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Chen JI, Bui D, Iwashyna TJ, Shahoumian TA, Hickok A, Shepherd-Banigan M, Hawkins EJ, Naylor J, Govier DJ, Osborne TF, Smith VA, Bowling CB, Boyko EJ, Ioannou GN, Maciejewski ML, O'Hare AM, Viglianti EM, Bohnert ASB, Hynes DM. Correction to: Impact of SARS-CoV-2 Infection on Long-Term Depression Symptoms among Veterans. J Gen Intern Med 2024:10.1007/s11606-024-08800-z. [PMID: 38743168 DOI: 10.1007/s11606-024-08800-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Affiliation(s)
- Jason I Chen
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA.
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
| | - David Bui
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Theodore J Iwashyna
- Departments of Medicine and Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
| | | | - Alex Hickok
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Eric J Hawkins
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound HCS, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Jennifer Naylor
- School of Medicine, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- VISN 6 Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Durham VA HCS, Durham, NC, USA
| | - Diana J Govier
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- OHSU-Portland State University School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Thomas F Osborne
- VA Palo Alto HCS, Palo Alto, CA, USA
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham VA HCS, Durham, NC, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research Information Center, VA Puget Sound HCS, Seattle, WA, USA
| | - George N Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Ann M O'Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Hospital and Specialty Medicine Service, VA Puget Sound HCS, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amy S-B Bohnert
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- College of Public Health and Human Sciences, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
- School of Nursing, Oregon Health & Science University (OHSU), Portland, OR, USA
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Moon AM, Swier RM, Lane LM, Barritt AS, Sanoff HK, Olshan AF, Wheeler SB, Ioannou GN, Kim NJ, Hagan S, Vutien P, Benefield T, Henderson LM. Statewide Survey of Primary Care and Subspecialty Providers on Hepatocellular Carcinoma Risk-Stratification and Surveillance Practices. Dig Dis Sci 2024:10.1007/s10620-024-08442-5. [PMID: 38652392 DOI: 10.1007/s10620-024-08442-5] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is associated with improved survival. Provision of HCC surveillance is low in the US, particularly in primary care settings. AIMS To evaluate current hepatitis C virus (HCV) and HCC surveillance practices and physician attitudes regarding HCC risk-stratification among primary care and subspecialty providers. METHODS Using the Tailored Design Method, we delivered a 34-item online survey to 7654 North Carolina-licensed internal/family medicine or gastroenterology/hepatology physicians and advanced practice providers in 2022. We included the domains of HCV treatment, cirrhosis diagnosis, HCC surveillance practices, barriers to surveillance, and interest in risk-stratification tools. We performed descriptive analyses to summarize responses. Tabulations were weighted based on sampling weights accounting for non-response and inter-specialty comparisons were made using chi-squared or t test statistics. RESULTS After exclusions, 266 responses were included in the final sample (response rate 3.8%). Most respondents (78%) diagnosed cirrhosis using imaging and a minority used non-invasive tests that were blood-based (~ 15%) or transient elastography (31%). Compared to primary care providers, subspecialists were more likely to perform HCC surveillance every 6-months (vs annual) (98% vs 35%, p < 0.0001). Most respondents (80%) believed there were strong data to support HCC surveillance, but primary care providers did not know which liver disease patients needed surveillance. Most providers (> 70%) expressed interest in potential solutions to improve HCC risk-stratification. CONCLUSIONS In this statewide survey, there were great knowledge gaps in HCC surveillance among PCPs and most respondents expressed interest in strategies to increase appropriate HCC surveillance.
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Affiliation(s)
- Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- UNC Liver Center, University of North Carolina at Chapel Hill School of Medicine, 8009 Burnett Womack Bldg, CB#7584, Chapel Hill, NC, 27599-7584, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| | - Rachel M Swier
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lindsay M Lane
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Liver Center, University of North Carolina at Chapel Hill School of Medicine, 8009 Burnett Womack Bldg, CB#7584, Chapel Hill, NC, 27599-7584, USA
| | - Hanna K Sanoff
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Andrew F Olshan
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicole J Kim
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Scott Hagan
- Division of General Internal Medicine, University of Washington, VA Puget Sound Healthcare System, Seattle, USA
| | - Philip Vutien
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Thad Benefield
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Louise M Henderson
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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3
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Chen JI, Bui D, Iwashyna TJ, Shahoumian TA, Hickok A, Shepherd-Banigan M, Hawkins EJ, Naylor J, Govier DJ, Osborne TF, Smith VA, Bowling CB, Boyko EJ, Ioannou GN, Maciejewski ML, O'Hare AM, Viglianti EM, Bohnert ASB, Hynes DM. Impact of SARS-CoV-2 Infection on Long-Term Depression Symptoms among Veterans. J Gen Intern Med 2024:10.1007/s11606-024-08630-z. [PMID: 38625482 DOI: 10.1007/s11606-024-08630-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/11/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Prior research demonstrates that SARS-COV-2 infection can be associated with a broad range of mental health outcomes including depression symptoms. Veterans, in particular, may be at elevated risk of increased depression following SARS-COV-2 infection given their high rates of pre-existing mental and physical health comorbidities. However, few studies have tried to isolate SARS-COV-2 infection associations with long term, patient-reported depression symptoms from other factors (e.g., physical health comorbidities, pandemic-related stress). OBJECTIVE To evaluate the association between SARS-COV-2 infection and subsequent depression symptoms among United States Military Veterans. DESIGN Survey-based non-randomized cohort study with matched comparators. PARTICIPANTS A matched-dyadic sample from a larger, stratified random sample of participants with and without known to SARS-COV-2 infection were invited to participate in a survey evaluating mental health and wellness 18-months after their index infection date. Sampled participants were stratified by infection severity of the participant infected with SARS-COV-2 (hospitalized or not) and by month of index date. A total of 186 participants in each group agreed to participate in the survey and had sufficient data for inclusion in analyses. Those in the uninfected group who were later infected were excluded from analyses. MAIN MEASURES Participants were administered the Patient Health Questionnaire-9 as part of a phone interview survey. Demographics, physical and mental health comorbidities were extracted from VHA administrative data. KEY RESULTS Veterans infected with SARS-COV-2 had significantly higher depression symptoms scores compared with those uninfected. In particular, psychological symptoms (e.g., low mood, suicidal ideation) scores were elevated relative to the comparator group (MInfected = 3.16, 95%CI: 2.5, 3.8; MUninfected = 1.96, 95%CI: 1.4, 2.5). Findings were similar regardless of history of depression. CONCLUSION SARS-COV-2 infection was associated with more depression symptoms among Veterans at 18-months post-infection. Routine evaluation of depression symptoms over time following SARS-COV-2 infection is important to facilitate adequate assessment and treatment.
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Affiliation(s)
- Jason I Chen
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA.
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
| | - David Bui
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Theodore J Iwashyna
- Departments of Medicine and Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
| | | | - Alex Hickok
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Eric J Hawkins
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound HCS, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Jennifer Naylor
- School of Medicine, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- VISN 6 Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Durham VA HCS, Durham, NC, USA
| | - Diana J Govier
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- OHSU-Portland State University School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Thomas F Osborne
- VA Palo Alto HCS, Palo Alto, CA, USA
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham VA HCS, Durham, NC, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research Information Center, VA Puget Sound HCS, Seattle, WA, USA
| | - George N Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Ann M O'Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Hospital and Specialty Medicine Service, VA Puget Sound HCS, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amy S-B Bohnert
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- College of Public Health and Human Sciences, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
- School of Nursing, Oregon Health & Science University (OHSU), Portland, OR, USA
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McCurdy H, Nobbe A, Scott D, Patton H, Morgan TR, Bajaj JS, Yakovchenko V, Merante M, Gibson S, Lamorte C, Baffy G, Ioannou GN, Taddei TH, Rozenberg-Ben-Dror K, Anwar J, Dominitz JA, Rogal SS. Organizational and Implementation Factors Associated with Cirrhosis Care in the Veterans Health Administration. Dig Dis Sci 2024:10.1007/s10620-024-08409-6. [PMID: 38616215 DOI: 10.1007/s10620-024-08409-6] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The Veterans Health Administration provides care to more than 100,000 Veterans with cirrhosis. AIMS This implementation evaluation aimed to understand organizational resources and barriers associated with cirrhosis care. METHODS Clinicians across 145 Department of Veterans Affairs (VA) medical centers (VAMCs) were surveyed in 2022 about implementing guideline-concordant cirrhosis care. VA Corporate Data Warehouse data were used to assess VAMC performance on two national cirrhosis quality measures: HCC surveillance and esophageal variceal surveillance or treatment (EVST). Organizational factors associated with higher performance were identified using linear regression models. RESULTS Responding VAMCs (n = 124, 86%) ranged in resource availability, perceived barriers, and care processes. In multivariable models, factors independently associated with HCC surveillance included on-site interventional radiology and identifying patients overdue for surveillance using a national cirrhosis population management tool ("dashboard"). EVST was significantly associated with dashboard use and on-site gastroenterology services. For larger VAMCs, the average HCC surveillance rate was similar between VAMCs using vs. not using the dashboard (47% vs. 41%), while for smaller and less resourced VAMCs, dashboard use resulted in a 13% rate difference (46% vs. 33%). Likewise, higher EVST rates were more strongly associated with dashboard use in smaller (55% vs. 50%) compared to larger (57% vs. 55%) VAMCs. CONCLUSIONS Resources, barriers, and care processes varied across diverse VAMCs. Smaller VAMCs without specialty care achieved HCC and EVST surveillance rates nearly as high as more complex and resourced VAMCs if they used a population management tool to identify the patients due for cirrhosis care.
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Affiliation(s)
- Heather McCurdy
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Anna Nobbe
- Digestive Diseases Section, Cincinnati VA Medical Center, Cincinnati, OH, USA
| | - Dawn Scott
- VA Central Texas Healthcare System, Temple, TX, USA
| | - Heather Patton
- VA San Diego Healthcare System, San Diego, CA, USA
- University of California San Diego, La Jolla, CA, USA
| | - Timothy R Morgan
- VA Long Beach Healthcare System, Long Beach, CA, USA
- Department of Medicine, University of California, Irvine, CA, USA
- National Gastroenterology and Hepatology Program, Department of Veterans Affairs, Veterans Health Administration, Washington, DC, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Central Virginia VA Health Care System, Richmond, VA, USA
| | - Vera Yakovchenko
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Monica Merante
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Sandra Gibson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Gyorgy Baffy
- Section of Gastroenterology, Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - George N Ioannou
- VA Puget Sound Health Care System, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, CT, USA
- Yale University, New Haven, CT, USA
| | | | - Jennifer Anwar
- VA Long Beach Healthcare System, Long Beach, CA, USA
- National Gastroenterology and Hepatology Program, Department of Veterans Affairs, Veterans Health Administration, Washington, DC, USA
| | - Jason A Dominitz
- National Gastroenterology and Hepatology Program, Department of Veterans Affairs, Veterans Health Administration, Washington, DC, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Building 30 Room 2A113, University Drive (151C), Pittsburgh, PA, 15240, USA.
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5
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Govier DJ, Niederhausen M, Takata Y, Hickok A, Rowneki M, McCready H, Smith VA, Osborne TF, Boyko EJ, Ioannou GN, Maciejewski ML, Viglianti EM, Bohnert ASB, O’Hare AM, Iwashyna TJ, Hynes DM. Risk of Potentially Preventable Hospitalizations After SARS-CoV-2 Infection. JAMA Netw Open 2024; 7:e245786. [PMID: 38598237 PMCID: PMC11007577 DOI: 10.1001/jamanetworkopen.2024.5786] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/11/2024] [Indexed: 04/11/2024] Open
Abstract
Importance Research demonstrates that SARS-CoV-2 infection is associated with increased risk of all-cause hospitalization. However, no prior studies have assessed the association between SARS-CoV-2 and potentially preventable hospitalizations-that is, hospitalizations for conditions that can usually be effectively managed in ambulatory care settings. Objective To examine whether SARS-CoV-2 is associated with potentially preventable hospitalization in a nationwide cohort of US veterans. Design, Setting, and Participants This cohort study used an emulated target randomized trial design with monthly sequential trials to compare risk of a potentially preventable hospitalization among veterans with SARS-CoV-2 and matched comparators without SARS-CoV-2. A total of 189 136 US veterans enrolled in the Veterans Health Administration (VHA) who were diagnosed with SARS-CoV-2 between March 1, 2020, and April 30, 2021, and 943 084 matched comparators were included in the analysis. Data were analyzed from May 10, 2023, to January 26, 2024. Exposure SARS-CoV-2 infection. Main Outcomes and Measures The primary outcome was a first potentially preventable hospitalization in VHA facilities, VHA-purchased community care, or Medicare fee-for-service care. Extended Cox models were used to examine adjusted hazard ratios (AHRs) of potentially preventable hospitalization among veterans with SARS-CoV-2 and comparators during follow-up periods of 0 to 30, 0 to 90, 0 to 180, and 0 to 365 days. The start of follow-up was defined as the date of each veteran's first positive SARS-CoV-2 diagnosis, with the same index date applied to their matched comparators. Results The 1 132 220 participants were predominantly men (89.06%), with a mean (SD) age of 60.3 (16.4) years. Most veterans were of Black (23.44%) or White (69.37%) race. Veterans with SARS-CoV-2 and comparators were well-balanced (standardized mean differences, all <0.100) on observable baseline clinical and sociodemographic characteristics. Overall, 3.10% of veterans (3.81% of those with SARS-CoV-2 and 2.96% of comparators) had a potentially preventable hospitalization during 1-year follow-up. Risk of a potentially preventable hospitalization was greater among veterans with SARS-CoV-2 than comparators in 4 follow-up periods: 0- to 30-day AHR of 3.26 (95% CI, 3.06-3.46); 0- to 90-day AHR of 2.12 (95% CI, 2.03-2.21); 0- to 180-day AHR of 1.69 (95% CI, 1.63-1.75); and 0- to 365-day AHR of 1.44 (95% CI, 1.40-1.48). Conclusions and Relevance In this cohort study, an increased risk of preventable hospitalization in veterans with SARS-CoV-2, which persisted for at least 1 year after initial infection, highlights the need for research on ways in which SARS-CoV-2 shapes postinfection care needs and engagement with the health system. Solutions are needed to mitigate preventable hospitalization after SARS-CoV-2.
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Affiliation(s)
- Diana J. Govier
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
- Oregon Health & Science University–Portland State University School of Public Health, Portland
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
- Oregon Health & Science University–Portland State University School of Public Health, Portland
| | - Yumie Takata
- College of Health, Oregon State University, Corvallis
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
| | - Mazhgan Rowneki
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
| | - Holly McCready
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, VA Durham Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Thomas F. Osborne
- VA Palo Alto Health Care System, Palo Alto, California
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington
| | - George N. Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, VA Durham Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth M. Viglianti
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Ann M. O’Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Theodore J. Iwashyna
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Denise M. Hynes
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
- College of Health, Oregon State University, Corvallis
- Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon
- School of Nursing, Oregon Health & Science University, Portland
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6
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Iwashyna TJ, Smith VA, Seelye S, Bohnert ASB, Boyko EJ, Hynes DM, Ioannou GN, Maciejewski ML, O'Hare AM, Viglianti EM, Berkowitz TS, Pura J, Womer J, Kamphuis LA, Monahan ML, Bowling CB. Self-Reported Everyday Functioning After COVID-19 Infection. JAMA Netw Open 2024; 7:e240869. [PMID: 38427352 PMCID: PMC10907923 DOI: 10.1001/jamanetworkopen.2024.0869] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Importance Changes in everyday functioning are crucial to assessing the long-term impact of COVID-19 infection. Objective To examine the impact of COVID-19 infection on everyday functioning 18 months after infection among veterans with and without histories of COVID-19 infection. Design, Setting, and Participants This cohort study used data from the US Veterans Affairs (VA) and included 186 veterans who had COVID-19 between October 2020 and April 2021 (ie, COVID-19 cohort) and 186 matched comparators who did not have documented COVID-19 infections (ie, control cohort). This match balanced the risk of COVID-19 based on 39 variables measured in the 24 months before infection or match, using principles of target trial emulation. Data were analyzed from December 2022 to December 2023. Exposure First documented COVID-19. Main Outcome and Measures The differences in self-reported everyday functioning 18 months after COVID-19 infection were estimated and compared with their matched comparators. Within-matched pair logistic and linear regressions assessed differences in outcomes and were weighted to account for sampling and nonresponse. Results Among the 186 matched pairs of participants, their weighted mean age was 60.4 (95% CI, 57.5 to 63.2) years among veterans in the COVID-19 cohort (weighted sample, 91 459 of 101 133 [90.4%] male; 30 611 [30.3%] Black or African American veterans; 65 196 [64.4%] White veterans) and 61.1 (95% CI, 57.8 to 64.4) years among their comparators in the control cohort (91 459 [90.4%] male; 24 576 [24.3%] Black or African American veterans; 70 157 [69.4%] White veterans). A high proportion of veterans in the COVID-19 cohort (weighted percentage, 44.9% [95% CI, 34.2% to 56.2%]) reported that they could do less than what they felt they could do at the beginning of 2020 compared with the control cohort (weighted percentage, 35.3%; [95% CI, 25.6% to 46.4%]; within-matched pair adjusted odds ratio [OR], 1.52 [95% CI, 0.79 to 2.91]). There was no association of documented COVID-19 infection with fatigue, substantial pain, limitations in either activities of daily living and instrumental activities of daily living, severely curtailed life-space mobility, employment, or mean health-related quality of life on a utility scale. Conclusions and Relevance In this cohort study of veterans with and without documented COVID-19, many reported a substantial loss of everyday functioning during the pandemic regardless of whether or not they had a documented infection with COVID-19. Future work with larger samples is needed to validate the estimated associations.
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Affiliation(s)
- Theodore J Iwashyna
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Departments of Anesthesiology, Epidemiology, and Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington
- University of Washington, Seattle
| | - Denise M Hynes
- VA Portland Healthcare System, Center to Improve Veteran Involvement in Care, Portland, Oregon
- College of Health, and Center for Quantitative Life Sciences, Oregon State University, Corvallis
- School of Nursing, Oregon Health and Science University, Portland
| | - George N Ioannou
- University of Washington, Seattle
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- School of Nursing, Oregon Health and Science University, Portland
| | - Ann M O'Hare
- University of Washington, Seattle
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
| | - Elizabeth M Viglianti
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Theodore S Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - John Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - James Womer
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lee A Kamphuis
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
| | - Max L Monahan
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
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7
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Hynes DM, Niederhausen M, Chen JI, Shahoumian TA, Rowneki M, Hickok A, Shepherd-Banigan M, Hawkins EJ, Naylor J, Teo A, Govier DJ, Berry K, McCready H, Osborne TF, Wong E, Hebert PL, Smith VA, Bowling CB, Boyko EJ, Ioannou GN, Iwashyna TJ, Maciejewski ML, O'Hare AM, Viglianti EM, Bohnert ASB. Risk of Suicide-Related Outcomes After SARS-COV-2 Infection: Results from a Nationwide Observational Matched Cohort of US Veterans. J Gen Intern Med 2024; 39:626-635. [PMID: 37884839 DOI: 10.1007/s11606-023-08440-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/18/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Negative mental health-related effects of SARS-COV-2 infection are increasingly evident. However, the impact on suicide-related outcomes is poorly understood, especially among populations at elevated risk. OBJECTIVE To determine risk of suicide attempts and other self-directed violence (SDV) after SARS-COV-2 infection in a high-risk population. DESIGN We employed an observational design supported by comprehensive electronic health records from the Veterans Health Administration (VHA) to examine the association of SARS-COV-2 infection with suicide attempts and other SDV within one year of infection. Veterans with SARS-COV-2 infections were matched 1:5 with non-infected comparators each month. Three periods after index were evaluated: days 1-30, days 31-365, and days 1-365. PARTICIPANTS VHA patients infected with SARS-COV-2 between March 1, 2020 and March 31, 2021 and matched non-infected Veteran comparators. MAIN MEASURES Suicide attempt and other SDV events for the COVID-19 and non-infected comparator groups were analyzed using incidence rates per 100,000 person years and hazard ratios from Cox regressions modeling time from matched index date to first event. Subgroups were also examined. KEY RESULTS 198,938 veterans with SARS-COV-2 (COVID-19 group) and 992,036 comparators were included. Unadjusted one-year incidence per 100,000 for suicide attempt and other SDV was higher among the COVID-19 group: 355 vs 250 and 327 vs 235, respectively. The COVID-19 group had higher risk than comparators for suicide attempts: days 1-30 hazard ratio (HR) = 2.54 (CI:2.05, 3.15), days 31-365 HR = 1.30 (CI:1.19, 1.43) and days 1-365 HR = 1.41 (CI:1.30, 1.54), and for other SDV: days 1-30 HR = 1.94 (CI:1.51, 2.49), days 31-365 HR = 1.32 (CI:1.20, 1.45) and days 1-365 HR = 1.38 (CI:1.26, 1.51). CONCLUSIONS COVID-19 patients had higher risks of both suicide attempts and other forms of SDV compared to uninfected comparators, which persisted for at least one year after infection. Results support suicide risk screening of those infected with SARS-COV-2 to identify opportunities to prevent self-harm.
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Affiliation(s)
- Denise M Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA.
- College of Health, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA.
- School of Nursing, Oregon Health & Science University (OHSU), Portland, OR, USA.
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- OHSU-Portland State University School of Public Health, OHSU, Portland, OR, USA
| | - Jason I Chen
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- Department of Psychiatry, OHSU, Portland, OR, USA
| | | | - Mazhgan Rowneki
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Eric J Hawkins
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound HCS, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Jennifer Naylor
- School of Medicine, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Education and Clinical Center, VISN 6 Mental Illness Research, Durham, NC, USA
- Durham VA HCS, Durham, NC, USA
| | - Alan Teo
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- Department of Psychiatry, OHSU, Portland, OR, USA
| | - Diana J Govier
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- OHSU-Portland State University School of Public Health, OHSU, Portland, OR, USA
| | - Kristin Berry
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
| | - Holly McCready
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- Department of Psychiatry, OHSU, Portland, OR, USA
| | - Thomas F Osborne
- VA Palo Alto HCS, Palo Alto, CA, USA
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Edwin Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
| | - Paul L Hebert
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham VA HCS, Durham, NC, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research Information Center, VA Puget Sound HCS, Seattle, WA, USA
| | - George N Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Theodore J Iwashyna
- Departments of Medicine and Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Ann M O'Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Hospital and Specialty Medicine Service, VA Puget Sound HCS, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amy S-B Bohnert
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
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Hebert PL, Kumbier KE, Smith VA, Hynes DM, Govier DJ, Wong E, Kaufman BG, Shepherd-Banigan M, Rowneki M, Bohnert ASB, Ioannou GN, Boyko EJ, Iwashyna TJ, O’Hare AM, Bowling CB, Viglianti EM, Maciejewski ML. Changes in Outpatient Health Care Use After COVID-19 Infection Among Veterans. JAMA Netw Open 2024; 7:e2355387. [PMID: 38334995 PMCID: PMC10858406 DOI: 10.1001/jamanetworkopen.2023.55387] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/18/2023] [Indexed: 02/10/2024] Open
Abstract
Importance The association of COVID-19 infection with outpatient care utilization is unclear. Many studies reported population surveillance studies rather than comparing outpatient health care use between COVID-19-infected and uninfected cohorts. Objective To compare outpatient health care use across 6 categories of care (primary care, specialty care, surgery care, mental health, emergency care, and diagnostic and/or other care) between veterans with or without COVID-19 infection. Design, Setting, and Participants In a retrospective cohort study of Veterans Affairs primary care patients, veterans with COVID-19 infection were matched to a cohort of uninfected veterans. Data were obtained from the Veterans Affairs Corporate Data Warehouse and the Centers for Medicare & Medicaid Services Fee-for-Service Carrier/Physician Supplier file from January 2019 through December 2022. Data analysis was performed from September 2022 to April 2023. Exposure COVID-19 infection. Main Outcomes and Measures The primary outcome was the count of outpatient visits after COVID-19 infection. Negative binomial regression models compared outpatient use over a 1-year preinfection period, and peri-infection (0-30 days), intermediate (31-183 days), and long-term (184-365 days) postinfection periods. Results The infected (202 803 veterans; mean [SD] age, 60.5 [16.2] years; 178 624 men [88.1%]) and uninfected (202 803 veterans; mean [SD] age, 60.4 [16.5] years; 178 624 men [88.1%]) cohorts were well matched across all covariates. Outpatient use in all categories (except surgical care) was significantly elevated during the peri-infection period for veterans with COVID-19 infection compared with the uninfected cohort, with an increase in all visits of 5.12 visits per 30 days (95% CI, 5.09-5.16 visits per 30 days), predominantly owing to primary care visits (increase of 1.86 visits per 30 days; 95% CI, 1.85-1.87 visits per 30 days). Differences in outpatient use attenuated over time but remained statistically significantly higher at 184 to 365 days after infection (increase of 0.25 visit per 30 days; 95% CI, 0.23-0.27 visit per 30 days). One-half of the increased outpatient visits were delivered via telehealth. The utilization increase was greatest for veterans aged 85 years and older (6.1 visits, 95% CI, 5.9-6.3 visits) vs those aged 20 to 44 years (4.8 visits, 95% CI, 4.7-4.8 visits) and unvaccinated veterans (4.5 visits, 95% CI, 4.3-4.6 visits) vs vaccinated veterans (3.2 visits; 95% CI, 3.4-4.8 visits). Conclusions and Relevance This study found that outpatient use increased significantly in the month after infection, then attenuated but remained greater than the uninfected cohorts' use through 12 months, which suggests that there are sustained impacts of COVID-19 infection.
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Affiliation(s)
- Paul L. Hebert
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle
| | - Kyle E. Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Health Management and Policy, Health Data and Informatics Program, Center for Quantitative Life Sciences, College of Health, Oregon State University, Corvallis
| | - Diana J. Govier
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- School of Nursing, Oregon Health & Science University, Portland
| | - Edwin Wong
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle
| | - Brystana G. Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Amy S. B. Bohnert
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - George N. Ioannou
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, University of Washington, Seattle
| | - Edward J. Boyko
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle
| | - Theodore J. Iwashyna
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Ann M. O’Hare
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle
| | - C. Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Elizabeth M. Viglianti
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- School of Nursing, Oregon Health & Science University, Portland
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Vutien P, Kim NJ, Moon AM, Johnson KM, Berry K, Green PK, Ioannou GN. Hepatocellular carcinoma risk decreases as time accrues following hepatitis C virus eradication. Aliment Pharmacol Ther 2024; 59:361-371. [PMID: 37955206 PMCID: PMC10842311 DOI: 10.1111/apt.17802] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/27/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND It is unclear whether the risk of hepatocellular carcinoma (HCC) decreases over time following hepatitis C virus (HCV) eradication. AIM To determine if patients who have accrued longer time since sustained virologic response (SVR) have a lower risk of HCC than those with less time since SVR METHODS: We conducted a retrospective cohort study of all HCV-infected Veterans Affairs patients who achieved SVR before 1 January 2018 and remained alive without a diagnosis of HCC as of 1 January 2019 (n = 75,965). We ascertained their baseline characteristics as of 1 January 2019 (time zero), including time accrued since SVR and followed them for the subsequent 12 months for incident HCC. We used multivariable Cox proportional hazards regression to determine the association between time since SVR and HCC risk after adjusting for age, race/ethnicity, sex, diabetes, hypertension, body mass index, alcohol use, Charlson Comorbidity Index, Fibrosis-4 score, HCV genotype, hepatitis B virus co-infection and HIV co-infection. RESULTS 96.0% were male; mean age was 64.6 years. Among those with cirrhosis (n = 19,678, 25.9%), compared to patients who had accrued only ≥1 to 2 years since SVR (HCC incidence 2.71/100 person-years), those who had accrued >2 to 4 years (2.11/100 person-years, aHR 0.80, 95% CI 0.63-1.01) and >4 to 6 years (1.65/100 person-years, aHR 0.61, 95% CI 0.41-0.90) had progressively lower HCC risk. However, HCC risk appeared to plateau for those with >6 years since SVR (1.68/100 person-years, aHR 0.70, 95% CI 0.46-1.07). Among those without cirrhosis, HCC risk was 0.23-0.27/100 person-years without a significant association between time since SVR and HCC risk. CONCLUSIONS Among patients with cirrhosis and cured HCV infection, HCC risk declined progressively up to 6 years post-SVR-although it remained well above thresholds that warrant screening. This suggests that time since SVR can inform HCC surveillance strategies in patients with cured HCV infection and can be incorporated into HCC risk prediction models.
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Affiliation(s)
- Philip Vutien
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Nicole J Kim
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kay M Johnson
- Hospital and Specialty Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kristin Berry
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Pamela K Green
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - George N Ioannou
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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Vutien P, Kim NJ, Moon AM, Johnson KM, Berry K, Green PK, Ioannou GN. Editorial: How does the risk of hepatocellular carcinoma change over time in patients with a hepatitis C cure? Authors' reply. Aliment Pharmacol Ther 2024; 59:419-420. [PMID: 38197705 DOI: 10.1111/apt.17841] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
LINKED CONTENTThis article is linked to Vutien et al papers. To view these articles, visit https://doi.org/10.1111/apt.17802 and https://doi.org/10.1111/apt.17818
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Affiliation(s)
- Philip Vutien
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Nicole J Kim
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kay M Johnson
- Hospital and Specialty Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kristin Berry
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Pamela K Green
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - George N Ioannou
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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Rogal SS, Taddei TH, Monto A, Yakovchenko V, Patton H, Merante M, Spoutz P, Chia L, Yudkevich J, Aytaman A, Rabiee A, John BV, Blechacz B, Cai CX, Gilles H, Shah AS, McCurdy H, Puri P, Jou J, Mazhar K, Dominitz JA, Anwar J, Morgan TR, Ioannou GN. Hepatocellular Carcinoma Diagnosis and Management in 2021: A National Veterans Affairs Quality Improvement Project. Clin Gastroenterol Hepatol 2024; 22:324-338. [PMID: 37460005 PMCID: PMC10788380 DOI: 10.1016/j.cgh.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/16/2023] [Accepted: 07/02/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND & AIMS The coronavirus disease-2019 pandemic profoundly disrupted preventative health care services including cancer screening. As the largest provider of cirrhosis care in the United States, the Department of Veterans Affairs (VA) National Gastroenterology and Hepatology Program aimed to assess factors associated with hepatocellular carcinoma (HCC) stage at diagnosis, treatment, and survival. METHODS Veterans with a new diagnosis of HCC in 2021 were identified from electronic health records (N = 2306). Structured medical record extraction was performed by expert reviewers in a 10% random subsample of Veterans with new HCC diagnoses. Factors associated with stage at diagnosis, receipt of treatment, and survival were assessed using multivariable models. RESULTS Among 199 patients with confirmed HCC, the average age was 71 years and most (72%) had underlying cirrhosis. More than half (54%) were at an early stage (T1 or T2) at diagnosis. Less-advanced liver disease, number of imaging tests adequate for HCC screening, HCC diagnosis in the VA, and receipt of VA primary care were associated significantly with early stage diagnosis. HCC-directed treatments were administered to 145 (73%) patients after a median of 37 days (interquartile range, 19-54 d) from diagnosis, including 70 (35%) patients who received potentially curative treatments. Factors associated with potentially curative (vs no) treatments included HCC screening, early stage at diagnosis, and better performance status. Having fewer comorbidities and better performance status were associated significantly with noncurative (vs no) treatment. Early stage diagnosis, diagnosis in the VA system, and receipt of curative treatment were associated significantly with survival. CONCLUSIONS These results highlight the importance of HCC screening and engagement in care for HCC diagnosis, treatment, and survival while demonstrating the feasibility of developing a national quality improvement agenda for HCC screening, diagnosis, and treatment.
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Affiliation(s)
- Shari S Rogal
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut; Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexander Monto
- San Francisco VA Health Care System, San Francisco, California
| | - Vera Yakovchenko
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Heather Patton
- Gastroenterology Section, Jennifer Moreno VA San Diego Healthcare System, San Diego, California
| | - Monica Merante
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Patrick Spoutz
- Pharmacy Benefits Management, Veterans Integrated Service Network 20, Vancouver, Washington
| | - Linda Chia
- Pharmacy Benefits Management, Veterans Integrated Service Network 20, Vancouver, Washington
| | - Jennifer Yudkevich
- VA New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, New York
| | - Ayse Aytaman
- VA New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, New York; SUNY Health Science Center Brooklyn, Brooklyn, New York
| | - Atoosa Rabiee
- Washington DC VA Medical Center, Washington, District of Columbia
| | - Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Healthcare System, Miami, Florida; Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Boris Blechacz
- Department of Gastroenterology and Hepatology, VA South Texas Health Care System, San Antonio, Texas
| | - Cindy X Cai
- Department of Gastroenterology and Hepatology, VA Loma Linda Healthcare System, Loma Linda, California; Loma Linda University, Loma Linda, California; Department of Internal Medicine, University of California, Riverside, Riverside, California
| | - HoChong Gilles
- Division of Gastroenterology and Hepatology, Central Virginia VA Healthcare System, Richmond, Virginia
| | - Anand S Shah
- Division of Gastroenterology, Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, Georgia; Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Puneet Puri
- Division of Gastroenterology and Hepatology, Central Virginia VA Healthcare System, Richmond, Virginia; Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Janice Jou
- VA Portland Healthcare System, Portland, Oregon; Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Khurram Mazhar
- VA North Texas Health Care System, Dallas, Texas; Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Jennifer Anwar
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, California
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, California; Division of Gastroenterology, Department of Medicine, University of California, Irvine, California
| | - George N Ioannou
- VA Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
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12
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Soyer EM, Frost MC, Fletcher OV, Ioannou GN, Tsui JI, Edelman EJ, Weiner BJ, Bachrach RL, Chen JA, Williams EC. Perspectives of clinical stakeholders and patients from four VA liver clinics to tailor practice facilitation for implementing evidence-based alcohol-related care. Addict Sci Clin Pract 2024; 19:3. [PMID: 38200496 PMCID: PMC10782537 DOI: 10.1186/s13722-023-00429-3] [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: 02/08/2023] [Accepted: 11/29/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Unhealthy alcohol use (UAU) is particularly dangerous for people with chronic liver disease. Liver clinics may be an important setting in which to provide effective alcohol-related care by integrating evidence-based strategies, such as brief intervention and medications for alcohol use disorder. We conducted qualitative interviews with clinical stakeholders and patients at liver clinics in four Veterans Health Administration (VA) medical centers to understand barriers and facilitators of integrating alcohol-related care and to support tailoring of a practice facilitation implementation intervention. METHODS Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process (RAP) guided by the CFIR. RESULTS We interviewed 46 clinical stakeholders and 41 patient participants and analyzed findings based on the CFIR. Clinical stakeholders described barriers and facilitators that ranged from operations/clinic resource-based (e.g., time and capacity, desire for additional provider types, referral processes) to individual perspective and preference-based (e.g., supportiveness of leadership, individual experiences/beliefs). Patient participants shared barriers and facilitators that ranged from relationship-based (e.g., trusting the provider and feeling judged) to resource and education-based (e.g., connection to a range of treatment options, education about impact of alcohol). Many barriers and facilitators to integrating alcohol-related care in liver clinics were similar to those identified in other clinical settings (e.g., time, resources, role clarity, stigmatizing beliefs). However, some barriers (e.g., fellow-led care and lack of integration of liver clinics with addictions specialists) and facilitators (e.g., presence of quality improvement staff in clinics and integrated pharmacists and behavioral health specialists) were more unique to liver clinics. CONCLUSIONS These findings support the possibility of integrating alcohol-related care into liver clinics but highlight the importance of tailoring efforts to account for variation in provider beliefs and experiences and clinic resources. The barriers and facilitators identified in these interviews were used to tailor a practice facilitation implementation intervention in each clinic setting.
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Affiliation(s)
- Elena M Soyer
- Department of Health Systems and Population Health, University of Washington School of Public Health, 3980 15th Ave NE, Seattle, WA, 98195, USA.
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA.
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, 3980 15th Ave NE, Seattle, WA, 98195, USA
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - Olivia V Fletcher
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
| | - George N Ioannou
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Seattle, WA, 98104, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Seattle, WA, 98104, USA
| | - E Jennifer Edelman
- Yale Schools of Medicine and Public Health, 367 Cedar Street, ES Harkness, Suite 401, New Haven, CT, 06510, USA
| | - Bryan J Weiner
- Department of Health Systems and Population Health, University of Washington School of Public Health, 3980 15th Ave NE, Seattle, WA, 98195, USA
- Department of Global Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Rachel L Bachrach
- Department of Psychiatry, University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI, 48109, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI, 48105, USA
| | - Jessica A Chen
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
- Department of Psychiatry and Behavioral Science, University of Washington School of Medicine, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, 3980 15th Ave NE, Seattle, WA, 98195, USA
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA
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13
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Xu FX, Ioannou GN, Lee SP, Savard C, Horn CL, Fu D. Discrimination of lipid composition and cellular localization in human liver tissues by stimulated Raman scattering microscopy. J Biomed Opt 2024; 29:016008. [PMID: 38269081 PMCID: PMC10807871 DOI: 10.1117/1.jbo.29.1.016008] [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] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/26/2024]
Abstract
Significance The molecular mechanisms driving the progression from nonalcoholic fatty liver (NAFL) to fibrosing steatohepatitis (NASH) are insufficiently understood. Techniques enabling the characterization of different lipid species with both chemical and spatial information can provide valuable insights into their contributions to the disease progression. Aim We extend the utility of stimulated Raman scattering (SRS) microscopy to characterize and quantify lipid species in liver tissue sections from patients with NAFL and NASH. Approach We applied a dual-band hyperspectral SRS microscopy system for imaging tissue sections in both the C-H stretching and fingerprint regions. The same sections were imaged with polarization microscopy for detecting birefringent liquid crystals in the tissues. Results Our imaging and analysis pipeline provides accurate classification and quantification of free cholesterol, saturated cholesteryl esters (CEs), unsaturated CE, and triglycerides in liver tissue sections. The subcellular resolution enables investigations of the heterogeneous distribution of saturated CE, which has been under-examined in previous studies. We also discovered that the birefringent crystals, previously found to be associated with NASH development, are predominantly composed of saturated CE. Conclusions Our method allows for a detailed characterization of lipid composition in human liver tissues and enables further investigation into the potential mechanism of NASH progression.
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Affiliation(s)
- Fiona Xi Xu
- University of Washington, Department of Chemistry, Seattle, Washington, United States
| | - George N. Ioannou
- Veterans Affairs Puget Sound Health Care System, Department of Medicine, Division of Gastroenterology, Seattle, Washington, United States
- University of Washington, Department of Medicine, Division of Gastroenterology, Seattle, Washington, United States
- Veterans Affairs Puget Sound Health Care System, Research and Development, Seattle, Washington, United States
| | - Sum P. Lee
- University of Washington, Department of Medicine, Division of Gastroenterology, Seattle, Washington, United States
| | - Christopher Savard
- Veterans Affairs Puget Sound Health Care System, Department of Medicine, Division of Gastroenterology, Seattle, Washington, United States
- University of Washington, Department of Medicine, Division of Gastroenterology, Seattle, Washington, United States
- Veterans Affairs Puget Sound Health Care System, Research and Development, Seattle, Washington, United States
| | - Christian L. Horn
- San Antonio Military Medical Center, Department of Medicine, Division of Gastroenterology and Hepatology, Fort Sam Houston, Texas, United States
| | - Dan Fu
- University of Washington, Department of Chemistry, Seattle, Washington, United States
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14
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Wander PL, Baraff A, Fox A, Cho K, Maripuri M, Honerlaw JP, Ho YL, Dey AT, O’Hare AM, Bohnert ASB, Boyko EJ, Maciejewski ML, Viglianti E, Iwashyna TJ, Hynes DM, Osborne TF, Ioannou GN. Rates of ICD-10 Code U09.9 Documentation and Clinical Characteristics of VA Patients With Post-COVID-19 Condition. JAMA Netw Open 2023; 6:e2346783. [PMID: 38064215 PMCID: PMC10709773 DOI: 10.1001/jamanetworkopen.2023.46783] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/26/2023] [Indexed: 12/18/2023] Open
Abstract
Importance A significant proportion of SARS-CoV-2 infected individuals experience post-COVID-19 condition months after initial infection. Objective To determine the rates, clinical setting, risk factors, and symptoms associated with the documentation of International Statistical Classification of Diseases Tenth Revision (ICD-10), code U09.9 for post-COVID-19 condition after acute infection. Design, Setting, and Participants This retrospective cohort study was performed within the US Department of Veterans Affairs (VA) health care system. Veterans with a positive SARS-CoV-2 test result between October 1, 2021, the date ICD-10 code U09.9 was introduced, and January 31, 2023 (n = 388 980), and a randomly selected subsample of patients with the U09.9 code (n = 350) whose symptom prevalence was assessed by systematic medical record review, were included in the analysis. Exposure Positive SARS-CoV-2 test result. Main Outcomes and Measures Rates, clinical setting, risk factors, and symptoms associated with ICD-10 code U09.9 in the medical record. Results Among the 388 980 persons with a positive SARS-CoV-2 test, the mean (SD) age was 61.4 (16.1) years; 87.3% were men. In terms of race and ethnicity, 0.8% were American Indian or Alaska Native, 1.4% were Asian, 20.7% were Black, 9.3% were Hispanic or Latino, 1.0% were Native Hawaiian or Other Pacific Islander; and 67.8% were White. Cumulative incidence of U09.9 documentation was 4.79% (95% CI, 4.73%-4.87%) at 6 months and 5.28% (95% CI, 5.21%-5.36%) at 12 months after infection. Factors independently associated with U09.9 documentation included older age, female sex, Hispanic or Latino ethnicity, comorbidity burden, and severe acute infection manifesting by symptoms, hospitalization, or ventilation. Primary vaccination (adjusted hazard ratio [AHR], 0.80 [95% CI, 0.78-0.83]) and booster vaccination (AHR, 0.66 [95% CI, 0.64-0.69]) were associated with a lower likelihood of U09.9 documentation. Marked differences by geographic region and facility in U09.9 code documentation may reflect local screening and care practices. Among the 350 patients undergoing systematic medical record review, the most common symptoms documented in the medical records among patients with the U09.9 code were shortness of breath (130 [37.1%]), fatigue or exhaustion (78 [22.3%]), cough (63 [18.0%]), reduced cognitive function or brain fog (22 [6.3%]), and change in smell and/or taste (20 [5.7%]). Conclusions and Relevance In this cohort study of 388 980 veterans, documentation of ICD-10 code U09.9 had marked regional and facility-level variability. Strong risk factors for U09.9 documentation were identified, while vaccination appeared to be protective. Accurate and consistent documentation of U09.9 is needed to maximize its utility in tracking patients for clinical care and research. Future studies should examine the long-term trajectory of individuals with U09.9 documentation.
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Affiliation(s)
- Pandora L. Wander
- Division of General Internal Medicine, Veterans Affairs (VA) Puget Sound Health Care System and University of Washington, Seattle
| | - Aaron Baraff
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington
| | - Kelly Cho
- VA Centralized Interactive Phenomics Resources–VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, Mass General Brigham, Harvard Medical School, Boston, Massachusetts
| | - Monika Maripuri
- VA Centralized Interactive Phenomics Resources–VA Boston Healthcare System, Boston, Massachusetts
| | - Jacqueline P. Honerlaw
- VA Centralized Interactive Phenomics Resources–VA Boston Healthcare System, Boston, Massachusetts
| | - Yuk-Lam Ho
- VA Centralized Interactive Phenomics Resources–VA Boston Healthcare System, Boston, Massachusetts
| | - Andrew T. Dey
- VA Centralized Interactive Phenomics Resources–VA Boston Healthcare System, Boston, Massachusetts
| | - Ann M. O’Hare
- Division of Nephrology, VA Puget Sound Healthcare System and University of Washington, Seattle
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Edward J. Boyko
- Division of General Internal Medicine, Veterans Affairs (VA) Puget Sound Health Care System and University of Washington, Seattle
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University School of Medicine, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth Viglianti
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Health Data and Informatics Program, Center for Genome Research and Biocomputing, Oregon State University, Corvallis
| | - Thomas F. Osborne
- VA Palo Alto Health Care System, Palo Alto, California
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - George N. Ioannou
- Division of Gastroenterology, VA Puget Sound Health Care System and University of Washington, Seattle
- Research and Development, VA Puget Sound Health Care System, Seattle, Washington
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Kothari V, Savard C, Tang J, Lee SP, Subramanian S, Wang S, den Hartigh LJ, Bornfeldt KE, Ioannou GN. sTREM2 is a plasma biomarker for human NASH and promotes hepatocyte lipid accumulation. Hepatol Commun 2023; 7:e0265. [PMID: 37820278 PMCID: PMC10578746 DOI: 10.1097/hc9.0000000000000265] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/28/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Pathogenetic mechanisms of the progression of NAFL to advanced NASH coupled with potential noninvasive biomarkers and novel therapeutic targets are active areas of investigation. The recent finding that increased plasma levels of a protein shed by myeloid cells -soluble Triggering Receptor Expressed on Myeloid cells 2 (sTREM2) -may be a biomarker for NASH has received much interest. We aimed to test sTREM2 as a biomarker for human NASH and investigate the role of sTREM2 in the pathogenesis of NASH. METHODS We conducted studies in both humans (comparing patients with NASH vs. NAFL) and in mice (comparing different mouse models of NASH) involving measurements of TREM2 gene and protein expression levels in the liver as well as circulating sTREM2 levels in plasma. We investigated the pathogenetic role of sTREM2 in hepatic steatosis using primary hepatocytes and bone marrow derived macrophages. RESULTS RNA sequencing analysis of livers from patients with NASH or NAFL as well as livers from 2 mouse models of NASH revealed elevated TREM2 expression in patients/mice with NASH as compared with NAFL. Plasma levels of sTREM2 were significantly higher in a well-characterized cohort of patients with biopsy-proven NASH versus NAFL (area under receiver-operating curve 0.807). Mechanistic studies revealed that cocultures of primary hepatocytes and macrophages with an impaired ability to shed sTREM2 resulted in reduced hepatocyte lipid droplet formation on palmitate stimulation, an effect that was counteracted by the addition of exogenous sTREM2 chimeric protein. Conversely, exogenous sTREM2 chimeric protein increased lipid droplet formation, triglyceride content, and expression of the lipid transporter CD36 in hepatocytes. Furthermore, inhibition of CD36 markedly attenuated sTREM2-induced lipid droplet formation in mouse primary hepatocytes. CONCLUSIONS Elevated levels of sTREM2 due to TREM2 shedding may directly contribute to the pathogenesis of NAFLD by promoting hepatocyte lipid accumulation, as well as serving as a biomarker for distinguishing patients with NASH versus NAFL. Further investigation of sTREM2 as a clinically useful diagnostic biomarker and of the therapeutic effects of targeting sTREM2 in NASH is warranted.
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Affiliation(s)
- Vishal Kothari
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, UW Medicine Diabetes Institute, University of Washington, Seattle, Washington, USA
| | - Christopher Savard
- Department of Medicine, Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Jingjing Tang
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, UW Medicine Diabetes Institute, University of Washington, Seattle, Washington, USA
| | - Sum P. Lee
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Savitha Subramanian
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, UW Medicine Diabetes Institute, University of Washington, Seattle, Washington, USA
| | - Shari Wang
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, UW Medicine Diabetes Institute, University of Washington, Seattle, Washington, USA
| | - Laura J. den Hartigh
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, UW Medicine Diabetes Institute, University of Washington, Seattle, Washington, USA
| | - Karin E. Bornfeldt
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, UW Medicine Diabetes Institute, University of Washington, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - George N. Ioannou
- Department of Medicine, Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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16
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Ioannou GN, Berry K, Rajeevan N, Li Y, Mutalik P, Yan L, Bui D, Cunningham F, Hynes DM, Rowneki M, Bohnert A, Boyko EJ, Iwashyna TJ, Maciejewski ML, Osborne TF, Viglianti EM, Aslan M, Huang GD, Bajema KL. Effectiveness of Nirmatrelvir-Ritonavir Against the Development of Post-COVID-19 Conditions Among U.S. Veterans : A Target Trial Emulation. Ann Intern Med 2023; 176:1486-1497. [PMID: 37903369 PMCID: PMC10620954 DOI: 10.7326/m23-1394] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND COVID-19 has been linked to the development of many post-COVID-19 conditions (PCCs) after acute infection. Limited information is available on the effectiveness of oral antivirals used to treat acute COVID-19 in preventing the development of PCCs. OBJECTIVE To measure the effectiveness of outpatient treatment of COVID-19 with nirmatrelvir-ritonavir in preventing PCCs. DESIGN Retrospective target trial emulation study comparing matched cohorts receiving nirmatrelvir-ritonavir versus no treatment. SETTING Veterans Health Administration (VHA). PARTICIPANTS Nonhospitalized veterans in VHA care who were at risk for severe COVID-19 and tested positive for SARS-CoV-2 during January through July 2022. INTERVENTION Nirmatrelvir-ritonavir treatment for acute COVID-19. MEASUREMENTS Cumulative incidence of 31 potential PCCs at 31 to 180 days after treatment or a matched index date, including cardiac, pulmonary, renal, thromboembolic, gastrointestinal, neurologic, mental health, musculoskeletal, endocrine, and general conditions and symptoms. RESULTS Eighty-six percent of the participants were male, with a median age of 66 years, and 17.5% were unvaccinated. Baseline characteristics were well balanced between participants treated with nirmatrelvir-ritonavir and matched untreated comparators. No differences were observed between participants treated with nirmatrelvir-ritonavir (n = 9593) and their matched untreated comparators in the incidence of most PCCs examined individually or grouped by organ system, except for lower combined risk for venous thromboembolism and pulmonary embolism (subhazard ratio, 0.65 [95% CI, 0.44 to 0.97]; cumulative incidence difference, -0.29 percentage points [CI, -0.52 to -0.05 percentage points]). LIMITATIONS Ascertainment of PCCs using International Classification of Diseases, 10th Revision, codes may be inaccurate. Evaluation of many outcomes could have resulted in spurious associations with combined thromboembolic events by chance. CONCLUSION Out of 31 potential PCCs, only combined thromboembolic events seemed to be reduced by nirmatrelvir-ritonavir. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- George N Ioannou
- Research and Development and Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, and Division of Gastroenterology, University of Washington, Seattle, Washington (G.N.I.)
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (K.B.)
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut (N.R., P.M.)
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (Y.L.)
| | - Pradeep Mutalik
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut (N.R., P.M.)
| | - Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut (L.Y.)
| | - David Bui
- Veterans Affairs Portland Health Care System, Portland, Oregon (D.B.)
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety - Pharmacy Benefit Management (PBM) Services, Hines, Illinois (F.C.)
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon; Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon; and Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon (D.M.H.)
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon (M.R.)
| | - Amy Bohnert
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (A.B.)
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (E.J.B.)
| | - Theodore J Iwashyna
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and Schools of Medicine and Public Health, Johns Hopkins University, Baltimore, Maryland (T.J.I.)
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center; Department of Population Health Sciences, Duke University School of Medicine; and Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina (M.L.M.)
| | - Thomas F Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Department of Radiology, Stanford University School of Medicine, Stanford, California (T.F.O.)
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (E.M.V.)
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Department of Medicine, Yale School of Medicine, New Haven, Connecticut (M.A.)
| | - Grant D Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC (G.D.H.)
| | - Kristina L Bajema
- Veterans Affairs Portland Health Care System, and Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon (K.L.B.)
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Dempsey JL, Ioannou GN, Carr RM. Mechanisms of Lipid Droplet Accumulation in Steatotic Liver Diseases. Semin Liver Dis 2023; 43:367-382. [PMID: 37799111 DOI: 10.1055/a-2186-3557] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
The steatotic diseases of metabolic dysfunction-associated steatotic liver disease (MASLD), alcohol-associated liver disease (ALD), and chronic hepatitis C (HCV) account for the majority of liver disease prevalence, morbidity, and mortality worldwide. While these diseases have distinct pathogenic and clinical features, dysregulated lipid droplet (LD) organelle biology represents a convergence of pathogenesis in all three. With increasing understanding of hepatocyte LD biology, we now understand the roles of LD proteins involved in these diseases but also how genetics modulate LD biology to either exacerbate or protect against the phenotypes associated with steatotic liver diseases. Here, we review the history of the LD organelle and its biogenesis and catabolism. We also review how this organelle is critical not only for the steatotic phenotype of liver diseases but also for their advanced phenotypes. Finally, we summarize the latest attempts and challenges of leveraging LD biology for therapeutic gain in steatotic diseases. In conclusion, the study of dysregulated LD biology may lead to novel therapeutics for the prevention of disease progression in the highly prevalent steatotic liver diseases of MASLD, ALD, and HCV.
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Affiliation(s)
- Joseph L Dempsey
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System Seattle, Washington
| | - Rotonya M Carr
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
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18
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Iwashyna TJ, Seelye S, Berkowitz TS, Pura J, Bohnert ASB, Bowling CB, Boyko EJ, Hynes DM, Ioannou GN, Maciejewski ML, O’Hare AM, Viglianti EM, Womer J, Prescott HC, Smith VA. Late Mortality After COVID-19 Infection Among US Veterans vs Risk-Matched Comparators: A 2-Year Cohort Analysis. JAMA Intern Med 2023; 183:1111-1119. [PMID: 37603339 PMCID: PMC10442778 DOI: 10.1001/jamainternmed.2023.3587] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/09/2023] [Indexed: 08/22/2023]
Abstract
Importance Despite growing evidence of persistent problems after acute COVID-19, how long the excess mortality risk associated with COVID-19 persists is unknown. Objective To measure the time course of differential mortality among Veterans who had a first-documented COVID-19 infection by separately assessing acute mortality from later mortality among matched groups with infected and uninfected individuals who survived and were uncensored at the start of each period. Design, Settings, and Participants This retrospective cohort study used prospectively collected health record data from Veterans Affairs hospitals across the US on Veterans who had COVID-19 between March 2020 and April 2021. Each individual was matched with up to 5 comparators who had not been infected with COVID-19 at the time of matching. This match balanced, on a month-by-month basis, the risk of developing COVID-19 using 37 variables measured in the 24 months before the date of the infection or match. A primary analysis censored comparators when they developed COVID-19 with inverse probability of censoring weighting in Cox regression. A secondary analysis did not censor. Data analyses were performed from April 2021 through June 2023. Exposure First-documented case of COVID-19 (SARS-CoV-2) infection. Main Outcome Measures Hazard ratios for all-cause mortality at clinically meaningful intervals after infection: 0 to 90, 91 to 180, 181 to 365, and 366 to 730 days. Results The study sample comprised 208 061 Veterans with first-documented COVID-19 infection (mean [SD] age, 60.5 (16.2) years; 21 936 (10.5) women; 47 645 [22.9] Black and 139 604 [67.1] White individuals) and 1 037 423 matched uninfected comparators with similar characteristics. Veterans with COVID-19 had an unadjusted mortality rate of 8.7% during the 2-year period after the initial infection compared with 4.1% among uninfected comparators, with censoring if the comparator later developed COVID-19-an adjusted hazard ratio (aHR) of 2.01 (95% CI, 1.98-2.04). The risk of excess death varied, being highest during days 0 to 90 after infection (aHR, 6.36; 95% CI, 6.20-6.51) and still elevated during days 91 to 180 (aHR, 1.18; 95% CI, 1.12-1.23). Those who survived COVID-19 had decreased mortality on days 181 to 365 (aHR, 0.92; 95% CI, 0.89-0.95) and 366 to 730 (aHR, 0.89; 95% CI, 0.85-0.92). These patterns were consistent across sensitivity analyses. Conclusion and Relevance The findings of this retrospective cohort study indicate that although overall 2-year mortality risk was worse among those infected with COVID-19, by day 180 after infection they had no excess mortality during the next 1.5 years.
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Affiliation(s)
- Theodore J. Iwashyna
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Sarah Seelye
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
| | - Theodore S. Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - John Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - Amy S. B. Bohnert
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor
| | - C. Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Durham VA Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Edward J. Boyko
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Denise M. Hynes
- VA Center to Improve Veteran Involvement in Care, Portland, Oregon
- College of Public Health and Human Sciences and Center for Quantitative Life Sciences, Oregon State University, Corvallis
- School of Nursing, Oregon Health and Science University, Portland
| | - George N. Ioannou
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Ann M. O’Hare
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Elizabeth M. Viglianti
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - James Womer
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Hallie C. Prescott
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
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19
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Smith VA, Berkowitz TSZ, Hebert P, Wong ES, Niederhausen M, Pura JA, Berry K, Green P, Korpak A, Fox A, Baraff A, Hickok A, Shahoumian TA, Bohnert ASB, Hynes DM, Boyko EJ, Ioannou GN, Iwashyna TJ, Bowling CB, O'Hare AM, Maciejewski ML. Correction: Design and analysis of outcomes following SARS-CoV-2 infection in veterans. BMC Med Res Methodol 2023; 23:194. [PMID: 37620765 PMCID: PMC10463685 DOI: 10.1186/s12874-023-02021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
Affiliation(s)
- Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Theodore S Z Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Paul Hebert
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Edwin S Wong
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University (OHSU), Portland, OR, USA
- Portland State University School of Public Health, Portland, OR, USA
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Kristin Berry
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Pamela Green
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Anna Korpak
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Aaron Baraff
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Troy A Shahoumian
- Population Health: Health Solutions, Veterans Health Administration, Washington, DC, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, Ann Arbor, VA, MI, USA
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- College of Public Health and Human Sciences, Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - George N Ioannou
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Theodore J Iwashyna
- VA Center for Clinical Management Research, Ann Arbor, VA, MI, USA
- National Clinical Scholars Program, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ann M O'Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Nephrology, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA.
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20
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VoPham T, Cravero A, Feld LD, Green P, Feng Z, Berry K, Kim NJ, Vutien P, Mendoza JA, Ioannou GN. Associations of Race and Ethnicity with Hepatocellular Carcinoma, Decompensation, and Mortality in US Veterans with Cirrhosis. Cancer Epidemiol Biomarkers Prev 2023; 32:1069-1078. [PMID: 37255388 PMCID: PMC10390887 DOI: 10.1158/1055-9965.epi-22-1291] [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: 12/22/2022] [Revised: 03/27/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Among patients with cirrhosis, it remains unclear whether there are racial/ethnic differences in cirrhosis complications and mortality. We examined the associations between race/ethnicity and risk for hepatocellular carcinoma (HCC), cirrhosis decompensation, and all-cause mortality overall and by cirrhosis etiology. METHODS US Veterans diagnosed with cirrhosis from 2001 to 2014 (n = 120,992), due to hepatitis C virus (HCV; n = 55,814), alcohol-associated liver disease (ALD; n = 36,323), hepatitis B virus (HBV; n = 1,972), nonalcoholic fatty liver disease (NAFLD; n = 17,789), or other (n = 9,094), were followed through 2020 for incident HCC (n = 10,242), cirrhosis decompensation (n = 27,887), and mortality (n = 81,441). Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). RESULTS Compared with non-Hispanic White patients, Hispanic patients had higher risk for HCC overall (aHR, 1.32; 95% CI, 1.24-1.41) and by cirrhosis etiology, particularly for ALD- (aHR, 1.63; 95% CI, 1.42-1.87) and NAFLD-cirrhosis (aHR, 1.76; 95% CI, 1.41-2.20), whereas non-Hispanic Black patients had lower HCC risk in ALD- (aHR, 0.79; 95% CI, 0.63-0.98) and NAFLD-cirrhosis (aHR, 0.54; 95% CI, 0.33-0.89). Asian patients had higher HCC risk (aHR, 1.70; 95% CI, 1.29-2.23), driven by HCV- and HBV-cirrhosis. Non-Hispanic Black patients had lower risk for cirrhosis decompensation overall (aHR, 0.71; 95% CI, 0.68-0.74) and by cirrhosis etiology. There was lower risk for mortality among all other racial/ethnic groups compared with non-Hispanic White patients. CONCLUSIONS Race/ethnicity is an important predictor for risk of developing HCC, decompensation, and mortality. IMPACT Future research should examine factors underlying these racial/ethnic differences to inform prevention, screening, and treatment for patients with cirrhosis.
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Affiliation(s)
- Trang VoPham
- Epidemiology Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Anne Cravero
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lauren D. Feld
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ziding Feng
- Biostatistics Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Nicole J. Kim
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Philip Vutien
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Jason A. Mendoza
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics and Nutritional Sciences Program, University of Washington, Seattle, Washington
- Cancer Prevention Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - George N. Ioannou
- Epidemiology Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
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21
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Yan L, Streja E, Li Y, Rajeevan N, Rowneki M, Berry K, Hynes DM, Cunningham F, Huang GD, Aslan M, Ioannou GN, Bajema KL. Anti-SARS-CoV-2 Pharmacotherapies Among Nonhospitalized US Veterans, January 2022 to January 2023. JAMA Netw Open 2023; 6:e2331249. [PMID: 37651140 PMCID: PMC10472184 DOI: 10.1001/jamanetworkopen.2023.31249] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/11/2023] [Indexed: 09/01/2023] Open
Abstract
Importance Several pharmacotherapies have been authorized to treat nonhospitalized persons with symptomatic COVID-19. Longitudinal information on the use of these therapies is needed. Objective To analyze trends and factors associated with prescription of outpatient COVID-19 pharmacotherapies within the Veterans Health Administration (VHA). Design, Setting, and Participants This cohort study evaluated nonhospitalized veterans in VHA care who tested positive for SARS-CoV-2 from January 2022 through January 2023 using VHA and linked Community Care and Medicare databases. Exposures Demographic characteristics, underlying medical conditions, COVID-19 vaccination, and regional and local systems of care, including Veterans Integrated Services Networks (VISNs). Main Outcomes and Measures Monthly receipt of any COVID-19 pharmacotherapy (nirmatrelvir-ritonavir, molnupiravir, sotrovimab, or bebtelovimab) was described. Multivariable logistic regression was used to identify factors independently associated with receipt of any vs no COVID-19 pharmacotherapy. Results Among 285 710 veterans (median [IQR] age, 63.1 [49.9-73.7] years; 247 358 males [86.6%]; 28 444 Hispanic [10.0%]; 61 269 Black [21.4%] and 198 863 White [69.6%]) who tested positive for SARS-CoV-2 between January 2022 and January 2023, the proportion receiving any pharmacotherapy increased from 3285 of 102 343 veterans (3.2%) in January 2022 to 5180 of 21 688 veterans (23.9%) in August 2022. The proportion declined to 2194 of 10 551 veterans (20.8%) by January 2023. Across VISNs, the range in proportion of patients who tested positive who received nirmatrelvir-ritonavir or molnupiravir during January 2023 was 41 of 692 veterans (5.9%) to 106 of 494 veterans (21.4%) and 2.1% to 120 of 1074 veterans (11.1%), respectively. Veterans receiving any treatment were more likely to be older (adjusted odds ratio [aOR] for ages 65-74 vs 50-64 years, 1.18; 95% CI, 1.14-1.22; aOR for ages ≥75 vs 50-64 years, 1.19; 95% CI, 1.15-1.23) and have a higher Charlson Comorbidity Index score (aOR for CCI ≥6 vs 0, 1.52; 95% CI, 1.44-1.59). Compared with White veterans, Black veterans (aOR, 1.06; 95% CI, 1.02-1.09) were more likely to receive treatment, and compared with non-Hispanic veterans, Hispanic veterans (aOR 1.06; 95% CI, 1.01-1.11) were more likely to receive treatment. Conclusions And Relevance This study found that prescription of outpatient COVID-19 pharmacotherapies in the VHA peaked in August 2022 and declined thereafter. There were large regional differences in patterns of nirmatrelvir-ritonavir and molnupiravir use.
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Affiliation(s)
- Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences; Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Francesca Cunningham
- Pharmacy Benefit Management Services, Veterans Affairs Center for Medication Safety, Hines, Illinois
| | - Grant D. Huang
- Office of Research and Development, Veterans Health Administration, Washington, District of Columbia
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - George N. Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Sciences University, Portland
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22
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Kim NJ, Cravero A, VoPham T, Vutien P, Carr R, Issaka RB, Johnston J, McMahon B, Mera J, Ioannou GN. Addressing racial and ethnic disparities in US liver cancer care. Hepatol Commun 2023; 7:e00190. [PMID: 37347221 DOI: 10.1097/hc9.0000000000000190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/09/2023] [Indexed: 06/23/2023] Open
Abstract
HCC, the most common form of primary liver cancer, is the fastest rising cause of cancer-related death in the United States. HCC disproportionately affects racial and ethnic minorities in the United States. A practical framework is needed to organize the complex patient, provider, health system, and societal factors that drive these racial and ethnic disparities. In this narrative review, we adapted and applied the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to the HCC care continuum, as a step toward better understanding and addressing existing HCC-related disparities. We first summarize the literature on HCC-related disparities by race and ethnicity organized by the framework's 5 domains (biological, behavioral, physical/built environment, sociocultural environment, and health care system) and 4 levels (individual, interpersonal, community, and societal) of influence. We then offer strategies to guide future research initiatives toward promotion of health equity in HCC care. Clinicians and researchers may help mitigate further inequities and better address racial and ethnic disparities in HCC care by prioritizing the following in HCC research: (1) increasing racial and ethnic minority representation, (2) collecting and reporting HCC-related data by racial and ethnic subgroups, (3) assessing the patient experience of HCC care by race and ethnicity, and (4) evaluating HCC-specific social determinants of health by race and ethnicity. These 4 priorities will help inform the development of future programs and interventions that are tailored to the unique experiences of each racial and ethnic group.
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Affiliation(s)
- Nicole J Kim
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Anne Cravero
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Trang VoPham
- Epidemiology Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Philip Vutien
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Rotonya Carr
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Rachel B Issaka
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Janet Johnston
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Brian McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Jorge Mera
- Cherokee Nation Health Services, Tahlequah, Oklahoma
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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23
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Vutien P, Li R, Karkar R, Munson SA, Fogarty J, Walter K, Yacoub M, Ioannou GN. Evaluating a Novel, Portable, Self-Administrable Device ("Beacon") That Measures Critical Flicker Frequency as a Test for Hepatic Encephalopathy. Am J Gastroenterol 2023; 118:1096-1100. [PMID: 36746413 PMCID: PMC10238616 DOI: 10.14309/ajg.0000000000002211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/26/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION We compared critical flicker frequency (CFF) thresholds obtained using a novel portable device "Beacon" with thresholds from the commercially available Lafayette Flicker Fusion System (Lafayette-FFS) in patients with cirrhosis. METHODS One hundred fifty-three participants with chronic liver disease underwent CFF testing using Beacon and Lafayette-FFS with a method-of-limits and/or forced-choice protocol. RESULTS Beacon demonstrated excellent test-retest reliability (intraclass correlation 0.91-0.97) and good correlation with the Lafayette-FFS values (intraclass correlation 0.77-0.84). Forced-choice CFF were on average 4.1 Hz higher than method-of-limits descending CFFs. DISCUSSION Beacon can be self-administered by patients with chronic liver disease and cirrhosis to measure CFF, a validated screening test for minimal hepatic encephalopathy.
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Affiliation(s)
- Philip Vutien
- University of Washington, Division of Gastroenterology and Hepatology, Seattle, WA, USA
- Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Richard Li
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA, USA
| | - Ravi Karkar
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA, USA
- Manning College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Sean A. Munson
- Human Centered Design & Engineering, University of Washington, Seattle, WA, USA
| | - James Fogarty
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA, USA
| | - Kara Walter
- University of Washington, Division of Gastroenterology and Hepatology, Seattle, WA, USA
| | - Michael Yacoub
- University of Washington, Division of Gastroenterology and Hepatology, Seattle, WA, USA
| | - George N. Ioannou
- University of Washington, Division of Gastroenterology and Hepatology, Seattle, WA, USA
- Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
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Bajema KL, Berry K, Streja E, Rajeevan N, Li Y, Mutalik P, Yan L, Cunningham F, Hynes DM, Rowneki M, Bohnert A, Boyko EJ, Iwashyna TJ, Maciejewski ML, Osborne TF, Viglianti EM, Aslan M, Huang GD, Ioannou GN. Effectiveness of COVID-19 Treatment With Nirmatrelvir-Ritonavir or Molnupiravir Among U.S. Veterans: Target Trial Emulation Studies With One-Month and Six-Month Outcomes. Ann Intern Med 2023; 176:807-816. [PMID: 37276589 PMCID: PMC10243488 DOI: 10.7326/m22-3565] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Information about the effectiveness of oral antivirals in preventing short- and long-term COVID-19-related outcomes in the setting of Omicron variant transmission and COVID-19 vaccination is limited. OBJECTIVE To measure the effectiveness of nirmatrelvir-ritonavir and molnupiravir for outpatient treatment of COVID-19. DESIGN Three retrospective target trial emulation studies comparing matched cohorts of nirmatrelvir-ritonavir versus no treatment, molnupiravir versus no treatment, and nirmatrelvir-ritonavir versus molnupiravir. SETTING Veterans Health Administration (VHA). PARTICIPANTS Nonhospitalized veterans in VHA care who were at risk for severe COVID-19 and tested positive for SARS-CoV-2 during January through July 2022. INTERVENTION Nirmatrelvir-ritonavir or molnupiravir pharmacotherapy. MEASUREMENTS Incidence of any hospitalization or all-cause mortality at 30 days and from 31 to 180 days. RESULTS Eighty-seven percent of participants were male; the median age was 66 years, and 18% were unvaccinated. Compared with matched untreated control participants, those treated with nirmatrelvir-ritonavir (n = 9607) had lower 30-day risk for hospitalization (22.07 vs. 30.32 per 1000 participants; risk difference [RD], -8.25 [95% CI, -12.27 to -4.23] per 1000 participants) and death (1.25 vs. 5.47 per 1000 participants; RD, -4.22 [CI, -5.45 to -3.00] per 1000 participants). Among persons alive at day 31, reductions were seen in 31- to 180-day incidence of death (hazard ratio, 0.66 [CI, 0.49 to 0.89]) but not hospitalization (subhazard ratio, 0.90 [CI, 0.79 to 1.02]). Molnupiravir-treated participants (n = 3504) had lower 30-day and 31- to 180-day risks for death (3.14 vs. 13.56 per 1000 participants at 30 days; RD, -10.42 [CI, -13.49 to -7.35] per 1000 participants; hazard ratio at 31 to 180 days, 0.67 [CI, 0.48 to 0.95]) but not hospitalization. A difference in 30-day or 31- to 180-day risk for hospitalization or death was not observed between matched nirmatrelvir- or molnupiravir-treated participants. LIMITATION The date of COVID-19 symptom onset for most veterans was unknown. CONCLUSION Nirmatrelvir-ritonavir was effective in reducing 30-day hospitalization and death. Molnupiravir was associated with a benefit for 30-day mortality but not hospitalization. Further reductions in mortality from 31 to 180 days were observed with both antivirals. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Kristina L Bajema
- Veterans Affairs Portland Health Care System, and Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon (K.L.B.)
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (K.B.)
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (E.S., Y.L.)
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut (N.R., P.M.)
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (E.S., Y.L.)
| | - Pradeep Mutalik
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut (N.R., P.M.)
| | - Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut (L.Y.)
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety - Pharmacy Benefit Management (PBM) Services, Hines, Illinois (F.C.)
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon, and Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, and Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon (D.M.H.)
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon (M.R.)
| | - Amy Bohnert
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (A.B.)
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (E.J.B.)
| | - Theodore J Iwashyna
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and Schools of Medicine and Public Health, Johns Hopkins University, Baltimore, Maryland (T.J.I.)
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center; Department of Population Health Sciences, Duke University School of Medicine; and Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina (M.L.M.)
| | - Thomas F Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Department of Radiology, Stanford University School of Medicine, Stanford, California (T.F.O.)
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (E.M.V.)
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Department of Medicine, Yale School of Medicine, New Haven, Connecticut (M.A.)
| | - Grant D Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC (G.D.H.)
| | - George N Ioannou
- Research and Development and Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, and Division of Gastroenterology, University of Washington, Seattle, Washington (G.N.I.)
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Bohnert AS, Kumbier K, Rowneki M, Gupta A, Bajema K, Hynes DM, Viglianti E, O'Hare AM, Osborne T, Boyko EJ, Young-Xu Y, Iwashyna TJ, Maciejewski M, Schildhouse R, Dimcheff D, Ioannou GN. Adverse outcomes of SARS-CoV-2 infection with delta and omicron variants in vaccinated versus unvaccinated US veterans: retrospective cohort study. BMJ 2023; 381:e074521. [PMID: 37220941 DOI: 10.1136/bmj-2022-074521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To determine the association between covid-19 vaccination types and doses with adverse outcomes of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection during the periods of delta (B.1.617.2) and omicron (B.1.1.529) variant predominance. DESIGN Retrospective cohort. SETTING US Veterans Affairs healthcare system. PARTICIPANTS Adults (≥18 years) who are affiliated to Veterans Affairs with a first documented SARS-CoV-2 infection during the periods of delta (1 July-30 November 2021) or omicron (1 January-30 June 2022) variant predominance. The combined cohorts had a mean age of 59.4 (standard deviation 16.3) and 87% were male. INTERVENTIONS Covid-19 vaccination with mRNA vaccines (BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna)) and adenovirus vector vaccine (Ad26.COV2.S (Janssen/Johnson & Johnson)). MAIN OUTCOME MEASURES Stay in hospital, intensive care unit admission, use of ventilation, and mortality measured 30 days after a positive test result for SARS-CoV-2. RESULTS In the delta period, 95 336 patients had infections with 47.6% having at least one vaccine dose, compared with 184 653 patients in the omicron period, with 72.6% vaccinated. After adjustment for patient demographic and clinical characteristics, in the delta period, two doses of the mRNA vaccines were associated with lower odds of hospital admission (adjusted odds ratio 0.41 (95% confidence interval 0.39 to 0.43)), intensive care unit admission (0.33 (0.31 to 0.36)), ventilation (0.27 (0.24 to 0.30)), and death (0.21 (0.19 to 0.23)), compared with no vaccination. In the omicron period, receipt of two mRNA doses were associated with lower odds of hospital admission (0.60 (0.57 to 0.63)), intensive care unit admission (0.57 (0.53 to 0.62)), ventilation (0.59 (0.51 to 0.67)), and death (0.43 (0.39 to 0.48)). Additionally, a third mRNA dose was associated with lower odds of all outcomes compared with two doses: hospital admission (0.65 (0.63 to 0.69)), intensive care unit admission (0.65 (0.59 to 0.70)), ventilation (0.70 (0.61 to 0.80)), and death (0.51 (0.46 to 0.57)). The Ad26.COV2.S vaccination was associated with better outcomes relative to no vaccination, but higher odds of hospital stay and intensive care unit admission than with two mRNA doses. BNT162b2 was generally associated with worse outcomes than mRNA-1273 (adjusted odds ratios between 0.97 and 1.42). CONCLUSIONS In veterans with recent healthcare use and high occurrence of multimorbidity, vaccination was robustly associated with lower odds of 30 day morbidity and mortality compared with no vaccination among patients infected with covid-19. The vaccination type and number of doses had a significant association with outcomes.
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Affiliation(s)
- Amy Sb Bohnert
- Lieutenant Colonel Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kyle Kumbier
- Lieutenant Colonel Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA
| | - Ashwin Gupta
- Lieutenant Colonel Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kristina Bajema
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, OR, USA
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
- Health Data and Informatics Program, Center for Genome Research and Biocomputing, Oregon State University, Corvallis, OR, USA
| | - Elizabeth Viglianti
- Lieutenant Colonel Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ann M O'Hare
- Nephrology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
- VA Center of Innovation for Veteran-Centered and Value Driven Care, Seattle, WA, USA
| | - Thomas Osborne
- National Center for Collaborative Healthcare Innovation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Edward J Boyko
- General Internal Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Yinong Young-Xu
- White River Junction Veterans Affairs Medical Center, White River Junction, VT, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | - Matthew Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Richard Schildhouse
- Lieutenant Colonel Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Derek Dimcheff
- Lieutenant Colonel Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - George N Ioannou
- Health Services Research and Development, Center of Innovation, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
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26
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McMahon B, Cohen C, Brown Jr RS, El-Serag H, Ioannou GN, Lok AS, Roberts LR, Singal AG, Block T. Opportunities to address gaps in early detection and improve outcomes of liver cancer. JNCI Cancer Spectr 2023; 7:pkad034. [PMID: 37144952 PMCID: PMC10212536 DOI: 10.1093/jncics/pkad034] [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: 02/22/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023] Open
Abstract
Death rates from primary liver cancer (hepatocellular carcinoma [HCC]) have continued to rise in the United States over the recent decades despite the availability of an increasing range of treatment modalities, including new systemic therapies. Prognosis is strongly associated with tumor stage at diagnosis; however, most cases of HCC are diagnosed beyond an early stage. This lack of early detection has contributed to low survival rates. Professional society guidelines recommend semiannual ultrasound-based HCC screening for at-risk populations, yet HCC surveillance continues to be underused in clinical practice. On April 28, 2022, the Hepatitis B Foundation convened a workshop to discuss the most pressing challenges and barriers to early HCC detection and the need to better leverage existing and emerging tools and technologies that could improve HCC screening and early detection. In this commentary, we summarize technical, patient-level, provider-level, and system-level challenges and opportunities to improve processes and outcomes across the HCC screening continuum. We highlight promising approaches to HCC risk stratification and screening, including new biomarkers, advanced imaging incorporating artificial intelligence, and algorithms for risk stratification. Workshop participants emphasized that action to improve early detection and reduce HCC mortality is urgently needed, noting concern that many of the challenges we face today are the same or similar to those faced a decade ago and that HCC mortality rates have not meaningfully improved. Increasing the uptake of HCC screening was identified as a short-term priority while developing and validating better screening tests and risk-appropriate surveillance strategies.
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Affiliation(s)
- Brian McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK, USA
| | | | - Robert S Brown Jr
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - George N Ioannou
- Department of Medicine, Division of Gastroenterology, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Anna S Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lewis R Roberts
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Amit G Singal
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern, Dallas, TX, USA
| | - Timothy Block
- Baruch S. Blumberg Institute and Hepatitis B Foundation, Doylestown, PA, USA
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27
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Giustini AB, Ioannou GN, Sirlin C, Loomba R. Review article: Available modalities for screening and imaging diagnosis of hepatocellular carcinoma-Current gaps and challenges. Aliment Pharmacol Ther 2023; 57:1056-1065. [PMID: 37038283 PMCID: PMC10792522 DOI: 10.1111/apt.17506] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/17/2022] [Accepted: 03/24/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) incidence and mortality continue to rise worldwide. Society guidelines recommend HCC screening for patients with chronic hepatitis B (CHB) or cirrhosis. Unfortunately, HCC screening rates remain relatively low, and the performance characteristics of current screening modalities are suboptimal. AIM The aim of the study was to discuss the current state of HCC screening and imaging diagnosis utilising standard and emerging imaging modalities in addition to outlining areas of need and ongoing study. METHODS A review of the field was performed combining literature searches and expert opinion. RESULTS The development of the Liver Imaging Reporting and Data System (LI-RADS version 2018) algorithms have advanced and standardised the imaging diagnosis of HCC. While guidelines recommend US for HCC screening, the sensitivity of ultrasound is highly variable for the detection of early-stage HCC with sensitivity reports ranging from 40% to 80%. Biomarker-based scores such as GALAD and alternative imaging modalities such as abbreviated MRI are promising tools to improve HCC early detection. Patients with non-alcoholic fatty liver disease (NAFLD) and patients hepatitis C (HCV) who have achieved sustained virologic response (SVR) can present a clinical dilemma regarding the need for HCC screening. Biomarkers and elastography can aid in identification of individuals at high risk for HCC in these populations. CONCLUSIONS The LI-RADS system has standardised the imaging interpretation and diagnosis of HCC. Work remains regarding screening in special populations and optimization of screening modalities.
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Affiliation(s)
- Abbey Barnard Giustini
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington, USA
| | - George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington, USA
| | - Claude Sirlin
- Liver Imaging Group, Department of Radiology, University of California at San Diego, La Jolla, California, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, California, USA
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28
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Vutien P, Kim NJ, Merrill JO, Duncan MH, Ioannou GN, Collins SE. Extended-release Naltrexone Is Not Linked to Hepatotoxicity in Adults Experiencing Homelessness and Alcohol Use Disorder. J Addict Med 2023; 17:363-366. [PMID: 37267194 PMCID: PMC10248188 DOI: 10.1097/adm.0000000000001121] [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] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The use of extended-release naltrexone (XR-NTX) as treatment for alcohol use disorder (AUD) has been limited by a prior black box warning for hepatotoxicity. We performed a secondary analysis of data from a randomized clinical trial to compare serum liver enzyme levels for those randomized to XR-NTX versus placebo. METHODS The parent study aimed to test the efficacy of combined pharmacobehavioral harm-reduction treatment in improving alcohol and quality-of-life outcomes for adults experiencing homelessness and AUD. We compared the 2 arms that received intramuscular injections of either 380 mg XR-NTX (n = 74) or placebo (n = 77). Outcomes included ( a ) liver enzyme levels and ( b ) liver enzyme values categorized as normal (<1× upper limit of normal [ULN]), elevated (1-3× ULN), or high (>3× ULN). We performed multinomial logistic regression and negative binomial generalized estimating equations modeling to assess the effects of treatment group and the time × treatment group interaction on liver enzyme outcomes. RESULTS The mean age was 47.9 ± 9.9 years, and the mean baseline alcohol consumption was 23.2 ± 14.0 drinks per day. There were no significant differences in the development of liver enzyme elevations 1 to 3× ULN or more than 3× ULN (all P s > 0.25) or in the change in liver enzyme values (all P s > 0.41) between the placebo and the XR-NTX groups over the treatment course. CONCLUSIONS In our study of adults experiencing homelessness and AUD, receipt of XR-NTX was not associated with hepatotoxicity. These findings support the use of XR-NTX to treat AUD even in patients who are drinking heavily and physiologically dependent on alcohol.
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Affiliation(s)
- Philip Vutien
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Nicole J. Kim
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | | | - Mark H. Duncan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - George N. Ioannou
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
- Division of Gastroenterology, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Susan E. Collins
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
- Department of Psychology, Washington State University, Spokane, WA, USA
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29
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Smith VA, Berkowitz TSZ, Hebert P, Wong ES, Niederhausen M, Pura JA, Berry K, Green P, Korpak A, Fox A, Baraff A, Hickok A, Shahoumian TA, Bohnert ASB, Hynes DM, Boyko EJ, Ioannou GN, Iwashyna TJ, Bowling CB, O'Hare AM, Maciejewski ML. Design and analysis of outcomes following SARS-CoV-2 infection in veterans. BMC Med Res Methodol 2023; 23:81. [PMID: 37016340 PMCID: PMC10071454 DOI: 10.1186/s12874-023-01882-z] [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: 06/02/2022] [Accepted: 03/03/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Understanding how SARS-CoV-2 infection impacts long-term patient outcomes requires identification of comparable persons with and without infection. We report the design and implementation of a matching strategy employed by the Department of Veterans Affairs' (VA) COVID-19 Observational Research Collaboratory (CORC) to develop comparable cohorts of SARS-CoV-2 infected and uninfected persons for the purpose of inferring potential causative long-term adverse effects of SARS-CoV-2 infection in the Veteran population. METHODS In a retrospective cohort study, we identified VA health care system patients who were and were not infected with SARS-CoV-2 on a rolling monthly basis. We generated matched cohorts within each month utilizing a combination of exact and time-varying propensity score matching based on electronic health record (EHR)-derived covariates that can be confounders or risk factors across a range of outcomes. RESULTS From an initial pool of 126,689,864 person-months of observation, we generated final matched cohorts of 208,536 Veterans infected between March 2020-April 2021 and 3,014,091 uninfected Veterans. Matched cohorts were well-balanced on all 39 covariates used in matching after excluding patients for: no VA health care utilization; implausible age, weight, or height; living outside of the 50 states or Washington, D.C.; prior SARS-CoV-2 diagnosis per Medicare claims; or lack of a suitable match. Most Veterans in the matched cohort were male (88.3%), non-Hispanic (87.1%), white (67.2%), and living in urban areas (71.5%), with a mean age of 60.6, BMI of 31.3, Gagne comorbidity score of 1.4 and a mean of 2.3 CDC high-risk conditions. The most common diagnoses were hypertension (61.4%), diabetes (34.3%), major depression (32.2%), coronary heart disease (28.5%), PTSD (25.5%), anxiety (22.5%), and chronic kidney disease (22.5%). CONCLUSION This successful creation of matched SARS-CoV-2 infected and uninfected patient cohorts from the largest integrated health system in the United States will support cohort studies of outcomes derived from EHRs and sample selection for qualitative interviews and patient surveys. These studies will increase our understanding of the long-term outcomes of Veterans who were infected with SARS-CoV-2.
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Affiliation(s)
- Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Theodore S Z Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Paul Hebert
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Edwin S Wong
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University (OHSU), Portland, OR, USA
- Portland State University School of Public Health, Portland, OR, USA
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Kristin Berry
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Pamela Green
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Anna Korpak
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Aaron Baraff
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Troy A Shahoumian
- Population Health: Health Solutions, Veterans Health Administration, Washington, DC, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, Ann Arbor, VA, MI, USA
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- College of Public Health and Human Sciences, Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - George N Ioannou
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Theodore J Iwashyna
- VA Center for Clinical Management Research, Ann Arbor, VA, MI, USA
- National Clinical Scholars Program, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ann M O'Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Nephrology, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA.
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Ioannou GN, Horn CL, Kothari V, Yeh MM, Shyu I, Lee SP, Savard CE. Genetic deletion or pharmacologic inhibition of the Nlrp3 inflammasome did not ameliorate experimental NASH. J Lipid Res 2023; 64:100330. [PMID: 36641116 PMCID: PMC9944495 DOI: 10.1016/j.jlr.2023.100330] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 11/30/2022] [Accepted: 12/09/2022] [Indexed: 01/13/2023] Open
Abstract
It has been postulated that inflammasomes, in particular the NLRP3 (NLR family pyrin domain containing 3) inflammasome, mediate the necroinflammation and fibrosis that characterize nonalcoholic steatohepatitis (NASH) by engaging innate immune responses. We aimed to investigate the impact of genetic deletion or pharmacologic inhibition of the NLRP3 inflammasome on experimental steatohepatitis. Global Nlrp3 KO (expected to inhibit the NLRP3 inflammasome) or Casp1 KO (expected to inhibit all inflammasomes) mice were compared to wild type controls after 6 months on a high-fat, high-cholesterol (HFHC, 1% cholesterol) diet known to induce fibrosing steatohepatitis. Additionally, wildtype mice on a HFHC diet (0.75% or 0.5% cholesterol) for 6 months were either treated or not treated with an oral, pharmacologic inhibitor of Nlrp3 (MCC950) that was delivered in the drinking water (0.3 mg/ml). We found that genetic deletion or pharmacologic inhibition of the NLRP3 inflammasome did not ameliorate any of the histological components of fibrosing NASH in HFHC-fed mice. Collectively, these results do not support NLRP3 inhibition as a potential target for human NASH.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gastroenterology, Department of Medicine, University of Washington, Seattle WA, USA; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
| | - Christian L Horn
- Division of Gastroenterology and Hepatology, Department of Medicine, San Antonio Military Medical Center, Fort Sam Houston, TX, USA
| | - Vishal Kothari
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, UW Medicine Diabetes Institute, Seattle, WA, USA
| | - Matthew M Yeh
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Irene Shyu
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Sum P Lee
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle WA, USA
| | - Christopher E Savard
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gastroenterology, Department of Medicine, University of Washington, Seattle WA, USA; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
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Bajema KL, Rowneki M, Berry K, Bohnert A, Bowling CB, Boyko EJ, Iwashyna TJ, Maciejewski ML, O’Hare AM, Osborne TF, Viglianti EM, Hynes DM, Ioannou GN. Rates of and Factors Associated With Primary and Booster COVID-19 Vaccine Receipt by US Veterans, December 2020 to June 2022. JAMA Netw Open 2023; 6:e2254387. [PMID: 36729454 PMCID: PMC9896301 DOI: 10.1001/jamanetworkopen.2022.54387] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE COVID-19 vaccination rates remain suboptimal in the US. Identifying factors associated with vaccination can highlight existing gaps and guide targeted interventions to improve vaccination access and uptake. OBJECTIVE To describe incidence and patient characteristics associated with primary, first booster, and second booster COVID-19 vaccination in the Veterans Health Administration (VHA). DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed US veterans receiving care in VHA medical centers and outpatient clinics as of December 1, 2020. All VHA enrollees with an inpatient, outpatient, or telehealth encounter in VHA as well as a primary care physician appointment in the preceding 24 months were included. EXPOSURES Demographic characteristics, place of residence, prior SARS-CoV-2 infection, and underlying medical conditions. MAIN OUTCOMES AND MEASURES Cumulative incidence of primary, first booster, and second booster COVID-19 vaccination through June 2022. Cox proportional hazards regression was used to identify factors independently associated with COVID-19 vaccination. RESULTS Among 5 632 413 veterans included in the study, 5 094 392 (90.4%) were male, the median (IQR) age was 66 (51-74) years, 1 032 334 (18.3%) were Black, 448 714 (8.0%) were Hispanic, and 4 202 173 (74.6%) were White. Through June 2022, cumulative incidences were 69.0% for primary vaccination, 42.9% for first booster, and 9.3% for second booster. Cumulative incidence for primary vaccination increased with increasing age, from 46.9% (95% CI, 46.8%-47.0%) among veterans aged 18 to 49 years to 82.9% (95% CI, 82.8%-83.0%) among veterans aged 80 to 84 years. More Black veterans completed primary vaccination (71.7%; 95% CI, 71.6%-71.8%) compared with White veterans (68.9%; 95% CI, 68.9%-69.0%), and more urban-dwelling veterans completed primary vaccination (70.9%; 95% CI, 70.9%-71.0%) compared with highly rural-dwelling veterans (63.8%; 95% CI, 63.4%-64.1%). Factors independently associated with higher likelihood of both primary and booster vaccination included older age, female sex, Asian or Black race, Hispanic ethnicity, urban residence, and lack of prior SARS-CoV-2 infection. CONCLUSIONS AND RELEVANCE In this cohort study of US veterans, COVID-19 vaccination coverage through June 2022 was suboptimal. Primary vaccination can be improved among younger, rural-dwelling veterans. Greater uptake of booster vaccination among all veterans is needed.
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Affiliation(s)
- Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Kristin Berry
- Center of Innovation for Veteran Centered Value Driven Care, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Amy Bohnert
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - C. Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Healthcare Seattle, Washington
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Schools of Medicine and Public Health, Johns Hopkins, Baltimore, Maryland
| | - Matthew L. Maciejewski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Ann M. O’Hare
- Veterans Affairs Puget Sound Healthcare Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Thomas F. Osborne
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Elizabeth M. Viglianti
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Jett KA, Baker ZN, Hossain A, Boulet A, Cobine PA, Ghosh S, Ng P, Yilmaz O, Barreto K, DeCoteau J, Mochoruk K, Ioannou GN, Savard C, Yuan S, Abdalla OH, Lowden C, Kim BE, Cheng HYM, Battersby BJ, Gohil VM, Leary SC. Mitochondrial dysfunction reactivates α-fetoprotein expression that drives copper-dependent immunosuppression in mitochondrial disease models. J Clin Invest 2023; 133:154684. [PMID: 36301669 PMCID: PMC9797342 DOI: 10.1172/jci154684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/26/2022] [Indexed: 02/04/2023] Open
Abstract
Signaling circuits crucial to systemic physiology are widespread, yet uncovering their molecular underpinnings remains a barrier to understanding the etiology of many metabolic disorders. Here, we identified a copper-linked signaling circuit activated by disruption of mitochondrial function in the murine liver or heart that resulted in atrophy of the spleen and thymus and caused a peripheral white blood cell deficiency. We demonstrated that the leukopenia was caused by α-fetoprotein, which required copper and the cell surface receptor CCR5 to promote white blood cell death. We further showed that α-fetoprotein expression was upregulated in several cell types upon inhibition of oxidative phosphorylation. Collectively, our data argue that α-fetoprotein may be secreted by bioenergetically stressed tissue to suppress the immune system, an effect that may explain the recurrent or chronic infections that are observed in a subset of mitochondrial diseases or in other disorders with secondary mitochondrial dysfunction.
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Affiliation(s)
- Kimberly A. Jett
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Canada
| | - Zakery N. Baker
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Canada
| | - Amzad Hossain
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Canada
| | - Aren Boulet
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Canada
| | - Paul A. Cobine
- Department of Biological Sciences, Auburn University, Auburn, Alabama, USA
| | - Sagnika Ghosh
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, Texas, USA
| | - Philip Ng
- Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Orhan Yilmaz
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Canada
| | - Kris Barreto
- Department of Laboratory and Pathology Medicine, University of Saskatchewan, Saskatoon, Canada
| | - John DeCoteau
- Department of Laboratory and Pathology Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Karen Mochoruk
- Department of Laboratory and Pathology Medicine, University of Saskatchewan, Saskatoon, Canada
| | - George N. Ioannou
- Division of Gastroenterology,,Research and Development, Veterans Affairs Puget Sound Health Care System and the,Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher Savard
- Division of Gastroenterology,,Research and Development, Veterans Affairs Puget Sound Health Care System and the,Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sai Yuan
- Department of Animal and Avian Sciences, University of Maryland, College Park, Maryland, USA
| | - Osama H.M.H. Abdalla
- Department of Biology, University of Toronto Mississauga, Mississauga, Ontario, Canada.,Department of Cell and Systems Biology, University of Toronto, Toronto, Canada
| | - Christopher Lowden
- Department of Biology, University of Toronto Mississauga, Mississauga, Ontario, Canada.,Department of Cell and Systems Biology, University of Toronto, Toronto, Canada
| | - Byung-Eun Kim
- Department of Animal and Avian Sciences, University of Maryland, College Park, Maryland, USA
| | - Hai-Ying Mary Cheng
- Department of Biology, University of Toronto Mississauga, Mississauga, Ontario, Canada.,Department of Cell and Systems Biology, University of Toronto, Toronto, Canada
| | | | - Vishal M. Gohil
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, Texas, USA
| | - Scot C. Leary
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Canada
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Yu L, Paski SC, Dodge J, Bambha K, Biggins SW, Ioannou GN. Effect of dietary branched chain amino acids on liver related mortality: Results from a large cohort of North American patients with advanced HCV infection. PLoS One 2023; 18:e0284739. [PMID: 37098004 PMCID: PMC10128927 DOI: 10.1371/journal.pone.0284739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 04/06/2023] [Indexed: 04/26/2023] Open
Abstract
Branched chain amino acids (BCAA) supplementation may reduce the incidence of liver failure and hepatocellular carcinoma in patients with cirrhosis. We aimed to determine whether long-term dietary intake of BCAA is associated with liver-related mortality in a well-characterized cohort of North American patients with advanced fibrosis or compensated cirrhosis. We performed a retrospective cohort study using extended follow-up data from the Hepatitis C Antiviral Long-term Treatment against Cirrhosis (HALT-C) Trial. The analysis included 656 patients who completed two Food Frequency Questionnaires. The primary exposure was BCAA intake measured in grams (g) per 1000 kilocalories (kcal) of energy intake (range 3.0-34.8 g/1000 kcal). During a median follow-up of 5.0 years, the incidence of liver-related death or transplantation was not significantly different among the four quartiles of BCAA intake before and after adjustment of confounders (AHR 1.02, 95% CI 0.81-1.27, P-value for trend = 0.89). There remains no association when BCAA was modeled as a ratio of BCAA to total protein intake or as absolute BCAA intake. Finally, BCAA intake was not associated with the risk of hepatocellular carcinoma, encephalopathy or clinical hepatic decompensation. We concluded that dietary BCAA intake was not associated with liver-related outcomes in HCV-infected patients with advanced fibrosis or compensated cirrhosis. The precise effect of BCAA in patients with liver disease warrants further study.
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Affiliation(s)
- Lei Yu
- Division of Gastroenterology, University of Washington, Seattle, Washington, United States of America
| | - Shirley C Paski
- Division of Gastroenterology, Cedar Sinai School of Medicine, Los Angeles, California, United States of America
| | - Jennifer Dodge
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Kiran Bambha
- Division of Gastroenterology, University of Washington, Seattle, Washington, United States of America
| | - Scott W Biggins
- Division of Gastroenterology, University of Washington, Seattle, Washington, United States of America
| | - George N Ioannou
- Division of Gastroenterology, University of Washington, Seattle, Washington, United States of America
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States of America
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Bajema KL, Berry K, Streja E, Rajeevan N, Li Y, Yan L, Cunningham F, Hynes DM, Rowneki M, Bohnert A, Boyko EJ, Iwashyna TJ, Maciejewski ML, Osborne TF, Viglianti EM, Aslan M, Huang GD, Ioannou GN. Effectiveness of COVID-19 treatment with nirmatrelvir-ritonavir or molnupiravir among U.S. Veterans: target trial emulation studies with one-month and six-month outcomes. medRxiv 2022:2022.12.05.22283134. [PMID: 36561190 PMCID: PMC9774229 DOI: 10.1101/2022.12.05.22283134] [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] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Information about the effectiveness of oral antivirals in preventing short- and long-term COVID-19-related outcomes during the Omicron surge is limited. We sought to determine the effectiveness of nirmatrelvir-ritonavir and molnupiravir for the outpatient treatment of COVID-19. Methods We conducted three retrospective target trial emulation studies comparing matched patient cohorts who received nirmatrelvir-ritonavir versus no treatment, molnupiravir versus no treatment, and nirmatrelvir-ritonavir versus molnupiravir in the Veterans Health Administration (VHA). Participants were Veterans in VHA care at risk for severe COVID-19 who tested positive for SARS-CoV-2 in the outpatient setting during January and February 2022. Primary outcomes included all-cause 30-day hospitalization or death and 31-180-day incidence of acute or long-term care admission, death, or post-COVID-19 conditions. For 30-day outcomes, we calculated unadjusted risk rates, risk differences, and risk ratios. For 31-180-day outcomes, we used unadjusted time-to-event analyses. Results Participants were 90% male with median age 67 years and 26% unvaccinated. Compared to matched untreated controls, nirmatrelvir-ritonavir-treated participants (N=1,587) had a lower 30-day risk of hospitalization (27.10/1000 versus 41.06/1000, risk difference [RD] - 13.97, 95% CI -23.85 to -4.09) and death (3.15/1000 versus 14.86/1000, RD -11.71, 95% CI - 16.07 to -7.35). Among persons who were alive at day 31, further significant reductions in 31-180-day incidence of hospitalization (sub-hazard ratio 1.07, 95% CI 0.83 to 1.37) or death (hazard ratio 0.61, 95% CI 0.35 to 1.08) were not observed. Molnupiravir-treated participants aged ≥65 years (n=543) had a lower combined 30-day risk of hospitalization or death (55.25/1000 versus 82.35/1000, RD -27.10, 95% CI -50.63 to -3.58). A statistically significant difference in 30-day or 31-180-day risk of hospitalization or death was not observed between matched nirmatrelvir- or molnupiravir-treated participants. Incidence of most post-COVID conditions was similar across comparison groups. Conclusions Nirmatrelvir-ritonavir was highly effective in preventing 30-day hospitalization and death. Short-term benefit from molnupiravir was observed in older groups. Significant reductions in adverse outcomes from 31-180 days were not observed with either antiviral.
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Affiliation(s)
- Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, OR,Division of Infectious Diseases, Department of Medicine, Oregon Health and Sciences University, Portland, OR
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT,Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety - Pharmacy Benefit Management (PBM) Services, Hines, IL
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), VA Portland Healthcare System, Portland, OR,Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences; Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), VA Portland Healthcare System, Portland, OR
| | - Amy Bohnert
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Schools of Medicine and Public Health, Johns Hopkins, Baltimore, MD
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC,Duke-Margolis Center for Health Policy, Duke University, Durham, NC
| | - Thomas F. Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA,Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Elizabeth M. Viglianti
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT,Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Grant D. Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC
| | - George N. Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA,Divisions of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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Vutien P, Berry K, Feng Z, VoPham T, He Q, Green PK, Ioannou GN. Combining FIB-4 and Liver Stiffness Into the FIB-5, a Single Model that Accurately Predicts Complications of Portal Hypertension. Am J Gastroenterol 2022; 117:1999-2008. [PMID: 35849630 PMCID: PMC9741846 DOI: 10.14309/ajg.0000000000001906] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/24/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION We aimed to combine the fibrosis (FIB)-4 score and fibroscan-derived liver stiffness (LS) into a single score (FIB-5) that predicts incident complications of portal hypertension (PH) in persons with compensated liver disease. METHODS In this retrospective cohort study, we identified 5849 US veterans who underwent LS measurement from May 01, 2014 to June 30, 2019, and laboratory tests enabling FIB-4 calculation within 6 months of LS measurement. Patients were followed up from the LS measurement date until February 05, 2020, for incident complications of PH. We combined LS values and the individual components of the FIB-4 score (i.e. age, aspartate aminotransferase, alanine aminotransferase, and platelet count) using multivariable Cox proportional hazards modeling and the machine learning algorithm eXtreme gradient boosting to develop the C-FIB-5 and X-FIB-5 models, respectively. Models were internally validated using optimism-corrected measures. RESULTS Among 5,849 patients, the mean age was 62.8 years, 95.9% were men, and the mean follow-up time was 2.14 ± 1.21 years. Within 3 years after LS measurement date, 116 (2.0%) patients developed complications of PH. The X-FIB-5 (area under the receiver operating characteristic [AUROC] 0.845) and C-FIB-5 scores (AUROC 0.868) demonstrated superior discrimination over LS (AUROC 0.688) and FIB-4 (AUROC 0.672) for predicting incident complications of PH. Both the X-FIB-5 and C-FIB-5 models demonstrated higher classification accuracy across all sensitivity cutoffs when compared with LS or FIB-4 alone. DISCUSSION We combined LS and the individual components of the FIB-4 into a single scoring system (FIB-5, www.fib5.net ), which can help identify patients with compensated liver disease at risk of developing complications of PH.
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Affiliation(s)
- Philip Vutien
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Kristin Berry
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Ziding Feng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Trang VoPham
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Qianchuan He
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Pamela K Green
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - George N Ioannou
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Health Service Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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36
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Ioannou GN, Bohnert ASB, O'Hare AM, Boyko EJ, Maciejewski ML, Smith VA, Bowling CB, Viglianti E, Iwashyna TJ, Hynes DM, Berry K. Effectiveness of mRNA COVID-19 Vaccine Boosters Against Infection, Hospitalization, and Death: A Target Trial Emulation in the Omicron (B.1.1.529) Variant Era. Ann Intern Med 2022; 175:1693-1706. [PMID: 36215715 PMCID: PMC9575390 DOI: 10.7326/m22-1856] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The effectiveness of a third mRNA COVID-19 vaccine dose (booster dose) against the Omicron (B.1.1.529) variant is uncertain, especially in older, high-risk populations. OBJECTIVE To determine mRNA booster vaccine effectiveness (VE) against SARS-CoV-2 infection, hospitalization, and death in the Omicron era by booster type, primary vaccine type, time since primary vaccination, age, and comorbidity burden. DESIGN Retrospective matched cohort study designed to emulate a target trial of booster vaccination versus no booster, conducted from 1 December 2021 to 31 March 2022. SETTING U.S. Department of Veterans Affairs health care system. PARTICIPANTS Persons who had received 2 mRNA COVID-19 vaccine doses at least 5 months earlier. INTERVENTION Booster monovalent mRNA vaccination (Pfizer-BioNTech's BNT162b2 or Moderna's mRNA-1273) versus no booster. MEASUREMENTS Booster VE. RESULTS Each group included 490 838 well-matched persons, who were predominantly male (88%), had a mean age of 63.0 years (SD, 14.0), and were followed for up to 121 days (mean, 79.8 days). Booster VE more than 10 days after a booster dose was 42.3% (95% CI, 40.6% to 43.9%) against SARS-CoV-2 infection, 53.3% (CI, 48.1% to 58.0%) against SARS-CoV-2-related hospitalization, and 79.1% (CI, 71.2% to 84.9%) against SARS-CoV-2-related death. Booster VE was similar for different booster types (BNT162b2 or mRNA-1273), age groups, and primary vaccination regimens but was significantly higher with longer time since primary vaccination and higher comorbidity burden. LIMITATION Predominantly male population. CONCLUSION Booster mRNA vaccination was highly effective in preventing death and moderately effective in preventing infection and hospitalization for up to 4 months after administration in the Omicron era. Increased uptake of booster vaccination, which is currently suboptimal, should be pursued to limit the morbidity and mortality of SARS-CoV-2 infection, especially in persons with high comorbidity burden. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, University of Washington, and Research and Development and Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (G.N.I.)
| | - Amy S B Bohnert
- Department of Anesthesiology, University of Michigan Medical School, and Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan (A.S.B.B.)
| | - Ann M O'Hare
- Nephrology, Veterans Affairs Puget Sound Health Care System, and University of Washington, Seattle, Washington (A.M.O.)
| | - Edward J Boyko
- General Internal Medicine, Veterans Affairs Puget Sound Health Care System, and University of Washington, Seattle, Washington (E.J.B.)
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, and Department of Population Health Sciences, Duke-Margolis Center for Health Policy, and Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina (M.L.M.)
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, and Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina (V.A.S.)
| | - C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), and Department of Medicine, Duke University, Durham, North Carolina (C.B.B.)
| | - Elizabeth Viglianti
- Center for Clinical Management Research, VA Ann Arbor Health System, and Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (E.V., T.J.I.)
| | - Theodore J Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Health System, and Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (E.V., T.J.I.)
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, and Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, and Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon (D.M.H.)
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (K.B.)
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Admon AJ, Wander PL, Iwashyna TJ, Ioannou GN, Boyko EJ, Hynes DM, Bowling CB, Bohnert AS, O’Hare AM, Smith VA, Pura J, Hebert PL, Wong ES, Niederhausen M, Maciejewski ML. Consensus elements for observational research on COVID-19-related long-term outcomes. Medicine (Baltimore) 2022; 101:e31248. [PMID: 36401423 PMCID: PMC9678399 DOI: 10.1097/md.0000000000031248] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its long-term outcomes may be jointly caused by a wide range of clinical, social, and economic characteristics. Studies aiming to identify mechanisms for SARS-CoV-2 morbidity and mortality must measure and account for these characteristics to arrive at unbiased, accurate conclusions. We sought to inform the design, measurement, and analysis of longitudinal studies of long-term outcomes among people infected with SARS-CoV-2. We fielded a survey to an interprofessional group of clinicians and scientists to identify factors associated with SARS-CoV-2 infection and subsequent outcomes. Using an iterative process, we refined the resulting list of factors into a consensus causal diagram relating infection and 12-month mortality. Finally, we operationalized concepts from the causal diagram into minimally sufficient adjustment sets using common medical record data elements. Total 31 investigators identified 49 potential risk factors for and 72 potential consequences of SARS-CoV-2 infection. Risk factors for infection with SARS-CoV-2 were grouped into five domains: demographics, physical health, mental health, personal social, and economic factors, and external social and economic factors. Consequences of coronavirus disease 2019 (COVID-19) were grouped into clinical consequences, social consequences, and economic consequences. Risk factors for SARS-CoV-2 infection were developed into a consensus directed acyclic graph for mortality that included two minimally sufficient adjustment sets. We present a collectively developed and iteratively refined list of data elements for observational research in SARS-CoV-2 infection and disease. By accounting for these elements, studies aimed at identifying causal pathways for long-term outcomes of SARS-CoV-2 infection can be made more informative.
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Affiliation(s)
- Andrew J. Admon
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Department of Internal Medicine, University of Michigan Medical School, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Pandora L. Wander
- Veterans Affairs Puget Sound Health Care System, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Theodore J. Iwashyna
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; U-M Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - George N. Ioannou
- Divisions of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle Epidemiologic Research and Information Center, Seattle, WA, USA
| | - Edward J. Boyko
- Veterans Affairs Puget Sound Health Care System Seattle Division, Seattle, Washington; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Denise M. Hynes
- Center to Improve Veteran Involvement in Care, VA Portland health care System, Portland, OR, College of Public Health and Human Sciences, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
| | - C. Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Department of Medicine, Duke University, Durham, NC, USA
| | - Amy S.B. Bohnert
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Department of Anesthesiology, University of Michigan Medical School, Department of Epidemiology, University of Michigan School of Public Health, U-M Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Ann M. O’Hare
- Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation, VA Puget Sound Health Care System and Department of Medicine, University of Washington, Seattle, WA, USA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Department of Population Health Sciences, Duke University Medical Center, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - John Pura
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Paul L. Hebert
- Veterans Affairs Puget Sound Health Care System, Department of Medicine, University of Washington School of Public Health, Seattle WA, USA
| | - Edwin S. Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System; Department of Health Services, University of Washington, Seattle, WA, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland health care System, Oregon Health and Science University-Portland State University School of Public Health, Oregon Health and Science University, Portland, OR, USA
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center; Department of Population Health Sciences, Duke University, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
- * Correspondence: Matthew L. Maciejewski, Department of Population Health Sciences, Duke University Medical Center, 508 Fulton St, Ste 600, Durham NC 27705, USA (e-mail: )
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Bajema KL, Wang XQ, Hynes DM, Rowneki M, Hickok A, Cunningham F, Bohnert A, Boyko EJ, Iwashyna TJ, Maciejewski ML, Viglianti EM, Streja E, Yan L, Aslan M, Huang GD, Ioannou GN. Early Adoption of Anti-SARS-CoV-2 Pharmacotherapies Among US Veterans With Mild to Moderate COVID-19, January and February 2022. JAMA Netw Open 2022; 5:e2241434. [PMID: 36367727 PMCID: PMC9652752 DOI: 10.1001/jamanetworkopen.2022.41434] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IMPORTANCE Older adults and individuals with medical comorbidities are at increased risk for severe COVID-19. Several pharmacotherapies demonstrated to reduce the risk of COVID-19-related hospitalization and death have been authorized for use. OBJECTIVE To describe factors associated with receipt of outpatient COVID-19 pharmacotherapies in the Veterans Affairs (VA) health care system. DESIGN, SETTINGS, AND PARTICIPANTS This cohort study assessed outpatient veterans with risk factors for severe COVID-19 who tested positive for SARS-CoV-2 during January and February 2022. The setting was the VA health care system, the largest integrated health care system in the US. EXPOSURES Demographic characteristics, place of residence, underlying medical conditions, and COVID-19 vaccination. MAIN OUTCOMES AND MEASURES The odds of receipt of any COVID-19 pharmacotherapy, including sotrovimab, nirmatrelvir boosted with ritonavir, molnupiravir, or remdesivir were estimated using multivariable logistic regression. RESULTS Among 111 717 veterans included in this study (median [IQR] age, 60 [46-72] years; 96 482 [86.4%] male, 23 362 [20.9%] Black, 10 740 [9.6%] Hispanic, 75 973 [68.0%] White) who tested positive for SARS-CoV-2 during January to February 2022, 4233 (3.8%) received any COVID-19 pharmacotherapy, including 2870 of 92 396 (3.1%) in January and 1363 of 19 321 (7.1%) in February. Among a subset of 56 285 veterans with documented COVID-19-related symptoms in the 30 days preceding a positive SARS-CoV-2 test, 3079 (5.5%) received any COVID-19 pharmacotherapy. Untreated veterans had a median (IQR) age of 60 (46-71) years and a median (IQR) of 3 (2-5) underlying medical conditions. Veterans receiving any treatment were more likely to be older (aged 65 to 74 years vs 50 to 64 years: adjusted odds ratio [aOR], 1.66 [95% CI, 1.52-1.80]; aged at least 75 years vs 50 to 64 years: aOR, 1.67 [95% CI, 1.53-1.84]) and have a higher number of underlying conditions (at least 5 conditions vs 1 to 2 conditions: aOR, 2.17 [95% CI, 1.98-2.39]). Compared with White veterans, Black veterans (aOR, 0.65 [95% CI, 0.60-0.72]) were less likely to receive treatment; and compared with non-Hispanic veterans, Hispanic veterans (aOR, 0.88 [95% CI, 0.77-0.99]) were less likely to receive treatment. There were 16 546 courses of sotrovimab, nirmatrelvir, and molnupiravir allocated across the VA during this period. CONCLUSIONS AND RELEVANCE In this cohort study of veterans who tested positive for SARS-CoV-2 during January and February when supply of outpatient COVID-19 pharmacotherapies was limited, prescription of these pharmacotherapies was underused, and many veterans with risk factors for severe COVID-19 did not receive treatment. Veterans from minority racial and ethnic groups were less likely to receive any pharmacotherapy.
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Affiliation(s)
- Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Sciences University, Portland
| | - Xiao Qing Wang
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
- Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Alex Hickok
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety - Pharmacy Benefit Management (PBM) Services, Hines, Illinois
| | - Amy Bohnert
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Elizabeth M. Viglianti
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Health Care System, West Haven
| | - Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Health Care System, West Haven
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Health Care System, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Grant D. Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC
| | - George N. Ioannou
- Divisions of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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O’Hare AM, Vig EK, Iwashyna TJ, Fox A, Taylor JS, Viglianti EM, Butler CR, Vranas KC, Helfand M, Tuepker A, Nugent SM, Winchell KA, Laundry RJ, Bowling CB, Hynes DM, Maciejewski ML, Bohnert ASB, Locke ER, Boyko EJ, Ioannou GN. Complexity and Challenges of the Clinical Diagnosis and Management of Long COVID. JAMA Netw Open 2022; 5:e2240332. [PMID: 36326761 PMCID: PMC9634500 DOI: 10.1001/jamanetworkopen.2022.40332] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
IMPORTANCE There is increasing recognition of the long-term health effects of SARS-CoV-2 infection (sometimes called long COVID). However, little is yet known about the clinical diagnosis and management of long COVID within health systems. OBJECTIVE To describe dominant themes pertaining to the clinical diagnosis and management of long COVID in the electronic health records (EHRs) of patients with a diagnostic code for this condition (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code U09.9). DESIGN, SETTING, AND PARTICIPANTS This qualitative analysis used data from EHRs of a national random sample of 200 patients receiving care in the Department of Veterans Affairs (VA) with documentation of a positive result on a polymerase chain reaction (PCR) test for SARS-CoV-2 between February 27, 2020, and December 31, 2021, and an ICD-10 diagnostic code for long COVID between October 1, 2021, when the code was implemented, and March 1, 2022. Data were analyzed from February 5 to May 31, 2022. MAIN OUTCOMES AND MEASURES A text word search and qualitative analysis of patients' VA-wide EHRs was performed to identify dominant themes pertaining to the clinical diagnosis and management of long COVID. RESULTS In this qualitative analysis of documentation in the VA-wide EHR, the mean (SD) age of the 200 sampled patients at the time of their first positive PCR test result for SARS-CoV-2 in VA records was 60 (14.5) years. The sample included 173 (86.5%) men; 45 individuals (22.5%) were identified as Black and 136 individuals (68.0%) were identified as White. In qualitative analysis of documentation pertaining to long COVID in patients' EHRs 2 dominant themes were identified: (1) clinical uncertainty, in that it was often unclear whether particular symptoms could be attributed to long COVID, given the medical complexity and functional limitations of many patients and absence of specific markers for this condition, which could lead to ongoing monitoring, diagnostic testing, and specialist referral; and (2) care fragmentation, describing how post-COVID-19 care processes were often siloed from and poorly coordinated with other aspects of care and could be burdensome to patients. CONCLUSIONS AND RELEVANCE This qualitative study of documentation in the VA EHR highlights the complexity of diagnosing long COVID in clinical settings and the challenges of caring for patients who have or are suspected of having this condition.
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Affiliation(s)
- Ann M. O’Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Elizabeth K. Vig
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Theodore J. Iwashyna
- Pulmonary and Critical Care Medicine, Department of Health Policy & Management, School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | | | - Elizabeth M. Viglianti
- Department of Internal Medicine Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
| | - Catherine R. Butler
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Mark Helfand
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Anaïs Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Shannon M. Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
| | - Kara A. Winchell
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Ryan J. Laundry
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - C. Barrett Bowling
- Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Denise M. Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland
- College of Public Health and Human Sciences and Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Emily R. Locke
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | - Edward J. Boyko
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
| | - George N. Ioannou
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, Washington
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Kim NJ, Vutien P, Berry K, Ioannou GN. Hepatocellular Carcinoma Risk Declines but Remains High Enough for Screening in the First 7 Years After Hepatitis C Virus Cure With Direct-Acting Antivirals in Patients With Cirrhosis or High Fibrosis-4 Score. Gastroenterology 2022; 163:1104-1106.e3. [PMID: 35777481 PMCID: PMC9586012 DOI: 10.1053/j.gastro.2022.06.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/15/2022] [Accepted: 06/18/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Nicole J Kim
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Philip Vutien
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.
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VoPham T, Kim NJ, Berry K, Mendoza JA, Kaufman JD, Ioannou GN. PM 2.5 air pollution exposure and nonalcoholic fatty liver disease in the Nationwide Inpatient Sample. Environ Res 2022; 213:113611. [PMID: 35688225 PMCID: PMC9378584 DOI: 10.1016/j.envres.2022.113611] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 03/24/2022] [Revised: 05/13/2022] [Accepted: 06/02/2022] [Indexed: 05/04/2023]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Particulate matter air pollution <2.5 μm in diameter (PM2.5) is a ubiquitous exposure primarily produced from fossil fuel combustion. Previous epidemiologic studies have been mixed. The objective of this study was to examine the association between ambient PM2.5 exposure and NAFLD among hospitalized patients in the Nationwide Inpatient Sample (NIS). METHODS We conducted a cross-sectional analysis of hospitalizations from 2001 to 2011 using the NIS, the largest nationally representative all-payer inpatient care administrative database in the United States. Average annual PM2.5 exposure was estimated by linking census tracts (based on NIS-provided hospital ZIP Codes) with a spatiotemporal exposure model. Clinical conditions were identified using hospital discharge diagnosis codes. Multivariable logistic regression incorporating discharge weights was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between PM2.5 exposure and odds of NAFLD among hospitalized patients adjusting for age, sex, race/ethnicity, year, individual- and area-level socioeconomic status, urbanicity, region, obesity, diabetes, metabolic syndrome, impaired fasting glucose, dyslipidemia, hypertension, obstructive sleep apnea, and smoking. RESULTS There were 269,705 hospitalized patients with NAFLD from 2001 to 2011 (total unweighted n = 45,433,392 hospitalizations). Higher ambient PM2.5 exposure was associated with increased odds of NAFLD among hospitalized patients (adjusted OR: 1.24 per 10 μg/m3 increase, 95% CI 1.15-1.33, p < 0.01). There were statistically significant interactions between PM2.5 exposure and age, race/ethnicity, diabetes, smoking, and region, with stronger positive associations among patients who were aged ≥45 years, non-Hispanic White or Asian/Pacific Islander, non-diabetics, non-smokers, or in the Midwest and West regions, respectively. CONCLUSIONS In this nationwide cross-sectional analysis of the NIS database, there was a positive association between ambient PM2.5 exposure and odds of NAFLD among hospitalized patients. Future research should examine the effects of long-term historical PM2.5 exposure and incident NAFLD cases.
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Affiliation(s)
- Trang VoPham
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
| | - Nicole J Kim
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Jason A Mendoza
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics and Nutritional Sciences Program, University of Washington, Seattle, WA, USA; Cancer Prevention Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Joel D Kaufman
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA; Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, WA, USA
| | - George N Ioannou
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA; Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
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Johnson KM, Newman KL, Berry K, Itani K, Wu P, Kamath PS, Harris AHS, Cornia PB, Green PK, Beste LA, Ioannou GN. Risk factors for adverse outcomes in emergency versus nonemergency open umbilical hernia repair and opportunities for elective repair in a national cohort of patients with cirrhosis. Surgery 2022; 172:184-192. [PMID: 35058058 DOI: 10.1016/j.surg.2021.12.004] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Whether to perform umbilical hernia repair in patients with cirrhosis is a common dilemma for surgeons. We aimed to determine the incidence, morbidity, and mortality associated with emergency and nonemergency umbilical hernia repair in patients with and without cirrhosis, and to explore opportunities for nonemergency repair. METHODS Veterans diagnosed with cirrhosis between 2001 and 2014 and a frequency-matched sample of veterans without cirrhosis were followed through September 2017. Veterans Affairs Surgical Quality Improvement Program data provided outcomes and risk factors for mortality after umbilical hernia repair. We performed chart review of a random sample of patients undergoing emergency umbilical hernia repair. RESULTS Among 119,605 veterans with cirrhosis and 118,125 matched veterans without cirrhosis, the Veterans Affairs Surgical Quality Improvement Program database included 1,475 and 552 open umbilical hernia repairs, respectively. In patients with cirrhosis, 30-day mortality was 1.2% after nonemergency umbilical hernia repair and 12.2% after emergency umbilical hernia repair, contrasting with zero deaths in patients without cirrhosis undergoing these repairs. In patients with cirrhosis but no ascites in the prior month, 30-day mortality after nonemergency umbilical hernia repair was 0.7%, compared to 2.2% in those with ascites. Chart review of patients requiring emergency umbilical hernia repair revealed that elective umbilical hernia repair may have been feasible in 30% of these patients in the prior year; fewer than half of those undergoing emergency umbilical hernia repair had received a general surgery consultation in the prior 2 years. CONCLUSIONS Nonemergency open umbilical hernia repair was associated with relatively low perioperative mortality in patients with cirrhosis and no recent ascites. About 30% of patients undergoing emergency umbilical hernia repair may have been candidates for nonemergency repair in the prior year.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Kira L Newman
- Gastroenterology Fellowship Program, University of Michigan Medical School, Ann Arbor, MI
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, MA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, and Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Lauren A Beste
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle WA and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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Ioannou GN, Baraff A, Fox A, Shahoumian T, Hickok A, O’Hare AM, Bohnert ASB, Boyko EJ, Maciejewski ML, Bowling CB, Viglianti E, Iwashyna TJ, Hynes DM. Rates and Factors Associated With Documentation of Diagnostic Codes for Long COVID in the National Veterans Affairs Health Care System. JAMA Netw Open 2022; 5:e2224359. [PMID: 35904783 PMCID: PMC9338411 DOI: 10.1001/jamanetworkopen.2022.24359] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Some persons infected with SARS-CoV-2 experience symptoms or impairments many months after acute infection. OBJECTIVES To determine the rates, clinical setting, and factors associated with documented receipt of COVID-19-related care 3 or more months after acute infection. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the US Department of Veterans Affairs health care system. Participants included persons with a positive SARS-CoV-2 test between February 1, 2020, and April 30, 2021, who were still alive 3 months after infection and did not have evidence of reinfection. Data analysis was performed from February 2020 to December 2021. EXPOSURES Positive SARS-CoV-2 test. MAIN OUTCOMES AND MEASURES Rates and factors associated with documentation of COVID-19-related International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (U07.1, Z86.16, U09.9, and J12.82) 3 or more months after acute infection (hereafter, long-COVID care), with follow-up extending to December 31, 2021. RESULTS Among 198 601 SARS-CoV-2-positive persons included in the study, the mean (SD) age was 60.4 (17.7) years, 176 942 individuals (89.1%) were male, 133 924 (67.4%) were White, 44 733 (22.5%) were Black, and 19 735 (9.9%) were Hispanic. During a mean (SD) follow-up of 13.5 (3.6) months, long-COVID care was documented in a wide variety of clinics, most commonly primary care and general internal medicine (18 634 of 56 310 encounters [33.1%]), pulmonary (7360 of 56 310 encounters [13.1%]), and geriatrics (5454 of 56 310 encounters [9.7%]). Long-COVID care was documented in 26 745 cohort members (13.5%), with great variability across geographical regions (range, 10.8%-18.1%) and medical centers (range, 3.0%-41.0%). Factors significantly associated with documented long-COVID care included older age, Black or American Indian/Alaska Native race, Hispanic ethnicity, geographical region, high Charlson Comorbidity Index score, having documented symptoms at the time of acute infection (adjusted odds ratio [AOR], 1.71; 95% CI, 1.65-1.78) and requiring hospitalization (AOR, 2.60; 95% CI, 2.51-2.69) or mechanical ventilation (AOR, 2.46; 95% CI, 2.26-2.69). Patients who were fully vaccinated at the time of infection were less likely to receive long-COVID care (AOR, 0.78; 95% CI, 0.68-0.90). CONCLUSIONS AND RELEVANCE Long-COVID care was documented in a variety of clinical settings, with great variability across regions and medical centers and was documented more commonly in older persons, those with higher comorbidity burden, those with more severe acute COVID-19 presentation and those who were unvaccinated at the time of infection. These findings provide support and guidance for health care systems to develop systematic approaches to the evaluation and management of patients who may be experiencing long COVID.
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Affiliation(s)
- George N. Ioannou
- Health Services Research and Development, Center of Innovation, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle
| | - Aaron Baraff
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Troy Shahoumian
- Department of Veterans Affairs, Population Health, Palo Alto Healthcare System, Palo Alto, California
| | - Alex Hickok
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon
| | - Ann M. O’Hare
- Nephrology Section, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
- Division of Nephrology, University of Washington, Seattle
| | - Amy S. B. Bohnert
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Edward J. Boyko
- General Internal Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
- Division of General Internal Medicine, University of Washington, Seattle
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University School of Medicine, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - C. Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Elizabeth Viglianti
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Theodore J. Iwashyna
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Corvallis, Oregon
- Health Data and Informatics Program, Center for Genome Research and Biocomputing, Oregon State University, Corvallis
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Corvallis, Oregon
- Health Data and Informatics Program, Center for Genome Research and Biocomputing, Oregon State University, Corvallis
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Kim NJ, Vutien P, Cleveland E, Cravero A, Ioannou GN. Fibrosis Stage-specific Incidence of Hepatocellular Cancer After Hepatitis C Cure With Direct-acting Antivirals: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00438-4. [PMID: 35525392 PMCID: PMC9636072 DOI: 10.1016/j.cgh.2022.04.013] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hepatitis C virus (HCV) eradication with direct-acting antivirals reduces hepatocellular carcinoma (HCC) risk. Pooled HCC incidence rates by cirrhosis status and fibrosis stage have not been estimated using meta-analysis. METHODS We searched PubMed, Web of Science, Embase, and Cochrane Library from January 1, 2014 to December 31, 2020 to identify studies assessing HCC incidence or outcomes by cirrhosis status, in adults with HCV who achieved sustained virologic response (SVR) after direct-acting antivirals. Pooled estimates were obtained using random-effects modeling. Subgroup, sensitivity, and meta-regression analyses were performed to evaluate heterogeneity. RESULTS We included 31 studies involving 27,711 patients with cirrhosis (mean follow-up, 2.1 years) and 11 studies involving 32,123 patients without cirrhosis (mean follow-up, 2.6 years). HCC incidence was 2.99/100 person-years (95% confidence interval [CI], 2.52-3.54; I2 = 75%) in patients with cirrhosis, 0.47/100 person-years (95% CI, 0.32-0.70, I2 = 71%) in patients without cirrhosis, and 0.63/100 person-years (95% CI: 0.34-1.20, I2 = 0%) in stage 3 (F3) fibrosis. Among patients with cirrhosis, HCC incidence was highest in studies with <1 year of follow-up (6.17/100 person-years [95% CI, 3.73-10.19]) and progressively lower in studies with longer follow-up (1-2 years: 2.75/100 person-years [95% CI, 2.48-3.06]; 2-3 years: 2.90/100 person-years [95% CI, 1.90-4.44]; ≥3 years: 1.83/100 person-years [95% CI, 0.88-3.80]). CONCLUSION Pooled HCC incidence after SVR in patients with cirrhosis was very high (2.99/100 person-years) but may be declining as longer time accrues after SVR. In patients without cirrhosis, including F3 fibrosis, HCC incidence was lower than thresholds associated with cost-effective HCC screening. In patients with F3 fibrosis, the lack of between-study heterogeneity provides strong evidence that HCC screening may not be warranted.
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Affiliation(s)
- Nicole J. Kim
- Division of Gastroenterology, University of Washington
| | - Philip Vutien
- Division of Gastroenterology, University of Washington
| | | | - Anne Cravero
- Department of Medicine, University of Washington
| | - George N. Ioannou
- Division of Gastroenterology, University of Washington,Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System
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Asrani SK, Ghabril MS, Kuo A, Merriman RB, Morgan T, Parikh ND, Ovchinsky N, Kanwal F, Volk ML, Ho C, Serper M, Mehta S, Agopian V, Cabrera R, Chernyak V, El-Serag HB, Heimbach J, Ioannou GN, Kaplan D, Marrero J, Mehta N, Singal A, Salem R, Taddei T, Walling AM, Tapper EB. Quality measures in HCC care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases. Hepatology 2022; 75:1289-1299. [PMID: 34778999 DOI: 10.1002/hep.32240] [Citation(s) in RCA: 10] [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] [Received: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 12/14/2022]
Abstract
The burden of HCC is substantial. To address gaps in HCC care, the American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) aimed to develop a standard set of process-based measures and patient-reported outcomes (PROs) along the HCC care continuum. We identified candidate process and outcomes measures for HCC care based on structured literature review. A 13-member panel with content expertise across the HCC care continuum evaluated candidate measures on importance and performance gap using a modified Delphi approach (two rounds of rating) to define the final set of measures. Candidate PROs based on a structured scoping review were ranked by 74 patients with HCC across 7 diverse institutions. Out of 135 measures, 29 measures made the final set. These covered surveillance (6 measures), diagnosis (6 measures), staging (2 measures), treatment (10 measures), and outcomes (5 measures). Examples included the use of ultrasound (± alpha-fetoprotein [AFP]) every 6 months, need for surveillance in high-risk populations, diagnostic testing for patients with a new AFP elevation, multidisciplinary liver tumor board (MLTB) review of Liver Imaging-Reporting and Data System 4 lesions, standard evaluation at diagnosis, treatment recommendations based on Barcelona Clinic Liver Cancer staging, MLTB discussion of treatment options, appropriate referral for evaluation of liver transplantation candidacy, and role of palliative therapy. PROs include those related to pain, anxiety, fear of treatment, and uncertainty about the best individual treatment and the future. The AASLD PMC has developed a set of explicit quality measures in HCC care to help bridge the gap between guideline recommendations and measurable processes and outcomes. Measurement and subsequent implementation of these metrics could be a central step in the improvement of patient care and outcomes in this high-risk population.
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Affiliation(s)
| | - Marwan S Ghabril
- 12250Division of GastroenterologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Alexander Kuo
- Division of GastroenterologyCedars-Sinai Medical CenterUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Raphael B Merriman
- Division of General and Transplant HepatologyCalifornia Pacific Medical Center and Research InstituteSan FranciscoCaliforniaUSA
| | - Timothy Morgan
- Medicine and Research ServicesVA Long Beach Healthcare SystemLong BeachCaliforniaUSA
| | - Neehar D Parikh
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Nadia Ovchinsky
- Division of Pediatric GastroenterologyChildren's Hospital at MontefioreBronxNew YorkUSA
| | - Fasiha Kanwal
- Section of Gastroenterology and HepatologyDepartment of MedicineBaylor College of MedicineHoustonTexasUSA.,Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA.,Section of Health Services ResearchDepartment of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Michael L Volk
- 4608Division of Gastroenterology and Transplantation InstituteLoma Linda UniversityLoma LindaCaliforniaUSA
| | - Chanda Ho
- Department of TransplantationCalifornia Pacific Medical CenterSan FranciscoCaliforniaUSA
| | - Marina Serper
- Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA.,Leonard Davis Institute of Health EconomicsPhiladelphiaPennsylvaniaUSA
| | | | - Vatche Agopian
- Division of Liver and Pancreas TransplantationDepartment of SurgeryDavid Geffen School of Medicine at University of CaliforniaLos AngelesCaliforniaUSA
| | - Roniel Cabrera
- Department of MedicineDivision of Gastroenterology, Hepatology and NutritionUniversity of FloridaGainesvilleFloridaUSA
| | | | | | - Julie Heimbach
- Division of Transplant SurgeryWilliam J. von Liebig Transplant CenterMayo ClinicRochesterMinnesotaUSA
| | - George N Ioannou
- Division of GastroenterologyDepartment of MedicineVeterans Affairs Puget Sound Health Care System and University of WashingtonSeattleWashingtonUSA
| | - David Kaplan
- Division of Gastroenterology and HepatologyPerelman University of Pennsylvania School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Jorge Marrero
- Digestive and Liver Diseases DivisionDepartment of Internal MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Neil Mehta
- Division of GastroenterologyUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Amit Singal
- Division of Digestive and Liver DiseasesUT Southwestern Medical CenterDallasTexasUSA
| | - Riad Salem
- Division of Interventional RadiologyDepartment of RadiologyNorthwestern UniversityChicagoIllinoisUSA
| | - Tamar Taddei
- Section of Digestive DiseasesYale School of MedicineNew HavenConnecticutUSA.,VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - Anne M Walling
- VA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA.,Division of General Internal Medicine and Health Services ResearchUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Elliot B Tapper
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
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Ioannou GN, Lee SP, Linsley PS, Gersuk V, Yeh MM, Chen Y, Peng Y, Dutta M, Mascarinas G, Molla B, Cui JY, Savard C. Pcsk9 Deletion Promotes Murine Nonalcoholic Steatohepatitis and Hepatic Carcinogenesis: Role of Cholesterol. Hepatol Commun 2022; 6:780-794. [PMID: 34816633 PMCID: PMC8948564 DOI: 10.1002/hep4.1858] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [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] [Received: 05/28/2021] [Revised: 09/24/2021] [Accepted: 10/14/2021] [Indexed: 01/02/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (Pcsk9) binds to hepatic low-density lipoprotein receptor (LDLR) and induces its internalization and degradation. Pcsk9 inhibition increases LDLR expression by hepatocytes, which causes increased uptake of circulating LDL, thereby reducing plasma LDL-cholesterol. However, by increasing the uptake of LDL by the liver, Pcsk9 inhibition increases the exposure of the liver to cholesterol, which may result in higher risk of steatohepatitis and ever carcinogenesis. We compared Pcsk9-/- knockout (KO) mice and appropriate wild-type (WT) controls of the same strain assigned to a high-fat (15%, wt/wt) diet for 9 months supplemented with 0.25%, 0.5%, or 0.75% dietary cholesterol. Pcsk9 KO mice on a high-fat, high-cholesterol diet exhibited higher levels of hepatic free cholesterol loading and hepatic cholesterol crystallization than their WT counterparts. Pcsk9 KO mice developed crown-like structures of macrophages surrounding cholesterol crystal-containing lipid droplets and hepatocytes, exhibited higher levels of apoptosis, and developed significantly more hepatic inflammation and fibrosis consistent with fibrosing steatohepatitis, including 5-fold and 11-fold more fibrosis at 0.5% and 0.75% dietary cholesterol, respectively. When injected with diethylnitrosamine, a hepatic carcinogen, early-in-life Pcsk9 KO mice were more likely to develop liver cancer than WT mice. Conclusion: Pcsk9 KO mice on high-cholesterol diets developed increased hepatic free cholesterol and cholesterol crystals and fibrosing steatohepatitis with a higher predisposition to liver cancer compared with WT mice. Future studies should evaluate whether patients on long-term treatment with anti-PSCK9 monoclonal antibodies are at increased risk of hepatic steatosis, steatohepatitis or liver cancer, while accounting for concurrent use of statins.
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Affiliation(s)
- George N. Ioannou
- Division of GastroenterologyDepartment of MedicineVeterans Affairs Puget Sound Health Care SystemSeattleWAUSA
- Division of GastroenterologyDepartment of MedicineUniversity of WashingtonSeattleWAUSA
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWAUSA
| | - Sum P. Lee
- Division of GastroenterologyDepartment of MedicineUniversity of WashingtonSeattleWAUSA
| | | | - Vivian Gersuk
- Systems ImmunologyBenaroya Research InstituteSeattleWAUSA
| | - Matthew M. Yeh
- Division of GastroenterologyDepartment of MedicineUniversity of WashingtonSeattleWAUSA
- Department of Laboratory Medicine and PathologyUniversity of WashingtonSeattleWAUSA
| | - Yen‐Ying Chen
- Department of Laboratory Medicine and PathologyUniversity of WashingtonSeattleWAUSA
- Department of Pathology and Laboratory MedicineSchool of MedicineTaipei Veterans General HospitalNational Yang‐Ming UniversityTaipeiTaiwan
- Present address:
Department of PathologyShuang Ho Hospital and School of MedicineCollege of MedicineTaipei Medical UniversityTaipeiTaiwan
| | - Yi‐Jen Peng
- Department of Laboratory Medicine and PathologyUniversity of WashingtonSeattleWAUSA
- Department of PathologyTri‐Service General HospitalNational Defense Medical CenterTaipeiTaiwan
| | - Moumita Dutta
- Department of Environmental and Occupational Health SciencesUniversity of WashingtonSeattleWAUSA
| | - Gabby Mascarinas
- Department of Environmental and Occupational Health SciencesUniversity of WashingtonSeattleWAUSA
| | - Bruk Molla
- Department of Environmental and Occupational Health SciencesUniversity of WashingtonSeattleWAUSA
| | - Julia Yue Cui
- Department of Environmental and Occupational Health SciencesUniversity of WashingtonSeattleWAUSA
| | - Christopher Savard
- Division of GastroenterologyDepartment of MedicineVeterans Affairs Puget Sound Health Care SystemSeattleWAUSA
- Division of GastroenterologyDepartment of MedicineUniversity of WashingtonSeattleWAUSA
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWAUSA
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Ioannou GN, Locke ER, O'Hare AM, Bohnert ASB, Boyko EJ, Hynes DM, Berry K. COVID-19 Vaccination Effectiveness Against Infection or Death in a National U.S. Health Care System : A Target Trial Emulation Study. Ann Intern Med 2022; 175:352-361. [PMID: 34928700 PMCID: PMC8697485 DOI: 10.7326/m21-3256] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Little is known about real-world COVID-19 vaccine effectiveness (VE) in racially and ethnically diverse, elderly populations with high comorbidity burden. OBJECTIVE To determine the effectiveness of messenger RNA COVID-19 vaccines. DESIGN Target trial emulation study comparing newly vaccinated persons with matched unvaccinated controls. SETTING U.S. Department of Veterans Affairs health care system. PARTICIPANTS Among persons receiving care in the Veterans Affairs health care system (n = 5 766 638), those who received at least 1 dose of the Moderna or Pfizer-BioNTech COVID-19 vaccine from 11 December 2020 to 25 March 2021 (n = 2 099 871) were matched to unvaccinated controls in a 1:1 ratio according to demographic, clinical, and geographic characteristics. INTERVENTION Follow-up for SARS-CoV-2 infection or SARS-CoV-2-related death, defined as death within 30 days of infection, began after the vaccination date or an identical index date for the matched unvaccinated controls and continued until up to 30 June 2021. MEASUREMENTS Vaccine effectiveness against SARS-CoV-2 infection or SARS-CoV-2-related death. RESULTS Vaccinated and unvaccinated groups were well matched; both were predominantly male (92.9% vs. 93.4%), had advanced age (mean, 68.7 years in both groups), had diverse racial and ethnic distribution (for example, Black: 17.3% vs. 17.0%, Hispanic: 6.5% vs. 6.1%), and had substantial comorbidity burden. Vaccine effectiveness 7 or more days after the second vaccine dose was 69% (95% CI, 67% to 70%) against SARS-CoV-2 infection and 86% (CI, 82% to 89%) against SARS-CoV-2-related death and was similar when follow-up was extended to 31 March versus 30 June. Vaccine effectiveness against infection decreased with increasing age and comorbidity burden. LIMITATION Predominantly male population and lack of data on SARS-CoV-2 variants. CONCLUSION In an elderly, diverse, high-comorbidity population, COVID-19 VE against infection was substantially lower than previously reported, but VE against death was high. Complementary infection mitigation efforts remain important for pandemic control, even with vaccination. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington (G.N.I.)
| | - Emily R Locke
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (E.R.L., K.B.)
| | - Ann M O'Hare
- Division of Nephrology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington (A.M.O.)
| | - Amy S B Bohnert
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School and VA Center for Clinical Management Research, Ann Arbor, Michigan (A.S.B.)
| | - Edward J Boyko
- General Medicine Service, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington (E.J.B.)
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, and Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon (D.M.H.)
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (E.R.L., K.B.)
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Ioannou GN, Locke ER, Green PK, Berry K. Comparison of Moderna versus Pfizer-BioNTech COVID-19 vaccine outcomes: A target trial emulation study in the U.S. Veterans Affairs healthcare system. EClinicalMedicine 2022; 45:101326. [PMID: 35261970 PMCID: PMC8896984 DOI: 10.1016/j.eclinm.2022.101326] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/27/2022] [Accepted: 02/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND mRNA COVID-19 vaccines manufactured by Pfizer-BioNTech (BNT162b2) and Moderna (mRNA-1273) have been shown to be efficacious but have not been compared in head-to-head clinical trials. METHODS We designed this observational study to emulate a target trial of COVID-19 vaccination by BNT162b2 versus mRNA-1273 among persons who underwent vaccination in the national U.S. Veterans Affairs (VA) healthcare system from 11/12/2020 to 25/03/2021 using combined VA and Medicare electronic health records. We identified the best matching mRNA-1273 recipient(s) for each BNT162b2 recipient, using exact/coarsened-exact matching (calendar week, VA integrated service network, age buckets and Charlson comorbidity index buckets) followed by propensity score matching. Vaccine recipients were followed from the date of first vaccine dose until 25/08/2021 for the development of SARS-CoV-2 infection, SARS-CoV-2-related hospitalization or SARS-CoV-2-related death. FINDINGS Each group included 902,235 well-matched vaccine recipients, followed for a mean of 192 days, during which 16,890 SARS-CoV-2 infections, 3591 SARS-CoV-2-related hospitalizations and 381 SARS-CoV-2-related deaths were documented. Compared to BNT162b2, mRNA-1273 recipients had significantly lower risk of SARS-CoV-2 infection (adjusted hazard ratio [aHR] 0.736, 95% CI 0.696-0.779) and SARS-CoV-2-related hospitalization (aHR 0.633, 95% CI 0.562-0.713), which persisted across all age groups, comorbidity burden categories and black/white race. The differences between mRNA-1273 and BNT162b2 in risk of infection or hospitalization were progressively greater when the follow-up period was longer, i.e. extending to March 31, June 30 or August 25, 2021. These differences were more pronounced when we analyzed separately the outcomes that occurred during the follow-up period from July 1 to August 25, 2021 when the Delta variant became predominant in the U.S. (aHR for infection 0.584, 95% CI 0.533-0.639 and aHR for hospitalization 0.387, 95% 0.311-0.482). SARS-CoV-2-related deaths were less common in mRNA-1273 versus BNT162b2 recipients (168 versus 213) but this difference was not statistically significant (aHR 0.808, 95% CI 0.592-1.103). INTERPRETATION In conclusion, although absolute rates of infection, hospitalization and death in both vaccine groups were low regardless of the vaccine received, our data suggests that compared to BNT162b2, vaccination with mRNA-1273 resulted in significantly lower rates of SARS-CoV-2-infection and SARS-CoV-2-related hospitalization. These differences were greater with longer follow-up time since vaccination and even more pronounced in the Delta variant era. FUNDING U.S. Department of Veterans Affairs, grant numbers COVID19-8900-11 and C19 21-278.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, 1660 S. Columbian Way, Seattle, WA 98108, USA
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Corresponding author at: Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, 1660 S. Columbian Way, Seattle, WA 98108, USA.
| | - Emily R. Locke
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Pamela K. Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
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Beste LA, Zhang X, Su GL, Van T, Ioannou GN, Oselio B, Tincopa M, Liu B, Singal AG, Zhu J, Waljee AK. Adapted time-varying covariates Cox model for predicting future cirrhosis development performs well in a large hepatitis C cohort. BMC Med Inform Decis Mak 2021; 21:347. [PMID: 34903225 PMCID: PMC8670121 DOI: 10.1186/s12911-021-01711-7] [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: 09/24/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background Patients with hepatitis C virus (HCV) frequently remain at risk for cirrhosis after sustained virologic response (SVR). Existing cirrhosis predictive models for HCV do not account for dynamic antiviral treatment status and are limited by fixed laboratory covariates and short follow up time. Advanced fibrosis assessment modalities, such as transient elastography, remain inaccessible in many settings. Improved cirrhosis predictive models are needed. Methods We developed a laboratory-based model to predict progression of liver disease after SVR. This prediction model used a time-varying covariates Cox model adapted to utilize longitudinal laboratory data and to account for antiretroviral treatment. Individuals were included if they had a history of detectable HCV RNA and at least 2 AST-to-platelet ratio index (APRI) scores available in the national Veterans Health Administration from 2000 to 2015, Observation time extended through January 2019. We excluded individuals with preexisting cirrhosis. Covariates included baseline patient characteristics and 16 time-varying laboratory predictors. SVR, defined as permanently undetectable HCV RNA after antiviral treatment, was modeled as a step function of time. Cirrhosis development was defined as two consecutive APRI scores > 2. We predicted cirrhosis development at 1-, 3-, and 5-years follow-up. Results In a national sample of HCV patients (n = 182,772) with a mean follow-up of 6.32 years, 42% (n = 76,854) achieved SVR before 2016 and 16.2% (n = 29,566) subsequently developed cirrhosis. The model demonstrated good discrimination for predicting cirrhosis across all combinations of laboratory data windows and cirrhosis prediction intervals. AUROCs ranged from 0.781 to 0.815, with moderate sensitivity 0.703–0.749 and specificity 0.723–0.767. Conclusion A novel adaptation of time-varying covariates Cox modeling technique using longitudinal laboratory values and dynamic antiviral treatment status accurately predicts cirrhosis development at 1-, 3-, and 5-years among patients with HCV, with and without SVR. It improves upon earlier cirrhosis predictive models and has many potential population-based applications, especially in settings without transient elastography available. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01711-7.
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Affiliation(s)
- Lauren A Beste
- General Medicine Service, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA.,Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Xuefei Zhang
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, MI, USA.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA
| | - Grace L Su
- Gastroenterology Service, VA Ann Arbor Healthcare System, 2215 Fuller Road, Gastroenterology 111D, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Tony Van
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - George N Ioannou
- Gastroenterology Service, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Brandon Oselio
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Monica Tincopa
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Boang Liu
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Amit G Singal
- Harold C. Simmons Comprehensive Cancer Center UT Southwestern Medical Center, Dallas, TX, USA.,Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Internal Medicine, Parkland Health and Hospital System, Dallas, TX, USA
| | - Ji Zhu
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Akbar K Waljee
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, MI, USA. .,Gastroenterology Service, VA Ann Arbor Healthcare System, 2215 Fuller Road, Gastroenterology 111D, Ann Arbor, MI, 48105, USA. .,Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA. .,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
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Ioannou GN, Green P, Locke ER, Berry K. Factors associated with early receipt of COVID-19 vaccination and adherence to second dose in the Veterans Affairs healthcare system. PLoS One 2021; 16:e0259696. [PMID: 34851970 PMCID: PMC8635372 DOI: 10.1371/journal.pone.0259696] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 06/11/2021] [Accepted: 10/24/2021] [Indexed: 12/15/2022] Open
Abstract
Background We aimed to determine factors independently associated with early COVID-19 vaccination and adherence to two-dose regimens. Methods Among persons receiving care in the Veterans Affairs (VA) healthcare system (n = 5,766,638), we identified those who received at least one dose of COVID-19 vaccination through the VA, during the first ~3months following emergency use authorization, from December 11, 2020 to March 9, 2021 (n = 1,569,099, or 27.2%, including 880,200 (56.1%) Moderna, 676,279 (43.1%) Pfizer-BioNTech and 12,620 (0.8%) Janssen vaccines). Results Follow-up for receipt of vaccination began on December 11, 2020. After adjustment for baseline characteristics ascertained as of December 11, 2020, factors significantly associated with vaccination included older age, higher comorbidity burden, higher body mass index category, Black (vs. White) race (adjusted hazard ratio [AHR] 1.19, 95% CI 1.19–1.20), Hispanic (vs. non-Hispanic) ethnicity (AHR 1.12, 95% CI 1.11–1.13), urban (vs. rural) residence (AHR 1.31, 95% CI 1.31–1.31), and geographical region, while AI/AN race (vs. White), was associated with lower vaccination rate (AHR 0.85, 95% CI 0.84–0.87). Among persons who received both doses of Moderna or Pfizer-BioNTech vaccines, 95.3% received the second dose within ±4 days of the recommended date. Among persons who received the first vaccine dose, only 3.2% did not receive the second dose within 42 days for Pfizer versus 4.0% for Moderna (p<0.001). Factors independently associated with higher likelihood of missing the second dose included younger age (10.83% in 18–50 yo vs. 2.72% in 70–75 yo), AI/AN race, female sex, rural location, geographical region and prior positive test for SARS-CoV-2. Conclusions We identified sociodemographic and clinical factors that may be used to target vaccination efforts and to further improve adherence to second vaccine dosing.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, United States of America
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America
- * E-mail:
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America
| | - Emily R. Locke
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States of America
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