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Harrington LB, Benz L, Haneuse S, Johnson E, Coleman KJ, Courcoulas AP, Li RA, Theis MK, Cooper J, Chin PL, Grinberg GG, Daigle CR, Chang JH, Um SS, Yenumula PR, Getty JZ, Arterburn DE. Bariatric Surgery and the Long-Term Risk of Venous Thromboembolism: A Population-Based Cohort Study. Obes Surg 2024:10.1007/s11695-024-07236-y. [PMID: 38689074 DOI: 10.1007/s11695-024-07236-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/05/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Bariatric surgery is associated with a greater venous thromboembolism (VTE) risk in the weeks following surgery, but the long-term risk of VTE is incompletely characterized. We evaluated bariatric surgery in relation to long-term VTE risk. MATERIALS AND METHODS This population-based retrospective matched cohort study within three United States-based integrated health care systems included adults with body mass index (BMI) ≥ 35 kg/m2 who underwent bariatric surgery between January 2005 and September 2015 (n = 30,171), matched to nonsurgical patients on site, age, sex, BMI, diabetes, insulin use, race/ethnicity, comorbidity score, and health care utilization (n = 218,961). Follow-up for incident VTE ended September 2015 (median 9.3, max 10.7 years). RESULTS Our population included 30,171 bariatric surgery patients and 218,961 controls; we identified 4068 VTE events. At 30 days post-index date, bariatric surgery was associated with a fivefold greater VTE risk (HRadj = 5.01; 95% CI = 4.14, 6.05) and a nearly fourfold greater PE risk (HRadj = 3.93; 95% CI = 2.87, 5.38) than no bariatric surgery. At 1 year post-index date, bariatric surgery was associated with a 48% lower VTE risk and a 70% lower PE risk (HRadj = 0.52; 95% CI = 0.41, 0.66 and HRadj = 0.30; 95% CI = 0.21, 0.44, respectively). At 5 years post-index date, lower VTE risks persisted, with bariatric surgery associated with a 41% lower VTE risk and a 55% lower PE risk (HRadj = 0.59; 95% CI = 0.48, 0.73 and HRadj = 0.45; 95% CI = 0.32, 0.64, respectively). CONCLUSION Although in the short-term bariatric surgery is associated with a greater VTE risk, in the long-term, it is associated with a substantially lower risk.
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Affiliation(s)
- Laura B Harrington
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA.
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, 98195, USA.
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, 91101, USA.
| | - Luke Benz
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Eric Johnson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Karen J Coleman
- Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Anita P Courcoulas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Robert A Li
- Kaiser Permanente Northern California, Oakland, CA, 94611, USA
| | - Mary Kay Theis
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Julie Cooper
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Philip L Chin
- Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Gary G Grinberg
- Kaiser Permanente Northern California, Oakland, CA, 94611, USA
| | - Christopher R Daigle
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Julietta H Chang
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Scott S Um
- Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | | | | | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, 98104, USA
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Harrington LB, Ehlert AN, Thacker EL, Jenny NS, Lopez O, Cushman M, Olson NC, Fitzpatrick A, Mukamal KJ, Jensen MK. Levels of procoagulant factors and peak thrombin generation in relation to dementia risk in older adults: The Cardiovascular Health Study. Thromb Res 2024; 235:148-154. [PMID: 38340522 PMCID: PMC10929657 DOI: 10.1016/j.thromres.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Markers of hemostasis such as procoagulant factors and peak thrombin generation are associated with cardiovascular outcomes, but their associations with dementia risk are unclear. We aimed to evaluate prospective associations of selected procoagulant factors and peak thrombin generation with dementia risk. METHODS We measured levels of 7 hemostatic factors (fibrinogen, factor VII coagulant activity [FVIIc], activated factor VII [FVIIa], factor VIIa-antithrombin [FVIIa-AT], factor XI antigen [FXI], peak thrombin generation, and platelet count) among participants in the Cardiovascular Health Study, a cohort of older adults free of dementia in 1992/1993 (n = 3185). Dementia was adjudicated and classified by DSM-IV criteria through 1998/1999. Cox proportional hazards models estimated hazard ratios (HRs) for any dementia associated with 1-standard deviation (SD) differences, adjusting for sociodemographic and clinical factors and APOE genotype. Secondary analyses separately evaluated the risk of vascular dementia, Alzheimer's disease, and mixed dementia. RESULTS At baseline, participants had a median age of 73 years. Over 5.4 years of follow-up, we identified 448 dementia cases. There was no evidence of linear associations between levels of these hemostatic factors with any dementia risk (HRs per 1-SD difference ranged from 1.0 to 1.1; 95 % confidence intervals included 1.0). Results of secondary analyses by dementia subtype were similar. CONCLUSIONS In this prospective study, there was no strong evidence of linear associations between levels of fibrinogen, FVIIc, FVIIa, FVIIa-AT, FXI, peak thrombin generation, or platelet count with dementia risk. Despite their associations with cardiovascular disease, higher levels of these biomarkers measured among older adults may not reflect dementia risk.
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Affiliation(s)
- Laura B Harrington
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Alexa N Ehlert
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Evan L Thacker
- Department of Public Health, Brigham Young University, Provo, UT, USA
| | - Nancy S Jenny
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine, Colchester, VT, USA
| | - Oscar Lopez
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Cushman
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine, Colchester, VT, USA; Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Nels C Olson
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine, Colchester, VT, USA
| | | | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Majken K Jensen
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Lo Re III V, Cocoros NM, Hubbard RA, Dutcher SK, Newcomb CW, Connolly JG, Perez-Vilar S, Carbonari DM, Kempner ME, Hernández-Muñoz JJ, Petrone AB, Pishko AM, Rogers Driscoll ME, Brash JT, Burnett S, Cohet C, Dahl M, DeFor TA, Delmestri A, Djibo DA, Duarte-Salles T, Harrington LB, Kampman M, Kuntz JL, Kurz X, Mercadé-Besora N, Pawloski PA, Rijnbeek PR, Seager S, Steiner CA, Verhamme K, Wu F, Zhou Y, Burn E, Paterson JM, Prieto-Alhambra D. Risk of Arterial and Venous Thrombotic Events Among Patients with COVID-19: A Multi-National Collaboration of Regulatory Agencies from Canada, Europe, and United States. Clin Epidemiol 2024; 16:71-89. [PMID: 38357585 PMCID: PMC10865892 DOI: 10.2147/clep.s448980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 02/16/2024] Open
Abstract
Purpose Few studies have examined how the absolute risk of thromboembolism with COVID-19 has evolved over time across different countries. Researchers from the European Medicines Agency, Health Canada, and the United States (US) Food and Drug Administration established a collaboration to evaluate the absolute risk of arterial (ATE) and venous thromboembolism (VTE) in the 90 days after diagnosis of COVID-19 in the ambulatory (eg, outpatient, emergency department, nursing facility) setting from seven countries across North America (Canada, US) and Europe (England, Germany, Italy, Netherlands, and Spain) within periods before and during COVID-19 vaccine availability. Patients and Methods We conducted cohort studies of patients initially diagnosed with COVID-19 in the ambulatory setting from the seven specified countries. Patients were followed for 90 days after COVID-19 diagnosis. The primary outcomes were ATE and VTE over 90 days from diagnosis date. We measured country-level estimates of 90-day absolute risk (with 95% confidence intervals) of ATE and VTE. Results The seven cohorts included 1,061,565 patients initially diagnosed with COVID-19 in the ambulatory setting before COVID-19 vaccines were available (through November 2020). The 90-day absolute risk of ATE during this period ranged from 0.11% (0.09-0.13%) in Canada to 1.01% (0.97-1.05%) in the US, and the 90-day absolute risk of VTE ranged from 0.23% (0.21-0.26%) in Canada to 0.84% (0.80-0.89%) in England. The seven cohorts included 3,544,062 patients with COVID-19 during vaccine availability (beginning December 2020). The 90-day absolute risk of ATE during this period ranged from 0.06% (0.06-0.07%) in England to 1.04% (1.01-1.06%) in the US, and the 90-day absolute risk of VTE ranged from 0.25% (0.24-0.26%) in England to 1.02% (0.99-1.04%) in the US. Conclusion There was heterogeneity by country in 90-day absolute risk of ATE and VTE after ambulatory COVID-19 diagnosis both before and during COVID-19 vaccine availability.
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Affiliation(s)
- Vincent Lo Re III
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Harvard Pilgrim Healthcare Institute, Boston, MA, USA
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah K Dutcher
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Craig W Newcomb
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John G Connolly
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Harvard Pilgrim Healthcare Institute, Boston, MA, USA
| | - Silvia Perez-Vilar
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Dena M Carbonari
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria E Kempner
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Harvard Pilgrim Healthcare Institute, Boston, MA, USA
| | - José J Hernández-Muñoz
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Andrew B Petrone
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Harvard Pilgrim Healthcare Institute, Boston, MA, USA
| | - Allyson M Pishko
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Meighan E Rogers Driscoll
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Harvard Pilgrim Healthcare Institute, Boston, MA, USA
| | | | - Sean Burnett
- Canadian Network for Observational Drug Effect Studies (CNODES), Toronto, Ontario, Canada
- Therapeutics Initiative, University of British Columbia, Vancouver, British Columbia, Canada
| | - Catherine Cohet
- Data Analytics and Methods Task Force, European Medicines Agency, Amsterdam, Netherlands
| | - Matthew Dahl
- Canadian Network for Observational Drug Effect Studies (CNODES), Toronto, Ontario, Canada
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Antonella Delmestri
- Pharmaco- and Device Epidemiology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | | | - Talita Duarte-Salles
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Laura B Harrington
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Jennifer L Kuntz
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Xavier Kurz
- Data Analytics and Methods Task Force, European Medicines Agency, Amsterdam, Netherlands
| | - Núria Mercadé-Besora
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | | | - Peter R Rijnbeek
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Claudia A Steiner
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
| | - Katia Verhamme
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Fangyun Wu
- Canadian Network for Observational Drug Effect Studies (CNODES), Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Yunping Zhou
- Humana Healthcare Research, Inc., Louisville, KY, USA
| | - Edward Burn
- Pharmaco- and Device Epidemiology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - J Michael Paterson
- Canadian Network for Observational Drug Effect Studies (CNODES), Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Daniel Prieto-Alhambra
- Pharmaco- and Device Epidemiology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
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Lo Re V, Dutcher SK, Connolly JG, Perez-Vilar S, Carbonari DM, DeFor TA, Djibo DA, Harrington LB, Hou L, Hennessy S, Hubbard RA, Kempner ME, Kuntz JL, McMahill-Walraven CN, Mosley J, Pawloski PA, Petrone AB, Pishko AM, Rogers Driscoll M, Steiner CA, Zhou Y, Cocoros NM. Risk of admission to hospital with arterial or venous thromboembolism among patients diagnosed in the ambulatory setting with covid-19 compared with influenza: retrospective cohort study. BMJ Med 2023; 2:e000421. [PMID: 37303490 PMCID: PMC10254785 DOI: 10.1136/bmjmed-2022-000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/03/2023] [Indexed: 06/13/2023]
Abstract
Objective To measure the 90 day risk of arterial thromboembolism and venous thromboembolism among patients diagnosed with covid-19 in the ambulatory (ie, outpatient, emergency department, or institutional) setting during periods before and during covid-19 vaccine availability and compare results to patients with ambulatory diagnosed influenza. Design Retrospective cohort study. Setting Four integrated health systems and two national health insurers in the US Food and Drug Administration's Sentinel System. Participants Patients with ambulatory diagnosed covid-19 when vaccines were unavailable in the US (period 1, 1 April-30 November 2020; n=272 065) and when vaccines were available in the US (period 2, 1 December 2020-31 May 2021; n=342 103), and patients with ambulatory diagnosed influenza (1 October 2018-30 April 2019; n=118 618). Main outcome measures Arterial thromboembolism (hospital diagnosis of acute myocardial infarction or ischemic stroke) and venous thromboembolism (hospital diagnosis of acute deep venous thrombosis or pulmonary embolism) within 90 days after ambulatory covid-19 or influenza diagnosis. We developed propensity scores to account for differences between the cohorts and used weighted Cox regression to estimate adjusted hazard ratios of outcomes with 95% confidence intervals for covid-19 during periods 1 and 2 versus influenza. Results 90 day absolute risk of arterial thromboembolism with covid-19 was 1.01% (95% confidence interval 0.97% to 1.05%) during period 1, 1.06% (1.03% to 1.10%) during period 2, and with influenza was 0.45% (0.41% to 0.49%). The risk of arterial thromboembolism was higher for patients with covid-19 during period 1 (adjusted hazard ratio 1.53 (95% confidence interval 1.38 to 1.69)) and period 2 (1.69 (1.53 to 1.86)) than for patients with influenza. 90 day absolute risk of venous thromboembolism with covid-19 was 0.73% (0.70% to 0.77%) during period 1, 0.88% (0.84 to 0.91%) during period 2, and with influenza was 0.18% (0.16% to 0.21%). Risk of venous thromboembolism was higher with covid-19 during period 1 (adjusted hazard ratio 2.86 (2.46 to 3.32)) and period 2 (3.56 (3.08 to 4.12)) than with influenza. Conclusions Patients diagnosed with covid-19 in the ambulatory setting had a higher 90 day risk of admission to hospital with arterial thromboembolism and venous thromboembolism both before and after covid-19 vaccine availability compared with patients with influenza.
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Affiliation(s)
- Vincent Lo Re
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah K Dutcher
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - John G Connolly
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Inc, Wellesley, MA, USA
| | - Silvia Perez-Vilar
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Dena M Carbonari
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Djeneba Audrey Djibo
- CVS Health Clinical Trial Services, an affiliate of Aetna, CVS Health Company, Blue Bell, PA, USA
| | - Laura B Harrington
- Kaiser Permanente Washington Health Research Institute and Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Laura Hou
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Inc, Wellesley, MA, USA
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria E Kempner
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Inc, Wellesley, MA, USA
| | - Jennifer L Kuntz
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | | | - Jolene Mosley
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Inc, Wellesley, MA, USA
| | | | - Andrew B Petrone
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Inc, Wellesley, MA, USA
| | - Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Meighan Rogers Driscoll
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Inc, Wellesley, MA, USA
| | - Claudia A Steiner
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
| | - Yunping Zhou
- Humana Healthcare Research, Inc, Louisville, KY, USA
| | - Noelle M Cocoros
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Inc, Wellesley, MA, USA
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Floyd JS, Walker RL, Kuntz JL, Shortreed SM, Fortmann SP, Bayliss EA, Harrington LB, Fuller S, Albertson-Junkans LH, Powers JD, Lee MH, Temposky LA, Dublin S. Association Between Diabetes Severity and Risks of COVID-19 Infection and Outcomes. J Gen Intern Med 2023; 38:1484-1492. [PMID: 36795328 PMCID: PMC9933797 DOI: 10.1007/s11606-023-08076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Little is known about whether diabetes increases the risk of COVID-19 infection and whether measures of diabetes severity are related to COVID-19 outcomes. OBJECTIVE Investigate diabetes severity measures as potential risk factors for COVID-19 infection and COVID-19 outcomes. DESIGN, PARTICIPANTS, MEASURES In integrated healthcare systems in Colorado, Oregon, and Washington, we identified a cohort of adults on February 29, 2020 (n = 1,086,918) and conducted follow-up through February 28, 2021. Electronic health data and death certificates were used to identify markers of diabetes severity, covariates, and outcomes. Outcomes were COVID-19 infection (positive nucleic acid antigen test, COVID-19 hospitalization, or COVID-19 death) and severe COVID-19 (invasive mechanical ventilation or COVID-19 death). Individuals with diabetes (n = 142,340) and categories of diabetes severity measures were compared with a referent group with no diabetes (n = 944,578), adjusting for demographic variables, neighborhood deprivation index, body mass index, and comorbidities. RESULTS Of 30,935 patients with COVID-19 infection, 996 met the criteria for severe COVID-19. Type 1 (odds ratio [OR] 1.41, 95% CI 1.27-1.57) and type 2 diabetes (OR 1.27, 95% CI 1.23-1.31) were associated with increased risk of COVID-19 infection. Insulin treatment was associated with greater COVID-19 infection risk (OR 1.43, 95% CI 1.34-1.52) than treatment with non-insulin drugs (OR 1.26, 95% 1.20-1.33) or no treatment (OR 1.24; 1.18-1.29). The relationship between glycemic control and COVID-19 infection risk was dose-dependent: from an OR of 1.21 (95% CI 1.15-1.26) for hemoglobin A1c (HbA1c) < 7% to an OR of 1.62 (95% CI 1.51-1.75) for HbA1c ≥ 9%. Risk factors for severe COVID-19 were type 1 diabetes (OR 2.87; 95% CI 1.99-4.15), type 2 diabetes (OR 1.80; 95% CI 1.55-2.09), insulin treatment (OR 2.65; 95% CI 2.13-3.28), and HbA1c ≥ 9% (OR 2.61; 95% CI 1.94-3.52). CONCLUSIONS Diabetes and greater diabetes severity were associated with increased risks of COVID-19 infection and worse COVID-19 outcomes.
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Affiliation(s)
- James S. Floyd
- Department of Medicine, University of Washington, Seattle, WA USA
- Department of Epidemiology, University of Washington, Seattle, WA USA
- Cardiovascular Health Research Unit, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA 98101 USA
| | - Rod L. Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
| | | | - Susan M. Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
- Department of Biostatistics, University of Washington, Seattle, WA USA
| | - Stephen P. Fortmann
- Kaiser Permanente Center for Health Research, Portland, OR USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Laura B. Harrington
- Department of Epidemiology, University of Washington, Seattle, WA USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
| | | | - John D. Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO USA
| | - Mi H. Lee
- Kaiser Permanente Center for Health Research, Portland, OR USA
| | - Lisa A. Temposky
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
| | - Sascha Dublin
- Department of Epidemiology, University of Washington, Seattle, WA USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA
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6
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Shortreed SM, Gray R, Akosile MA, Walker RL, Fuller S, Temposky L, Fortmann SP, Albertson-Junkans L, Floyd JS, Bayliss EA, Harrington LB, Lee MH, Dublin S. Increased COVID-19 Infection Risk Drives Racial and Ethnic Disparities in Severe COVID-19 Outcomes. J Racial Ethn Health Disparities 2023; 10:149-159. [PMID: 35072944 PMCID: PMC8785693 DOI: 10.1007/s40615-021-01205-2] [Citation(s) in RCA: 16] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 02/03/2023]
Abstract
COVID-19 inequities have been well-documented. We evaluated whether higher rates of severe COVID-19 in racial and ethnic minority groups were driven by higher infection rates by evaluating if disparities remained when analyses were restricted to people with infection. We conducted a retrospective cohort study of adults insured through Kaiser Permanente (Colorado, Northwest, Washington), follow-up in March-September 2020. Laboratory results and hospitalization diagnosis codes identified individuals with COVID-19. Severe COVID-19 was defined as invasive mechanical ventilation or mortality. Self-reported race and ethnicity, demographics, and medical comorbidities were extracted from health records. Modified Poisson regression estimated adjusted relative risks (aRRs) of severe COVID-19 in full cohort and among individuals with infection. Our cohort included 1,052,774 individuals, representing diverse racial and ethnic minority groups (e.g., 68,887 Asian, 41,243 Black/African American, 93,580 Hispanic or Latino/a individuals). Among 7,399 infections, 442 individuals experienced severe COVID-19. In the full cohort, severe COVID-19 aRRs for Asian, Black/African American, and Hispanic individuals were 2.09 (95% CI: 1.36, 3.21), 2.02 (1.39, 2.93), and 2.09 (1.57, 2.78), respectively, compared to non-Hispanic Whites. In analyses restricted to individuals with COVID-19, all aRRs were near 1, except among Asian Americans (aRR 1.82 [1.23, 2.68]). These results indicate increased incidence of severe COVID-19 among Black/African American and Hispanic individuals is due to higher infection rates, not increased susceptibility to progression. COVID-19 disparities most likely result from social, not biological, factors. Future work should explore reasons for increased severe COVID-19 risk among Asian Americans. Our findings highlight the importance of equity in vaccine distribution.
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Affiliation(s)
- Susan M. Shortreed
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA ,Department of Biostatistics, University of Washington, F-600, Health Sciences Building, 1705 NE Pacific Street, Seattle, WA 98195-7232 USA
| | - Regan Gray
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA
| | - Mary Abisola Akosile
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA
| | - Rod L. Walker
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA
| | - Lisa Temposky
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA
| | - Stephen P. Fortmann
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR 97227 USA
| | - Ladia Albertson-Junkans
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA
| | - James S. Floyd
- Department of Medicine, University of Washington, RR-512, Health Sciences Building, 1959 NE Pacific Street, Seattle, WA 98195 USA ,Department of Epidemiology, University of Washington, 3980 15th Ave NE, Seattle, WA 98195 USA
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Rd, Suite 200, Aurora, CO 80014 USA ,Department of Family Medicine, University of Colorado School of Medicine, 12631 East 17th Ave, Box F 496, Aurora, CO 80045 USA
| | - Laura B. Harrington
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA ,Department of Epidemiology, University of Washington, 3980 15th Ave NE, Seattle, WA 98195 USA
| | - Mi H. Lee
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR 97227 USA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Ste 1600, Seattle, WA 98101 USA ,Department of Epidemiology, University of Washington, 3980 15th Ave NE, Seattle, WA 98195 USA
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Lo Re V, Dutcher SK, Connolly JG, Perez-Vilar S, Carbonari DM, DeFor TA, Djibo DA, Harrington LB, Hou L, Hennessy S, Hubbard RA, Kempner ME, Kuntz JL, McMahill-Walraven CN, Mosley J, Pawloski PA, Petrone AB, Pishko AM, Driscoll MR, Steiner CA, Zhou Y, Cocoros NM. Association of COVID-19 vs Influenza With Risk of Arterial and Venous Thrombotic Events Among Hospitalized Patients. JAMA 2022; 328:637-651. [PMID: 35972486 PMCID: PMC9382447 DOI: 10.1001/jama.2022.13072] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE The incidence of arterial thromboembolism and venous thromboembolism in persons with COVID-19 remains unclear. OBJECTIVE To measure the 90-day risk of arterial thromboembolism and venous thromboembolism in patients hospitalized with COVID-19 before or during COVID-19 vaccine availability vs patients hospitalized with influenza. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 41 443 patients hospitalized with COVID-19 before vaccine availability (April-November 2020), 44 194 patients hospitalized with COVID-19 during vaccine availability (December 2020-May 2021), and 8269 patients hospitalized with influenza (October 2018-April 2019) in the US Food and Drug Administration Sentinel System (data from 2 national health insurers and 4 regional integrated health systems). EXPOSURES COVID-19 or influenza (identified by hospital diagnosis or nucleic acid test). MAIN OUTCOMES AND MEASURES Hospital diagnosis of arterial thromboembolism (acute myocardial infarction or ischemic stroke) and venous thromboembolism (deep vein thrombosis or pulmonary embolism) within 90 days. Outcomes were ascertained through July 2019 for patients with influenza and through August 2021 for patients with COVID-19. Propensity scores with fine stratification were developed to account for differences between the influenza and COVID-19 cohorts. Weighted Cox regression was used to estimate the adjusted hazard ratios (HRs) for outcomes during each COVID-19 vaccine availability period vs the influenza period. RESULTS A total of 85 637 patients with COVID-19 (mean age, 72 [SD, 13.0] years; 50.5% were male) and 8269 with influenza (mean age, 72 [SD, 13.3] years; 45.0% were male) were included. The 90-day absolute risk of arterial thromboembolism was 14.4% (95% CI, 13.6%-15.2%) in patients with influenza vs 15.8% (95% CI, 15.5%-16.2%) in patients with COVID-19 before vaccine availability (risk difference, 1.4% [95% CI, 1.0%-2.3%]) and 16.3% (95% CI, 16.0%-16.6%) in patients with COVID-19 during vaccine availability (risk difference, 1.9% [95% CI, 1.1%-2.7%]). Compared with patients with influenza, the risk of arterial thromboembolism was not significantly higher among patients with COVID-19 before vaccine availability (adjusted HR, 1.04 [95% CI, 0.97-1.11]) or during vaccine availability (adjusted HR, 1.07 [95% CI, 1.00-1.14]). The 90-day absolute risk of venous thromboembolism was 5.3% (95% CI, 4.9%-5.8%) in patients with influenza vs 9.5% (95% CI, 9.2%-9.7%) in patients with COVID-19 before vaccine availability (risk difference, 4.1% [95% CI, 3.6%-4.7%]) and 10.9% (95% CI, 10.6%-11.1%) in patients with COVID-19 during vaccine availability (risk difference, 5.5% [95% CI, 5.0%-6.1%]). Compared with patients with influenza, the risk of venous thromboembolism was significantly higher among patients with COVID-19 before vaccine availability (adjusted HR, 1.60 [95% CI, 1.43-1.79]) and during vaccine availability (adjusted HR, 1.89 [95% CI, 1.68-2.12]). CONCLUSIONS AND RELEVANCE Based on data from a US public health surveillance system, hospitalization with COVID-19 before and during vaccine availability, vs hospitalization with influenza in 2018-2019, was significantly associated with a higher risk of venous thromboembolism within 90 days, but there was no significant difference in the risk of arterial thromboembolism within 90 days.
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Affiliation(s)
- Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarah K. Dutcher
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - John G. Connolly
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Silvia Perez-Vilar
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Dena M. Carbonari
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | | | - Laura Hou
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rebecca A. Hubbard
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Maria E. Kempner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Jennifer L. Kuntz
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | | | - Jolene Mosley
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | | | - Andrew B. Petrone
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Allyson M. Pishko
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Meighan Rogers Driscoll
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | | | - Yunping Zhou
- Humana Healthcare Research Inc, Louisville, Kentucky
| | - Noelle M. Cocoros
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
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Lidstrom SC, Wiggins KL, Harrington LB, McKnight B, Blondon M, Smith NL. Incident thrombus location and predicting risk of recurrent venous thromboembolism. Res Pract Thromb Haemost 2022; 6:e12762. [PMID: 35910943 PMCID: PMC9326286 DOI: 10.1002/rth2.12762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/19/2022] [Accepted: 06/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Understanding venous thromboembolism (VTE) recurrence risk is central to determining the appropriate treatment course. Whether this risk varies after discontinuing anticoagulation or overall by type of incident event (pulmonary embolism [PE] vs deep vein thrombosis [DVT]) and by the detailed location of the DVT needs further clarification. Methods In this population‐based inception cohort of incident VTE cases with follow‐up by electronic health record review, incident DVT was categorized as distal, popliteal, or iliofemoral. We used the Fine‐Gray regression model to describe the predictive association of the thrombus location with the risk of recurrence before death. Results Among 2766 participants with an incident event from 2002 to 2010, 1713 (62%) ceased anticoagulation and were followed for recurrent events; 301 events were observed during the 4.5 years of follow‐up. Relative to participants with an incident thrombus in an iliofemoral location and no PE, those with a thrombus in a popliteal location and no PE had a similar risk of recurrence (adjusted subdistribution hazard ratio [aSHR], 0.82 [95% confidence interval (CI), 0.57–1.19]), while those with a thrombus in a distal location and no PE and those with a thrombus that included a PE had lower risk of recurrence: aSHR, 0.34 (95% CI, 0.20‐0.57); and aSHR, 0.58 (95% CI 0.45‐0.76), respectively. Conclusions The findings of this population‐based inception cohort confirm that the risk of recurrent VTE after discontinuing anticoagulants is similar after iliofemoral and popliteal DVT but is lower after distal DVT. Recurrence may be lower after PE than proximal DVT.
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Affiliation(s)
- Sara C Lidstrom
- Department of Epidemiology University of Washington Seattle Washington USA
| | - Kerri L Wiggins
- Department of Medicine University of Washington Seattle Washington USA
| | - Laura B Harrington
- Department of Epidemiology University of Washington Seattle Washington USA.,Kaiser Permanente Washington Health Research Institute Seattle Washington USA.,Department of Health Systems Science Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena California USA.,Department of Nutrition Harvard T.H. Chan School of Public Health Boston Massachusetts USA
| | - Barbara McKnight
- Department of Biostatistics University of Washington Seattle Washington USA
| | - Marc Blondon
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Nicholas L Smith
- Department of Epidemiology University of Washington Seattle Washington USA.,Kaiser Permanente Washington Health Research Institute Seattle Washington USA.,Department of Veterans Affairs Seattle Epidemiologic Research and Information Center, Office of Research & Development Seattle Washington USA
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Blondon M, Timmons AK, Baraff AJ, Floyd JS, Harrington LB, Korpak AM, Smith NL. Comparative venous thromboembolic safety of oral and transdermal postmenopausal hormone therapies among women Veterans. Menopause 2021; 28:1125-1129. [PMID: 34313612 PMCID: PMC8478712 DOI: 10.1097/gme.0000000000001823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hormone therapy (HT) is used by menopausal women to treat vasomotor symptoms. Venous thromboembolism (VTE) is an important risk of HT use, and more knowledge on the comparative safety of different estrogenic compounds is useful for women who use HT for these symptoms. The objective was to compare the risk of VTE among users of oral conjugated equine estrogen (CEE), oral estradiol (E2), and transdermal E2, in a cohort of women veterans. METHODS This retrospective cohort study included all women veterans aged 40 to 89 years, using CEE or E2, without prior VTE, between 2003 and 2011. All incident VTE events were adjudicated. Time-to-event analyses using a time-varying HT exposure evaluated the relative VTE risk between estrogen subtypes, with adjustment for age, race, and body mass index, with stratification for prevalent versus incident use of HT. RESULTS Among 51,571 users of HT (74.5% CEE, 12.6% oral, and 12.9% transdermal E2 at cohort entry), with a mean age of 54.0 years, the incidence of VTE was 1.9/1,000 person-years. Compared with CEE use, in the multivariable regression model, there was no difference in the risk of incident VTE associated with oral E2 use (hazard ratio 0.96, 95% CI 0.64-1.46) or with transdermal E2 use (hazard ratio 0.95, 95% CI 0.60-1.49). Results were unchanged when restricting to incident users of HT. CONCLUSIONS Among women veterans, the risk of VTE was similar in users of oral CEE, oral E2, and transdermal E2. These findings do not confirm the previously observed greater safety of transdermal and oral E2 over CEE.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Andrew K. Timmons
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - Aaron J. Baraff
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - James S. Floyd
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Laura B. Harrington
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Anna M. Korpak
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - Nicholas L. Smith
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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10
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Harrington LB, Ehlert AN, Thacker EL, Jenny NS, Lopez O, Cushman M, Fitzpatrick A, Mukamal KJ, Jensen MK. Hemostatic factor levels and cognitive decline in older adults: The Cardiovascular Health Study. J Thromb Haemost 2021; 19:1219-1227. [PMID: 33725412 PMCID: PMC8136364 DOI: 10.1111/jth.15300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 02/16/2021] [Accepted: 03/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemostasis is a key factor in cerebrovascular disease, but the association of hemostatic factors with cognitive decline is unclear. OBJECTIVE To prospectively evaluate associations of 20 hemostatic factor levels with changes in cognition during ≥8 years of follow-up in the Cardiovascular Health Study (CHS) of older adults. METHODS We included participants of an existing CHS cross-sectional substudy (n = 400) with hemostatic factors measured in 1989-1990. Between 1989-1990 and 1998-1999, cognitive function was measured using the Modified Mini-Mental State Examination (3MSE) and Digit Symbol Substitution Tests. Mixed-effects linear regression models estimated change in cognitive function over time, adjusting for sociodemographic and clinical factors and APOE genotype, using Bonferroni adjustment. We also derived principal components to account for the interrelationship among factors. RESULTS Of 20 factors evaluated individually, only higher levels of plasmin-α2 -antiplasmin complex (PAP), tissue factor pathway inhibitor (TFPI), and lower factor X (FXc) levels were associated with faster cognitive decline, estimated by annual change in 3MSE points (1 standard deviation PAP β = -0.65, 95% confidence interval [CI]: -1.08 to -0.21; TFPI β = -0.55, 95% CI: -0.90 to -0.19; FXc β = 0.52, 95% CI: 0.21-0.84). One of four principal components, loading positively on D-dimer, prothrombin fragment 1.2 (F1.2), and PAP was significantly associated with change in 3MSE. CONCLUSIONS Levels of PAP, TPFI, and FXc and a combination of factors driven by PAP, D-dimer, and F1.2 were associated with cognitive decline. Whether these findings can be used to improve dementia prevention or prediction requires further study.
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Affiliation(s)
- Laura B Harrington
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Alexa N Ehlert
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Evan L Thacker
- Department of Public Health, Brigham Young University, Provo, UT, USA
| | - Nancy S Jenny
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine, Colchester, VT, USA
| | - Oscar Lopez
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Cushman
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine, Colchester, VT, USA
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | | | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Majken K Jensen
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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11
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Dublin S, Walker RL, Floyd JS, Shortreed SM, Fuller S, Albertson-Junkans L, Harrington LB, Greenwood-Hickman MA, Green BB, Psaty BM. Renin-Angiotensin-Aldosterone System Inhibitors and COVID-19 Infection or Hospitalization: A Cohort Study. Am J Hypertens 2021; 34:339-347. [PMID: 33048112 PMCID: PMC7665332 DOI: 10.1093/ajh/hpaa168] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 12/16/2022] Open
Abstract
Background Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers
(ARBs) may increase the risk of coronavirus disease 2019 (COVID-19) infection or affect
disease severity. Prior studies have not examined risks by medication dose. Methods This retrospective cohort study included people aged ≥18 years enrolled in a US
integrated healthcare system for at least 4 months as of 2/29/2020. Current ACEI and ARB
use was identified from pharmacy data, and the estimated daily dose was calculated and
standardized across medications. COVID-19 infections and hospitalizations were
identified through 6/14/2020 from laboratory and hospitalization data. We used logistic
regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting
for race/ethnicity, obesity, and other covariates. Results Among 322,044 individuals, 826 developed COVID-19 infection. Among people using
ACEI/ARBs, 204/56,105 developed COVID-19 (3.6 per 1,000 individuals) compared with
622/265,939 without ACEI/ARB use (2.3 per 1,000), yielding an adjusted OR of 0.91 (95%
CI 0.74–1.12). For use of <1 defined daily dose (DDD) vs. nonuse, the adjusted OR for
infection was 0.92 (95% CI 0.66–1.28); for 1 to <2 DDDs, 0.89 (95% CI 0.66–1.19); and
for ≥2 DDDs, 0.92 (95% CI 0.72–1.18). The OR was similar for ACEIs and ARBs and in
subgroups by age and sex. 26% of people with COVID-19 infection were hospitalized; the
adjusted OR for hospitalization in relation to ACEI/ARB use was 0.98 (95% CI 0.63–1.54),
and there was no association with dose. Conclusions These findings support current recommendations that individuals on these medications
continue their use.
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Affiliation(s)
- Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - James S Floyd
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Ladia Albertson-Junkans
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Laura B Harrington
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | | | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Bruce M Psaty
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Health Services, University of Washington, Seattle, Washington, USA
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Dublin S, Walker RL, Floyd JS, Shortreed SM, Fuller S, Albertson-Junkans L, Harrington LB, Greenwood-Hickman MA, Green BB, Psaty BM. Response to "ACE-2 Downregulation and Incidence of Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) Infection". Am J Hypertens 2021; 34:427. [PMID: 33320177 PMCID: PMC7799315 DOI: 10.1093/ajh/hpaa212] [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: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - James S Floyd
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | | | - Laura B Harrington
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | | | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Bruce M Psaty
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Health Services, University of Washington, Seattle, Washington, USA
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13
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Dublin S, Walker R, Floyd JS, Shortreed SM, Fuller S, Albertson-Junkans L, Harrington LB, Greenwood-Hickman MA, Green BB, Psaty BM. Renin-angiotensin-aldosterone system inhibitors and COVID-19 infection or hospitalization: a cohort study. medRxiv 2020. [PMID: 32676610 PMCID: PMC7359535 DOI: 10.1101/2020.07.06.20120386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
There are plausible mechanisms by which angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase the risk of COVID-19 infection or affect disease severity. To examine the association between these medications and COVID-19 infection or hospitalization, we conducted a retrospective cohort study within a US integrated healthcare system. Among people aged ≥18 years enrolled in the health plan for at least 4 months as of 2/29/2020, current ACEI and ARB use was identified from pharmacy data, and the estimated daily dose was calculated and standardized across medications. COVID-19 infections were identified through 6/14/2020 from laboratory and hospitalization data. We used logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals. Among 322,044 individuals, 720 developed COVID-19 infection. Among people using ACEI/ARBs, 183/56,105 developed COVID-19 (3.3 per 1000 individuals) compared with 537/265,939 without ACEI/ARB use (2.0 per 1000), yielding an adjusted OR of 0.94 (95% CI 0.75-1.16). For use of < 1 defined daily dose vs. nonuse, the adjusted OR for infection was 0.89 (95% CI 0.62-1.26); for 1 to < 2 defined daily doses, 0.97 (95% CI 0.71-1.31); and for ≥2 defined daily doses, 0.94 (95% CI 0.72-1.23). The OR was similar for ACEIs and ARBs and in subgroups by age and sex. 29% of people with COVID-19 infection were hospitalized; the adjusted OR for hospitalization in relation to ACEI/ARB use was 0.92 (95% CI 0.54-1.57), and there was no association with dose. These findings support current recommendations that individuals on these medications continue their use. People taking angiotensin converting enzyme inhibitors and angiotensin receptor blockers, including those using high doses, can continue to take them without concern about higher risk of COVID 19 infection.
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Affiliation(s)
- Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA.,Department of Epidemiology, University of Washington, Seattle, WA
| | - Rod Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - James S Floyd
- Kaiser Permanente Washington Health Research Institute, Seattle, WA.,Department of Epidemiology, University of Washington, Seattle, WA.,Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA.,Department of Biostatistics, University of Washington, Seattle, WA
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | - Laura B Harrington
- Kaiser Permanente Washington Health Research Institute, Seattle, WA.,Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Bruce M Psaty
- Kaiser Permanente Washington Health Research Institute, Seattle, WA.,Department of Epidemiology, University of Washington, Seattle, WA.,Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA.,Department of Health Services, University of Washington, Seattle, WA
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Gu X, Koch M, Tabung FK, Marchand N, Harrington LB, Shadyab AH, Zaslavsky O, Sachs BC, Li W, Johnson KC, Snetselaar LG, Wactawski-Wende J, Rapp SR, Resnick SM, Haring B, Hayden KM, Mukamal KJ, Eaton CB, Manson JE, Jensen MK. P1‐010: THE EMPIRICAL INFLAMMATORY DIETARY PATTERN IN RELATION TO COGNITIVE FUNCTION AND RISK OF MILD COGNITIVE IMPAIRMENT AND DEMENTIA IN THE WOMEN'S HEALTH INITIATIVE MEMORY STUDY. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Xiao Gu
- Harvard T.H. Chan School of Public Health Boston MA USA
| | - Manja Koch
- Harvard T.H. Chan School of Public Health Boston MA USA
| | - Fred K. Tabung
- Ohio State University Columbus OH USA
- Harvard TH Chan School of Public Health Boston MA USA
| | | | - Laura B. Harrington
- Harvard T.H. Chan School of Public Health Boston MA USA
- Kaiser Permanente Washington Health Research Institute Seattle WA USA
| | | | - Oleg Zaslavsky
- University of Washington School of Nursing Seattle WA USA
| | | | - Wenjun Li
- University of Massachusetts Medical School Worcester MA USA
| | | | | | - Jean Wactawski-Wende
- University at Buffalo School of Public Health and Health Professions Buffalo NY USA
| | | | | | | | | | | | | | - JoAnn E. Manson
- Brigham and Women's Hospital Harvard Medical School Boston MA USA
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15
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Hagan KA, Harrington LB, Kim J, Lindström S, Camargo CA, Grodstein F, Kabrhel C. Adiposity throughout the life course and risk of venous thromboembolism. Thromb Res 2018; 172:67-73. [PMID: 30384037 DOI: 10.1016/j.thromres.2018.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/05/2018] [Accepted: 10/24/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Adult body mass index (BMI) is strongly associated with venous thromboembolism (VTE), however whether earlier-life adiposity or other measures of adult adiposity are associated with VTE risk remains largely unknown. MATERIALS AND METHODS We evaluated associations of childhood somatotype, BMI in early adulthood, adult adiposity, and change in weight since early adulthood with incident VTE risk over ≥20 years of follow-up among 205,935 participants from Nurses' Health Studies (NHS/NHS II) and Health Professionals Follow-Up Study (HPFS), ages 29-76 at baseline. We estimated multivariable-adjusted hazard ratios for VTE using Cox proportional hazards models. RESULTS AND CONCLUSIONS Somatotype in childhood and young adulthood BMI were not significantly associated with VTE risk, after accounting for adult BMI. Adult BMI was strongly associated with VTE in all three cohorts (e.g., multivariable-adjusted HRs comparing ≥35 kg/m2 vs. <22.5 kg/m2: NHS:3.03[95% CI: 2.58, 3.56], NHS II:3.82[95% CI: 3.24, 4.51], HPFS:2.81 [95% CI: 2.08, 3.80]; all p-trends < 0.01). Adult waist circumference was associated with greater VTE risk, even after adjusting for adult BMI (all p-trends < 0.01). Increasing weight gain from young adulthood was significantly associated with VTE after adjusting for current BMI among women (HR comparing gain ≥20 kg vs. no change: NHS:1.36[95% CI: 1.13, 1.65], NHS II:1.48[95% CI: 1.17, 1.87]) and not men (HPFS:1.20[95% CI: 0.97, 1.50]). These results indicate that BMI and adiposity are likely more important acutely than cumulatively over time in the etiology and prevention of VTE. Clinically, encouraging weight loss in individuals who are overweight or obese could help reduce VTE risk.
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Affiliation(s)
- Kaitlin A Hagan
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA 02115, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
| | - Laura B Harrington
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
| | - Jihye Kim
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
| | - Sara Lindström
- Department of Epidemiology, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N., Seattle, WA 98109, USA.
| | - Carlos A Camargo
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA 02115, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA; Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Zero Emerson Place, Ste 3B, Boston, MA 02114, USA.
| | - Francine Grodstein
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA 02115, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Zero Emerson Place, Ste 3B, Boston, MA 02114, USA.
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Hagan KA, Harrington LB, Kim J, Zeleznik O, Rimm EB, Grodstein F, Kabrhel C. Reduction in physical function in women after venous thromboembolism. J Thromb Haemost 2018; 16:S1538-7836(22)02216-4. [PMID: 29883039 PMCID: PMC6286689 DOI: 10.1111/jth.14196] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Indexed: 11/30/2022]
Abstract
Essentials The association of venous thromboembolism (VTE) with subsequent physical function remains unclear. We prospectively evaluated this relationship among women from the Nurses' Health Studies. We found a decline in physical function over four years in women with incident VTE. This decline was somewhat greater among women specifically reporting a pulmonary embolism. SUMMARY Background Physical function is integral to healthy aging; however, limited research has examined the association of venous thromboembolism(VTE) with subsequent physical function. Objectives To prospectively evaluate the relationship between VTE and decline in physical function among 80 836 women from the Nurses' Health Study(NHS), ages 46-72 in 1992, and 84 304 women from the Nurses' Health Study II(NHS II), ages 29-48 in 1993. Methods Physical function was measured by the Medical Outcomes Short Form-36 physical function scale, administered every 4 years. We compared change in physical function for women with vs. without an incident VTE in each 4-year follow-up period using multivariable linear regression. Results We observed a decline in physical function over 4 years when comparing women with vs. those without incident VTE in both older (NHS) and younger (NHS II) women (multivariable-adjusted mean difference NHS, -6.5 points [95% CI -7.4, -5.6] per 4 years; NHS II, -3.8 [95% CI -5.6, -2.0]). This difference appeared greater among women specifically reporting a pulmonary embolism (NHS, -7.4 [95% CI -8.7, -6.1]; NHS II, -4.8 [95% CI -6.8, -2.8]), and was equivalent to 6.2 years of aging. Whereas longer-term slopes of physical function decline following a VTE were not different from the slopes of decline in women without a VTE, the absolute level of physical function of women with VTE was worse at the end of follow-up compared to women without VTE. Conclusions In this prospective cohort, incident VTE was strongly associated with an acute decline in physical function. These results suggest it may be clinically important to consider approaches to ameliorating functional deficits shortly after VTE diagnosis.
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Affiliation(s)
- Kaitlin A Hagan
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Laura B Harrington
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jihye Kim
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Oana Zeleznik
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eric B. Rimm
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Francine Grodstein
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Harrington LB, Blondon M, Cushman M, Kaunitz AM, Allison MA, Wang L, Sullivan S, Woods NF, LaCroix AZ, Heckbert SR, McKnight B, Rossouw J, Smith NL. Vasomotor symptoms and the risk of incident venous thrombosis in postmenopausal women. J Thromb Haemost 2018; 16:886-892. [PMID: 29504242 PMCID: PMC5932241 DOI: 10.1111/jth.13993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Indexed: 11/30/2022]
Abstract
Essentials Vasomotor symptoms have been proposed as markers of changing cardiovascular risk. In this cohort study, we evaluated these symptoms as markers of venous thrombosis (VT) risk. We found no evidence that vasomotor symptom presence or severity were associated with VT risk. Among these postmenopausal women, vasomotor symptoms are not a useful marker of VT risk. SUMMARY Background Vasomotor symptoms may be markers of changes in cardiovascular risk, but it is unknown whether these symptoms are associated with the risk of venous thrombosis (VT). Objective To evaluate the association of vasomotor symptom presence and severity with incident VT risk among postmenopausal women, independent of potential explanatory variables. Methods This cohort study included participants of the Women's Health Initiative (WHI) Hormone Therapy Trials (n = 24 508) and Observational Study (n = 87 783), analyzed separately. At baseline, women reported whether hot flashes or night sweats were present and, if so, their severity. Using Cox proportional hazards models, we estimated the VT risk associated with vasomotor symptom presence and severity, adjusted for potential explanatory variables: age, body mass index, smoking status, race/ethnicity, and time-varying current hormone therapy use. Results At baseline, WHI Hormone Therapy Trial participants were aged 64 years and WHI Observational Study participants were aged 63 years, on average. In the WHI Hormone Therapy Trials over a median of 8.2 years of follow-up, 522 women experienced a VT event. In the WHI Observational Study, over 7.9 years of follow-up, 1103 women experienced a VT event. In adjusted analyses, we found no evidence of an association between vasomotor symptom presence (hazard ratio [HR]adj 0.91, 95% confidence interval [CI] 0.75-1.1 in the WHI Hormone Therapy Trials; HRadj 1.1, 95% CI 0.99-1.3 in the WHI Observational Study) or severity (HRadj for severe versus mild 0.99, 95% CI 0.53-1.9 in the WHI Hormone Therapy Trials; HRadj 1.3, 95% CI 0.89-2.0) in the WHI Observational Study) and the risk of incident VT. Conclusions Although vasomotor symptoms have been associated with the risk of other cardiovascular events in published studies, our findings do not suggest that vasomotor symptoms constitute a marker of VT risk.
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Affiliation(s)
- L B Harrington
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - M Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M Cushman
- Department of Medicine, University of Vermont, Burlington, VT, USA
| | - A M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - M A Allison
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - L Wang
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - S Sullivan
- Department of Endocrinology, Medstar Georgetown University Hospital and Medstar Washington Hospital Center, Washington, DC, USA
| | - N F Woods
- School of Nursing, University of Washington, Seattle, WA, USA
| | - A Z LaCroix
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - S R Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - B McKnight
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - J Rossouw
- National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - N L Smith
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Group Health Cooperative, Seattle, WA, USA
- Department of Veterans Affairs Office of Research and Development, Seattle Epidemiologic Research and Information Center, Seattle, WA, USA
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18
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Kim J, Kraft P, Hagan KA, Harrington LB, Lindstroem S, Kabrhel C. Interaction of a genetic risk score with physical activity, physical inactivity, and body mass index in relation to venous thromboembolism risk. Genet Epidemiol 2018. [PMID: 29520861 DOI: 10.1002/gepi.22118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is highly heritable. Physical activity, physical inactivity and body mass index (BMI) are also risk factors, but evidence of interaction between genetic and environmental risk factors is limited. METHODS Data on 2,134 VTE cases and 3,890 matched controls were obtained from the Nurses' Health Study (NHS), Nurses' Health Study II (NHS II), and Health Professionals Follow-up Study (HPFS). We calculated a weighted genetic risk score (wGRS) using 16 single nucleotide polymorphisms associated with VTE risk in published genome-wide association studies (GWAS). Data on three risk factors, physical activity (metabolic equivalent [MET] hours per week), physical inactivity (sitting hours per week) and BMI, were obtained from biennial questionnaires. VTE cases were incident since cohort inception; controls were matched to cases on age, cohort, and genotype array. Using conditional logistic regression, we assessed joint effects and interaction effects on both additive and multiplicative scales. We also ran models using continuous wGRS stratified by risk-factor categories. RESULTS We observed a supra-additive interaction between wGRS and BMI. Having both high wGRS and high BMI was associated with a 3.4-fold greater risk of VTE (relative excess risk due to interaction = 0.69, p = 0.046). However, we did not find evidence for a multiplicative interaction with BMI. No interactions were observed for physical activity or inactivity. CONCLUSION We found a synergetic effect between a genetic risk score and high BMI on the risk of VTE. Intervention efforts lowering BMI to decrease VTE risk may have particularly large beneficial effects among individuals with high genetic risk.
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Affiliation(s)
- Jihye Kim
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Peter Kraft
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kaitlin A Hagan
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Laura B Harrington
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sara Lindstroem
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Christopher Kabrhel
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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19
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Harrington LB, Marck BT, Wiggins KL, McKnight B, Heckbert SR, Woods NF, LaCroix AZ, Blondon M, Psaty BM, Rosendaal FR, Matsumoto AM, Smith NL. Cross-sectional association of endogenous steroid hormone, sex hormone-binding globulin, and precursor steroid levels with hemostatic factor levels in postmenopausal women. J Thromb Haemost 2017; 15:80-90. [PMID: 27797446 PMCID: PMC5280337 DOI: 10.1111/jth.13554] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 11/12/2015] [Indexed: 11/27/2022]
Abstract
Essentials Endogenous hormone levels' influence on hemostatic factor levels is not fully characterized. We tested for associations of endogenous hormone with hemostatic factor levels in postmenopause. Estrone levels were inversely associated with the natural anticoagulant, protein S antigen. Dehydroepiandrosterone sulfate levels were inversely associated with thrombin generation. SUMMARY Background Oral use of exogenous estrogen/progestin alters hemostatic factor levels. The influence of endogenous hormones on these levels is incompletely characterized. Objectives Our study aimed to test whether, among postmenopausal women, high levels of estradiol (E2), estrone (E1), testosterone (T), dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA), and androstenedione, and low levels of sex hormone-binding globulin (SHBG), are positively associated with measures of thrombin generation (TG), a normalized activated protein C sensitivity ratio (nAPCsr), and factor VII activity (FVIIc), and negatively associated with antithrombin activity (ATc) and total protein S antigen (PSAg). Methods This Heart and Vascular Health study cross-sectional analysis included 131 postmenopausal women without a prior venous thrombosis who were not currently using hormone therapy. Adjusted mean differences in TG, nAPCsr, FVIIc, ATc and PSAg levels associated with differences in hormone levels were estimated using multiple linear regression. We measured E2, E1, total T, DHEAS, DHEA and androstenedione levels by mass spectrometry, SHBG levels by immunoassay, and calculated the level of free T. Results One picogram per milliliter higher E1 levels were associated with 0.24% lower PSAg levels (95% Confidence Interval [CI]: -0.35, -0.12) and 1 μg mL-1 higher DHEAS levels were associated with 40.8 nm lower TG peak values (95% CI: -59.5, -22.2) and 140.7 nm×min lower TG endogenous thrombin potential (ETP) (95% CI: -212.1, -69.4). After multiple comparisons correction, there was no evidence for other associations. Conclusions As hypothesized, higher E1 levels were associated with lower levels of the natural anticoagulant PSAg. Contrary to hypotheses, higher DHEAS levels were associated with differences in TG peak and ETP that suggest less generation of thrombin.
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Affiliation(s)
- Laura B. Harrington
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brett T. Marck
- Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Kerri L. Wiggins
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Barbara McKnight
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
| | - Nancy F. Woods
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Andrea Z. LaCroix
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - Marc Blondon
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Division of Angiology and Haemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Bruce M. Psaty
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alvin M. Matsumoto
- Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Gerontology & Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicholas L. Smith
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
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Abstract
Venous thromboembolism (VTE) includes deep vein thrombosis and pulmonary embolism, and a combination of environmental and genetic risk factors contributes to VTE risk. Within environmental risk factors, some are provoking (e.g., cancer, surgery, trauma or fracture, immobilization, pregnancy and the postpartum period, long-distance travel, hospitalization, catheterization, and acute infection) and others are nonprovoking (e.g., age, sex, race/ethnicity, body mass index and obesity, oral contraceptive or hormone therapy use, corticosteroid use, statin use, diet, physical activity, sedentary time, and air pollution). Additionally, VTE has a strong genetic basis, with approximately 50 to 60% of the variance in VTE incidence attributed to genetic effects. Some genetic susceptibility variants that contribute to risk have been identified in candidate genes, mostly related to the clotting system and responsible for inherited hypercoagulable states (e.g., factor V Leiden, prothrombin, fibrinogen gamma, or blood group non-O). Other susceptibility single-nucleotide polymorphisms have been identified from genome-wide association studies, such as the two new loci in TSPAN15 (rs78707713) and SCL44A2 (rs2288904) genes. Risk factors are not always associated with VTE in isolation; however, and an understanding of how environmental and genetic factors interact may provide insight into the pathophysiology of VTE, possibly identifying opportunities for targeted prevention and treatment.
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Affiliation(s)
- Marta Crous-Bou
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laura B Harrington
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts
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21
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Smith NL, Harrington LB, Blondon M, Wiggins KL, Floyd JS, Sitlani CM, McKnight B, Larson EB, Rosendaal FR, Heckbert SR, Psaty BM. The association of statin therapy with the risk of recurrent venous thrombosis. J Thromb Haemost 2016; 14:1384-92. [PMID: 27061794 PMCID: PMC4966556 DOI: 10.1111/jth.13334] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 09/02/2015] [Accepted: 02/09/2016] [Indexed: 12/19/2022]
Abstract
UNLABELLED Essentials A lowered risk of recurrent venous thrombosis (VT) with statin treatment is controversial. Among observational inception cohort of 2,798 adults with incident VT, 457 had recurrent VT. Time-to-event models with time-varying statin use and adjustment for potential confounders was used for analysis. Compared to nonuse, current statin use was associated with 26% lower risk of recurrent VT. Click to hear Prof. Büller's perspective on Anticoagulant Therapy in the Treatment of Venous Thromboembolism SUMMARY Background Meta-analyses of randomized controlled trials suggest that treatment with hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) lowers the risk of incident venous thrombosis (VT), particularly among those without prevalent clinical cardiovascular disease (CVD). Whether this is true for the prevention of recurrent VT is debated. We used an observational inception cohort to estimate the association of current statin use with the risk of recurrent VT. Methods and Results The study setting was a large healthcare organization with detailed medical record and pharmacy information at cohort entry and throughout follow-up. We followed 2798 subjects 18-89 years of age who experienced a validated incident VT between January 1, 2002, and December 31, 2010, for a first recurrent VT, validated by medical record review. During follow-up, 457 (16%) developed a first recurrent VT. In time-to-event models incorporating time-varying statin use and adjusting for potential confounders, current statin use was associated with a 26% lower risk of recurrent VT: hazard ratio 0.74, 95% confidence interval 0.59-0.94. Among cohort members free of CVD (n = 2134), current statin use was also associated with a lower risk (38%) of recurrent VT: hazard ratio 0.62, 95% confidence interval 0.45-0.85. We found similar results when restricting to new users of statins and in subgroups of different statin types and doses. Conclusions In a population-based cohort of subjects who had experienced an incident VT, statin use, compared with nonuse, was associated with a clinically relevant lower risk of recurrent VT. These findings suggest a potential secondary benefit of statins among patients who have experienced an incident VT.
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Affiliation(s)
- N L Smith
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Group Health Cooperative, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - L B Harrington
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - M Blondon
- Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - K L Wiggins
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - J S Floyd
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - C M Sitlani
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - B McKnight
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - E B Larson
- Group Health Research Institute, Group Health Cooperative, Seattle, WA, USA
| | - F R Rosendaal
- Departments of Clinical Epidemiology and of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S R Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Group Health Cooperative, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - B M Psaty
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Group Health Cooperative, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
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Blondon M, Harrington LB, Boehlen F, Robert-Ebadi H, Righini M, Smith NL. Pre-pregnancy BMI, delivery BMI, gestational weight gain and the risk of postpartum venous thrombosis. Thromb Res 2016; 145:151-6. [PMID: 27421192 DOI: 10.1016/j.thromres.2016.06.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To characterize the risk of postpartum venous thromboembolism (VTE) associated with body-mass-index (BMI) in both pre-pregnancy and at delivery, and with gestational weight gain (GWG). METHODS In a population-based, case-control study, we identified all women in Washington State with ICD-9 codes for VTE in the postpartum period between 2003 and 2011. Controls were women without VTE in the postpartum period, matched by delivery year to cases. Pre-pregnancy BMI, delivery BMI, and covariates were abstracted from birth certificates. Adjusted logistic regression models separately estimated postpartum VTE risk associated with categories of BMI in pre-pregnancy and at delivery. RESULTS Cases (n=289) had a higher mean BMI than controls (n=4208) pre-pregnancy (29.9kg/m(2) and 26.3kg/m(2), respectively) and at delivery (34.8kg/m(2) vs. 31.4kg/m(2), respectively), with similar gestational weight gains. Compared with women with a normal pre-pregnancy BMI (18.5-24.9kg/m(2)), overweight (BMI 25-29.9kg/m(2)) and obese (BMI≥30kg/m(2)) women were at a 1.5-fold and 1.8-4 fold greater risk of postpartum VTE, respectively, with greatest risks in women with class III obesity (BMI≥40kg/m(2): OR 4.0, 95%CI 2.7-6.3). Observed associations of delivery BMI with postpartum VTE were less strong than those of pre-pregnancy BMI. Large weight gains during pregnancy (>22kg) also contributed to greater VTE risks (OR 1.5, 95%CI 1.0-2.2). CONCLUSION Maternal BMI is an important risk factor for postpartum VTE, grading from weak in overweight women to very strong in women with class III obesity. Care providers may prefer to use pre-pregnancy BMI, along gestational weight gain, when stratifying the risk of postpartum VTE at delivery.
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Affiliation(s)
- M Blondon
- Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Department of Epidemiology, University of Washington, Seattle, USA.
| | - L B Harrington
- Department of Epidemiology, University of Washington, Seattle, USA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, USA
| | - F Boehlen
- Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - H Robert-Ebadi
- Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M Righini
- Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - N L Smith
- Department of Epidemiology, University of Washington, Seattle, USA; Group Health Research Institute, Group Health Cooperative, Seattle, USA; Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, USA
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Callegari LS, Gray KE, Zephyrin LC, Harrington LB, Gerber MR, Cochrane BB, Weitlauf JC, Bean-Mayberry B, Bastian LA, Mattocks KM, Haskell SG, Katon JG. Hysterectomy and Bilateral Salpingo-Oophorectomy: Variations by History of Military Service and Birth Cohort. Gerontologist 2016; 56 Suppl 1:S67-77. [PMID: 26768393 DOI: 10.1093/geront/gnv666] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Little is known about hysterectomy and bilateral salpingo-oophorectomy (BSO), which are associated with both health risks and benefits, among women Veterans. PURPOSE OF THE STUDY To compare the prevalence of hysterectomy with or without BSO, and early hysterectomy, between postmenopausal Veterans and non-Veterans. DESIGN AND METHODS We used baseline data from the Women's Health Initiative Clinical Trial and Observational Study. Multinomial logistic regression models examined differences in the prevalence of hysterectomy (neither hysterectomy nor BSO, hysterectomy without BSO, and hysterectomy with BSO) between Veterans and non-Veterans. Generalized linear models were used to determine whether early hysterectomy (before age 40) differed between Veterans and non-Veterans. Analyses were stratified by birth cohort (<65, ≥65 years at enrollment). RESULTS The unadjusted prevalence of hysterectomy without BSO was similar among Veterans and non-Veterans in both birth cohorts (<65: 22% vs 21%; ≥65: 22% vs 21%). The unadjusted prevalence of hysterectomy with BSO was equivalent among Veterans and non-Veterans in the >65 cohort (21%), but higher among Veterans in the <65 cohort (22% vs 19%). In adjusted analyses, although no differences were observed in the >65 cohort, Veterans in the <65 cohort had higher odds of hysterectomy without BSO (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03, 1.36) and with BSO (OR 1.26, 95% CI 1.10, 1.45), as well as elevated risk of early hysterectomy (relative risk 1.32, 95% CI 1.19, 1.47), compared with non-Veterans. IMPLICATIONS Aging women Veterans may have higher prevalence of hysterectomy and BSO than non-Veterans. This information contributes to understanding the health needs and risks of women Veterans and can inform clinical practice and policy for this population.
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Affiliation(s)
- Lisa S Callegari
- Department of Obstetrics and Gynecology, University of Washington, Seattle. VA Puget Sound Health Care System, Health Services Research and Development (HSR&D), Seattle, Washington.
| | - Kristen E Gray
- VA Puget Sound Health Care System, Health Services Research and Development (HSR&D), Seattle, Washington. Department of Health Services, University of Washington School of Public Health, Seattle
| | - Laurie C Zephyrin
- VA Office of Patient Care, Women's Health Services, Washington, DC. VA New York Harbor. Department of Obstetrics and Gynecology, New York University Langone School of Medicine. Department of Veterans Affairs, Veterans Health Administration, Washington, DC
| | - Laura B Harrington
- Department of Epidemiology, University of Washington School of Public Health, Seattle
| | - Megan R Gerber
- VA Boston Healthcare System, Massachusetts. Department of Medicine, Boston University School of Medicine, Massachusetts
| | - Barbara B Cochrane
- de Tornyay Center for Healthy Aging, University of Washington School of Nursing, Seattle. Fred Hutchinson Cancer Research Center, Public Health Sciences, Seattle, Washington
| | - Julie C Weitlauf
- VA Palo Alto Health Care System, California. Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, California
| | - Bevanne Bean-Mayberry
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, California. Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles
| | - Lori A Bastian
- VA Connecticut, West Haven. Division of General Internal Medicine, University of Connecticut, Farmington
| | - Kristin M Mattocks
- VA Central Western Massachusetts, Leeds. University of Massachusetts Medical School, Worcester
| | - Sally G Haskell
- VA Office of Patient Care, Women's Health Services, Washington, DC. VA Connecticut Health Care System, New Haven
| | - Jodie G Katon
- VA Puget Sound Health Care System, Health Services Research and Development (HSR&D), Seattle, Washington. Department of Health Services, University of Washington School of Public Health, Seattle. VA Office of Patient Care, Women's Health Services, Washington, DC
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Harrington LB, Wiggins KL, Sitlani CM, Blondon M, van Hylckama Vlieg A, Rosendaal FR, Heckbert SR, Psaty BM, Smith NL. The association of F11 genetic variants with the risk of incident venous thrombosis among women, by statin use. Thromb Haemost 2015; 115:682-4. [PMID: 26631918 DOI: 10.1160/th15-08-0683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/29/2015] [Indexed: 11/05/2022]
Abstract
Supplementary Material to this article is available online at www.thrombosis-online.com.
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Affiliation(s)
- Laura B Harrington
- Laura B. Harrington, PhD, Department of Nutrition, Harvard T. H. Chan School of Public Health, 655 Huntington Ave., Boston, MA 02115, USA, Tel.: +1 617 432 1841, Fax: +1 617 432 2435, E-mail:
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Katon JG, Gray KE, Gerber MR, Harrington LB, Woods NF, Weitlauf JC, Bean-Mayberry B, Goldstein KM, Hunt JR, Katon WJ, Haskell SG, McCutcheon SJ, Gass ML, Gibson CJ, Zephyrin LC. Vasomotor Symptoms and Quality of Life Among Veteran and Non-Veteran Postmenopausal Women. GERONT 2015. [DOI: 10.1093/geront/gnv104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Blondon M, Quon BS, Harrington LB, Bounameaux H, Smith NL. Association between newborn birth weight and the risk of postpartum maternal venous thromboembolism: a population-based case-control study. Circulation 2015; 131:1471-6; discussion 1476. [PMID: 25745022 DOI: 10.1161/circulationaha.114.012749] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 02/13/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Postpartum venous thromboembolism (VTE) is a potentially fatal and preventable event leading to substantial short- and long-term morbidity. We sought to evaluate whether the delivery of term newborns of low or high birth weight was associated with greater risks of VTE. METHODS AND RESULTS In a population-based case-control study conducted in Washington State from 1987 through 2011, cases of hospitalized VTE within 3 months of delivery were identified by using selected International Classification of Diseases, Ninth Revision, Clinical Modification codes. Controls were randomly selected postpartum women without VTE, matched on birth year. Birth weight and other maternal and pregnancy characteristics were extracted from birth certificate data. Among term live singleton deliveries, we compared the risk of VTE for mothers of newborns of low and high birth weights (<2500 g and >4000 g, respectively) versus mothers of newborns of normal birth weight (2500-4000 g). Logistic regression models were adjusted for maternal age, race, education, body mass index, parity, delivery methods, gestational length, smoking, gestational diabetes mellitus, and preeclampsia. Patients with VTE (n=547) were older, had a higher body mass index, and experienced more pregnancy-related complications than controls (n=9482). In comparison with mothers of newborns with normal birth weight, mothers of newborns with low birth weight had a 3-fold increased risk of VTE, which persisted after multivariable adjustment (odds ratio, 2.98; 95% confidence interval, 1.80-4.93). Mothers of newborns with high birth weight had only a slightly increased risk of VTE, which was attenuated after multivariable adjustment (odds ratio, 1.26; 95% confidence interval, 0.99-1.61). CONCLUSIONS The delivery of a newborn with low birth weight is associated with a 3-fold increased risk of maternal postpartum VTE. This should be considered when assessing VTE risk at delivery.
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Affiliation(s)
- Marc Blondon
- From Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland (M.B., H.B.); Department of Epidemiology, University of Washington, Seattle (M.B., L.B.H., N.L.S.); Division of Respirology, Department of Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada (B.S.Q.); Group Health Research Institute, Group Health Cooperative, Seattle, WA (N.L.S.); and Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA (N.L.S.).
| | - Bradley S Quon
- From Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland (M.B., H.B.); Department of Epidemiology, University of Washington, Seattle (M.B., L.B.H., N.L.S.); Division of Respirology, Department of Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada (B.S.Q.); Group Health Research Institute, Group Health Cooperative, Seattle, WA (N.L.S.); and Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA (N.L.S.)
| | - Laura B Harrington
- From Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland (M.B., H.B.); Department of Epidemiology, University of Washington, Seattle (M.B., L.B.H., N.L.S.); Division of Respirology, Department of Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada (B.S.Q.); Group Health Research Institute, Group Health Cooperative, Seattle, WA (N.L.S.); and Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA (N.L.S.)
| | - Henri Bounameaux
- From Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland (M.B., H.B.); Department of Epidemiology, University of Washington, Seattle (M.B., L.B.H., N.L.S.); Division of Respirology, Department of Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada (B.S.Q.); Group Health Research Institute, Group Health Cooperative, Seattle, WA (N.L.S.); and Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA (N.L.S.)
| | - Nicholas L Smith
- From Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland (M.B., H.B.); Department of Epidemiology, University of Washington, Seattle (M.B., L.B.H., N.L.S.); Division of Respirology, Department of Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada (B.S.Q.); Group Health Research Institute, Group Health Cooperative, Seattle, WA (N.L.S.); and Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA (N.L.S.)
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Blondon M, Harrington LB, Righini M, Boehlen F, Bounameaux H, Smith NL. Racial and ethnic differences in the risk of postpartum venous thromboembolism: a population-based, case-control study. J Thromb Haemost 2014; 12:2002-9. [PMID: 25279442 DOI: 10.1111/jth.12747] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [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: 06/04/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major contributor of maternal morbidity and mortality. Whether maternal race/ethnicity is associated with the risk of postpartum VTE remains unclear. METHODS AND RESULTS We conducted a population-based, case-control study in Washington State, from 1987 through 2011. Cases comprised all women with selected International Classification of Diseases, Ninth Edition, Clinical Modification codes for hospitalized VTE within 3 months post-delivery. Controls were randomly selected postpartum women who did not experience a VTE. Characteristics of women and their deliveries were abstracted from birth certificates. Using logistic regression models, we compared the risk of postpartum VTE in black, Asian, and Hispanic women with that in non-Hispanic white women, after adjustment for maternal characteristics (age, body mass index, parity, education), pregnancy complications, and delivery methods. RESULTS Our study comprised 688 cases and 10 246 controls. Among controls, the mean age and body mass index were 27.5 years and 26.3 kg m(-2) , respectively. Compared with white women, black and Asian women had a greater and lower risk of postpartum VTE (adjusted odds ratio [OR] 1.50, 95% confidence interval [CI] 1.10-2.04 and OR 0.67, 95%CI 0.48-0.94, respectively). A lower risk was present in Hispanic women (adjusted OR 0.80, 95% CI 0.61-1.06) but was not statistically significant. In subgroup analyses, we observed an increased risk for black compared with white women among women who delivered via cesarean section (OR 2.03, 95% CI 1.34-3.07) but not among vaginal deliveries (OR 1.03, 95% CI 0.61-1.74). CONCLUSIONS Maternal race/ethnicity is associated with the risk of postpartum VTE, independently of other risk factors, and should be considered when assessing the use of thromboprophylaxis after delivery.
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Affiliation(s)
- M Blondon
- Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Department of Epidemiology, University of Washington, Seattle, WA, USA
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Dombkowski KJ, Costello LE, Harrington LB, Dong S, Kolasa M, Clark SJ. Age-specific strategies for immunization reminders and recalls: a registry-based randomized trial. Am J Prev Med 2014; 47:1-8. [PMID: 24750973 DOI: 10.1016/j.amepre.2014.02.009] [Citation(s) in RCA: 14] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 01/31/2014] [Accepted: 02/12/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although previous studies have found reminder/recall to be effective in increasing immunization rates, little guidance exists regarding the specific ages at which it is optimal to send reminder/recall notices. PURPOSE To assess the relative effectiveness of centralized reminder/recall strategies targeting age-specific vaccination milestones among children in urban areas during June 2008-June 2009. METHODS Three reminder/recall strategies used capabilities of the Michigan Care Improvement Registry (MCIR), a statewide immunization information system: a 7-month recall strategy, a 12-month reminder strategy, and a 19-month recall strategy. Eligible children were randomized to notification (intervention) or no notification groups (control). Primary study outcomes included MCIR-recorded immunization activity (administration of ≥1 new dose, entry of ≥1 historic dose, entry of immunization waiver) within 60 days following each notification cycle. RESULTS A total of 10,175 children were included: 2,072 for the 7-month recall, 3,502 for the 12-month reminder, and 4,601 for the 19-month recall. Immunization activity was similar between notification versus no notification groups at both 7 and 12 months. Significantly more 19-month-old children in the recall group (26%) had immunization activity compared to their counterparts who did not receive a recall notification (19%). CONCLUSIONS Although recall notifications can positively affect immunization activity, the effect may vary by targeted age group. Many 7- and 12-month-olds had immunization activity following reminder/recall; however, levels of activity were similar irrespective of notification, suggesting that these groups were likely to receive medical care or immunization services without prompting.
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Affiliation(s)
- Kevin J Dombkowski
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan.
| | - Lauren E Costello
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Laura B Harrington
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Shiming Dong
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Maureen Kolasa
- National Center for Immunization and Respiratory Diseases, the CDC, Atlanta, Georgia
| | - Sarah J Clark
- National Center for Immunization and Respiratory Diseases, the CDC, Atlanta, Georgia
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Blondon M, van Hylckama Vlieg A, Wiggins KL, Harrington LB, McKnight B, Rice KM, Rosendaal FR, Heckbert SR, Psaty BM, Smith NL. Differential associations of oral estradiol and conjugated equine estrogen with hemostatic biomarkers. J Thromb Haemost 2014; 12:879-86. [PMID: 24628832 PMCID: PMC5371691 DOI: 10.1111/jth.12560] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND The risk of venous thrombosis (VT) associated with oral hormone therapy (HT) may differ by type of estrogen compound. OBJECTIVE To compare the thrombotic profile of women using oral conjugated equine estrogens (CEE) with that of women using oral estradiol (E2). METHODS In postmenopausal, female, health maintenance organization (HMO) members with no history of VT, we measured thrombin generation, levels of factor VII activity, antithrombin activity and total protein S antigen. Mean levels of hemostasis biomarkers were cross-sectionally compared by use and type of estrogen using multiple linear regressions. The type of estrogen used was determined primarily by the HMO formulary, which changed its preferred estrogen from CEE to E2 during the study period. RESULTS The sample included 92 E2 users and 48 CEE users, with a mean age of 64.1 years and mean BMI of 29.1 kg m(-2) . Twenty-seven per cent of HT contained medroxyprogesterone acetate. Compared with E2 users, CEE users had greater thrombin generation peak values and endogenous thrombin potential, and lower total protein S (multivariate adjusted differences of 49.8 nm (95% CI, 21.0, 78.6), 175.0 nm × Min (95% CI, 54.4, 295.7) and -13.4% (95% CI, -19.8, -6.9), respectively). Factor VII and antithrombin levels were not different between E2 and CEE users. Results were similar in subgroups of users of unopposed HT, opposed HT, low-dose estrogen and standard dose estrogen. CONCLUSION The hemostatic profile of women using CEE is more prothrombotic than that of women using E2. These findings provide further evidence for a different thrombotic risk for oral CEE and oral E2.
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Affiliation(s)
- M Blondon
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
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Smith NL, Blondon M, Wiggins KL, Harrington LB, van Hylckama Vlieg A, Floyd JS, Hwang M, Bis JC, McKnight B, Rice KM, Lumley T, Rosendaal FR, Heckbert SR, Psaty BM. Lower risk of cardiovascular events in postmenopausal women taking oral estradiol compared with oral conjugated equine estrogens. JAMA Intern Med 2014; 174:25-31. [PMID: 24081194 PMCID: PMC4636198 DOI: 10.1001/jamainternmed.2013.11074] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Little is known about the comparative cardiovascular safety of oral hormone therapy products, which impedes women from making informed safety decisions about hormone therapy to treat menopausal symptoms. OBJECTIVE To compare the relative clinical cardiovascular safety of 2 commonly used oral estrogen drugs-conjugated equine estrogens (CEEs) and estradiol. DESIGN, SETTING, AND PARTICIPANTS Population-based, case-control study from January 1, 2003, to December 31, 2009, comparing cardiovascular event risk associated with current CEEs and estradiol use in a large health maintenance organization in which the preferred formulary estrogen changed from CEEs to estradiol during the course of data collection. Participants were 384 postmenopausal women aged 30 to 79 years using oral hormone therapy. MAIN OUTCOMES AND MEASURES Incident venous thrombosis was the primary clinical outcome, and incident myocardial infarction and ischemic stroke were secondary outcomes. As validation, an intermediate clotting phenotype, the endogenous thrombin potential-based normalized activated protein C sensitivity ratio, was measured in plasma of controls. RESULTS We studied 68 venous thrombosis, 67 myocardial infarction, and 48 ischemic stroke cases, with 201 matched controls; all participants were current users of oral CEEs or estradiol. In adjusted analyses, current oral CEEs use compared with current oral estradiol use was associated with an increased venous thrombosis risk (odds ratio, 2.08; 95% CI, 1.02-4.27; P = .045) and an increased myocardial infarction risk that did not reach statistical significance (odds ratio, 1.87; 95% CI, 0.91-3.84; P = .09) and was not associated with ischemic stroke risk (odds ratio, 1.13; 95% CI, 0.55-2.31; P = .74). Among 140 controls, CEEs users compared with estradiol users had higher endogenous thrombin potential-based normalized activated protein C sensitivity ratios (P < .001), indicating a stronger clotting propensity. CONCLUSIONS AND RELEVANCE In an observational study of oral hormone therapy users, CEEs use was associated with a higher risk of incident venous thrombosis and possibly myocardial infarction than estradiol use. This risk differential was supported by biologic data. These findings need replication and suggest that various oral estrogen drugs may be associated with different levels of cardiovascular risk.
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Affiliation(s)
- Nicholas L Smith
- Department of Epidemiology, University of Washington, Seattle2Group Health Research Institute, Group Health Cooperative, Seattle, Washington3Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Devel
| | - Marc Blondon
- Department of Epidemiology, University of Washington, Seattle4Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | | | | | | | - James S Floyd
- Department of Medicine, University of Washington, Seattle
| | - Melody Hwang
- Department of Epidemiology, University of Washington, Seattle
| | - Joshua C Bis
- Department of Medicine, University of Washington, Seattle
| | | | - Kenneth M Rice
- Department of Biostatistics, University of Washington, Seattle
| | - Thomas Lumley
- Department of Biostatistics, University of Washington, Seattle8Department of Statistics, University of Auckland, Auckland, New Zealand
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands9Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle2Group Health Research Institute, Group Health Cooperative, Seattle, Washington
| | - Bruce M Psaty
- Department of Epidemiology, University of Washington, Seattle2Group Health Research Institute, Group Health Cooperative, Seattle, Washington5Department of Medicine, University of Washington, Seattle10Department of Health Services, University of Washington
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Blondon M, Wiggins KL, Harrington LB, Psaty BM, Smith NL. Lack of strong effect modification by NFE2L2/CYP3A5/ABO of the risk of venous thrombosis associated with oral hormone therapy. J Thromb Haemost 2013; 11:1617-9. [PMID: 23734777 PMCID: PMC4363936 DOI: 10.1111/jth.12309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Indexed: 10/26/2022]
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Dombkowski KJ, Cowan AE, Harrington LB, Allred NJ, Hudson E, Clark SJ. Feasibility of initiating and sustaining registry-based immunization recall in private practices. Acad Pediatr 2012; 12:104-9. [PMID: 22321815 DOI: 10.1016/j.acap.2012.01.002] [Citation(s) in RCA: 15] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 12/22/2011] [Accepted: 01/01/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the feasibility of initiating and sustaining immunization recall by private practices, including the barriers and costs, using a statewide immunization information system (IIS). METHODS Private practices in southeast Michigan were recruited in 2007 to perform IIS-based immunization recalls. Enrolled practices were provided with training and asked to conduct 4 recalls during the course of 12 months of children 19 to 35 months of age. Each practice recorded the time they spent performing recall-related activities; labor costs were estimated. Formative and summative evaluations with semistructured interviews were conducted to identify barriers. RESULTS Of 97 eligible pediatric and family medicine practices, 44 declined to participate, 32 did not respond to repeated contacts, and 20 agreed to enroll in the study (21%). A total of 56 recalls were conducted during the study period, with 9 practices completing at least 4 recalls and 7 practices completing 1 to 3 recalls; 4 practices conducted no recalls. Common barriers reported included time constraints and executing all steps of the recalls. Practice costs per patient recalled ranged from $0.05 to more than $6 and were primarily driven by the type of personnel who performed recalls. The costs of creating a roster of current patients comprised nearly one-half of total labor costs. CONCLUSIONS Few private provider practices that we contacted were willing to participate in this study of IIS-based recall, and less than one-half of enrolled practices completed the desired 4 recall cycles in 12 months. Time constraints and other real-world problems should not be underestimated in determining the feasibility of practice-based immunization recall. Efforts to increase the use of a statewide IIS for recall in private practice settings should emphasize ongoing training and technical support to practice staff. Improved interoperability with electronic health record systems may foster practice-based recall by reducing the labor intensity of roster building and other recall activities.
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Affiliation(s)
- Kevin J Dombkowski
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, 48109-5456, USA.
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Dombkowski KJ, Harrington LB, Dong S, Clark SJ. Seasonal influenza vaccination reminders for children with high-risk conditions: a registry-based randomized trial. Am J Prev Med 2012; 42:71-5. [PMID: 22176850 DOI: 10.1016/j.amepre.2011.09.028] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 07/21/2011] [Accepted: 09/13/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with chronic conditions have an increased risk of complications from influenza and have low influenza vaccination rates. PURPOSE To assess the feasibility and effectiveness of using a statewide immunization information system (IIS) for seasonal influenza vaccine reminders from local health departments (LHDs) targeting children with high-risk conditions. DESIGN A randomized community intervention. SETTING/PARTICIPANTS The study was conducted in a population of 3618 children aged 24-60 months with a high-risk condition residing in three Michigan counties. Children were identified using a statewide IIS in October 2008. INTERVENTION Children were randomized to intervention (reminder) or control (no reminder) groups. Reminders for seasonal influenza vaccination were mailed by LHDs in November 2008. MAIN OUTCOME MEASURES Feasibility of notification (address validity, address deliverability) was assessed (November 2008-February 2009), and frequencies of notification feasibility measures were determined (analyses conducted in 2010). Effectiveness of notification (seasonal influenza vaccine receipt) was assessed using bivariate logistic regression. RESULTS Among 3618 children with a high-risk condition, 2730 (75.5%) had not received a 2008-2009 influenza vaccination and were eligible at the time of notification. Among children assigned to the reminder group (n=1374), 42.6% had an address determined to be either invalid, undeliverable, or both. Among those with valid addresses (n=2001), a greater percentage of children with deliverable reminders received at least one influenza vaccination (30.8%) during the outcome observation period than did children assigned to no reminder (24.3%, OR=1.39, 95% CI=1.13, 1.72); children with an undeliverable reminder had an influenza vaccination rate (22.8%) similar to children assigned to no reminder. CONCLUSIONS Receipt of a reminder was positively associated with seasonal influenza vaccination. However, more than 40% of children assigned to receive a reminder were determined to have an invalid or undeliverable address, emphasizing the need for increased quality of IIS contact information. TRIAL REGISTRATION This study is registered at www.ClinicalTrials.gov NCT01431183.
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Affiliation(s)
- Kevin J Dombkowski
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan 48109-5456, USA.
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