance in HIV-positive persons to assess whether the same or different bioenergetics pathways might be implicated. We performed an observational cohort study of 70 nondiabetic, HIV-positive individuals (50% with body mass index ≥30 kg/m2) on efavirenz, tenofovir, and emtricitabine with suppressed HIV-1 RNA levels (<50 copies/mL) for at least 2 years and a CD4+ count over 350 cells/μL. We measured fasting insulin resistance using the homeostatic model assessment 2, plasma free fatty acids (FFA) using gas chromatography, and amino acids, acylcarnitines, and organic acids using liquid chromatography/mass spectrometry. We assessed the relationship of plasma metabolites with insulin resistance using multivariable linear regression. The median age was 45 years, median CD4+ count was 701 cells/μL, and median hemoglobin A1c was 5.2%. Insulin resistance was associated with higher plasma C3 acylcarnitines (p = .01), but not BCAA or C5 acylcarnitines. However, insulin resistance was associated with lower plasma levels of C18, C16, C12, and C2 acylcarnitines (p ≤ .03 for all), and lower C18 and C16 acylcarnitine:FFA ratios (p = .002, and p = .03, respectively). In HIV-positive persons, lower levels of plasma acylcarnitines, including the C2 product of complete fatty acid oxidation, are a more prominent feature of insulin resistance than changes in BCAA, suggesting impaired fatty acid uptake and/or mitochondrial oxidation is a central aspect of glucose intolerance in this population.
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Affiliation(s)
- Samuel S. Bailin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cathy A. Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher Petucci
- Sanford Burnham Prebys Metabolomics Core at the Southeast Center for Integrated Metabolomics, University of Florida, Gainesville, Florida
| | - Jeffrey A. Culver
- Sanford Burnham Prebys Metabolomics Core at the Southeast Center for Integrated Metabolomics, University of Florida, Gainesville, Florida
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joshua P. Fessel
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Hulgan
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John R. Koethe
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
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Fink VI, Jenkins CA, Castilho JL, Person AK, Shepherd BE, Grinsztejn B, Netto J, Crabtree-Ramirez B, Cortés CP, Padgett D, Jayathilake K, McGowan C, Cahn P. Survival after cancer diagnosis in a cohort of HIV-positive individuals in Latin America. Infect Agent Cancer 2018; 13:16. [PMID: 29760767 PMCID: PMC5941620 DOI: 10.1186/s13027-018-0188-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/25/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND This study aimed to evaluate trends and predictors of survival after cancer diagnosis in persons living with HIV in the Caribbean, Central, and South America network for HIV epidemiology cohort. METHODS Demographic, cancer, and HIV-related data from HIV-positive adults diagnosed with cancer ≤ 1 year before or any time after HIV diagnosis from January 1, 2000-June 30, 2015 were retrospectively collected. Cancer cases were classified as AIDS-defining cancers (ADC) and non-AIDS-defining cancers (NADC). The association of mortality with cancer- and HIV-related factors was assessed using Kaplan-Meier curves and Cox proportional hazards models stratified by clinic site and cancer type. RESULTS Among 15,869 patients, 783 had an eligible cancer diagnosis; 82% were male and median age at cancer diagnosis was 39 years (interquartile range [IQR]: 32-47). Patients were from Brazil (36.5%), Argentina (19.9%), Chile (19.7%), Mexico (19.3%), and Honduras (4.6%). A total of 564 ADC and 219 NADC were diagnosed. Patients with NADC had similar survival probabilities as those with ADC at one year (81% vs. 79%) but lower survival at five years (60% vs. 69%). In the adjusted analysis, risk of mortality increased with detectable viral load (adjusted hazard ratio [aHR] = 1.63, p = 0.02), age (aHR = 1.02 per year, p = 0.002) and time between HIV and cancer diagnoses (aHR = 1.03 per year, p = 0.01). CONCLUSION ADC remain the most frequent cancers in the region. Overall mortality was related to detectable viral load and age. Longer-term survival was lower after diagnosis of NADC than for ADC, which may be due to factors unrelated to HIV.
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Affiliation(s)
- Valeria I. Fink
- Fundación Huésped, Pasaje Gianantonio 3932, C1202ABB Buenos Aires, Argentina
| | - Cathy A. Jenkins
- Vanderbilt University School of Medicine, 1161 21st Ave. S A2200 Medical Center North, Nashville, TN 37232 USA
| | - Jessica L. Castilho
- Vanderbilt University School of Medicine, 1161 21st Ave. S A2200 Medical Center North, Nashville, TN 37232 USA
| | - Anna K. Person
- Vanderbilt University School of Medicine, 1161 21st Ave. S A2200 Medical Center North, Nashville, TN 37232 USA
| | - Bryan E. Shepherd
- Vanderbilt University School of Medicine, 1161 21st Ave. S A2200 Medical Center North, Nashville, TN 37232 USA
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil, 4365 - Manguinhos, Rio de Janeiro, RJ 21040-900 Brasil
| | - Juliana Netto
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil, 4365 - Manguinhos, Rio de Janeiro, RJ 21040-900 Brasil
| | - Brenda Crabtree-Ramirez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán: Unidad del Paciente Ambulatorio (UPA), 5to piso Vasco de Quiroga # 15 Col. Sección XVI Delegación Tlalpan; C.P, 14000 Mexico City, Mexico
| | | | - Denis Padgett
- Instituto Hondureño de Seguridad Social, Barrio la Granja, Tegucigalpa Honduras, Hospital Escuela Universitario: Av La Salud, Tegucigalpa, Honduras
| | - Karu Jayathilake
- Vanderbilt University School of Medicine, 1161 21st Ave. S A2200 Medical Center North, Nashville, TN 37232 USA
| | - Catherine McGowan
- Vanderbilt University School of Medicine, 1161 21st Ave. S A2200 Medical Center North, Nashville, TN 37232 USA
| | - Pedro Cahn
- Fundación Huésped, Pasaje Gianantonio 3932, C1202ABB Buenos Aires, Argentina
| | - on behalf of CCASAnet
- Fundación Huésped, Pasaje Gianantonio 3932, C1202ABB Buenos Aires, Argentina
- Vanderbilt University School of Medicine, 1161 21st Ave. S A2200 Medical Center North, Nashville, TN 37232 USA
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil, 4365 - Manguinhos, Rio de Janeiro, RJ 21040-900 Brasil
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán: Unidad del Paciente Ambulatorio (UPA), 5to piso Vasco de Quiroga # 15 Col. Sección XVI Delegación Tlalpan; C.P, 14000 Mexico City, Mexico
- Fundación Arriarán, Santa Elvira 629, Santiago, Chile
- Instituto Hondureño de Seguridad Social, Barrio la Granja, Tegucigalpa Honduras, Hospital Escuela Universitario: Av La Salud, Tegucigalpa, Honduras
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Yiadom MYAB, Mumma BE, Baugh CW, Patterson BW, Mills AM, Salazar G, Tanski M, Jenkins CA, Vogus TJ, Miller KF, Jackson BE, Lehmann CU, Dorner SC, West JL, Wang TJ, Collins SP, Dittus RS, Bernard GR, Storrow AB, Liu D. Measuring outcome differences associated with STEMI screening and diagnostic performance: a multicentred retrospective cohort study protocol. BMJ Open 2018; 8:e022453. [PMID: 29724744 PMCID: PMC5942471 DOI: 10.1136/bmjopen-2018-022453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Advances in ST-segment elevation myocardial infarction (STEMI) management have involved improving the clinical processes connecting patients with timely emergency cardiovascular care. Screening upon emergency department (ED) arrival for an early ECG to diagnose STEMI, however, is not optimal for all patients. In addition, the degree to which timely screening and diagnosis are associated with improved time to intervention and postpercutaneous coronary intervention outcomes, under more contemporary practice conditions, is not known. METHODS We present the methods for a retrospective multicentre cohort study anticipated to include 1220 patients across seven EDs to (1) evaluate the relationship between timely screening and diagnosis with treatment and postintervention clinical outcomes; (2) introduce novel measures for cross-facility performance comparisons of screening and diagnostic care team performance including: door-to-screening, door-to-diagnosis and door-to-catheterisation laboratory arrival times and (3) describe the use of electronic health record data in tandem with an existing disease registry. ETHICS AND DISSEMINATION The completion of this study will provide critical feedback on the quality of screening and diagnostic performance within the contemporary STEMI care pathway that can be used to (1) improve emergency care delivery for patients with STEMI presenting to the ED, (2) present novel metrics for the comparison of screening and diagnostic care and (3) inform the development of screening and diagnostic support tools that could be translated to other care environments. We will disseminate our results via publication and quality performance data sharing with each site. Institutional ethics review approval was received prior to study initiation.
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Affiliation(s)
- Maame Yaa A B Yiadom
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California at Davis, Sacramento, California, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Brian W Patterson
- Department of Emergency Medicine, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University Medical Center, New York, USA
| | - Gilberto Salazar
- Department of Emergency Medicine, Parkland Hospital, University of Texas Southwestern, Dallas, Texas, USA
| | - Mary Tanski
- Department of Emergency Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Brittney E Jackson
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Christoph U Lehmann
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| | - Stephen C Dorner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Jennifer L West
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Thomas J Wang
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Robert S Dittus
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Gordon R Bernard
- Division of Critical Care, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
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Yiadom MY, Baugh CW, Jenkins CA, Tanski M, Mumma BE, Vogus TJ, Miller KF, Jackson BE, Lehmann CU, Dorner SC, West JL, Olubowale OO, Wang TJ, Collins SP, Dittus RS, Bernard GR, Storrow AB, Liu D. Abstract 185: Outcome Differences Associated With STEMI Diagnostic Delay: Disparities on the Frontlines of STEMI Care. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
AHA/ACC/ESC practice guidelines advise an ECG within 10 minutes for all patients with symptoms suggestive of ST-segment elevation myocardial infarction (STEMI). This facilitates early diagnosis and timely treatment. Earlier treatment, particularly percutaneous coronary intervention (PCI), has been associated with better clinical outcomes. Our objective was to quantify the impact of delayed screening on timely treatment and determine if there may be race, sex or presenting complaint disparities.
Methods:
We examined the association between time-to-first ECG (door-to-screening, or D2S) and time-to-PCI in a 3-center 1-year retrospective cohort study including all emergency department (ED) patients with acute STEMI per hospital discharge diagnosis who underwent catheterization for PCI. The primary outcome was door-to-balloon time (D2B) and the ED-centric secondary outcome was door-to-cath-lab arrival time (D2CAR).
Results:
Of 161,920 patients seen in the 3 EDs, 137 (0.08%) were diagnosed with STEMI. Of the 137, 75 (55%) underwent emergent PCI, and 31 (41%) of the ED STEMI PCI patients did not receive an ECG within 10 minutes. These 31 patients were more commonly female (55% vs. 19%, p=0.001), non-white (87% vs. 65%, p =0.028), and reported chest pain or shortness of breath less frequently (55% vs. 94%, p<0.001). In patients with D2S greater than 10 minutes, median D2CAR was longer (159 vs. 50 minutes, p=0.004) as was median D2B time (207 vs. 93 minutes, p=0.048).
Conclusion:
A significant proportion of ED patients with STEMI did not receive an ECG within 10 minutes of arrival resulting in a 2.2 fold increase in D2B time. They were more likely to be female, non-white, and with atypical chief complaints. Normalizing screening criteria for presentation diversity could improve more equitable access to timely STEMI treatment
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Affiliation(s)
| | | | | | - Mary Tanski
- Oregon Health and Sciences Univ, Portland, OR
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Yiadom MYAB, Baugh CW, Jenkins CA, Collins SP, Bhatia MC, Dittus RS, Storrow AB. Change in Care Transition Practice for Patients With Nonspecific Chest Pain After Emergency Department Evaluation 2006 to 2012. Acad Emerg Med 2017; 24:1527-1530. [PMID: 28833882 DOI: 10.1111/acem.13279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES From 2005 to 2010 health care financing shifts in the United States may have affected care transition practices for emergency department (ED) patients with nonspecific chest pain (CP) after ED evaluation. Despite being less acutely ill than those with myocardial infarction, these patients' management can be challenging. The risk of missing acute coronary syndrome is considerable enough to often warrant admission. Diagnostic advances and reimbursement limitations on the use of inpatient admission are encouraging the use of alternative ED care transition practices. In the setting of these health care changes, we hypothesized that there is a decline in inpatient admission rates for patients with nonspecific CP after ED evaluation. METHODS We retrospectively used the Nationwide ED Sample to quantify total and annual inpatient hospital admission rates from 2006 to 2012 for patients with a final ED diagnosis of nonspecific CP. We assessed the change in admission rates over time and stratified by facility characteristics including safety-net hospital status, U.S. geographic region, urban/teaching status, trauma-level designation, and hospital funding status. RESULTS The admission rate for all patients with a final ED diagnosis of nonspecific CP declined from 19.2% in 2006 to 11.3% in 2012. Variability across regions was observed, while metropolitan teaching hospitals and trauma centers reflected lower admission rates. CONCLUSION There was a 41.1% decline in inpatient hospital admission for patients with nonspecific CP after ED evaluation. This reduction is temporally associated with national policy changes affecting reimbursement for inpatient admissions.
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Affiliation(s)
| | | | | | | | | | - Robert S. Dittus
- Department of Internal Medicine; Nashville TN
- Geriatric Research, Education and Clinical Center; VA Tennessee Valley Healthcare System; Nashville TN
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Fermann GJ, Levy PD, Pang P, Butler J, Ayaz SI, Char D, Dunn P, Jenkins CA, Kampe C, Khan Y, Kumar VA, Lindenfeld J, Liu D, Miller K, Peacock WF, Rizk S, Robichaux C, Rothman RL, Schrock J, Singer A, Sterling SA, Storrow AB, Walsh C, Wilburn J, Collins SP. Design and Rationale of a Randomized Trial of a Care Transition Strategy in Patients With Acute Heart Failure Discharged From the Emergency Department: GUIDED-HF (Get With the Guidelines in Emergency Department Patients With Heart Failure). Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003581. [PMID: 28188268 DOI: 10.1161/circheartfailure.116.003581] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/18/2017] [Indexed: 11/16/2022]
Abstract
GUIDED-HF (Get With the Guidelines in Emergency Department Patients With Heart Failure) is a multicenter randomized trial of a patient-centered transitional care intervention in patients with acute heart failure (AHF) who are discharged either directly from the emergency department (ED) or after a brief period of ED-based observation. To optimize care and reduce ED and hospital revisits, there has been significant emphasis on improving transitions at the time of hospital discharge for patients with HF. Such efforts have been almost exclusively directed at hospitalized patients; individuals with AHF who are discharged from the ED or ED-based observation are not included in these transitional care initiatives. Patients with AHF discharged directly from the ED or after a brief period of ED-based observation are randomly assigned to our transition GUIDED-HF strategy or standard ED discharge. Patients in the GUIDED arm receive a tailored discharge plan via the study team, based on their identified barriers to outpatient management and associated guideline-based interventions. This plan includes conducting a home visit soon after ED discharge combined with close outpatient follow-up and subsequent coaching calls to improve postdischarge care and avoid subsequent ED revisits and inpatient admissions. Up to 700 patients at 11 sites will be enrolled over 3 years of the study. GUIDED-HF will test a novel approach to AHF management strategy that includes tailored transitional care for patients discharged from the ED or ED-based observation. If successful, this program may significantly alter the current paradigm of AHF patient care. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02519283.
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Affiliation(s)
- Gregory J Fermann
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Phillip D Levy
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Peter Pang
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Javed Butler
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - S Imran Ayaz
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Douglas Char
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Patrick Dunn
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Cathy A Jenkins
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Christy Kampe
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Yosef Khan
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Vijaya A Kumar
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - JoAnn Lindenfeld
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Dandan Liu
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Karen Miller
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - W Frank Peacock
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Samaa Rizk
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Chad Robichaux
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Russell L Rothman
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Jon Schrock
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Adam Singer
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Sarah A Sterling
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Alan B Storrow
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Cheryl Walsh
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - John Wilburn
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.)
| | - Sean P Collins
- From the Department of Emergency Medicine, University of Cincinnati, OH (G.J.F.); Department of Emergency Medicine, Wayne State University, Detroit, MI (P.D.L., S.I.A., V.A.K., S.R., J.W.); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.P.); Division of Cardiovascular Medicine (J.B.) and Department of Emergency Medicine (A.S.), Stony Brook University, NY; Division of Emergency Medicine, Washington University, St. Louis, MO (D.C.); American Heart Association/American Stroke Association, Dallas, TX (P.D., Y.K.); Department of Biostatistics (C.A.J., D.L.), Department of Emergency Medicine (C.K., K.M., A.B.S., C.W., S.P.C.), Division of Cardiovascular Disease (J.L.), and Department of Internal Medicine, Pediatrics and Health Policy (R.L.R.), Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W.F.P.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (C.R.); Department of Emergency Medicine, Metro Health, Cleveland, OH (J.S.); and Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (S.A.S.).
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Doering A, Jenkins CA, Storrow AB, Lindenfeld J, Fermann GJ, Miller KF, Sperling M, Collins SP. Markers of diuretic resistance in emergency department patients with acute heart failure. Int J Emerg Med 2017; 10:17. [PMID: 28484958 PMCID: PMC5422212 DOI: 10.1186/s12245-017-0143-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/25/2017] [Indexed: 11/21/2022] Open
Abstract
Background Loop diuretics are common therapy for emergency department (ED) patients with acute heart failure (AHF). Diuretic resistance (DR) is a term used to describe blunted natriuretic response to loop diuretics. It would be important to detect DR prior to it becoming clinically apparent, so early interventions can be initiated. However, several definitions have been proposed, and it is not clear if they identify similar patients. We compared these definitions and described the clinical characteristics of patients who fulfilled them. Methods To qualify for this secondary analysis of 1033 ED patients with AHF, all patients needed to receive intravenous diuretics in the ED and have urine available within 24 h of their ED evaluation. A poor diuretic response, suggesting DR, was characterized by (1) a fractional sodium excretion (FeNa) of less than 0.2%; (2) spot urinary sodium of less than 50 meq/L; and (3) a urinary Na/K ratio <1.0. McNemar’s test was used to compare the different cohorts identified by the three definitions. Secondary analyses evaluated associations between each DR definition and hospital length of stay (LOS), ED revisits and rehospitalizations for AHF, and mortality using the Wilcoxon rank-sum tests and linear regression or Pearson chi-square test and logistic regression, as appropriate. Results The median age of the 187 patients was 64, and 50% were African-American. There were 5.9% of patients with a FeNa less than 0.2%, 17.1% had urinary sodium less than 50 meq/L, and 10.7% had a urinary Na/K ratio <1.0. The three definitions identified significantly different patients with very little overlap (p < 0.02 for all comparisons). There were 37 (19.8%) patients who were readmitted to the ED or hospital or died within 30 days of ED evaluation. Patients with spot urinary sodium less than 50 meq/L were more likely to be readmitted (p = 0.03). Conclusions The patient proportion with poor natriuresis and DR varies depending on the definition used. Early ED therapy would be impacted at different rates if clinical decisions are made based on these definitions. These findings need to be further explored in a prospective ED-based study. Trial registration ClinicalTrials.gov, NCT00508638 Electronic supplementary material The online version of this article (doi:10.1186/s12245-017-0143-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrew Doering
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - JoAnn Lindenfeld
- Department of Internal Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Sperling
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Yiadom MYAB, Baugh CW, McWade CM, Liu X, Song KJ, Patterson BW, Jenkins CA, Tanski M, Mills AM, Salazar G, Wang TJ, Dittus RS, Liu D, Storrow AB. Performance of Emergency Department Screening Criteria for an Early ECG to Identify ST-Segment Elevation Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.116.003528. [PMID: 28232323 PMCID: PMC5523988 DOI: 10.1161/jaha.116.003528] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Timely diagnosis of ST‐segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Obtaining this test within 10 minutes of ED arrival is critical to achieving the best outcomes. We investigated variability in the timely identification of STEMI across institutions and whether performance variation was associated with the ED characteristics, the comprehensiveness of screening criteria, and the STEMI screening processes. Methods and Results We examined STEMI screening performance in 7 EDs, with the missed case rate (MCR) as our primary end point. The MCR is the proportion of primarily screened ED patients diagnosed with STEMI who did not receive an ECG within 15 minutes of ED arrival. STEMI was defined by hospital discharge diagnosis. Relationships between the MCR and ED characteristics, screening criteria, and STEMI screening processes were assessed, along with differences in door‐to‐ECG times for captured versus missed patients. The overall MCR for all 7 EDs was 12.8%. The lowest and highest MCRs were 3.4% and 32.6%, respectively. The mean difference in door‐to‐ECG times for captured and missed patients was 31 minutes, with a range of 14 to 80 minutes of additional myocardial ischemia time for missed cases. The prevalence of primarily screened ED STEMIs was 0.09%. EDs with the greatest informedness (sensitivity+specificity−1) demonstrated superior performance across all other screening measures. Conclusions The 29.2% difference in MCRs between the highest and lowest performing EDs demonstrates room for improving timely STEMI identification among primarily screened ED patients. The MCR and informedness can be used to compare screening across EDs and to understand variable performance.
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Affiliation(s)
| | | | | | - Xulei Liu
- Vanderbilt University, Nashville, TN
| | - Kyoung Jun Song
- Department of Emergency Medicine, University of California at Davis, Sacramento, CA
| | - Brian W Patterson
- Department of Emergency Medicine, University of Wisconsin at Madison, WI
| | | | - Mary Tanski
- Department of Emergency Medicine, Oregon Health & Sciences University, Portland, OR
| | - Angela M Mills
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gilberto Salazar
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX
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Shepherd BE, Liu Q, Mercaldo N, Jenkins CA, Lau B, Cole SR, Saag MS, Sterling TR. Comparing results from multiple imputation and dynamic marginal structural models for estimating when to start antiretroviral therapy. Stat Med 2016; 35:4335-4351. [PMID: 27264354 PMCID: PMC5048599 DOI: 10.1002/sim.7007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 05/06/2016] [Accepted: 05/11/2016] [Indexed: 12/14/2022]
Abstract
Optimal timing of initiating antiretroviral therapy has been a controversial topic in HIV research. Two highly publicized studies applied different analytical approaches, a dynamic marginal structural model and a multiple imputation method, to different observational databases and came up with different conclusions. Discrepancies between the two studies' results could be due to differences between patient populations, fundamental differences between statistical methods, or differences between implementation details. For example, the two studies adjusted for different covariates, compared different thresholds, and had different criteria for qualifying measurements. If both analytical approaches were applied to the same cohort holding technical details constant, would their results be similar? In this study, we applied both statistical approaches using observational data from 12,708 HIV-infected persons throughout the USA. We held technical details constant between the two methods and then repeated analyses varying technical details to understand what impact they had on findings. We also present results applying both approaches to simulated data. Results were similar, although not identical, when technical details were held constant between the two statistical methods. Confidence intervals for the dynamic marginal structural model tended to be wider than those from the imputation approach, although this may have been due in part to additional external data used in the imputation analysis. We also consider differences in the estimands, required data, and assumptions of the two statistical methods. Our study provides insights into assessing optimal dynamic treatment regimes in the context of starting antiretroviral therapy and in more general settings. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Qi Liu
- Vanderbilt University, Nashville, TN, U.S.A
| | | | | | - Bryan Lau
- Johns Hopkins University, Baltimore, MD, U.S.A
| | | | - Michael S Saag
- University of Alabama at Birmingham, Birmingham, AL, U.S.A
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Koethe JR, Jenkins CA, Petucci C, Culver J, Shepherd BE, Sterling TR. Superior Glucose Tolerance and Metabolomic Profiles, Independent of Adiposity, in HIV-Infected Women Compared With Men on Antiretroviral Therapy. Medicine (Baltimore) 2016; 95:e3634. [PMID: 27175676 PMCID: PMC4902518 DOI: 10.1097/md.0000000000003634] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In epidemiologic studies, human immunodeficiency virus (HIV)-infected men on antiretroviral therapy (ART) are at higher risk of incident diabetes mellitus compared with women with similar treatment histories. We used metabolomics to determine whether a sex difference in plasma amino acids, acylcarnitines, and organic acids predictive of diabetes and impaired energy metabolism is present in HIV-infected persons on long-term ART.We enrolled 70 HIV-infected adults (43% women) on efavirenz, tenofovir, and emtricitabine (Atripla) with HIV-1 RNA <50 copies/mL for over 2 years. Half of the HIV-infected subjects were obese, and these were matched with 30 obese HIV-negative controls. All subjects had no history of diabetes, statin use, or heavy alcohol use. Fasting insulin sensitivity was measured using homeostatic model assessment 2 (HOMA2), and adipose tissue was measured using dual-energy x-ray absorptiometry (DEXA). Liquid chromatography/mass spectrometry was used to quantitate fasting plasma branched chain and aromatic amino acids predictive of incident diabetes, and C3 and C5 acylcarnitinines and organic acids indicative of impaired energy metabolism.HIV-infected women had more baseline risk factors for insulin resistance: women were older (46 vs 44 years) and had a longer ART duration (8.4 vs 5.1 years, P < 0.05 for both) compared with men but had similar CD4+ count (median 701 cells/μL), smoking and hepatic C prevalence, and body mass index (BMI) (median 30.3 kg/m). However, women had higher insulin sensitivity compared with men (P < 0.01), and lower plasma levels of isoleucine, leucine, valine, phenylalanine, and tyrosine (P < 0.01 for all), and lower C3 and C5 acylcarnitines (P < 0.01 for all), in multivariable regression models after adjusting for DEXA fat mass index, age, race, CD4+ count, smoking, and ART duration. In the obese HIV-infected subjects and HIV-negative controls, the relationship of sex and plasma metabolite levels did not significantly differ according to HIV-status.HIV-infected women on non-nucleoside reverse transcriptase inhibitor-based ART had superior glucose tolerance and lower plasma metabolites associated with the development of diabetes compared with men with similar metabolic disease risk profiles. The relationship between sex and plasma metabolite levels did not significantly differ according to HIV-status among obese subjects, suggesting the observed sex-differences may not be specific to HIV infection.
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Affiliation(s)
- John R Koethe
- From the Division of Infectious Diseases (JRK, TRS); Department of Biostatistics (CAJ, BES), Vanderbilt University School of Medicine, Nashville, TN; and Sanford Burnham Prebys Metabolomics Core at the Southeast Center for Integrated Metabolomics, University of Florida (CP, JC), Gainesville, FL
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Gray AX, Jeong J, Aetukuri NP, Granitzka P, Chen Z, Kukreja R, Higley D, Chase T, Reid AH, Ohldag H, Marcus MA, Scholl A, Young AT, Doran A, Jenkins CA, Shafer P, Arenholz E, Samant MG, Parkin SSP, Dürr HA. Correlation-Driven Insulator-Metal Transition in Near-Ideal Vanadium Dioxide Films. Phys Rev Lett 2016; 116:116403. [PMID: 27035314 DOI: 10.1103/physrevlett.116.116403] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Indexed: 06/05/2023]
Abstract
We use polarization- and temperature-dependent x-ray absorption spectroscopy, in combination with photoelectron microscopy, x-ray diffraction, and electronic transport measurements, to study the driving force behind the insulator-metal transition in VO_{2}. We show that both the collapse of the insulating gap and the concomitant change in crystal symmetry in homogeneously strained single-crystalline VO_{2} films are preceded by the purely electronic softening of Coulomb correlations within V-V singlet dimers. This process starts 7 K (±0.3 K) below the transition temperature, as conventionally defined by electronic transport and x-ray diffraction measurements, and sets the energy scale for driving the near-room-temperature insulator-metal transition in this technologically promising material.
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Affiliation(s)
- A X Gray
- Stanford Institute for Materials and Energy Sciences, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
- Department of Physics, Temple University, 1925 North 12th Street, Philadelphia, Pennsylvania 19130, USA
| | - J Jeong
- IBM Almaden Research Center, 650 Harry Road, San Jose, California 95120, USA
| | - N P Aetukuri
- IBM Almaden Research Center, 650 Harry Road, San Jose, California 95120, USA
| | - P Granitzka
- Stanford Institute for Materials and Energy Sciences, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
- Van der Waals-Zeeman Institute, University of Amsterdam, 1018XE Amsterdam, The Netherlands
| | - Z Chen
- Stanford Institute for Materials and Energy Sciences, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
- Department of Physics, Stanford University, Stanford, California 94305, USA
| | - R Kukreja
- Stanford Institute for Materials and Energy Sciences, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
- Department of Materials Science and Engineering, Stanford University, Stanford, California 94305, USA
| | - D Higley
- Stanford Institute for Materials and Energy Sciences, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
- Department of Applied Physics, Stanford University, Stanford, California 94305, USA
| | - T Chase
- Stanford Institute for Materials and Energy Sciences, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
- Department of Applied Physics, Stanford University, Stanford, California 94305, USA
| | - A H Reid
- Stanford Institute for Materials and Energy Sciences, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
| | - H Ohldag
- Stanford Synchrotron Radiation Lightsource, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
| | - M A Marcus
- Advanced Light Source, Lawrence Berkeley National Laboratory, One Cyclotron Road, Berkeley, California 94720, USA
| | - A Scholl
- Advanced Light Source, Lawrence Berkeley National Laboratory, One Cyclotron Road, Berkeley, California 94720, USA
| | - A T Young
- Advanced Light Source, Lawrence Berkeley National Laboratory, One Cyclotron Road, Berkeley, California 94720, USA
| | - A Doran
- Advanced Light Source, Lawrence Berkeley National Laboratory, One Cyclotron Road, Berkeley, California 94720, USA
| | - C A Jenkins
- Advanced Light Source, Lawrence Berkeley National Laboratory, One Cyclotron Road, Berkeley, California 94720, USA
| | - P Shafer
- Advanced Light Source, Lawrence Berkeley National Laboratory, One Cyclotron Road, Berkeley, California 94720, USA
| | - E Arenholz
- Advanced Light Source, Lawrence Berkeley National Laboratory, One Cyclotron Road, Berkeley, California 94720, USA
| | - M G Samant
- IBM Almaden Research Center, 650 Harry Road, San Jose, California 95120, USA
| | - S S P Parkin
- IBM Almaden Research Center, 650 Harry Road, San Jose, California 95120, USA
| | - H A Dürr
- Stanford Institute for Materials and Energy Sciences, SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
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Barrett TW, Self WH, Darbar D, Jenkins CA, Wasserman BS, Kassim NA, Casner M, Shoemaker MB. Association of atrial fibrillation risk alleles and response to acute rate control therapy. Am J Emerg Med 2016; 34:735-40. [PMID: 26920668 DOI: 10.1016/j.ajem.2016.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/23/2016] [Accepted: 01/25/2016] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Given the sparse evidence for selection of first-line therapy for acute atrial fibrillation (AF) based on clinical factors alone, incorporation of genotype data may improve the effectiveness of treatment algorithms and advance the understanding of interpatient heterogeneity. We tested whether candidate nucleotide polymorphisms (SNPs) related to AF physiologic responses are associated with ventricular rate control after intravenous diltiazem in the emergency department (ED). METHODS We conducted an analysis within a prospective observational cohort of ED patients with acute symptomatic AF, ventricular rate >110 beats per minute within the first 2 hours, initially treated with intravenous diltiazem, and who had DNA available for analysis. We evaluated 24 candidate SNPs that were grouped into 3 categories based on their phenotype response (atrioventricular nodal [AVN] conduction, resting heart rate, disease susceptibility) and calculated 3 genetic scores for each patient. Our primary outcome was maximum heart rate reduction within 4 hours of diltiazem administration. Multivariable regression was used to identify associations with the outcome while adjusting for age, sex, baseline heart rate, and diltiazem dose. RESULTS Of the 142 patients, 127 had complete data for the primary outcome. None of the genetic scores for AVN conduction, resting heart rate, or AF susceptibility showed a significant association with maximal heart rate response. CONCLUSION Using a candidate SNP approach, screening for genetic variants associated with AVN conduction, resting heart rate, or AF susceptibility failed to provide significant data for predicting successful rate control response to intravenous diltiazem for treating acute AF in the ED.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Dawood Darbar
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Brian S Wasserman
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | - Natasha A Kassim
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | - Michael Casner
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - M Benjamin Shoemaker
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
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Koethe JR, Jenkins CA, Lau B, Shepherd BE, Justice AC, Tate JP, Buchacz K, Napravnik S, Mayor AM, Horberg MA, Blashill AJ, Willig A, Wester CW, Silverberg MJ, Gill J, Thorne JE, Klein M, Eron JJ, Kitahata MM, Sterling TR, Moore RD. Rising Obesity Prevalence and Weight Gain Among Adults Starting Antiretroviral Therapy in the United States and Canada. AIDS Res Hum Retroviruses 2016; 32:50-8. [PMID: 26352511 DOI: 10.1089/aid.2015.0147] [Citation(s) in RCA: 207] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The proportion of overweight and obese adults in the United States and Canada has increased over the past decade, but temporal trends in body mass index (BMI) and weight gain on antiretroviral therapy (ART) among HIV-infected adults have not been well characterized. We conducted a cohort study comparing HIV-infected adults in the North America AIDS Cohort Collaboration on Research and Design (NA-ACCORD) to United States National Health and Nutrition Examination Survey (NHANES) controls matched by sex, race, and age over the period 1998 to 2010. Multivariable linear regression assessed the relationship between BMI and year of ART initiation, adjusting for sex, race, age, and baseline CD4(+) count. Temporal trends in weight on ART were assessed using a generalized least-squares model further adjusted for HIV-1 RNA and first ART regimen class. A total of 14,084 patients from 17 cohorts contributed data; 83% were male, 57% were nonwhite, and the median age was 40 years. Median BMI at ART initiation increased from 23.8 to 24.8 kg/m(2) between 1998 and 2010 in NA-ACCORD, but the percentage of those obese (BMI ≥30 kg/m(2)) at ART initiation increased from 9% to 18%. After 3 years of ART, 22% of individuals with a normal BMI (18.5-24.9 kg/m(2)) at baseline had become overweight (BMI 25.0-29.9 kg/m(2)), and 18% of those overweight at baseline had become obese. HIV-infected white women had a higher BMI after 3 years of ART as compared to age-matched white women in NHANES (p = 0.02), while no difference in BMI after 3 years of ART was observed for HIV-infected men or non-white women compared to controls. The high prevalence of obesity we observed among ART-exposed HIV-infected adults in North America may contribute to health complications in the future.
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Affiliation(s)
- John R. Koethe
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Bryan Lau
- Johns Hopkins University, Baltimore, Maryland
| | | | - Amy C. Justice
- Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Janet P. Tate
- Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kate Buchacz
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | - Amanda Willig
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John Gill
- Alberta HIV Clinic, Sheldon M. Chumir Health Centre, Calgary, Alberta, Canada
| | | | - Marina Klein
- McGill University Health Center, Montreal, Quebec, Canada
| | - Joseph J. Eron
- University of North Carolina, Chapel Hill, North Carolina
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Cesar C, Jenkins CA, Shepherd BE, Padgett D, Mejía F, Ribeiro SR, Cortes CP, Pape JW, Madero JS, Fink V, Sued O, McGowan C, Cahn P. Incidence of virological failure and major regimen change of initial combination antiretroviral therapy in the Latin America and the Caribbean: an observational cohort study. Lancet HIV 2015; 2:e492-500. [PMID: 26520929 DOI: 10.1016/s2352-3018(15)00183-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 09/03/2015] [Accepted: 09/04/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Access to combination antiretroviral therapy (ART) is expanding in Latin America (Mexico, Central America, and South America) and the Caribbean. We assessed the incidence of and factors associated with regimen failure and regimen change of initial ART in this region. METHODS This observational cohort study included antiretroviral-naive adults starting ART from 2000 to 2014 at sites in seven countries throughout Latin America and the Caribbean. Primary outcomes were time from ART initiation until virological failure, major regimen modification, and a composite endpoint of the first of virological failure or major regimen modification. Cumulative incidence of the primary outcomes was estimated with death considered a competing event. FINDINGS 14,027 patients starting ART were followed up for a median of 3.9 years (2.0-6.5): 8374 (60%) men, median age 37 years (IQR 30-44), median CD4 count 156 cells per μL (61-253), median plasma HIV RNA 5.0 log10 copies per mL (4.4-5.4), and 3567 (28%) had clinical AIDS. 1719 (12%) patients had virological failure and 1955 (14%) had a major regimen change. Excluding the site in Haiti, which did not regularly measure HIV RNA, cumulative incidence of virological failure was 7.8% (95% CI 7.2-8.5) 1 year after ART initiation, 19.2% (18.2-20.2) at 3 years, and 25.8% (24.6-27.0) at 5 years; cumulative incidence of major regimen change was 5.9% (5.3-6.4) at 1 year, 12.7% (11.9-13.5) at 3 years, and 18.2% (17.2-19.2) at 5 years. Incidence of major regimen change at the site in Haiti was 10.7% (95% CI 9.7-11.6) at 5 years. Virological failure was associated with younger age (adjusted hazard ratio [HR] 2.03, 95% CI 1.68-2.44, for 20 years vs 40 years), infection through injection drug use (vs infection through heterosexual sex; 1.60, 1.02-2.52), and initiation in earlier calendar years (1.28, 1.13-1.46, for 2002 vs 2006), but was not significantly associated with boosted protease inhibitor-based regimens (vs non-nucleoside reverse transcriptase inhibitor; 1.17, 1.00-1.36). INTERPRETATION Incidence of virological failure in Latin America and the Caribbean was generally lower than that reported in North America or Europe. Our results suggest the need to design strategies to reduce failure and major regimen change in young patients and those with a history of injection drug use. FUNDING US National Institutes of Health.
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Affiliation(s)
| | | | | | - Denis Padgett
- Instituto Hondureño de Seguridad Social and Hospital Escuela, Tegucigalpa, Honduras
| | - Fernando Mejía
- Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru
| | - Sayonara Rocha Ribeiro
- Instituto de Pesquisa Clinica Evandro Chagas-Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | | | | | - Omar Sued
- Fundación Huésped, Buenos Aires, Argentina
| | | | - Pedro Cahn
- Fundación Huésped, Buenos Aires, Argentina
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Collins SP, Jenkins CA, Harrell FE, Liu D, Miller KF, Lindsell CJ, Naftilan AJ, McPherson JA, Maron DJ, Sawyer DB, Weintraub NL, Fermann GJ, Roll SK, Sperling M, Storrow AB. Identification of Emergency Department Patients With Acute Heart Failure at Low Risk for 30-Day Adverse Events: The STRATIFY Decision Tool. JACC Heart Fail 2015; 3:737-47. [PMID: 26449993 PMCID: PMC4625834 DOI: 10.1016/j.jchf.2015.05.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/19/2015] [Accepted: 05/25/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES No prospectively derived or validated decision tools identify emergency department (ED) patients with acute heart failure (AHF) at low risk for 30-day adverse events who are thus potential candidates for safe ED discharge. This study sought to accomplish that goal. BACKGROUND The nearly 1 million annual ED visits for AHF are associated with high proportions of admissions and consume significant resources. METHODS We prospectively enrolled 1,033 patients diagnosed with AHF in the ED from 4 hospitals between July 20, 2007, and February 4, 2011. We used an ordinal outcome hierarchy, defined as the incidence of the most severe adverse event within 30 days of ED evaluation (acute coronary syndrome, coronary revascularization, emergent dialysis, intubation, mechanical cardiac support, cardiopulmonary resuscitation, and death). RESULTS Of 1,033 patients enrolled, 126 (12%) experienced at least one 30-day adverse event. The decision tool had a C statistic of 0.68 (95% confidence interval: 0.63 to 0.74). Elevated troponin (p < 0.001) and renal function (p = 0.01) were significant predictors of adverse events in our multivariable model, whereas B-type natriuretic peptide (p = 0.09), tachypnea (p = 0.09), and patients undergoing dialysis (p = 0.07) trended toward significance. At risk thresholds of 1%, 3%, and 5%, we found 0%, 1.4%, and 13.0% patients were at low risk, with negative predictive values of 100%, 96%, and 93%, respectively. CONCLUSIONS The STRATIFY decision tool identifies ED patients with AHF who are at low risk for 30-day adverse events and may be candidates for safe ED discharge. After external testing, and perhaps when used as part of a shared decision-making strategy, it may significantly affect disposition strategies. (Improving Heart Failure Risk Stratification in the ED [STRATIFY]; NCT00508638).
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Affiliation(s)
- Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Allen J Naftilan
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A McPherson
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David J Maron
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Douglas B Sawyer
- Department of Medicine, Division of Cardiovascular Medicine, Maine Medical Center, Portland, Maine
| | - Neal L Weintraub
- Department of Medicine and Vascular Biology Center, Georgia Regents University, Augusta, Georgia
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Susan K Roll
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew Sperling
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Barrett TW, Vermeulen MJ, Self WH, Jenkins CA, Ferreira AJ, Atzema CL. Emergency department management of atrial fibrillation in the United States versus Ontario, Canada. J Am Coll Cardiol 2015; 65:2258-60. [PMID: 25998673 DOI: 10.1016/j.jacc.2015.01.064] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/10/2015] [Accepted: 01/20/2015] [Indexed: 11/26/2022]
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Castilho JL, Jenkins CA, Shepherd BE, Bebawy SS, Turner M, Sterling TR, Melekhin VV. Hormonal Contraception and Risk of Psychiatric and Other Noncommunicable Diseases in HIV-Infected Women. J Womens Health (Larchmt) 2015; 24:481-8. [PMID: 25751720 PMCID: PMC4490777 DOI: 10.1089/jwh.2014.5003] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Hormonal contraception use is common among human immunodeficiency virus (HIV)-infected women. Risk of psychiatric and other noninfectious complications of hormonal contraception use has not been described in this population. METHODS We performed a retrospective cohort study of HIV-infected women receiving care in Tennessee from 1998 to 2008 to examine the risks of incident psychiatric and other noncommunicable diseases (NCDs), including cardiovascular, hepatic, renal, and malignant diseases, and hormonal contraception use, including depot medroxyprogesterone acetate (DMPA) and combined estrogen- and progestin-containing hormonal contraceptives. We used marginal structural models with inverse probability weights to account for time-varying confounders associated with hormonal contraception use. RESULTS Of the 392 women included, 94 (24%) used hormonal contraception during the study period. Baseline psychiatric disease was similar between women who received and did not receive hormonal contraception. There were 69 incident psychiatric diagnoses and 72 NCDs. Only time-varying DMPA use was associated with increased risk of psychiatric disease (adjusted odds ratio [aOR] 3.70; 95% confidence interval [95% CI] 1.32-10.4) and mood disorders, specifically (aOR 4.70 [1.87-11.8]). Time-varying and cumulative combined hormonal contraception use were not statistically associated with other NCDs (aOR 1.64, 95% CI 0.64-4.12 and aOR 1.16, 95% CI 0.86-1.56, respectively). However, risk of incident NCDs was increased with cumulative DMPA exposure (per year exposure aOR 1.45, 95% CI 1.01-2.08). CONCLUSIONS Among HIV-infected women, DMPA was associated with risk of incident psychiatric diseases, particularly mood disorders, during periods of use. Cumulative DMPA exposure was also associated with risk of other NCDs. However, combined estrogen and progestin-containing hormonal contraception use was not statistically associated with risk of any NCDs.
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Affiliation(s)
- Jessica L. Castilho
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cathy A. Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sally S. Bebawy
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Megan Turner
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Timothy R. Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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48
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Koethe JR, Jenkins CA, Lau B, Shepherd BE, Silverberg MJ, Brown TT, Blashill AJ, Anema A, Willig A, Stinnette S, Napravnik S, Gill J, Crane HM, Sterling TR. Body mass index and early CD4 T-cell recovery among adults initiating antiretroviral therapy in North America, 1998-2010. HIV Med 2015; 16:572-7. [PMID: 25960080 DOI: 10.1111/hiv.12259] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Adipose tissue affects several aspects of the cellular immune system, but prior epidemiological studies have differed on whether a higher body mass index (BMI) promotes CD4 T-cell recovery on antiretroviral therapy (ART). The objective of this analysis was to assess the relationship between BMI at ART initiation and early changes in CD4 T-cell count. METHODS We used the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data set to analyse the relationship between pre-treatment BMI and 12-month CD4 T-cell recovery among adults who started ART between 1998 and 2010 and maintained HIV-1 RNA levels < 400 copies/mL for at least 6 months. Multivariable regression models were adjusted for age, race, sex, baseline CD4 count and HIV RNA level, year of ART initiation, ART regimen and clinical site. RESULTS A total of 8381 participants from 13 cohorts contributed data; 85% were male, 52% were nonwhite, 32% were overweight (BMI 25-29.9 kg/m(2) ) and 15% were obese (BMI > 30 kg/m(2) ). Pretreatment BMI was associated with 12-month CD4 T-cell change (P < 0.001), but the relationship was nonlinear (P < 0.001). Compared with a reference of 22 kg/m(2) , a BMI of 30 kg/m(2) was associated with a 36 cells/μL [95% confidence interval (CI) 14, 59 cells/μL] greater CD4 T-cell count recovery among women and a 19 cells/μL (95% CI 9, 30 cells/μL) greater recovery among men at 12 months. At a BMI > 30 kg/m(2) , the observed benefit was attenuated among men to a greater degree than among women, although this difference was not statistically significant. CONCLUSIONS A BMI of approximately 30 kg/m(2) at ART initiation was associated with greater CD4 T-cell recovery at 12 months compared with higher or lower BMI values, suggesting that body composition may affect peripheral CD4 T-cell recovery.
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Affiliation(s)
- J R Koethe
- Departments of Medicine and Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - C A Jenkins
- Departments of Medicine and Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - B Lau
- Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - B E Shepherd
- Departments of Medicine and Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - T T Brown
- Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - A Anema
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - A Willig
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - S Stinnette
- University of North Carolina, Chapel Hill, NC, USA
| | - S Napravnik
- University of North Carolina, Chapel Hill, NC, USA
| | - J Gill
- Alberta HIV Clinic, Sheldon M. Chumir Health Centre, Calgary, AB, Canada
| | - H M Crane
- Center for AIDS Research, University of Washington, Seattle, WA, USA
| | - T R Sterling
- Departments of Medicine and Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
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Barrett TW, Storrow AB, Jenkins CA, Abraham RL, Liu D, Miller KF, Moser KM, Russ S, Roden DM, Harrell FE, Darbar D. The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events. Am J Cardiol 2015; 115:763-70. [PMID: 25633190 PMCID: PMC4346475 DOI: 10.1016/j.amjcard.2014.12.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 12/18/2022]
Abstract
There is wide variation in the management of patients with atrial fibrillation (AF) in the emergency department (ED). We aimed to derive and internally validate the first prospective, ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events. We performed a prospective cohort study at a university-affiliated tertiary-care ED. Patients were enrolled from June 9, 2010, to February 28, 2013, and followed for 30 days. We enrolled a convenience sample of patients in ED presenting with symptomatic AF. Candidate predictors were based on ED data available in the first 2 hours. The decision aid was derived using model approximation (preconditioning) followed by strong bootstrap internal validation. We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation. Of 497 patients enrolled, stroke and AF-related death occurred in 13 (3%) and 4 (<1%) patients, respectively. The decision aid included the following: age, triage vitals (systolic blood pressure, temperature, respiratory rate, oxygen saturation, supplemental oxygen requirement), medical history (heart failure, home sotalol use, previous percutaneous coronary intervention, electrical cardioversion, cardiac ablation, frequency of AF symptoms), and ED data (2 hours heart rate, chest radiograph results, hemoglobin, creatinine, and brain natriuretic peptide). The decision aid's c-statistic in predicting any 30-day adverse event was 0.7 (95% confidence interval 0.65, 0.76). In conclusion, in patients with AF in the ED, Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence-based decision aid for identifying patients who are at low risk for 30-day adverse events and candidates for safe discharge.
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Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert L Abraham
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly M Moser
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dan M Roden
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Dawood Darbar
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
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50
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Koethe JR, Jenkins CA, Turner M, Bebawy S, Shepherd BE, Wester CW, Sterling TR. Body mass index and the risk of incident noncommunicable diseases after starting antiretroviral therapy. HIV Med 2015; 16:67-72. [PMID: 25230709 PMCID: PMC4268383 DOI: 10.1111/hiv.12178] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Obesity and HIV infection are associated with an increased incidence of noninfectious comorbid medical conditions, but the relationship between body mass index (BMI) and the development of noncommunicable diseases (NCDs) among individuals on antiretroviral therapy (ART) has not been well characterized. METHODS A cohort study of adults initiating ART between 1998 and 2010 at an academic centre with systematic laboratory and clinical data collection, including AIDS and NCD diagnoses, was carried out. The relationship between BMI at ART initiation and the risk of incident cardiovascular, hepatic, renal or oncological NCDs was assessed using Cox proportional hazard models. BMI was fitted using restricted cubic splines and models adjusted for age, sex, race, CD4 count, protease inhibitor use, year of initiation, and prior AIDS-defining illness. RESULTS Among 1089 patients in the analysis cohort, 54% had normal BMI, 28% were overweight, and 18% were obese. Baseline BMI was associated with developing an incident NCD (P<0.01), but the relationship was nonlinear. Compared with a BMI of 25 kg/m(2) , a BMI of 30 kg/m(2) conferred a lower risk of an incident NCD diagnosis [adjusted hazard ratio (AHR) 0.59; 95% confidence interval (CI) 0.40, 0.87]. This protective effect was attenuated at a BMI of 35 kg/m(2) (AHR 0.78; 95% CI 0.49, 1.23). Results were similar in sensitivity analyses incorporating tobacco, alcohol and illicit drug use, statin and antihypertensive exposure, and virological suppression. CONCLUSIONS Overweight individuals starting ART have a lower risk of developing NCDs compared with normal BMI individuals, which may reflect a biological effect of adipose tissue or differences in patient or provider behaviours.
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Affiliation(s)
- J R Koethe
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
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