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Brubaker L, Nodora J, Bavendam T, Connett J, Claussen AM, Lewis CE, Rudser K, Sutcliffe S, Wyman JF, Miller JM. A policy toolkit for authorship and dissemination policies may benefit NIH research consortia. Account Res 2024; 31:222-240. [PMID: 35998252 PMCID: PMC9975116 DOI: 10.1080/08989621.2022.2116318] [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] [Indexed: 12/30/2022]
Abstract
Authorship and dissemination policies vary across NIH research consortia. We aimed to describe elements of real-life policies in use by eligible U01 clinical research consortia. Principal investigators of eligible, active U01 clinical research projects identified in the NIH Research Portfolio Online Reporting Tools database shared relevant policies. The characteristics of key policy elements, determined a priori, were reviewed and quantified, when appropriate. Twenty one of 81 research projects met search criteria and provided policies. K elements (e.g., in quotations): "manuscript proposals reviewed and approved by committee" (90%); "guidelines for acknowledgements" (86%); "writing team formation" (71%); "process for final manuscript review and approval" (71%), "responsibilities for lead author" (67%), "guidelines for other types of publications" (67%); "draft manuscript review and approval" (62%); "recommendation for number of members per consortium site" (57%); and "requirement to identify individual contributions in the manuscript" (19%). Authorship/dissemination policies for large team science research projects are highly variable. Creation of an NIH policies repository and accompanying toolkit with model language and recommended key elements could improve comprehensiveness, ethical integrity, and efficiency in team science work while reducing burden and cost on newly funded consortia and directing time and resources to scientific endeavors.
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Affiliation(s)
- Linda Brubaker
- UC San Diego School of Medicine, University of California San Diego, La Jolla, California
| | - Jesse Nodora
- UC San Diego School of Medicine, University of California San Diego, La Jolla, California
| | | | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Amy M. Claussen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Cora E. Lewis
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kyle Rudser
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Siobhan Sutcliffe
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Jean F. Wyman
- School of Nursing, University of Minnesota, Minneapolis, Minnesota
| | - Janis M. Miller
- School of Nursing, University of Michigan, Ann Arbor, Michigan
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LaFon DC, Helgeson ES, Lindberg S, Voelker H, Bhatt SP, Casaburi R, Cassady SJ, Connett J, Criner GJ, Hatipoglu U, Kaminsky DA, Kunisaki KM, Lazarus SC, McEvoy CE, Reed RM, Sciurba FC, Stringer W, Dransfield MT. β-Blocker Use and Clinical Outcomes in Patients With COPD Following Acute Myocardial Infarction. JAMA Netw Open 2024; 7:e247535. [PMID: 38771577 DOI: 10.1001/jamanetworkopen.2024.7535] [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: 05/22/2024] Open
Abstract
Importance While β-blockers are associated with decreased mortality in cardiovascular disease (CVD), exacerbation-prone patients with chronic obstructive pulmonary disease (COPD) who received metoprolol in the Beta-Blockers for the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease (BLOCK-COPD) trial experienced increased risk of exacerbations requiring hospitalization. However, the study excluded individuals with established indications for the drug, raising questions about the overall risk and benefit in patients with COPD following acute myocardial infarction (AMI). Objective To investigate whether β-blocker prescription at hospital discharge is associated with increased risk of mortality or adverse cardiopulmonary outcomes in patients with COPD and AMI. Design, Setting, and Participants This prospective, longitudinal cohort study with 6 months of follow-up enrolled patients aged 35 years or older with COPD who underwent cardiac catheterization for AMI at 18 BLOCK-COPD network hospitals in the US from June 2020 through May 2022. Exposure Prescription for any β-blocker at hospital discharge. Main Outcomes and Measures The primary outcome was time to the composite outcome of death or all-cause hospitalization or revascularization. Secondary outcomes included death, hospitalization, or revascularization for CVD events, death or hospitalization for COPD or respiratory events, and treatment for COPD exacerbations. Results Among 3531 patients who underwent cardiac catheterization for AMI, prevalence of COPD was 17.1% (95% CI, 15.8%-18.4%). Of 579 total patients with COPD and AMI, 502 (86.7%) were prescribed a β-blocker at discharge. Among the 562 patients with COPD included in the final analysis, median age was 70.0 years (range, 38.0-94.0 years) and 329 (58.5%) were male; 553 of the 579 patients (95.5%) had follow-up information. Among those discharged with β-blockers, there was no increased risk of the primary end point of all-cause mortality, revascularization, or hospitalization (hazard ratio [HR], 1.01; 95% CI, 0.66-1.54; P = .96) or of cardiovascular events (HR, 1.11; 95% CI, 0.65-1.92; P = .69), COPD-related or respiratory events (HR, 0.75; 95% CI, 0.34-1.66; P = .48), or treatment for COPD exacerbations (rate ratio, 1.01; 95% CI, 0.53-1.91; P = .98). Conclusions and Relevance In this cohort study, β-blocker prescription at hospital discharge was not associated with increased risk of adverse outcomes in patients with COPD and AMI. These findings support use of β-blockers in patients with COPD and recent AMI.
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Affiliation(s)
- David C LaFon
- Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, The University of Alabama at Birmingham
- UAB Lung Health Center, Heersink School of Medicine, The University of Alabama at Birmingham
| | - Erika S Helgeson
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis
| | - Sarah Lindberg
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis
| | - Helen Voelker
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, The University of Alabama at Birmingham
- UAB Lung Health Center, Heersink School of Medicine, The University of Alabama at Birmingham
| | - Richard Casaburi
- Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California
| | - Steven J Cassady
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore
| | - John Connett
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis
| | - Gerard J Criner
- Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Umur Hatipoglu
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David A Kaminsky
- Pulmonary and Critical Care Medicine, University of Vermont, Burlington
| | - Ken M Kunisaki
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Stephen C Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco
- Cardiovascular Research Institute, University of California San Francisco
| | | | - Robert M Reed
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore
| | - Frank C Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William Stringer
- Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, The University of Alabama at Birmingham
- UAB Lung Health Center, Heersink School of Medicine, The University of Alabama at Birmingham
- Birmingham VA Medical Center, Birmingham, Alabama
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Lannon CM, Nuchovich N, Louis C, Henson J, Connett J, Nina RH, Marath A. Factors Associated With Lack of Long-Term Follow-Up Data After Global Cardiac Surgery Missions. World J Pediatr Congenit Heart Surg 2024; 15:325-331. [PMID: 38629174 PMCID: PMC11100267 DOI: 10.1177/21501351241239316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/06/2024] [Indexed: 05/18/2024]
Abstract
Background: Humanitarian medical missions attempt to lessen the burden of limited access to cardiac surgery in low- and middle-income countries. While organizations express difficulties obtaining follow-up information, there is currently little evidence to support the various assumptions for lack of data. This study examines the factors influencing long-term patient follow-ups on repeated short-term cardiac surgery missions across nine countries. Methods: A retrospective analysis of CardioStart International's database (RedCap) was conducted to investigate demographic, socioeconomic, and surgical factors associated with follow-ups. Results: A total of 550 pediatric (50%) and adult (50%) cardiac surgery patients displayed a follow-up rate of 14.7%, with no significant difference between populations (P = 1). Mean follow-up time was 1.5 years postoperative. Countries were highly variable, with Dominican Republic and Vietnam showing follow-up rates of 30.4% and 43.2%, respectively, while Brazil, Nepal, and Tanzania had no follow-ups (P < 0.0001). The 11 surrogate factors for socioeconomic status, including home amenities and technology access, were predominantly insignificant, with the exception of phone access showing an unexpectedly decreased follow-up rate (11.6%, P = 0.006). Surgical intervention was a significant factor (P = 0.009). No adult cardiac surgery trends were noted; however, congenital cases demonstrated increased follow-ups in patients with higher Risk Adjusted Congenital Heart Surgery scores, with ventricular septal defects (32.5%) exceeding atrial septal defects (7.3%). Conclusions: Follow-ups correlate with mission factors, including location and types of intervention, more so than previously assumed socioeconomic and technological factors. Thus, certain missions may require more allocation of resources and adapted organizational policies to overcome site-specific barriers to follow-up.
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Affiliation(s)
- Christine M. Lannon
- Texas A&M School of Engineering Medicine, Houston, TX, USA
- CardioStart International Inc., St. Petersburg, FL, USA
| | | | - Clauden Louis
- CardioStart International Inc., St. Petersburg, FL, USA
- Brigham and Women's Hospital Harvard University, Boston, MA, USA
| | - Janine Henson
- CardioStart International Inc., St. Petersburg, FL, USA
| | - John Connett
- CardioStart International Inc., St. Petersburg, FL, USA
| | - Rachel Haickel Nina
- CardioStart International Inc., St. Petersburg, FL, USA
- Federal University of Maranhao, Sao Luis, Brazil
| | - Aubyn Marath
- CardioStart International Inc., St. Petersburg, FL, USA
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Vickery KD, Gelberg L, Hyson AR, Strother E, Carter J, Oranday Perez O, Franco M, Kavistan S, Gust S, Adair E, Anderson-Campbell A, Brito L, Butler A, Robinson T, Connett J, Evans MD, Emmons KM, Comulada WS, Busch AM. Pilot trial results of D-HOMES: a behavioral-activation based intervention for diabetes medication adherence and psychological wellness among people who have been homeless. Front Psychiatry 2024; 15:1329138. [PMID: 38487573 PMCID: PMC10937567 DOI: 10.3389/fpsyt.2024.1329138] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 02/15/2024] [Indexed: 03/17/2024] Open
Abstract
Introduction People living with type 2 diabetes who experience homelessness face a myriad of barriers to engaging in diabetes self-care behaviors that lead to premature complications and death. This is exacerbated by high rates of comorbid mental illness, substance use disorder, and other physical health problems. Despite strong evidence to support lay health coach and behavioral activation, little research has effectively engaged people living with type 2 diabetes who had experienced homelessness (DH). Methods We used community engaged research and incremental behavioral treatment development to design the Diabetes HOmeless MEdication Support (D-HOMES) program, a one-on-one, 3 month, coaching intervention to improve medication adherence and psychological wellness for DH. We present results of our pilot randomized trial (with baseline, 3 mo., 6 mo. assessments) comparing D-HOMES to enhanced usual care (EUC; brief diabetes education session and routine care; NCT05258630). Participants were English-speaking adults with type 2 diabetes, current/recent (<24 mo.) homelessness, and an HbA1c‗7.5%. We focused on feasibility (recruitment, retention, engagement) and acceptability (Client Satisfaction Questionnaire, CSQ-8). Our primary clinical outcome was glycemic control (HbA1c) and primary behavioral outcome was medication adherence. Secondary outcomes included psychological wellness and diabetes self-care. Results Thirty-six eligible participants enrolled, 18 in each arm. Most participants identified as Black males, had high rates of co-morbidities, and lived in subsidized housing. We retained 100% of participants at 3-months, and 94% at 6-months. Participants reported high satisfaction (mean CSQ-8 scores=28.64 [SD 3.94] of 32). HbA1c reduced to clinically significant levels in both groups, but we found no between group differences. Mean blood pressure improved more in D-HOMES than EUC between baseline and 6 mo. with between group mean differences of systolic -19.5 mmHg (p=0.030) and diastolic blood pressure -11.1 mmHg (p=0.049). We found no significant between group differences in other secondary outcomes. Conclusion We effectively recruited and retained DH over 6 months. Data support that the D-HOMES intervention was acceptable and feasible. We observe preliminary blood pressure improvement favoring D-HOMES that were statistically and clinically significant. D-HOMES warrants testing in a fully powered trial which could inform future high quality behavioral trials to promote health equity. Clinical trial registration https://clinicaltrials.gov/study/NCT05258630?term=D-HOMES&rank=1, identifier NCT05258630.
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Affiliation(s)
- Katherine Diaz Vickery
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Lillian Gelberg
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- UCLA Fielding School of Public Health, Los Angeles, CA, United States
| | - Audrey Rose Hyson
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Ella Strother
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Jill Carter
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Oscar Oranday Perez
- The Behavioral Health Equity Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
| | - Moncies Franco
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Silvio Kavistan
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Susan Gust
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Edward Adair
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | | | - Lelis Brito
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Annette Butler
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Tahiti Robinson
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - John Connett
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Michael D. Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, United States
| | - Karen M. Emmons
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - W. Scott Comulada
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- UCLA Fielding School of Public Health, Los Angeles, CA, United States
| | - Andrew M. Busch
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- The Behavioral Health Equity Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
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Albert RK, Jurkovich GJ, Connett J, Helgeson ES, Keniston A, Voelker H, Lindberg S, Proper JL, Bochicchio G, Stein DM, Cain C, Tesoriero R, Brown CVR, Davis J, Napolitano L, Carver T, Cipolle M, Cardenas L, Minei J, Nirula R, Doucet J, Miller PR, Johnson J, Inaba K, Kao L. Sigh Ventilation in Patients With Trauma: The SiVent Randomized Clinical Trial. JAMA 2023; 330:1982-1990. [PMID: 37877609 PMCID: PMC10600720 DOI: 10.1001/jama.2023.21739] [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: 04/14/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023]
Abstract
Importance Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown. Objective To determine whether adding sigh breaths improves clinical outcomes. Design, Setting, and Participants A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours. Interventions Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished. Main Outcomes and Measures The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality. Results Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]). Conclusions and Relevance In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02582957.
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Affiliation(s)
| | | | - John Connett
- Division of Biostatistics, University of Minnesota, Minneapolis
| | | | | | - Helen Voelker
- Division of Biostatistics, University of Minnesota, Minneapolis
| | - Sarah Lindberg
- Division of Biostatistics, University of Minnesota, Minneapolis
| | | | - Grant Bochicchio
- Department of Surgery, Washington University, St Louis, St Louis, Missouri
| | | | - Christian Cain
- Department of Surgery, University of Maryland, Baltimore
| | - Ron Tesoriero
- Department of Surgery, University of Maryland, Baltimore
| | | | - James Davis
- Department of Surgery, University of California San Francisco, Fresno
| | | | - Thomas Carver
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Mark Cipolle
- Department of Surgery, Lehigh Valley Health Network, Bethlehem, Pennsylvania
| | - Luis Cardenas
- Department of Surgery, Christiana Care Health System, Wilmington, Delaware
| | - Joseph Minei
- Department of Surgery, University of Texas Southwestern, Dallas
| | | | - Jay Doucet
- Department of Surgery, University of California San Diego
| | - Preston R. Miller
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeffrey Johnson
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Kenji Inaba
- Department of Surgery, University of Southern California Los Angeles County
| | - Lillian Kao
- Department of Surgery, University of Texas, Houston
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Vickery KD, Ford BR, Gelberg L, Bonilla Z, Strother E, Gust S, Adair E, Montori VM, Linzer M, Evans MD, Connett J, Heisler M, O'Connor PJ, Busch AM. The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness. Front Psychol 2023; 14:1225777. [PMID: 37794913 PMCID: PMC10546874 DOI: 10.3389/fpsyg.2023.1225777] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/08/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH. Methods We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions). Results In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing. Discussion The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.
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Affiliation(s)
- Katherine Diaz Vickery
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Becky R. Ford
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles, CA, United States
| | - Zobeida Bonilla
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Ella Strother
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Susan Gust
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Edward Adair
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Victor M. Montori
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine and the Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Mark Linzer
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Michael D. Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, United States
| | - John Connett
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Michele Heisler
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Patrick J. O'Connor
- Center for Chronic Care Innovation, HealthPartners Institute, Bloomington, MN, United States
| | - Andrew M. Busch
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- The Behavioral Health Equity Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
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Bronfort G, Delitto A, Schneider M, Heagerty PJ, Chou R, Connett J, Evans R, George S, Glick RM, Greco C, Hanson L, Keefe F, Leininger B, Licciardone J, McFarland C, Meier E, Schulz C, Turk D. Effectiveness of spinal manipulation and biopsychosocial self-management compared to medical care for low back pain: a randomized trial study protocol. BMC Musculoskelet Disord 2023; 24:415. [PMID: 37231386 PMCID: PMC10209583 DOI: 10.1186/s12891-023-06549-w] [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: 04/26/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis. METHODS We have designed a phase 3 randomized trial with a 2 × 2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment. DISCUSSION By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03581123.
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Affiliation(s)
- Gert Bronfort
- Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota, Mayo Memorial Building C504, 420 Delaware Street, Minneapolis, MN 55414 USA
| | - Anthony Delitto
- School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, 4029 Forbes Tower, Pittsburgh, PA 15260 USA
| | - Michael Schneider
- School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 500, Pittsburgh, PA 15219 USA
| | - Patrick J. Heagerty
- School of Public Health, Department of Biostatistics, University of Washington, 1959 NE Pacific Street, Box 357232, Seattle, WA 98195 USA
| | - Roger Chou
- School of Medicine, Division of General Internal Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR 97239-3098 USA
| | - John Connett
- School of Public Health, Division of Biostatistics, University of Minnesota, 717 Delaware Street SE, 2nd Floor, Minneapolis, MN 5455 USA
| | - Roni Evans
- Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota, Mayo Memorial Building C504, 420 Delaware Street, Minneapolis, MN 55414 USA
| | - Steven George
- School of Medicine, Department of Orthopaedic Surgery, Duke University, 8020 North Pavilion, Durham, NC 27705 USA
| | - Ronald M. Glick
- School of Medicine, Departments of Psychiatry and Physical Medicine & Rehabilitation, University of Pittsburgh, 580 S. Aiken Avenue, Suite 310, Pittsburgh, PA 15232 USA
| | - Carol Greco
- School of Medicine, Department of Psychiatry, University of Pittsburgh, 580 S. Aiken Avenue, Suite 310, Pittsburgh, PA 15232 USA
| | - Linda Hanson
- Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota, Mayo Memorial Building C504, 420 Delaware Street, Minneapolis, MN 55414 USA
| | - Francis Keefe
- School of Medicine, Department of Medicine, Duke University, 2200 W Main St., Suite 340, Durham, NC 27705 USA
| | - Brent Leininger
- Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota, Mayo Memorial Building C504, 420 Delaware Street, Minneapolis, MN 55414 USA
| | - John Licciardone
- Health Science Center, University of North Texas, 3500 Camp Bowie Blvd, Fort Worth, TX 76107 USA
| | - Christine McFarland
- School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 500, Pittsburgh, PA 15219 USA
| | - Eric Meier
- School of Public Health, Department of Biostatistics, University of Washington, 4333 Brooklyn Avenue NE, Box 359461, Seattle, WA 98195 USA
| | - Craig Schulz
- Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota, Mayo Memorial Building C504, 420 Delaware Street, Minneapolis, MN 55414 USA
| | - Dennis Turk
- Department of Anesthesiology & Pain Medicine, University of Washington, Box 358045, Seattle, WA 98195 USA
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Bronfort G, Delitto A, Schneider M, Heagerty P, Chou R, Connett J, Evans R, George S, Glick R, Greco C, Hanson L, Keefe F, Leininger B, Licciardone J, McFarland C, Meier E, Schulz C, Turk D. Effectiveness of Spinal Manipulation and Biopsychosocial Self-Management compared to Medical Care for Low Back Pain: A Randomized Trial Study Protocol. Res Sq 2023:rs.3.rs-2865633. [PMID: 37205428 PMCID: PMC10187435 DOI: 10.21203/rs.3.rs-2865633/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis. Methods We have designed a phase 3 randomized trial with a 2x2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment. Discussion By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem. Trial registration: ClinicalTrials.gov Identifier: NCT03581123.
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Hooks M, Sandhu G, Maganti T, Chen KHA, Wang M, Cullen R, Velangi PS, Gu C, Wiederin J, Connett J, Brown R, Blaes A, Shenoy C, Nijjar PS. Incidental coronary calcium in cancer patients treated with anthracycline and/or trastuzumab. Eur J Prev Cardiol 2022; 29:2200-2210. [PMID: 36017793 DOI: 10.1093/eurjpc/zwac185] [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: 06/04/2022] [Revised: 07/25/2022] [Accepted: 08/15/2022] [Indexed: 01/11/2023]
Abstract
AIMS Cancer patients are at increased risk of cardiovascular disease (CVD) after treatment with potentially cardiotoxic treatments. Many cancer patients undergo non-gated chest computed tomography (NCCT) for cancer staging prior to treatment. We aimed to assess whether coronary artery calcification on NCCT predicts CVD risk in cancer patients. METHODS AND RESULTS Six hundred and three patients (mean age: 61.3 years, 30.8% male) with either breast cancer, lymphoma, or sarcoma were identified retrospectively. Primary endpoint was a major adverse cardiac event (MACE) composite including non-fatal myocardial infarction, new heart failure (HF) diagnosis, HF hospitalization, and cardiac death, with Fine-Gray analysis for non-cardiac death as competing risk. Secondary endpoints included a coronary composite and a HF composite. Coronary artery calcification was present in 194 (32.2%) and clinically reported in 85 (43.8%) patients. At a median follow-up of 5.3 years, 256 (42.5%) patients died of non-cardiac causes. Coronary artery calcification presence or extent was not an independent predictor of MACE [sub-distribution hazards ratio (SHR) 1.28; 0.73-2.27]. Coronary artery calcification extent was a significant predictor of the coronary composite outcome (SHR per two-fold increase 1.14; 1.01-1.28), but not of the HF composite outcome (SHR per two-fold increase 1.04; 0.95-1.14). CONCLUSION Coronary artery calcification detected incidentally on NCCT scans in cancer patients is prevalent and often not reported. Coronary artery calcification presence or extent did not independently predict MACE. Coronary artery calcification extent was independently associated with increased risk of CAD events but not HF events.
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Affiliation(s)
- Matthew Hooks
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Gurmandeep Sandhu
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Tejaswini Maganti
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Ko-Hsuan Amy Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Michelle Wang
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Ryan Cullen
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Pratik S Velangi
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, USA
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Christina Gu
- University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Jason Wiederin
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA
| | - John Connett
- Biostatistics, Epidemiology and Research Design (BERD), University of Minnesota, Minneapolis, MN 55455, USA
| | - Roland Brown
- Biostatistics, Epidemiology and Research Design (BERD), University of Minnesota, Minneapolis, MN 55455, USA
| | - Anne Blaes
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Prabhjot S Nijjar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
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Parekh TM, Helgeson ES, Connett J, Voelker H, Ling SX, Lazarus SC, Bhatt SP, MacDonald DM, Mkorombindo T, Kunisaki KM, Fortis S, Kaminsky D, Dransfield MT. Lung Function and the Risk of Exacerbation in the β-Blockers for the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease Trial. Ann Am Thorac Soc 2022; 19:1642-1649. [PMID: 35363600 PMCID: PMC9528740 DOI: 10.1513/annalsats.202109-1042oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/01/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: The BLOCK COPD (β-Blockers for the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease) study found that metoprolol was associated with a higher risk of severe exacerbation. Objectives: To determine the mechanism underlying these results, we compared changes in lung function over the course of the study between treatment groups and evaluated whether baseline bronchodilator response or early reduction in forced expiratory volume in 1 second (FEV1) or forced vital capacity (FVC) was associated with exacerbation risk. Methods: We compared changes in lung function (FEV1 and FVC) over the treatment period between treatment groups using linear mixed-effect models. Cox proportional hazards models were used to evaluate the association between baseline bronchodilator responsiveness (FEV1, FVC, and combined FEV1 and FVC), early post-randomization (14 d) change in lung function, and the interaction between treatment assignment and these measures with risk of any or severe or very severe exacerbations. Negative binomial models were used to evaluate the relationship between bronchodilator responsiveness, the interaction between bronchodilator responsiveness and treatment assignment, and exacerbation rate. Results: Over the 336-day treatment period, individuals in the metoprolol group had a significantly greater decrease in logarithmic FEV1 from baseline to visit on Day 28 than individuals in the placebo group. Individuals in the metoprolol group had a significantly greater decrease in FVC from baseline to visits on Days 14 and 28, and also a significantly greater decrease in logarithmic FVC from baseline to visits on Days 42 and 112 than individuals in the placebo group. There were no associations between early lung function reduction or interactions between lung function reduction and treatment assignment and time to any or severe or very severe exacerbations. There were no interactions between treatment arm and baseline bronchodilator responsiveness measures on risk or rate of exacerbations. However, those with baseline FVC bronchodilator responsiveness had a higher rate of severe or very severe exacerbations (adjusted rate ratio, 1.62; 95% confidence interval, 1.04-2.48). Conclusions: Metoprolol was associated with reduced lung function during the early part of the treatment period, but these effects were modest and did not persist. Early lung function reduction and baseline bronchodilator responsiveness did not interact with the treatment arm to predict exacerbations; however, baseline FVC bronchodilator responsiveness was associated with a 60% higher rate of severe or very severe exacerbations. Clinical trial registered with www.clinicaltrials.gov (NCT02587351).
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Affiliation(s)
| | - Erika S. Helgeson
- University of Minnesota Academic Health Center, Minneapolis, Minnesota
| | | | | | | | | | - Surya P. Bhatt
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Ken M. Kunisaki
- University of Minnesota, Minneapolis, Minnesota
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Spyridon Fortis
- University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - David Kaminsky
- University of Vermont College of Medicine, Burlington, Vermont
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Matas AJ, Helgeson E, Fieberg A, Leduc R, Gaston RS, Kasiske BL, Rush D, Hunsicker L, Cosio F, Grande JP, Cecka JM, Connett J, Mannon RB. Risk Prediction for Delayed Allograft Function: Analysis of the Deterioration of Kidney Allograft Function (DeKAF) Study Data. Transplantation 2022; 106:358-368. [PMID: 33675321 PMCID: PMC8380757 DOI: 10.1097/tp.0000000000003718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Delayed graft function (DGF) of a kidney transplant results in increased cost and complexity of management. For clinical care or a DGF trial, it would be ideal to accurately predict individual DGF risk and provide preemptive treatment. A calculator developed by Irish et al has been useful for predicting population but not individual risk. METHODS We analyzed the Irish calculator (IC) in the DeKAF prospective cohort (incidence of DGF = 20.4%) and investigated potential improvements. RESULTS We found that the predictive performance of the calculator in those meeting Irish inclusion criteria was comparable with that reported by Irish et al. For cohorts excluded by Irish: (a) in pump-perfused kidneys, the IC overestimated DGF risk; (b) in simultaneous pancreas kidney transplants, the DGF risk was exceptionally low. For all 3 cohorts, there was considerable overlap in IC scores between those with and those without DGF. Using a modified definition of DGF-excluding those with single dialysis in the first 24 h posttransplant-we found that the calculator had similar performance as with the traditional DGF definition. Studying whether DGF prediction could be improved, we found that recipient cardiovascular disease was strongly associated with DGF even after accounting for IC-predicted risk. CONCLUSIONS The IC can be a useful population guide for predicting DGF in the population for which it was intended but has limited scope in expanded populations (SPK, pump) and for individual risk prediction. DGF risk prediction can be improved by inclusion of recipient cardiovascular disease.
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Affiliation(s)
- Arthur J Matas
- Transplantation Division, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Erika Helgeson
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Ann Fieberg
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Robert Leduc
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Robert S Gaston
- Department of Medicine, University of Alabama, Birmingham, AL
| | | | - David Rush
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Fernando Cosio
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Joseph P Grande
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - J Michael Cecka
- Department of Pathology & Lab Medicine, David Geffen School of Medicine, University of California, UCLA Immunogenetics Center, Los Angeles, CA
| | - John Connett
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Roslyn B Mannon
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, NE
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12
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Helgeson ES, Mannon R, Grande J, Gaston RS, Cecka MJ, Kasiske BL, Rush D, Gourishankar S, Cosio F, Hunsicker L, Connett J, Matas AJ. i-IFTA and chronic active T cell-mediated rejection: A tale of 2 (DeKAF) cohorts. Am J Transplant 2021; 21:1866-1877. [PMID: 33052625 DOI: 10.1111/ajt.16352] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/24/2020] [Accepted: 09/30/2020] [Indexed: 01/25/2023]
Abstract
Inflammation in areas of fibrosis (i-IFTA) in posttransplant biopsies is part of the diagnostic criteria for chronic active TCMR (CA TCMR -- i-IFTA ≥ 2, ti ≥ 2, t ≥ 2). We evaluated i-IFTA and CA TCMR in the DeKAF indication biopsy cohorts: prospective (n = 585, mean time to biopsy = 1.7 years); cross-sectional (n = 458, mean time to biopsy = 7.8 years). Grouped by i-IFTA scores, the 3-year postbiopsy DC-GS is similar across cohorts. Although a previous acute rejection episode (AR) was more common in those with i-IFTA on biopsy, the majority of those with i-IFTA had not had previous AR. There was no association between type of previous AR (AMR, TCMR) and presence of i-IFTA. In both cohorts, i-IFTA was associated with markers of both cellular (increased Banff i, t, ti) and humoral (increased g, ptc, C4d, DSA) activity. Biopsies with i-IFTA = 1 and i-IFTA ≥ 2 with concurrent t ≥ 2 and ti ≥ 2 had similar DC-GS. These results suggest that (a) i-IFTA≥1 should be considered a threshold for diagnoses incorporating i-IFTA, ti, and t; (b) given that i-IFTA ≥ 2,t ≥ 2, ti ≥ 2 can occur in the absence of preceding TCMR and that the component histologic scores (i-IFTA,t,ti) each indicate an acute change (albeit i-IFTA on the nonspecific background of IFTA), the diagnostic category "CA TCMR" should be reconsidered.
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Affiliation(s)
- Erika S Helgeson
- School of Public Health, Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Roslyn Mannon
- University of Nebraska Medical Center and Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, Nebraska
| | | | - Robert S Gaston
- University of Nebraska Medical Center and Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, Nebraska
| | - Michael J Cecka
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, California
| | | | - David Rush
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sita Gourishankar
- Department of Medicine, Division of Nephrology, Univeristy of Alberta, Edmonton, Alberta, Canada
| | | | | | - John Connett
- School of Public Health, Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Arthur J Matas
- Department of Surgery, Transplantation Division, University of Minnesota, Minneapolis, Minnesota
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13
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Proper J, Connett J, Murray T. Alternative models and randomization techniques for Bayesian response-adaptive randomization with binary outcomes. Clin Trials 2021; 18:417-426. [PMID: 33926267 DOI: 10.1177/17407745211010139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bayesian response-adaptive designs, which data adaptively alter the allocation ratio in favor of the better performing treatment, are often criticized for engendering a non-trivial probability of a subject imbalance in favor of the inferior treatment, inflating type I error rate, and increasing sample size requirements. The implementation of these designs using the Thompson sampling methods has generally assumed a simple beta-binomial probability model in the literature; however, the effect of these choices on the resulting design operating characteristics relative to other reasonable alternatives has not been fully examined. Motivated by the Advanced R2 Eperfusion STrategies for Refractory Cardiac Arrest trial, we posit that a logistic probability model coupled with an urn or permuted block randomization method will alleviate some of the practical limitations engendered by the conventional implementation of a two-arm Bayesian response-adaptive design with binary outcomes. In this article, we discuss up to what extent this solution works and when it does not. METHODS A computer simulation study was performed to evaluate the relative merits of a Bayesian response-adaptive design for the Advanced R2 Eperfusion STrategies for Refractory Cardiac Arrest trial using the Thompson sampling methods based on a logistic regression probability model coupled with either an urn or permuted block randomization method that limits deviations from the evolving target allocation ratio. The different implementations of the response-adaptive design were evaluated for type I error rate control across various null response rates and power, among other performance metrics. RESULTS The logistic regression probability model engenders smaller average sample sizes with similar power, better control over type I error rate, and more favorable treatment arm sample size distributions than the conventional beta-binomial probability model, and designs using the alternative randomization methods have a negligible chance of a sample size imbalance in the wrong direction. CONCLUSION Pairing the logistic regression probability model with either of the alternative randomization methods results in a much improved response-adaptive design in regard to important operating characteristics, including type I error rate control and the risk of a sample size imbalance in favor of the inferior treatment.
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Affiliation(s)
- Jennifer Proper
- Division of Biostatistics, University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - John Connett
- Division of Biostatistics, University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Thomas Murray
- Division of Biostatistics, University of Minnesota Twin Cities, Minneapolis, MN, USA
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14
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Lakshminarayan K, Murray TA, Westberg SM, Connett J, Overton V, Nyman JA, Culhane-Pera KA, Pergament SL, Drawz P, Vollbrecht E, Xiong T, Everson-Rose SA. Mobile Health Intervention to Close the Guidelines-To-Practice Gap in Hypertension Treatment: Protocol for the mGlide Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e25424. [PMID: 33492231 PMCID: PMC7870345 DOI: 10.2196/25424] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 11/29/2020] [Accepted: 12/18/2020] [Indexed: 12/29/2022] Open
Abstract
Background Suboptimal treatment of hypertension remains a widespread problem, particularly among minorities and socioeconomically disadvantaged groups. We present a health system–based intervention with diverse patient populations using readily available smartphone technology. This intervention is designed to empower patients and create partnerships between patients and their provider team to promote hypertension control. Objective The mGlide randomized controlled trial is a National Institutes of Health–funded study, evaluating whether a mobile health (mHealth)-based intervention that is an active partnership between interprofessional health care teams and patients results in better hypertension control rates than a state-of-clinical care comparison. Methods We are recruiting 450 participants including stroke survivors and primary care patients with elevated cardiovascular disease risk from diverse health systems. These systems include an acute stroke service (n=100), an academic medical center (n=150), and community medical centers including Federally Qualified Health Centers serving low-income and minority (Latino, Hmong, African American, Somali) patients (n=200). The primary aim tests the clinical effectiveness of the 6-month mHealth intervention versus standard of care. Secondary aims evaluate sustained hypertension control rates at 12 months; describe provider experiences of system usability and satisfaction; examine patient experiences, including medication adherence and medication use self-efficacy, self-rated health and quality of life, and adverse event rates; and complete a cost-effectiveness analysis. Results To date, we have randomized 107 participants (54 intervention, 53 control). Conclusions This study will provide evidence for whether a readily available mHealth care model is better than state-of-clinical care for bridging the guideline-to-practice gap in hypertension treatment in health systems serving diverse patient populations. Trial Registration Clinicaltrials.gov NCT03612271; https://clinicaltrials.gov/ct2/show/NCT03612271 International Registered Report Identifier (IRRID) DERR1-10.2196/25424
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Affiliation(s)
- Kamakshi Lakshminarayan
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Sarah M Westberg
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Val Overton
- Fairview Health Services, Minneapolis, MN, United States
| | - John A Nyman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Kathleen A Culhane-Pera
- SoLaHmo Partnership for Health and Wellness, Minneapolis, MN, United States.,Minnesota Community Care, Saint Paul, MN, United States
| | | | - Paul Drawz
- Division of Renal Disease and Hypertension, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Emily Vollbrecht
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Txia Xiong
- SoLaHmo Partnership for Health and Wellness, Minneapolis, MN, United States
| | - Susan A Everson-Rose
- Department of Medicine and Program in Health Disparities Research, Medical School, University of Minnesota, Minneapolis, MN, United States
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15
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Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosmopoulos M, John R, Shaffer A, Frascone RJ, Wesley K, Conterato M, Biros M, Tolar J, Aufderheide TP. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet 2020; 396:1807-1816. [PMID: 33197396 PMCID: PMC7856571 DOI: 10.1016/s0140-6736(20)32338-2] [Citation(s) in RCA: 471] [Impact Index Per Article: 117.8] [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: 10/12/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Among patients with out-of-hospital cardiac arrest (OHCA) and ventricular fibrillation, more than half present with refractory ventricular fibrillation unresponsive to initial standard advanced cardiac life support (ACLS) treatment. We did the first randomised clinical trial in the USA of extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation versus standard ACLS treatment in patients with OHCA and refractory ventricular fibrillation. METHODS For this phase 2, single centre, open-label, adaptive, safety and efficacy randomised clinical trial, we included adults aged 18-75 years presenting to the University of Minnesota Medical Center (MN, USA) with OHCA and refractory ventricular fibrillation, no return of spontaneous circulation after three shocks, automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System, and estimated transfer time shorter than 30 min. Patients were randomly assigned to early ECMO-facilitated resuscitation or standard ACLS treatment on hospital arrival by use of a secure schedule generated with permuted blocks of randomly varying block sizes. Allocation concealment was achieved by use of a randomisation schedule that required scratching off an opaque layer to reveal assignment. The primary outcome was survival to hospital discharge. Secondary outcomes were safety, survival, and functional assessment at hospital discharge and at 3 months and 6 months after discharge. All analyses were done on an intention-to-treat basis. The study qualified for exception from informed consent (21 Code of Federal Regulations 50.24). The ARREST trial is registered with ClinicalTrials.gov, NCT03880565. FINDINGS Between Aug 8, 2019, and June 14, 2020, 36 patients were assessed for inclusion. After exclusion of six patients, 30 were randomly assigned to standard ACLS treatment (n=15) or to early ECMO-facilitated resuscitation (n=15). One patient in the ECMO-facilitated resuscitation group withdrew from the study before discharge. The mean age was 59 years (range 36-73), and 25 (83%) of 30 patients were men. Survival to hospital discharge was observed in one (7%) of 15 patients (95% credible interval 1·6-30·2) in the standard ACLS treatment group versus six (43%) of 14 patients (21·3-67·7) in the early ECMO-facilitated resuscitation group (risk difference 36·2%, 3·7-59·2; posterior probability of ECMO superiority 0·9861). The study was terminated at the first preplanned interim analysis by the National Heart, Lung, and Blood Institute after unanimous recommendation from the Data Safety Monitoring Board after enrolling 30 patients because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group than in the standard ACLS group. No unanticipated serious adverse events were observed. INTERPRETATION Early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation significantly improved survival to hospital discharge compared with standard ACLS treatment. FUNDING National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Jason Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ganesh Raveendran
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Emily Walser
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - John Connett
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Thomas A Murray
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Gary Collins
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Lin Zhang
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Andrew Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - R J Frascone
- St Paul Fire and Emergency Medical Services, St Paul, MN, USA
| | - Keith Wesley
- M Health Fairview Emergency Medical Services, Minneapolis, MN, USA
| | - Marc Conterato
- North Memorial Emergency Medical Services, Robbinsdale, MN, USA
| | - Michelle Biros
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jakub Tolar
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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16
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Williams BR, Vargo K, Newman DK, Yvette Lacoursiere D, Mueller ER, Connett J, Low LK, James AS, Smith AL, Schmitz KH, Burgio KL. It's About Time: The Temporal Burden of Lower Urinary Tract Symptoms Among Women. Urol Nurs 2020; 40:10.7257/1053-816x.2020.40.6.277. [PMID: 33642840 PMCID: PMC7906293 DOI: 10.7257/1053-816x.2020.40.6.277] [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] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This secondary analysis studied 50 transcripts of women who shared day-to-day experiences of lower urinary tract symptoms (LUTS) and characterized temporal (time-associated) features of living with LUTS. Findings revealed two overarching time-associated themes: The Complexity of LUTS and The Quest for Empowerment over LUTS. Findings suggest that the temporal burden of LUTS is the accumulated impact of symptoms and symptom management on women's daily lives within multiple contexts across the life course. Increasing nurses' knowledge of the temporal context of LUTS may heighten awareness and improve symptom detection and management.
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Affiliation(s)
- Beverly Rosa Williams
- University of Alabama at Birmingham School of Medicine, Department of Veterans Affairs, Birmingham, AL
| | - Keith Vargo
- University of Minnesota School of Public Health
| | - Diane K Newman
- Division of Urology, Department of Surgery, University of Pennsylvania, Perelman School of Medicine
| | | | | | | | | | - Aimee S James
- Washington University in St. Louis School of Medicine
| | | | | | - Kathryn L Burgio
- University of Alabama at Birmingham School of Medicine, Department of Veterans Affairs, Birmingham, AL
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17
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Baldomero AK, Kunisaki KM, Connett J, Pilon A, Wendt CH. Club Cell Secretory Protein (CCSP) is Reduced in Hospitalized Chronic Obstructive Pulmonary Disease (COPD) Exacerbations. Int J Chron Obstruct Pulmon Dis 2020; 15:2461-2464. [PMID: 33116461 PMCID: PMC7553259 DOI: 10.2147/copd.s264937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/18/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Arianne K Baldomero
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ken M Kunisaki
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Chris H Wendt
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
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18
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Matas AJ, Helgeson ES, Gaston R, Cosio F, Mannon R, Kasiske BL, Hunsicker L, Gourishankar S, Rush D, Michael Cecka J, Connett J, Grande JP. Inflammation in areas of fibrosis: The DeKAF prospective cohort. Am J Transplant 2020; 20:2509-2521. [PMID: 32185865 DOI: 10.1111/ajt.15862] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/13/2020] [Accepted: 02/27/2020] [Indexed: 01/25/2023]
Abstract
Inflammation in areas of fibrosis (i-IFTA) in posttransplant biopsy specimens has been associated with decreased death-censored graft survival (DC-GS). Additionally, an i-IFTA score ≥ 2 is part of the diagnostic criteria for chronic active TCMR (CA TCMR). We examined the impact of i-IFTA and t-IFTA (tubulitis in areas of atrophy) in the first biopsy for cause after 90 days posttransplant (n = 598); mean (SD) 1.7 ± 1.4 years posttransplant. I-IFTA, present in 196 biopsy specimens, was strongly correlated with t-IFTA, and Banff i. Of the 196, 37 (18.9%) had a previous acute rejection episode; 96 (49%) had concurrent i score = 0. Unlike previous studies, i-IFTA = 1 (vs 0) was associated with worse 3-year DC-GS: (i-IFTA = 0, 81.7%, [95% CI 77.7 to 85.9%]); i-IFTA = 1, 68.1%, [95% CI 59.7 to 77.6%]; i-IFTA = 2, 56.1%, [95% CI 43.2 to 72.8%], i-IFTA = 3, 48.5%, [95% CI 31.8 to 74.0%]). The association of i-IFTA with decreased DC-GS remained significant when adjusted for serum creatinine at the time of the biopsy, Banff i, ci and ct, C4d and DSA. T-IFTA was similarly associated with decreased DC-GS. Of these indication biopsies, those with i-IFTA ≥ 2, without meeting other criteria for CA TCMR had similar postbiopsy DC-GS as those with CA TCMR. Those with i-IFTA = 1 and t ≥ 2, ti ≥ 2 had postbiopsy DC-GS similar to CA TCMR. Biopsies with i-IFTA = 1 had similar survival as CA TCMR when biopsy specimens also met Banff criteria for TCMR and/or AMR. Studies of i-IFTA and t-IFTA in additional cohorts, integrating analyses of Banff scores meeting criteria for other Banff diagnoses, are needed.
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Affiliation(s)
- Arthur J Matas
- Transplantation Division, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Erika S Helgeson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert Gaston
- Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | | | - Roslyn Mannon
- Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | | | - Lawrence Hunsicker
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Sita Gourishankar
- Division of Nephrology, Department of Medicine, Univeristy of Alberta, Edmonton, Alberta, Canada
| | - David Rush
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - J Michael Cecka
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, California, USA
| | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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19
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Burgio KL, James AS, LaCoursiere DY, Mueller ER, Newman DK, Low LK, Weinfurt KP, Wyman JF, Cunningham SD, Vargo K, Connett J, Williams BR. Views of Normal Bladder Function Among Women Experiencing Lower Urinary Tract Symptoms. Urology 2020; 150:103-109. [PMID: 32841655 DOI: 10.1016/j.urology.2020.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/28/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To explore the perspectives of normal bladder function among women with lower urinary tract symptoms. METHODS This was a secondary analysis of qualitative data from structured interviews with 50 adult women with lower urinary tract symptoms. A directed content analysis of the transcripts explored women's perspectives on normal bladder function. RESULTS Participants' descriptions of "normal" took many forms and were based on several aspects of bladder function. A prominent feature of normal was that voiding occurred as a seamless process, beginning with an urge sensation, followed by voiding with ease and to completion, and then "being done." Descriptions of normal were based largely on concepts of voiding regularity, including voiding frequency, intervals, and patterns during the day and night. Another aspect of normal bladder function was the notion of having control in terms of not leaking urine, as well as the ability to hold urine and defer urination. Views of normal bladder function extended to the absence of symptoms and the impact of being symptom-free on day-to-day life, including not having to think about or worry about the bladder or limit daily activities. CONCLUSION Women's perspectives on normal bladder function are multifaceted, reflecting attributes most salient to each individual and likely informed by their personal experience with symptoms and their influence on daily life. This work has implications for how clinicians might engage women in discussing bladder symptoms and can inform future research and public health messaging about normal bladder function.
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Affiliation(s)
- Kathryn L Burgio
- University of Alabama at Birmingham School of Medicine, Birmingham, AL; Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL.
| | - Aimee S James
- Washington University School of Medicine, St. Louis, MO
| | | | | | - Diane K Newman
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Lisa Kane Low
- University of Michigan School of Nursing, Ann Arbor, MI
| | | | - Jean F Wyman
- University of Minnesota, School of Nursing, Minneapolis, MN
| | | | - Keith Vargo
- University of Minnesota School of Public Health, Minneapolis, MN
| | - John Connett
- University of Minnesota School of Public Health, Minneapolis, MN
| | - Beverly Rosa Williams
- University of Alabama at Birmingham School of Medicine, Birmingham, AL; Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL
| | -
- National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD
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20
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Leitao Filho FS, Mattman A, Schellenberg R, Criner GJ, Woodruff P, Lazarus SC, Albert RK, Connett J, Han MK, Gay SE, Martinez FJ, Fuhlbrigge AL, Stoller JK, MacIntyre NR, Casaburi R, Diaz P, Panos RJ, Cooper JA, Bailey WC, LaFon DC, Sciurba FC, Kanner RE, Yusen RD, Au DH, Pike KC, Fan VS, Leung JM, Man SFP, Aaron SD, Reed RM, Sin DD. Serum IgG Levels and Risk of COPD Hospitalization: A Pooled Meta-analysis. Chest 2020; 158:1420-1430. [PMID: 32439504 DOI: 10.1016/j.chest.2020.04.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hypogammaglobulinemia (serum IgG levels < 7.0 g/L) has been associated with increased risk of COPD exacerbations but has not yet been shown to predict hospitalizations. RESEARCH QUESTION To determine the relationship between hypogammaglobulinemia and the risk of hospitalization in patients with COPD. STUDY DESIGN AND METHODS Serum IgG levels were measured on baseline samples from four COPD cohorts (n = 2,259): Azithromycin for Prevention of AECOPD (MACRO, n = 976); Simvastatin in the Prevention of AECOPD (STATCOPE, n = 653), Long-Term Oxygen Treatment Trial (LOTT, n = 354), and COPD Activity: Serotonin Transporter, Cytokines and Depression (CASCADE, n = 276). IgG levels were determined by immunonephelometry (MACRO; STATCOPE) or mass spectrometry (LOTT; CASCADE). The effect of hypogammaglobulinemia on COPD hospitalization risk was evaluated using cumulative incidence functions for this outcome and deaths (competing risk). Fine-Gray models were performed to obtain adjusted subdistribution hazard ratios (SHR) related to IgG levels for each study and then combined using a meta-analysis. Rates of COPD hospitalizations per person-year were compared according to IgG status. RESULTS The overall frequency of hypogammaglobulinemia was 28.4%. Higher incidence estimates of COPD hospitalizations were observed among participants with low IgG levels compared with those with normal levels (Gray's test, P < .001); pooled SHR (meta-analysis) was 1.29 (95% CI, 1.06-1.56, P = .01). Among patients with prior COPD admissions (n = 757), the pooled SHR increased to 1.58 (95% CI, 1.20-2.07, P < .01). The risk of COPD admissions, however, was similar between IgG groups in patients with no prior hospitalizations: pooled SHR = 1.15 (95% CI, 0.86-1.52, P =.34). The hypogammaglobulinemia group also showed significantly higher rates of COPD hospitalizations per person-year: 0.48 ± 2.01 vs 0.29 ± 0.83, P < .001. INTERPRETATION Hypogammaglobulinemia is associated with a higher risk of COPD hospital admissions.
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Affiliation(s)
- Fernando Sergio Leitao Filho
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andre Mattman
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robert Schellenberg
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Prescott Woodruff
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Stephen C Lazarus
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | | | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Meilan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Steven E Gay
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Anne L Fuhlbrigge
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | - Neil R MacIntyre
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Richard Casaburi
- Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Philip Diaz
- Department of Internal Medicine, Ohio State University, Columbus, OH
| | - Ralph J Panos
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J Allen Cooper
- Birmingham VA Medical Center, Birmingham, AL; Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - William C Bailey
- Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - David C LaFon
- Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - Frank C Sciurba
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Richard E Kanner
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine in Saint Louis, Saint Louis, MO
| | - David H Au
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA
| | - Kenneth C Pike
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA
| | - Vincent S Fan
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA; VA Puget Sound Health Care System, Seattle, WA
| | - Janice M Leung
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shu-Fan Paul Man
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shawn D Aaron
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert M Reed
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Don D Sin
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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21
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Ingraham NE, Boulware D, Sparks MA, Schacker T, Benson B, Sparks JA, Murray T, Connett J, Chipman JG, Charles A, Tignanelli CJ. Shining a light on the evidence for hydroxychloroquine in SARS-CoV-2. Crit Care 2020; 24:182. [PMID: 32345336 PMCID: PMC7187670 DOI: 10.1186/s13054-020-02894-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/14/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Nicholas E Ingraham
- Division of Pulmonary and Critical Care, Department of Medicine, University of Minnesota, MMC 195, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | - David Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Matthew A Sparks
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC, USA
| | - Timothy Schacker
- Division of Medicine and Infectious Disease, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Bradley Benson
- Division of General Internal Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Jeffrey A Sparks
- Department of Medicine, Brigham and Women's Hospital; Harvard Medical School, Division of Rheumatology, Inflammation, and Immunity, Boston, MA, USA
| | - Thomas Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, USA
| | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, USA
| | - Jeffrey G Chipman
- Division of Acute Care Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,School of Public Health, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Christopher J Tignanelli
- School of Public Health, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
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22
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Kotalik A, Eaton A, Lian Q, Serrano C, Connett J, Neaton JD. A win ratio approach to the re-analysis of Multiple Risk Factor Intervention Trial. Clin Trials 2019; 16:626-634. [DOI: 10.1177/1740774519868233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Composite outcomes, which combine multiple types of clinical events into a single outcome, are common in clinical trials. The usual analysis considers the time to first occurrence of any event in the composite. The major criticisms of such an approach are (1) this implicitly treats the outcomes as if they were of equal importance, but they often vary in terms of clinical relevance and severity, (2) study participants often experience more than one type of event, and (3) often less severe events occur before more severe ones, but the usual analysis disregards any information beyond that first event. Methods: A novel approach, referred to as the win ratio, which addresses the aforementioned criticisms of composite outcomes, is illustrated with a re-analysis of data on fatal and non-fatal cardiovascular disease time-to-event outcomes reported for the Multiple Risk Factor Intervention Trial. In this trial, 12,866 participants were randomized to a special intervention group ( n = 6428) or a usual care ( n = 6438) group. Non-fatal outcomes were ranked by risk of cardiovascular disease death up to 20 years after trial. In one approach, participants in the special intervention and usual care groups were first matched on coronary heart disease risk at baseline and time of enrollment. Each matched pair was categorized as a winner or loser depending on which one experienced a cardiovascular disease death first. If neither died of cardiovascular disease causes, they were evaluated on the most severe non-fatal outcome. This process continued for all the non-fatal outcomes. A second win ratio statistic, obtained from Cox partial likelihood, was also estimated. This statistic provides a valid estimate of the win ratio using multiple events if the marginal and conditional survivor functions of each outcome satisfy proportional hazards. Loss ratio statistics (inverse of win ratios) are compared to hazard ratios from the usual first event analysis. A larger 11-event composite was also considered. Results: For the 7-event cardiovascular disease composite, the previously reported first event analysis based on 581 events in the special intervention group and 652 events in the usual care group yielded a hazard ratio (95% confidence interval) of 0.89 (0.79–0.99), compared to 0.86 (0.77–0.97) and 0.91 (0.81–1.02) for the severity ranked estimates. Results for the 11-event composite also confirmed the findings of the first event analysis. Conclusion: The win ratio analysis was able to leverage information collected past the first experienced event and rank events by severity. The results were similar to and confirmed previously reported traditional first event analysis. The win ratio statistic is a useful adjunct to the traditional first event analysis for trials with composite outcomes.
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Affiliation(s)
- Ales Kotalik
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Anne Eaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Qinshu Lian
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Carlos Serrano
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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23
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Weber-Main AM, Shanedling J, Kaizer AM, Connett J, Lamere M, El-Fakahany EE. A randomized controlled pilot study of the University of Minnesota mentoring excellence training academy: A hybrid learning approach to research mentor training. J Clin Transl Sci 2019; 3:152-164. [PMID: 31660240 PMCID: PMC6799418 DOI: 10.1017/cts.2019.368] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Research mentor training is a valuable professional development activity. Options for training customization (by delivery mode, dosage, content) are needed to address the many critical attributes of effective mentoring relationships and to support mentors in different institutional settings. METHODS We conducted a pilot randomized controlled trial to evaluate a hybrid mentor training approach consisting of an innovative, 90-minute, self-paced, online module (Optimizing the Practice of Mentoring, OPM) followed by workshops based on the Entering Mentoring (EM) curriculum. Mentors (n = 59) were randomized to intervention or control arms; the control condition was receipt of a two-page mentoring tip sheet. Surveys (pre, post, 3-month follow up) and focus groups assessed training impact (self-appraised knowledge, skills, behavior change) and participants' perceptions of the blended training model. RESULTS The intervention (∼6.5 hours) produced significant improvements in all outcomes, including skills gains on par with those reported previously for the 8-hour EM model. Knowledge gains and intention-to-change mentoring practices were realized after completion of OPM and augmented by the in-person sessions. Mentors valued the synergy of the blended learning format, noting the unique strengths of each modality and specific benefits to completing a foundational online module before in-person engagement. CONCLUSIONS Findings from this pilot trial support the value of e-learning approaches, both as standalone curricula or as a component of hybrid implementation models, for the professional development of research mentors.
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Affiliation(s)
- Anne Marie Weber-Main
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Janet Shanedling
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Alexander M. Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Aurora, CO, USA
| | - John Connett
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Michelle Lamere
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Esam E. El-Fakahany
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
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24
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Matas AJ, Fieberg A, Mannon RB, Leduc R, Grande J, Kasiske BL, Cecka M, Gaston R, Hunsicker L, Connett J, Cosio F, Gourishankar S, Rush D. Long-term follow-up of the DeKAF cross-sectional cohort study. Am J Transplant 2019; 19:1432-1443. [PMID: 30506642 PMCID: PMC7653899 DOI: 10.1111/ajt.15204] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/24/2018] [Accepted: 11/19/2018] [Indexed: 01/25/2023]
Abstract
The DeKAF study was developed to better understand the causes of late allograft loss. Preliminary findings from the DeKAF cross-sectional cohort (with follow-up < 20 months) have been published. Herein, we present long-term outcomes in those recipients (mean follow-up ± SD, 6.6 ± 0.7 years). Eligibility included being transplanted prior to October 1, 2005; serum creatinine ≤ 2.0 mg/dL on January 1, 2006; and subsequently developing new-onset graft dysfunction leading to a biopsy. Mean time from transplant to biopsy was 7.5 ± 6.1 years. Histologic findings and DSA were studied in relation to postbiopsy outcomes. Long-term follow-up confirms and expands the preliminary results of each of 3 studies: (1) increasing inflammation in area of atrophy (irrespective of inflammation in nonscarred areas [Banff i]) was associated with increasingly worse postbiopsy death-censored graft survival; (2) hierarchical analysis based on Banff scores defined clusters (entities) that differed in long-term death-censored graft survival; and (3) C4d-/DSA- recipients had significantly better (and C4d+/DSA+ worse) death-censored graft survival than other groups. C4d+/DSA- and C4d-/DSA+ had similar intermediate death-censored graft survival. Clinical and histologic findings at the time of new-onset graft dysfunction define high- vs low-risk groups for long-term death-censored graft survival, even years posttransplant. These findings can help differentiate groups for potential intervention studies.
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Affiliation(s)
- Arthur J. Matas
- Transplantation Division, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ann Fieberg
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Roslyn B. Mannon
- Department of Nephrology, University of Alabama, Birmingham, Alabama
| | - Robert Leduc
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Joe Grande
- Nephrology and Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Bertram L. Kasiske
- Chronic Disease and Research Group, Hennepin Healthcare, Minneapolis, Minnesota
| | - Michael Cecka
- Ronald Reagan UCLA Medicine Center, University of California, Los Angeles, California
| | - Robert Gaston
- Department of Nephrology, University of Alabama, Birmingham, Alabama
| | | | - John Connett
- Biostatistics Division, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Fernando Cosio
- Nephrology and Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Sita Gourishankar
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David Rush
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Vakayil V, Bauman B, Joppru K, Mallick R, Tignanelli C, Connett J, Ikramuddin S, Harmon JV. Surgical repair of perforated peptic ulcers: laparoscopic versus open approach. Surg Endosc 2019; 33:281-292. [PMID: 30043169 DOI: 10.1007/s00464-018-6366-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 07/20/2018] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Perforated peptic ulcers are a surgical emergency that can be repaired using either laparoscopic surgery (LS) or open surgery (OS). No consensus has been reached on the comparative outcomes and safety of each approach. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we conducted a 12-year retrospective review (2005-2016) and identified 6260 adult patients who underwent either LS (n = 616) or OS (n = 5644) to repair perforated peptic ulcers. To mitigate selection bias and adjust for the inherent heterogeneity between groups, we used propensity-score matching with a case (LS):control (OS) ratio of 1:3. We then compared intraoperative outcomes such as operative time, and 30-day postoperative outcomes including infectious and non-infectious complications, and mortality. RESULTS Propensity-score matching created a total of 2462 matched pairs (616 in the LS group, 1846 in the OS group). Univariate analysis demonstrated successful matching of patient characteristics and baseline clinical variables. We found that OS was associated with a shorter operative time (67.0 ± 28.6 min, OS versus 86.9 ± 57.5 min, LS; P < 0.001) but a longer hospital stay (8.6 ± 6.2 days, OS versus 7.8 ± 5.9 days, LS; P = 0.001). LS was associated with a lower rate of superficial surgical site infections (1.5%, LS versus 4.2%, OS; P = 0.032), wound dehiscence (0.3%, LS versus 1.6%, OS; P = 0.030), and mortality (3.2%, LS versus 5.4%, OS; P = 0.009). CONCLUSION Fewer than 10% of patients with perforated peptic ulcers underwent LS, which was associated with reduced length of stay, lower rate of superficial surgical site infections, wound dehiscence, and mortality. Given our results, a greater emphasis should be provided to a minimally invasive approach for the surgical repair of perforated peptic ulcers.
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Affiliation(s)
- Victor Vakayil
- Department of Surgery, University of Minnesota, Minneapolis, USA. .,School of Public Health, University of Minnesota, Minneapolis, USA. .,Critical Care and Acute Care Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA.
| | - Brent Bauman
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Keaton Joppru
- University of Minnesota Medical School, Minneapolis, USA
| | - Reema Mallick
- Department of Surgery, University of Alabama-Birmingham, Birmingham, USA
| | | | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, USA
| | | | - James V Harmon
- Department of Surgery, University of Minnesota, Minneapolis, USA
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Vickery KD, Shippee ND, Menk J, Owen R, Vock DM, Bodurtha P, Soderlund D, Hayward RA, Davis MM, Connett J, Linzer M. Integrated, Accountable Care For Medicaid Expansion Enrollees: A Comparative Evaluation of Hennepin Health. Med Care Res Rev 2018; 77:46-59. [DOI: 10.1177/1077558718769481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hennepin Health, a Medicaid accountable care organization, began serving early expansion enrollees (very low-income childless adults) in 2012. It uses an integrated care model to address social and behavioral needs. We compared health care utilization in Hennepin Health with other Medicaid managed care in the same area from 2012 to 2014, controlling for demographics, chronic conditions, and enrollment patterns. Homelessness and substance use were higher in Hennepin Health. Overall adjusted results showed Hennepin Health had 52% more emergency department visits and 11% more primary care visits than comparators. Over time, modeling a 6-month exposure to Hennepin Health, emergency department and primary care visits decreased and dental visits increased; hospitalizations decreased nonsignificantly but increased among comparators. Subgroup analysis of high utilizers showed lower hospitalizations in Hennepin Health. Integrated, accountable care under Medicaid expansion showed some desirable trends and subgroup benefits, but overall did not reduce acute health care utilization versus other managed care.
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Affiliation(s)
| | | | | | - Ross Owen
- Health Strategy Director, Hennepin County, Minneapolis, MN, USA
| | | | - Peter Bodurtha
- Hennepin County Center of Innovation and Excellence, Minneapolis, MN, USA
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Gaston RS, Fieberg A, Hunsicker L, Kasiske BL, Leduc R, Cosio FG, Gourishankar S, Grande J, Mannon RB, Rush D, Cecka JM, Connett J, Matas AJ. Late graft failure after kidney transplantation as the consequence of late versus early events. Am J Transplant 2018; 18:1158-1167. [PMID: 29139625 DOI: 10.1111/ajt.14590] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/10/2017] [Accepted: 11/05/2017] [Indexed: 01/25/2023]
Abstract
Beyond the first posttransplant year, 3% of kidney transplants fail annually. In a prospective, multicenter cohort study, we tested the relative impact of early versus late events on risk of long-term death-censored graft failure (DCGF). In grafts surviving at least 90 days, early events (acute rejection [AR] and delayed graft function [DGF] before day 90) were recorded; serum creatinine (Cr) at day 90 was defined as baseline. Thereafter, a 25% rise in serum Cr or new-onset proteinuria triggered graft biopsy (index biopsy, IBx), allowing comparison of risk of DCGF associated with early events (AR, DGF, baseline serum Cr >2.0 mg/dL) to that associated with later events (IBx). Among 3678 patients followed for 4.7 ± 1.9 years, 753 (20%) had IBx at a median of 15.3 months posttransplant. Early AR (HR = 1.77, P < .001) and elevated Cr at Day 90 (HR = 2.56, P < .0001) were associated with increased risk of DCGF; however, later-onset dysfunction requiring IBx had far greater impact (HR = 13.8, P < .0001). At 90 days, neither clinical characteristics nor early events distinguished those who subsequently did or did not undergo IBx or suffer DCGF. To improve long-term kidney allograft survival, management paradigms should promote prompt diagnosis and treatment of both early and later events.
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Affiliation(s)
| | - Ann Fieberg
- University of Minnesota, Minneapolis, MN, USA
| | | | | | | | | | | | | | | | - David Rush
- University of Manitoba, Winnipeg, Manitoba, Canada
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Yannopoulos D, Bartos JA, Raveendran G, Conterato M, Frascone RJ, Trembley A, John R, Connett J, Benditt DG, Lurie KG, Wilson RF, Aufderheide TP. Coronary Artery Disease in Patients With Out-of-Hospital Refractory Ventricular Fibrillation Cardiac Arrest. J Am Coll Cardiol 2017; 70:1109-1117. [DOI: 10.1016/j.jacc.2017.06.059] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 10/19/2022]
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Benzo R, Vickers K, Novotny PJ, Tucker S, Hoult J, Neuenfeldt P, Connett J, Lorig K, McEvoy C. Health Coaching and Chronic Obstructive Pulmonary Disease Rehospitalization. A Randomized Study. Am J Respir Crit Care Med 2017; 194:672-80. [PMID: 26953637 DOI: 10.1164/rccm.201512-2503oc] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Hospital readmission for chronic obstructive pulmonary disease (COPD) has attracted attention owing to the burden to patients and the health care system. There is a knowledge gap on approaches to reducing COPD readmissions. OBJECTIVES To determine the effect of comprehensive health coaching on the rate of COPD readmissions. METHODS A total of 215 patients hospitalized for a COPD exacerbation were randomized at hospital discharge to receive either (1) motivational interviewing-based health coaching plus a written action plan for exacerbations (the use of antibiotics and oral steroids) and brief exercise advice or (2) usual care. MEASUREMENTS AND MAIN RESULTS We evaluated the rate of COPD-related hospitalizations during 1 year of follow-up. The absolute risk reductions of COPD-related rehospitalization in the health coaching group were 7.5% (P = 0.01), 11.0% (P = 0.02), 11.6% (P = 0.03), 11.4% (P = 0.05), and 5.4% (P = 0.24) at 1, 3, 6, 9, and 12 months, respectively, compared with the control group. The odds ratios for COPD hospitalization in the intervention arm compared with the control arm were 0.09 (95% confidence interval [CI], 0.01-0.77) at 1 month postdischarge, 0.37 (95% CI, 0.15-0.91) at 3 months postdischarge, 0.43 (95% CI, 0.20-0.94) at 6 months postdischarge, and 0.60 (95% CI, 0.30-1.20) at 1 year postdischarge. The missing value rate for the primary outcome was 0.4% (one patient). Disease-specific quality of life improved significantly in the health coaching group compared with the control group at 6 and 12 months, based on the Chronic Respiratory Disease Questionnaire emotional score (emotion and mastery domains) and physical score (dyspnea and fatigue domains) (P < 0.05). There were no differences between groups in measured physical activity at any time point. CONCLUSIONS Health coaching may represent a feasible and possibly effective intervention designed to reduce COPD readmissions. Clinical trial registered with www.clinicaltrials.gov (NCT01058486).
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Affiliation(s)
- Roberto Benzo
- 1 Mindful Breathing Laboratory, Division of Pulmonary and Critical Care Medicine
| | | | - Paul J Novotny
- 3 Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Sharon Tucker
- 4 University of Iowa Hospitals & Clinics, Iowa City, Iowa
| | - Johanna Hoult
- 1 Mindful Breathing Laboratory, Division of Pulmonary and Critical Care Medicine
| | - Pamela Neuenfeldt
- 5 HealthPartners Institute for Education and Research, Bloomington, Minnesota
| | - John Connett
- 6 Academic Health Center, University of Minnesota, Minneapolis, Minnesota; and
| | - Kate Lorig
- 7 Stanford Patient Education Research Center, Palo Alto, California
| | - Charlene McEvoy
- 5 HealthPartners Institute for Education and Research, Bloomington, Minnesota
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Duffy S, Marron R, Voelker H, Albert R, Connett J, Bailey W, Casaburi R, Cooper JA, Curtis JL, Dransfield M, Han MK, Make B, Marchetti N, Martinez F, Lazarus S, Niewoehner D, Scanlon PD, Sciurba F, Scharf S, Reed RM, Washko G, Woodruff P, McEvoy C, Aaron S, Sin D, Criner GJ. Effect of beta-blockers on exacerbation rate and lung function in chronic obstructive pulmonary disease (COPD). Respir Res 2017. [PMID: 28629419 PMCID: PMC5477165 DOI: 10.1186/s12931-017-0609-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Beta-blockers are commonly prescribed for patients with cardiovascular disease. Providers have been wary of treating chronic obstructive pulmonary disease (COPD) patients with beta-blockers due to concern for bronchospasm, but retrospective studies have shown that cardio-selective beta-blockers are safe in COPD and possibly beneficial. However, these benefits may reflect symptom improvements due to the cardiac effects of the medication. The purpose of this study is to evaluate associations between beta-blocker use and both exacerbation rates and longitudinal measures of lung function in two well-characterized COPD cohorts. METHODS We retrospectively analyzed 1219 participants with over 180 days of follow up from the STATCOPE trial, which excluded most cardiac comorbidities, and from the placebo arm of the MACRO trial. Primary endpoints were exacerbation rates per person-year and change in spirometry over time in association with beta blocker use. RESULTS Overall 13.9% (170/1219) of participants reported taking beta-blockers at enrollment. We found no statistically significant differences in exacerbation rates with respect to beta-blocker use regardless of the prevalence of cardiac comorbidities. In the MACRO cohort, patients taking beta-blockers had an exacerbation rate of 1.72/person-year versus a rate of 1.71/person-year in patients not taking beta-blockers. In the STATCOPE cohort, patients taking beta-blockers had an exacerbation rate of 1.14/person-year. Patients without beta-blockers had an exacerbation rate of 1.34/person-year. We found no detrimental effect of beta blockers with respect to change in lung function over time. CONCLUSION We found no evidence that beta-blocker use was unsafe or associated with worse pulmonary outcomes in study participants with moderate to severe COPD.
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Affiliation(s)
- Sean Duffy
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA. .,Department of Thoracic Medicine and Surgery, Temple University School of Medicine, 712 Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
| | - Robert Marron
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | | | | | - William Bailey
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard Casaburi
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - J Allen Cooper
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - MeiLan K Han
- University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Nathaniel Marchetti
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Fernando Martinez
- Weill Cornell Medical College of Cornell University, New York, NY, USA
| | | | | | | | - Frank Sciurba
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | | | | - Shawn Aaron
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Don Sin
- Providence Heart + Lung Institute, Vancouver, BC, Canada
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Li X, Obeidat M, Zhou G, Leung JM, Tashkin D, Wise R, Connett J, Joubert P, Bossé Y, van den Berge M, Brandsma CA, Nickle DC, Hao K, Paré PD, Sin DD. Responsiveness to Ipratropium Bromide in Male and Female Patients with Mild to Moderate Chronic Obstructive Pulmonary Disease. EBioMedicine 2017; 19:139-145. [PMID: 28461224 PMCID: PMC5440622 DOI: 10.1016/j.ebiom.2017.04.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 03/30/2017] [Accepted: 04/11/2017] [Indexed: 02/07/2023] Open
Abstract
Introduction Although the prevalence of chronic obstructive pulmonary disease (COPD) is similar between men and women, current evidence used to support bronchodilator therapy has been generated in therapeutic trials that have predominately enrolled male patients. Here, we determined whether there is any significant sex-related differences in FEV1 responses to ipratropium bromide. Methods Data from the Lung Health Study (n = 5887; 37% females) were used to determine changes in FEV1 with ipratropium or placebo in male and female subjects with mild to moderate COPD over 5 years. Lung Expression Quantitative Trait Loci (eQTL) dataset was used to determine whether there were any sex-related differences in gene expression for muscarinic (M2 and M3) receptors in lungs of male and female patients. Results After 4 months, ipratropium therapy increased FEV1 by 6.0% in female and 2.9% in male subjects from baseline values (p = 2.42 × 10− 16). This effect was modified by body mass index (BMI) such that the biggest improvements in FEV1 with ipratropium were observed in thin female subjects (p for BMI ∗ sex interaction = 0.044). The sex-related changes in FEV1 related to ipratropium persisted for 2 years (p = 0.0134). Female compared with male lungs had greater gene expression for M3 relative to M2 receptors (p = 6.86 × 10− 8). Conclusion Ipratropium induces a larger bronchodilator response in female than in male patients and the benefits are particularly notable in non-obese females. Female lungs have greater gene expression for the M3 muscarinic receptor relative to M2 receptors than male lungs. Female patients are thus more likely to benefit from ipratropium than male COPD patients. Ipratropium; a muscarinic antagonist bronchodilator is more effective in female COPD patients compared to males. The effect was modified by body mass index (BMI) such that thin female subjects respond better. Female compared with male lungs had greater gene expression for the M3/M2 ratio of muscarinic receptors.
Most evidence used to support bronchodilator therapy in COPD has been generated in therapeutic trials with predominately male patients. Here, we determined whether there are any significant sex-related differences in lung function responses to the bronchodilator ipratropium bromide. After 4 months, ipratropium therapy increased lung function in females twice as much as males. This effect was modified by body mass index (BMI) such that the biggest improvements in lung function with ipratropium were observed in thin female subjects. Female compared with male lungs had greater gene expression for ipratropium receptors. Female patients are likely to benefit more from ipratropium than male COPD patients.
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Affiliation(s)
- Xuan Li
- UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Ma'en Obeidat
- UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Guohai Zhou
- UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Janice M Leung
- UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine (Pulmonary Division), University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald Tashkin
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert Wise
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John Connett
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Philippe Joubert
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada
| | - Yohan Bossé
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada; Department of Molecular Medicine, Laval University, Québec, Canada
| | - Maarten van den Berge
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, The Netherlands
| | - Corry-Anke Brandsma
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, The Netherlands
| | | | - Ke Hao
- Department of Genetics and Genomics Sciences, Mount Sinai School of Medicine, New York, NY, USA
| | - Peter D Paré
- UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine (Pulmonary Division), University of British Columbia, Vancouver, British Columbia, Canada
| | - Don D Sin
- UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine (Pulmonary Division), University of British Columbia, Vancouver, British Columbia, Canada.
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Sachdev S, Wang Q, Billington C, Connett J, Ahmed L, Inabnet W, Chua S, Ikramuddin S, Korner J. FGF 19 and Bile Acids Increase Following Roux-en-Y Gastric Bypass but Not After Medical Management in Patients with Type 2 Diabetes. Obes Surg 2016; 26:957-65. [PMID: 26259981 DOI: 10.1007/s11695-015-1834-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study aims to quantify changes in fibroblast growth factor 19 (FGF19) and bile acids (BAs) in patients with uncontrolled type 2 diabetes randomized to Roux-en-Y gastric bypass (RYGB) vs intensive medical management (IMM) and matched for similar reduction in HbA1c after 1 year of treatment. METHODS Blood samples were drawn from patients who underwent a test meal challenge before and 1 year after IMM (n = 15) or RYGB (n = 15). RESULTS Mean HbA1c decreased from 9.7 to 6.4% after RYGB and from 9.1 to 6.1% in the IMM group. At 12 months, the number of diabetes medications used per subject in the RYGB group (2.5 ± 0.5) was less than in the IMM group (4.6 ± 0.3). After RYGB, FGF19 increased in the fasted (93 ± 15 to 152 ± 19 pg/ml; P = 0.008) and postprandial states (area under the curve (AUC), 10.8 ± 1.9 to 23.4 ± 4.1 pg × h/ml × 10(3); P = 0.006) but remained unchanged following IMM. BAs increased after RYGB (AUC ×10(3), 6.63 ± 1.3 to 15.16 ± 2.56 μM × h; P = 0.003) and decreased after IMM (AUC ×10(3), 8.22 ± 1.24 to 5.70 ± 0.70; P = 0.01). No changes were observed in the ratio of 12α-hydroxylated/non-12α-hyroxylated BAs. Following RYGB, FGF19 AUC correlated with BAs (r = 0.54, P = 0.04) and trended negatively with HbA1c (r = -0.44; P = 0.09); these associations were not observed after IMM. CONCLUSIONS BA and FGF19 levels increased after RYGB but not after IMM in subjects who achieved similar improvement in glycemic control. Further studies are necessary to determine whether these hormonal changes facilitate improved glucose homeostasis.
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Affiliation(s)
- Saachi Sachdev
- Department of Medicine, Columbia University Medical Center, 650 West 168th St, Black Building, Room 905, New York, NY, 10032, USA
| | - Qi Wang
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | | | - John Connett
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Leaque Ahmed
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - William Inabnet
- Department of Surgery, Mount Sinai Medical Center, New York, NY, USA
| | - Streamson Chua
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sayeed Ikramuddin
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Judith Korner
- Department of Medicine, Columbia University Medical Center, 650 West 168th St, Black Building, Room 905, New York, NY, 10032, USA.
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Wey A, Vock DM, Connett J, Rudser K. Estimating restricted mean treatment effects with stacked survival models. Stat Med 2016; 35:3319-32. [PMID: 26934835 DOI: 10.1002/sim.6929] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 11/30/2015] [Accepted: 02/09/2016] [Indexed: 11/08/2022]
Abstract
The difference in restricted mean survival times between two groups is a clinically relevant summary measure. With observational data, there may be imbalances in confounding variables between the two groups. One approach to account for such imbalances is estimating a covariate-adjusted restricted mean difference by modeling the covariate-adjusted survival distribution and then marginalizing over the covariate distribution. Because the estimator for the restricted mean difference is defined by the estimator for the covariate-adjusted survival distribution, it is natural to expect that a better estimator of the covariate-adjusted survival distribution is associated with a better estimator of the restricted mean difference. We therefore propose estimating restricted mean differences with stacked survival models. Stacked survival models estimate a weighted average of several survival models by minimizing predicted error. By including a range of parametric, semi-parametric, and non-parametric models, stacked survival models can robustly estimate a covariate-adjusted survival distribution and, therefore, the restricted mean treatment effect in a wide range of scenarios. We demonstrate through a simulation study that better performance of the covariate-adjusted survival distribution often leads to better mean squared error of the restricted mean difference although there are notable exceptions. In addition, we demonstrate that the proposed estimator can perform nearly as well as Cox regression when the proportional hazards assumption is satisfied and significantly better when proportional hazards is violated. Finally, the proposed estimator is illustrated with data from the United Network for Organ Sharing to evaluate post-lung transplant survival between large-volume and small-volume centers. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Andrew Wey
- Minneapolis Medical Research Foundation, Minneapolis, MN, U.S.A.,Biostatistics and Data Management Core, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, U.S.A
| | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, U.S.A
| | - Kyle Rudser
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, U.S.A
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34
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Tkacova R, Dai DLY, Vonk JM, Leung JM, Hiemstra PS, van den Berge M, Kunz L, Hollander Z, Tashkin D, Wise R, Connett J, Ng R, McManus B, Paul Man SF, Postma DS, Sin DD. Airway hyperresponsiveness in chronic obstructive pulmonary disease: A marker of asthma-chronic obstructive pulmonary disease overlap syndrome? J Allergy Clin Immunol 2016; 138:1571-1579.e10. [PMID: 27345171 DOI: 10.1016/j.jaci.2016.04.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 04/02/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The impact of airway hyperreactivity (AHR) on respiratory mortality and systemic inflammation among patients with chronic obstructive pulmonary disease (COPD) is largely unknown. We used data from 2 large studies to determine the relationship between AHR and FEV1 decline, respiratory mortality, and systemic inflammation. OBJECTIVES We sought to determine the relationship of AHR with FEV1 decline, respiratory mortality, and systemic inflammatory burden in patients with COPD in the Lung Health Study (LHS) and the Groningen Leiden Universities Corticosteroids in Obstructive Lung Disease (GLUCOLD) study. METHODS The LHS enrolled current smokers with mild-to-moderate COPD (n = 5887), and the GLUCOLD study enrolled former and current smokers with moderate-to-severe COPD (n = 51). For the primary analysis, we defined AHR by a methacholine provocation concentration of 4 mg/mL or less, which led to a 20% reduction in FEV1 (PC20). RESULTS The primary outcomes were FEV1 decline, respiratory mortality, and biomarkers of systemic inflammation. Approximately 24% of LHS participants had AHR. Compared with patients without AHR, patients with AHR had a 2-fold increased risk of respiratory mortality (hazard ratio, 2.38; 95% CI, 1.38-4.11; P = .002) and experienced an accelerated FEV1 decline by 13.2 mL/y in the LHS (P = .007) and by 12.4 mL/y in the much smaller GLUCOLD study (P = .079). Patients with AHR had generally reduced burden of systemic inflammatory biomarkers than did those without AHR. CONCLUSIONS AHR is common in patients with mild-to-moderate COPD, affecting 1 in 4 patients and identifies a distinct subset of patients who have increased risk of disease progression and mortality. AHR may represent a spectrum of the asthma-COPD overlap phenotype that urgently requires disease modification.
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Affiliation(s)
- Ruzena Tkacova
- UBC James Hogg Research Center & the Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada; Faculty of Medicine, Department of Respiratory Medicine and Tuberculosis, P.J. Safarik University, Kosice, Slovakia
| | - Darlene L Y Dai
- UBC James Hogg Research Center & the Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada; PROOF Center of Excellence, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Judith M Vonk
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands
| | - Janice M Leung
- UBC James Hogg Research Center & the Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine (Pulmonary Division), University of British Columbia, Vancouver, British Columbia, Canada
| | - Pieter S Hiemstra
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten van den Berge
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands; Department of Pulmonary Diseases University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lisette Kunz
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Zsuzsanna Hollander
- UBC James Hogg Research Center & the Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada; PROOF Center of Excellence, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Donald Tashkin
- David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Robert Wise
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - John Connett
- University of Minnesota School of Public Health, Minneapolis, Minn
| | - Raymond Ng
- UBC James Hogg Research Center & the Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada; PROOF Center of Excellence, St Paul's Hospital, Vancouver, British Columbia, Canada; Department of Computer Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bruce McManus
- UBC James Hogg Research Center & the Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada; PROOF Center of Excellence, St Paul's Hospital, Vancouver, British Columbia, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - S F Paul Man
- UBC James Hogg Research Center & the Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine (Pulmonary Division), University of British Columbia, Vancouver, British Columbia, Canada
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands; Department of Pulmonary Diseases University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Don D Sin
- UBC James Hogg Research Center & the Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine (Pulmonary Division), University of British Columbia, Vancouver, British Columbia, Canada.
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Hansel NN, Paré PD, Rafaels N, Sin DD, Sandford A, Daley D, Vergara C, Huang L, Elliott WM, Pascoe CD, Arsenault BA, Postma DS, Boezen HM, Bossé Y, van den Berge M, Hiemstra PS, Cho MH, Litonjua AA, Sparrow D, Ober C, Wise RA, Connett J, Neptune ER, Beaty TH, Ruczinski I, Mathias RA, Barnes KC. Genome-Wide Association Study Identification of Novel Loci Associated with Airway Responsiveness in Chronic Obstructive Pulmonary Disease. Am J Respir Cell Mol Biol 2015; 53:226-34. [PMID: 25514360 DOI: 10.1165/rcmb.2014-0198oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Increased airway responsiveness is linked to lung function decline and mortality in subjects with chronic obstructive pulmonary disease (COPD); however, the genetic contribution to airway responsiveness remains largely unknown. A genome-wide association study (GWAS) was performed using the Illumina (San Diego, CA) Human660W-Quad BeadChip on European Americans with COPD from the Lung Health Study. Linear regression models with correlated meta-analyses, including data from baseline (n = 2,814) and Year 5 (n = 2,657), were used to test for common genetic variants associated with airway responsiveness. Genotypic imputation was performed using reference 1000 Genomes Project data. Expression quantitative trait loci (eQTL) analyses in lung tissues were assessed for the top 10 markers identified, and immunohistochemistry assays assessed protein staining for SGCD and MYH15. Four genes were identified within the top 10 associations with airway responsiveness. Markers on chromosome 9p21.2 flanked by LINGO2 met a predetermined threshold of genome-wide significance (P < 9.57 × 10(-8)). Markers on chromosomes 3q13.1 (flanked by MYH15), 5q33 (SGCD), and 6q21 (PDSS2) yielded suggestive evidence of association (9.57 × 10(-8) < P ≤ 4.6 × 10(-6)). Gene expression studies in lung tissue showed single nucleotide polymorphisms on chromosomes 5 and 3 to act as eQTL for SGCD (P = 2.57 × 10(-9)) and MYH15 (P = 1.62 × 10(-6)), respectively. Immunohistochemistry confirmed localization of SGCD protein to airway smooth muscle and vessels and MYH15 to airway epithelium, vascular endothelium, and inflammatory cells. We identified novel loci associated with airway responsiveness in a GWAS among smokers with COPD. Risk alleles on chromosomes 5 and 3 acted as eQTLs for SGCD and MYH15 messenger RNA, and these proteins were expressed in lung cells relevant to the development of airway responsiveness.
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Affiliation(s)
- Nadia N Hansel
- 1 Department of Medicine, School of Medicine; and.,Departments of 2 Environmental Health Sciences
| | - Peter D Paré
- 3 Department of Pathology, Centre for Heart Lung Innovation, St. Paul's Hospital, Division of Respirology, University of British Columbia, Vancouver, British Columbia
| | | | - Don D Sin
- 3 Department of Pathology, Centre for Heart Lung Innovation, St. Paul's Hospital, Division of Respirology, University of British Columbia, Vancouver, British Columbia
| | - Andrew Sandford
- 3 Department of Pathology, Centre for Heart Lung Innovation, St. Paul's Hospital, Division of Respirology, University of British Columbia, Vancouver, British Columbia
| | - Denise Daley
- 3 Department of Pathology, Centre for Heart Lung Innovation, St. Paul's Hospital, Division of Respirology, University of British Columbia, Vancouver, British Columbia
| | | | - Lili Huang
- 1 Department of Medicine, School of Medicine; and
| | - W Mark Elliott
- 3 Department of Pathology, Centre for Heart Lung Innovation, St. Paul's Hospital, Division of Respirology, University of British Columbia, Vancouver, British Columbia
| | - Chris D Pascoe
- 3 Department of Pathology, Centre for Heart Lung Innovation, St. Paul's Hospital, Division of Respirology, University of British Columbia, Vancouver, British Columbia
| | - Bryna A Arsenault
- 3 Department of Pathology, Centre for Heart Lung Innovation, St. Paul's Hospital, Division of Respirology, University of British Columbia, Vancouver, British Columbia
| | - Dirkje S Postma
- Departments of 4 Pulmonary Diseases and.,5 Groningen Research Institute for Asthma and COPD Research Institute, University Medical Center Groningen, Groningen; and
| | - H Marike Boezen
- 6 Epidemiology, and.,5 Groningen Research Institute for Asthma and COPD Research Institute, University Medical Center Groningen, Groningen; and
| | - Yohan Bossé
- 7 Department of Molecular Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Maarten van den Berge
- Departments of 4 Pulmonary Diseases and.,5 Groningen Research Institute for Asthma and COPD Research Institute, University Medical Center Groningen, Groningen; and
| | - Pieter S Hiemstra
- 8 Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Michael H Cho
- 9 Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Augusto A Litonjua
- 9 Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David Sparrow
- 10 VA Normative Aging Study and Boston University School of Medicine, Boston, Massachusetts
| | - Carole Ober
- 11 Department of Human Genetics, University of Chicago, Chicago, Illinois
| | | | - John Connett
- 12 Division of Biostatistics, School of Public Health, University of Minnesota, St. Paul, Minnesota
| | | | | | - Ingo Ruczinski
- 14 Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Kathleen C Barnes
- 1 Department of Medicine, School of Medicine; and.,13 Epidemiology, and
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Wey A, Connett J, Rudser K. Combining parametric, semi-parametric, and non-parametric survival models with stacked survival models. Biostatistics 2015; 16:537-49. [PMID: 25662068 DOI: 10.1093/biostatistics/kxv001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 01/05/2015] [Indexed: 11/13/2022] Open
Abstract
For estimating conditional survival functions, non-parametric estimators can be preferred to parametric and semi-parametric estimators due to relaxed assumptions that enable robust estimation. Yet, even when misspecified, parametric and semi-parametric estimators can possess better operating characteristics in small sample sizes due to smaller variance than non-parametric estimators. Fundamentally, this is a bias-variance trade-off situation in that the sample size is not large enough to take advantage of the low bias of non-parametric estimation. Stacked survival models estimate an optimally weighted combination of models that can span parametric, semi-parametric, and non-parametric models by minimizing prediction error. An extensive simulation study demonstrates that stacked survival models consistently perform well across a wide range of scenarios by adaptively balancing the strengths and weaknesses of individual candidate survival models. In addition, stacked survival models perform as well as or better than the model selected through cross-validation. Finally, stacked survival models are applied to a well-known German breast cancer study.
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Affiliation(s)
- Andrew Wey
- University of Hawaii, Honolulu, HI 96815, USAUniversity of Minnesota, Minneapolis, MN 55455, USA
| | - John Connett
- University of Hawaii, Honolulu, HI 96815, USAUniversity of Minnesota, Minneapolis, MN 55455, USA
| | - Kyle Rudser
- University of Hawaii, Honolulu, HI 96815, USAUniversity of Minnesota, Minneapolis, MN 55455, USA
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Begnaud A, Connett J, Harwood E, Mehta H. Measuring Central Airway Obstruction: What Do Bronchoscopists Do? Chest 2014. [DOI: 10.1378/chest.1993686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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39
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Ramos FL, Lindberg SM, Krahnke JS, Connett J, Albert RK, Criner GJ. Azithromycin and COPD Exacerbations in the Presence or Absence of Symptoms or Active Treatment for Gastroesophageal Reflux. Chronic Obstr Pulm Dis 2014; 1:221-228. [PMID: 29114567 DOI: 10.15326/jcopdf.1.2.2014.0132] [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] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction: Gastroesophageal reflux disease (GERD) is common in chronic obstructive pulmonary disease (COPD) and is associated with COPD exacerbations. Since macrolides have prokinetic effects and consequently may decrease GERD, we hypothesized that azithromycin may decrease exacerbations by decreasing GERD. Methods: We conducted a retrospective review of data collected in a prospective, randomized, controlled trial of azithromycin for preventing COPD exacerbations. Participants were classified as having GERD on the basis of having a history of GERD or having a history or being treated for GERD. Results: We analyzed 1116 participants, 478 (43%) and 568 (51%) had GERD on the basis of history and history or treatment respectively. Individuals with GERD developed exacerbations sooner and more frequently, and were more likely to be hospitalized than those without GERD but the difference only reached significance when GERD was defined by history or treatment (P = 0.02, 0.02, and 0.03, respectively). Azithromycin reduced exacerbations regardless of the presence of GERD, but had a greater effect in those without GERD. Conclusions: GERD is associated with more frequent and severe COPD exacerbations. Azithromycin reduces COPD exacerbations regardless of the presence or absence of GERD but does so to a greater degree in individuals without GERD.
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Affiliation(s)
- Frederick L Ramos
- Section of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, PA
| | | | - Jason S Krahnke
- Section of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, PA
| | - John Connett
- Division of Biostatistics, University of Minnesota, Minneapolis
| | - Richard K Albert
- Denver Health, Denver, CO and University of Colorado-Denver, Aurora, CO
| | - Gerard J Criner
- Section of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, PA
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40
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Han MK, Tayob N, Murray S, Dransfield MT, Washko G, Scanlon PD, Criner GJ, Casaburi R, Connett J, Lazarus SC, Albert R, Woodruff P, Martinez FJ. Predictors of chronic obstructive pulmonary disease exacerbation reduction in response to daily azithromycin therapy. Am J Respir Crit Care Med 2014; 189:1503-8. [PMID: 24779680 DOI: 10.1164/rccm.201402-0207oc] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RATIONALE Daily azithromycin decreases acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but long-term side effects are unknown. OBJECTIVES To identify the types of exacerbations most likely to be reduced and clinical subgroups most likely to benefit from azithromycin, 250 mg daily, added to usual care. METHODS Enrollment criteria included irreversible airflow limitation and AECOPD requiring corticosteroids, emergency department visit, or hospitalization in the prior year or use of supplemental oxygen. Recurrent events and cumulative incidence analyses compared treatment received for AECOPD by randomization group, stratified by subgroups of interest. Cox proportional hazards models estimated treatment effects in subgroups adjusted for age, sex, smoking status, FEV1% predicted, concomitant COPD medications, and oxygen use. MEASUREMENTS AND MAIN RESULTS Azithromycin was most effective in reducing AECOPD requiring both antibiotic and steroid treatment (n = 1,113; cumulative incidence analysis, P = 0.0002; recurrent events analysis, P = 0.002). No difference in treatment response by sex (P = 0.75), presence of chronic bronchitis (P = 0.19), concomitant inhaled therapy (P = 0.29), or supplemental oxygen use (P = 0.23) was observed. Older age and milder Global Initiative for Chronic Obstructive Lung Disease stage were associated with better treatment response (P = 0.02 and 0.04, respectively). A significant interaction between treatment and current smoking was seen (P = 0.03) and azithromycin did not reduce exacerbations in current smokers (hazard ratio, 0.99; 95% confidence interval, 0.71-1.38; P = 0.95). CONCLUSIONS Azithromycin is most effective in preventing AECOPD requiring both antibiotic and steroid treatment. Adjusting for confounders, we saw no difference in efficacy by sex, history of chronic bronchitis, oxygen use, or concomitant COPD therapy. Greater efficacy was seen in older patients and milder Global Initiative for Chronic Obstructive Lung Disease stages. We found little evidence of treatment effect among current smokers. Clinical trial registered with www.clinicaltrials.gov (NCT0011986 and NCT00325897).
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Affiliation(s)
- MeiLan K Han
- 1 University of Michigan Health System, Ann Arbor, Michigan
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Xia H, Bodempudi V, Benyumov A, Hergert P, Tank D, Herrera J, Braziunas J, Larsson O, Parker M, Rossi D, Smith K, Peterson M, Limper A, Jessurun J, Connett J, Ingbar D, Phan S, Bitterman PB, Henke CA. Identification of a cell-of-origin for fibroblasts comprising the fibrotic reticulum in idiopathic pulmonary fibrosis. Am J Pathol 2014; 184:1369-83. [PMID: 24631025 PMCID: PMC4005984 DOI: 10.1016/j.ajpath.2014.01.012] [Citation(s) in RCA: 45] [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] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 12/26/2013] [Accepted: 01/02/2014] [Indexed: 01/08/2023]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive disease of the middle aged and elderly with a prevalence of one million persons worldwide. The fibrosis spreads from affected alveoli into contiguous alveoli, creating a reticular network that leads to death by asphyxiation. Lung fibroblasts from patients with IPF have phenotypic hallmarks, distinguishing them from their normal counterparts: pathologically activated Akt signaling axis, increased collagen and α-smooth muscle actin expression, distinct gene expression profile, and ability to form fibrotic lesions in model organisms. Despite the centrality of these fibroblasts in disease pathogenesis, their origin remains uncertain. Here, we report the identification of cells in the lungs of patients with IPF with the properties of mesenchymal progenitors. In contrast to progenitors isolated from nonfibrotic lungs, IPF mesenchymal progenitor cells produce daughter cells manifesting the full spectrum of IPF hallmarks, including the ability to form fibrotic lesions in zebrafish embryos and mouse lungs, and a transcriptional profile reflecting these properties. Morphological analysis of IPF lung tissue revealed that mesenchymal progenitor cells and cells with the characteristics of their progeny comprised the fibrotic reticulum. These data establish that the lungs of patients with IPF contain pathological mesenchymal progenitor cells that are cells of origin for fibrosis-mediating fibroblasts. These fibrogenic mesenchymal progenitors and their progeny represent an unexplored target for novel therapies to interdict fibrosis.
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Affiliation(s)
- Hong Xia
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Vidya Bodempudi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Alexey Benyumov
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Polla Hergert
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Damien Tank
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jeremy Herrera
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jeff Braziunas
- Department of Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Ola Larsson
- Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Matthew Parker
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Rossi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Karen Smith
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mark Peterson
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Andrew Limper
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Jose Jessurun
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - John Connett
- Division of Biostatistics School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - David Ingbar
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Sem Phan
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Peter B Bitterman
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Craig A Henke
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
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Vinocur JM, Menk JS, Connett J, Moller JH, Kochilas LK. Surgical volume and center effects on early mortality after pediatric cardiac surgery: 25-year North American experience from a multi-institutional registry. Pediatr Cardiol 2013; 34:1226-36. [PMID: 23377381 PMCID: PMC4357309 DOI: 10.1007/s00246-013-0633-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 01/03/2013] [Indexed: 11/30/2022]
Abstract
Mortality after pediatric cardiac surgery varies among centers. Previous research suggests that surgical volume is an important predictor of this variation. This report characterizes the relative contribution of patient factors, center surgical volume, and a volume-independent center effect on early postoperative mortality in a retrospective cohort study of North American centers in the Pediatric Cardiac Care Consortium (up to 500 cases/center/year). From 1982 to 2007, 49 centers reported 109,475 operations, 85,023 of which were analyzed using hierarchical multivariate logistic regression analysis. Patient characteristics varied significantly among the centers. The adjusted odds ratio (OR) for mortality decreased more than 10-fold during the study period (1982 vs. 2007: OR, 12.27, 95 % confidence interval [CI], 8.52-17.66; p < 0.0001). Surgical volume was associated inversely with odds of death (additional 100 cases/year: OR, 0.84; 95 % CI, 0.78-0.90; p < 0.0001). In the analysis of interactions, this effect was fairly consistent across age groups, risk categories (except the lowest), and time periods. However, a volume-independent center effect contributed substantially more to the risk model than did the volume. The Risk Adjusted Classification for Congenital Heart Surgery, version 1 (RACHS-1) risk category remains the strongest predictor of postoperative mortality through the 25-year study period. In conclusion, center-specific variation exists but is only partially explained by operative volume. Low-risk operations are safely performed at centers in all volume categories, whereas regionalization or other quality improvement strategies appear to be warranted for moderate- and high-risk operations. Potentially preventable mortality occurs at centers in all volume categories studied, so referral or regionalization strategies must target centers by observed outcomes rather than assume that volume predicts quality.
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Affiliation(s)
- Jeffrey M. Vinocur
- Division of Pediatric Cardiology, Department of Pediatrics, University of Minnesota, East Building MB, 5th Floor, 2450 Riverside Avenue, Minneapolis, MN 55454, USA
| | - Jeremiah S. Menk
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - John Connett
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA. Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - James H. Moller
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA. Pediatric Cardiac Care Consortium, Minneapolis, MN, USA
| | - Lazaros K. Kochilas
- Division of Pediatric Cardiology, Department of Pediatrics, University of Minnesota, East Building MB, 5th Floor, 2450 Riverside Avenue, Minneapolis, MN 55454, USA. Pediatric Cardiac Care Consortium, Minneapolis, MN, USA
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Albert RK, Connett J, Curtis JL, Martinez FJ, Han MK, Lazarus SC, Woodruff PG. Mannose-binding lectin deficiency and acute exacerbations of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2012; 7:767-77. [PMID: 23226013 PMCID: PMC3514010 DOI: 10.2147/copd.s33714] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Indexed: 12/23/2022] Open
Abstract
Background: Mannose-binding lectin is a collectin involved in host defense against infection. Whether mannose-binding lectin deficiency is associated with acute exacerbations of chronic obstructive pulmonary disease is debated. Methods: Participants in a study designed to determine if azithromycin taken daily for one year decreased acute exacerbations had serum mannose-binding lectin concentrations measured at the time of enrollment. Results: Samples were obtained from 1037 subjects (91%) in the trial. The prevalence of mannose-binding lectin deficiency ranged from 0.5% to 52.2%, depending on how deficiency was defined. No differences in the prevalence of deficiency were observed with respect to any demographic variable assessed, and no differences were observed in time to first exacerbation, rate of exacerbations, or percentage of subjects requiring hospitalization for exacerbations in those with deficiency versus those without, regardless of how deficiency was defined. Conclusion: In a large sample of subjects with chronic obstructive pulmonary disease selected for having an increased risk of experiencing an acute exacerbation of chronic obstructive pulmonary disease, only 1.9% had mannose-binding lectin concentrations below the normal range and we found no association between mannose-binding lectin concentrations and time to first acute exacerbation or frequency of acute exacerbations during one year of prospective follow-up.
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Affiliation(s)
- Richard K Albert
- Medicine Service, Denver Health and Department of Medicine, University of Colorado Denver, USA.
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44
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Hansel NN, Ruczinski I, Rafaels N, Sin DD, Daley D, Malinina A, Huang L, Sandford A, Murray T, Kim Y, Vergara C, Heckbert SR, Psaty BM, Li G, Elliott WM, Aminuddin F, Dupuis J, O'Connor GT, Doheny K, Scott AF, Boezen HM, Postma DS, Smolonska J, Zanen P, Mohamed Hoesein FA, de Koning HJ, Crystal RG, Tanaka T, Ferrucci L, Silverman E, Wan E, Vestbo J, Lomas DA, Connett J, Wise RA, Neptune ER, Mathias RA, Paré PD, Beaty TH, Barnes KC. Genome-wide study identifies two loci associated with lung function decline in mild to moderate COPD. Hum Genet 2012; 132:79-90. [PMID: 22986903 DOI: 10.1007/s00439-012-1219-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/06/2012] [Indexed: 01/11/2023]
Abstract
Accelerated lung function decline is a key COPD phenotype; however, its genetic control remains largely unknown. We performed a genome-wide association study using the Illumina Human660W-Quad v.1_A BeadChip. Generalized estimation equations were used to assess genetic contributions to lung function decline over a 5-year period in 4,048 European American Lung Health Study participants with largely mild COPD. Genotype imputation was performed using reference HapMap II data. To validate regions meeting genome-wide significance, replication of top SNPs was attempted in independent cohorts. Three genes (TMEM26, ANK3 and FOXA1) within the regions of interest were selected for tissue expression studies using immunohistochemistry. Two intergenic SNPs (rs10761570, rs7911302) on chromosome 10 and one SNP on chromosome 14 (rs177852) met genome-wide significance after Bonferroni. Further support for the chromosome 10 region was obtained by imputation, the most significantly associated imputed SNPs (rs10761571, rs7896712) being flanked by observed markers rs10761570 and rs7911302. Results were not replicated in four general population cohorts or a smaller cohort of subjects with moderate to severe COPD; however, we show novel expression of genes near regions of significantly associated SNPS, including TMEM26 and FOXA1 in airway epithelium and lung parenchyma, and ANK3 in alveolar macrophages. Levels of expression were associated with lung function and COPD status. We identified two novel regions associated with lung function decline in mild COPD. Genes within these regions were expressed in relevant lung cells and their expression related to airflow limitation suggesting they may represent novel candidate genes for COPD susceptibility.
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Affiliation(s)
- Nadia N Hansel
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Tashkin DP, Rabinoff M, Noble EP, Ritchie TL, Simmons MS, Connett J. Association of dopamine-related gene alleles, smoking behavior and decline in FEV1 in subjects with COPD: findings from the lung health study. COPD 2012; 9:620-8. [PMID: 22958175 DOI: 10.3109/15412555.2012.712167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cigarette smoking is the major risk factor for chronic obstructive pulmonary disease (COPD). Specific dopamine related gene alleles have previously been found to be associated with smoking initiation, maintenance and cessation. We investigated the association between specific dopamine related gene alleles and both change in smoking behavior and lung function change over time in individuals with mild-to-moderate COPD. Subjects included a subset of participants in the Lung Health Study (LHS), a smoking intervention study in smokers with mild to moderate COPD. Smoking status was determined and lung function performed at baseline and annually for 5 years. In post-hoc analyses, we assessed the association of the dopamine receptor (DRD2) TaqI A1(+) allele (A1A1, A1A2 genotypes) and A1(-) allele (A2A2 genotype), and the dopamine transporter (DAT) 9R(+) allele (9R9R and 9R10R genotypes) and 9R(-) allele (10R10R genotype) with both changes in smoking status and lung function in a subset of LHS subjects. No significant associations were noted between variants in these genes and success in smoking cessation. However, in exploratory analyses that did not adjust for multiple comparisons, sustained male (but not female) quitters with the DRD2 A1(-) allele and/or the DAT 9R(+) allele showed an accelerated decline in FEV(1) similar to that of continuing smokers over 5 years after quitting smoking. These preliminary findings suggest that dopamine-related genes may play a role in the progression of COPD, at least in the subset of male ex-smokers whose disease continues to progress despite sustained quitting, and warrants additional confirmatory and mechanistic studies.
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Affiliation(s)
- Donald P Tashkin
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095-1690, USA.
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Dransfield MT, Harnden S, Burton RL, Albert RK, Bailey WC, Casaburi R, Connett J, Cooper JAD, Criner GJ, Curtis JL, Han MK, Make B, Marchetti N, Martinez FJ, McEvoy C, Nahm MH, Niewoehner DE, Porszasz J, Reilly J, Scanlon PD, Scharf SM, Sciurba FC, Washko GR, Woodruff PG, Lazarus SC. Long-term comparative immunogenicity of protein conjugate and free polysaccharide pneumococcal vaccines in chronic obstructive pulmonary disease. Clin Infect Dis 2012; 55:e35-44. [PMID: 22652582 PMCID: PMC3491850 DOI: 10.1093/cid/cis513] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 05/15/2012] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although the 23-valent pneumococcal polysaccharide vaccine (PPSV23) protects against invasive disease in young healthy persons, randomized controlled trials in chronic obstructive pulmonary disease (COPD) have demonstrated no benefit in the intention-to-treat population. We previously reported that the 7-valent diphtheria-conjugated pneumococcal polysaccharide vaccine (PCV7) is safe and induced greater serotype-specific immunoglobulin G (IgG) and functional antibody than did PPSV23 1 month after vaccination. We hypothesized that these advantages would persist at 1 and 2 years. METHODS One hundred eighty-one patients with moderate to severe COPD were randomized to receive PPSV23 (n = 90) or PCV7 (1.0 mL; n = 91). We measured IgG by enzyme-linked immunosorbent assay and assessed functional antibody activity by a standardized opsonophagocytosis assay, reported as a killing index (OPK). We determined differences in IgG and OPK between vaccine groups at 1 and 2 years. RESULTS Relative to PPSV23, PCV7 induced greater OPK at both 1 and 2 years for 6 of 7 serotypes (not 19F). This response was statistically greater for 5 of 7 serotypes at 1 year and 4 of 7 at 2 years. Comparable differences in IgG were observed but were less often statistically significant. Despite meeting Centers for Disease Control and Prevention criteria for PPSV23 administration, almost 50% of individuals had never been vaccinated. No differences in the frequency of acute exacerbations, pneumonia, or hospitalization were observed. CONCLUSIONS PCV7 induces a greater functional antibody response than PPSV23 in patients with COPD that persists for 2 years after vaccination. This superior functional response supports testing of conjugate vaccination in studies examining clinical end points. CLINICAL TRIALS REGISTRATION NCT00457977.
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Affiliation(s)
- Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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Tashkin DP, Wang HJ, Halpin D, Kleerup EC, Connett J, Li N, Elashoff R. Comparison of the variability of the annual rates of change in FEV₁ determined from serial measurements of the pre- versus post-bronchodilator FEV₁ over 5 years in mild to moderate COPD: results of the lung health study. Respir Res 2012; 13:70. [PMID: 22894725 PMCID: PMC3439318 DOI: 10.1186/1465-9921-13-70] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 08/10/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The impact of interventions on the progressive course of COPD is currently assessed by the slope of the annual decline in FEV₁ determined from serial measurements of the post-, in preference to the pre-, bronchodilator FEV₁. We therefore compared the yearly slope and the variability of the slope of the pre- versus the post-bronchodilator FEV₁ in men and women with mild to moderate COPD who participated in the 5-year Lung Health Study (LHS). METHODS Data were analyzed from 4484 of the 5887 LHS participants who had measurements of pre- and post-bronchodilator FEV₁ at baseline (screening visit 2) and all five annual visits. The annual rate of decline in FEV₁ (±SE) measured pre- and post-bronchodilator from the first to the fifth annual visit was estimated separately using a random coefficient model adjusted for relevant covariates. Analyses were performed separately within each of the three randomized intervention groups. In addition, individual rates of decline in pre- and post-bronchodilator FEV₁ were also determined for each participant. Furthermore, sample sizes were estimated for determining the significance of differences in slopes of decline between different interventions using pre- versus post-bronchodilator measurements. RESULTS Within each intervention group, mean adjusted and unadjusted slope estimates were slightly higher for the pre- than the post-bronchodilator FEV₁ (range of differences 2.6-5.2 ml/yr) and the standard errors around these estimates were only minimally higher for the pre- versus the post-bronchodilator FEV₁ (range 0.05-0.11 ml/yr). Conversely, the standard deviations of the mean FEV₁ determined at each annual visit were consistently slightly higher (range of differences 0.011 to 0.035 L) for the post- compared to the pre-bronchodilator FEV₁. Within each group, the proportion of individual participants with a statistically significant slope was similar (varying by only 1.4 to 2.7%) comparing the estimates from the pre- versus the post-bronchodilator FEV₁. However, sample size estimates were slightly higher when the pre- compared to the post-bronchodilator value was used to determine the significance of specified differences in slopes between interventions. CONCLUSION Serial measurements of the pre-bronchodilator FEV₁ are generally sufficient for comparing the impact of different interventions on the annual rate of change in FEV₁.
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Affiliation(s)
- Donald P Tashkin
- Departments of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., Los Angeles, CA, 90095, USA
| | - He-Jing Wang
- Departments of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Eric C Kleerup
- Departments of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - John Connett
- Department of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Ning Li
- Departments of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Robert Elashoff
- Departments of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Goldade K, Whembolua GL, Thomas J, Eischen S, Guo H, Connett J, Des Jarlais D, Resnicow K, Gelberg L, Owen G, Grant J, Ahluwalia JS, Okuyemi KS. Designing a smoking cessation intervention for the unique needs of homeless persons: a community-based randomized clinical trial. Clin Trials 2012; 8:744-54. [PMID: 22167112 DOI: 10.1177/1740774511423947] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although smoking prevalence remains strikingly high in homeless populations (~70% and three times the US national average), smoking cessation studies usually exclude homeless persons. Novel evidence-based interventions are needed for this high-risk subpopulation of smokers. PURPOSE To describe the aims and design of a first-ever smoking cessation clinical trial in the homeless population. The study was a two-group randomized community-based trial that enrolled participants (n = 430) residing across eight homeless shelters and transitional housing units in Minnesota. The study objective was to test the efficacy of motivational interviewing (MI) for enhancing adherence to nicotine replacement therapy (NRT; nicotine patch) and smoking cessation outcomes. METHODS Participants were randomized to one of the two groups: active (8 weeks of NRT + 6 sessions of MI) or control (NRT + standard care). Participants attended six in-person assessment sessions and eight retention visits at a location of their choice over 6 months. Nicotine patch in 2-week doses was administered at four visits over the first 8 weeks of the 26-week trial. The primary outcome was cotinine-verified 7-day point-prevalence abstinence at 6 months. Secondary outcomes included adherence to nicotine patch assessed through direct observation and patch counts. Other outcomes included the mediating and/or moderating effects of comorbid psychiatric and substance abuse disorders. RESULTS Lessons learned from the community-based cessation randomized trial for improving recruitment and retention in a mobile and vulnerable population included: (1) the importance of engaging the perspectives of shelter leadership by forming and convening a Community Advisory Board; (2) locating the study at the shelters for more visibility and easier access for participants; (3) minimizing exclusion criteria to allow enrollment of participants with stable psychiatric comorbid conditions; (4) delaying the baseline visit from the eligibility visit by a week to protect against attrition; and (5) regular and persistent calls to remind participants of upcoming appointments using cell phones and shelter-specific channels of communication. LIMITATIONS The study's limitations include generalizability due to the sample drawn from a single Midwestern city in the United States. Since inclusion criteria encompassed willingness to use NRT patch, all participants were motivated and were ready to quit smoking at the time of enrollment in the study. Findings from the self-select group will be generalizable only to those motivated and ready to quit smoking. High incentives may limit the degree to which the intervention is replicable. CONCLUSIONS Lessons learned reflect the need to engage communities in the design and implementation of community-based clinical trials with vulnerable populations.
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Affiliation(s)
- Kate Goldade
- Department of Family Medicine and Community Health, University of Minnesota, Medical School, Minneapolis, MN 55116, USA.
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Albert RK, Connett J, Bailey WC, Casaburi R, Cooper JAD, Criner GJ, Curtis JL, Dransfield MT, Han MK, Lazarus SC, Make B, Marchetti N, Martinez FJ, Madinger NE, McEvoy C, Niewoehner DE, Porsasz J, Price CS, Reilly J, Scanlon PD, Sciurba FC, Scharf SM, Washko GR, Woodruff PG, Anthonisen NR. Azithromycin for prevention of exacerbations of COPD. N Engl J Med 2011; 365:689-98. [PMID: 21864166 PMCID: PMC3220999 DOI: 10.1056/nejmoa1104623] [Citation(s) in RCA: 783] [Impact Index Per Article: 60.2] [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: 12/17/2022]
Abstract
BACKGROUND Acute exacerbations adversely affect patients with chronic obstructive pulmonary disease (COPD). Macrolide antibiotics benefit patients with a variety of inflammatory airway diseases. METHODS We performed a randomized trial to determine whether azithromycin decreased the frequency of exacerbations in participants with COPD who had an increased risk of exacerbations but no hearing impairment, resting tachycardia, or apparent risk of prolongation of the corrected QT interval. RESULTS A total of 1577 subjects were screened; 1142 (72%) were randomly assigned to receive azithromycin, at a dose of 250 mg daily (570 participants), or placebo (572 participants) for 1 year in addition to their usual care. The rate of 1-year follow-up was 89% in the azithromycin group and 90% in the placebo group. The median time to the first exacerbation was 266 days (95% confidence interval [CI], 227 to 313) among participants receiving azithromycin, as compared with 174 days (95% CI, 143 to 215) among participants receiving placebo (P<0.001). The frequency of exacerbations was 1.48 exacerbations per patient-year in the azithromycin group, as compared with 1.83 per patient-year in the placebo group (P=0.01), and the hazard ratio for having an acute exacerbation of COPD per patient-year in the azithromycin group was 0.73 (95% CI, 0.63 to 0.84; P<0.001). The scores on the St. George's Respiratory Questionnaire (on a scale of 0 to 100, with lower scores indicating better functioning) improved more in the azithromycin group than in the placebo group (a mean [±SD] decrease of 2.8±12.8 vs. 0.6±11.4, P=0.004); the percentage of participants with more than the minimal clinically important difference of -4 units was 43% in the azithromycin group, as compared with 36% in the placebo group (P=0.03). Hearing decrements were more common in the azithromycin group than in the placebo group (25% vs. 20%, P=0.04). CONCLUSIONS Among selected subjects with COPD, azithromycin taken daily for 1 year, when added to usual treatment, decreased the frequency of exacerbations and improved quality of life but caused hearing decrements in a small percentage of subjects. Although this intervention could change microbial resistance patterns, the effect of this change is not known. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00325897.).
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Affiliation(s)
- Richard K Albert
- Medicine Service, Denver Health and Department of Medicine, University of Colorado Denver Health Sciences Center, Denver, CO 80204-4507, USA.
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Vinocur JM, Menk JS, Larson V, Connett J, Louis JS, Moller J, Kochilas L. TRENDS IN THE RELATIONSHIP BETWEEN SURGICAL MORTALITY FOR CONGENITAL HEART DISEASES (CHD) AND SURGICAL VOLUME: 25 YEAR EXPERIENCE FROM A MULTI-INSTITUTIONAL REGISTRY. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60403-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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