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He R, Hornberger LK, Kaur A, Crawford S, Boehme C, McBrien A, Eckersley L. Risk of major congenital heart disease in pregestational maternal diabetes is modified by hemoglobin A1c. Ultrasound Obstet Gynecol 2024; 63:378-384. [PMID: 37594210 DOI: 10.1002/uog.27456] [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] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/26/2023] [Accepted: 08/04/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVES The association between pregestational diabetes mellitus (PDM) and risk of congenital heart disease (CHD) is well recognized; however, the importance of glycemic control and other coexisting risk factors during pregnancy is less clear. We sought to determine the relative risk (RR) of major CHD (mCHD) among offspring from pregnancies complicated by PDM and the effect of first-trimester glycemic control on mCHD risk. METHODS We determined the incidence of mCHD (requiring surgery within 1 year of birth or resulting in pregnancy termination or fetal demise) among registered births in Alberta, Canada. Linkage of diabetes status, maximum hemoglobin A1c (HbA1c) at < 16 weeks' gestation and other covariates was performed using data from the Alberta Perinatal Health Program registry. Risk of mCHD according to HbA1c was estimated as an adjusted RR (aRR), calculated using log-binomial modeling. RESULTS Of 1412 cases of mCHD in 594 773 (2.37/1000) births in the study period, mCHD was present in 48/7497 with PDM (6.4/1000; RR, 2.8 (95% CI, 2.1-3.7); P < 0.0001). In the entire cohort, increased maternal age (aRR, 1.03 (95% CI, 1.02-1.04); P < 0.0001) and multiple gestation (aRR, 1.37 (95% CI, 1.1-1.8); P = 0.02) were also associated with mCHD risk, whereas maternal prepregnancy weight > 91 kg was not. The stratified risk for mCHD associated with HbA1c ≤ 6.1%, > 6.1-8.0% and > 8.0% was 4.2/1000, 6.8/1000 and 17.1/1000 PDM/gestational diabetes mellitus births, respectively; the aRR of mCHD associated with PDM and HbA1c > 8.0% was 8.5 (95% CI, 5.0-14.4) compared to those without diabetes and 5.5 (95% CI, 1.6-19.4) compared to PDM with normal HbA1c (≤ 6.1%). CONCLUSIONS PDM is associated with a RR of 2.8 for mCHD, increasing to 8.5 in those with HbA1c > 8%. These data should facilitate refinement of referral indications for high-risk pregnancy screening. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R He
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - L K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - A Kaur
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - S Crawford
- Alberta Perinatal Health Program, Alberta Health Services, AB, Canada
| | - C Boehme
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - A McBrien
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - L Eckersley
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
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Kapoor A, Patel P, Chennupati S, Mbusa D, Sadiq H, Rampam S, Leung R, Miller M, Vargas KR, Fry P, Lowe MM, Catalano C, Harrison C, Catanzaro JN, Crawford S, Smith AM. Comparing the Efficacy of Targeted and Blast Portal Messaging in Message Opening Rate and Anticoagulation Initiation in Patients With Atrial Fibrillation in the Preventing Preventable Strokes Study II: Prospective Cohort Study. JMIR Cardio 2024; 8:e49590. [PMID: 38265849 PMCID: PMC10851125 DOI: 10.2196/49590] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/24/2023] [Accepted: 11/24/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND The gap in anticoagulation use among patients with atrial fibrillation (AF) is a major public health threat. Inadequate patient education contributes to this gap. Patient portal-based messaging linked to educational materials may help bridge this gap, but the most effective messaging approach is unknown. OBJECTIVE This study aims to compare the responsiveness of patients with AF to an AF or anticoagulation educational message between 2 portal messaging approaches: sending messages targeted at patients with upcoming outpatient appointments 1 week before their scheduled appointment (targeted) versus sending messages to all eligible patients in 1 blast, regardless of appointment scheduling status (blast), at 2 different health systems: the University of Massachusetts Chan Medical School (UMass) and the University of Florida College of Medicine-Jacksonville (UFL). METHODS Using the 2 approaches, we sent patient portal messages to patients with AF and grouped patients by high-risk patients on anticoagulation (group 1), high-risk patients off anticoagulation (group 2), and low-risk patients who may become eligible for anticoagulation in the future (group 3). Risk was classified based on the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age between 65 and 74 years, and sex category (CHA2DS2-VASc) score. The messages contained a link to the Upbeat website of the Heart Rhythm Society, which displays print and video materials about AF and anticoagulation. We then tracked message opening, review of the website, anticoagulation use, and administered patient surveys across messaging approaches and sites using Epic Systems (Epic Systems Corporation) electronic health record data and Google website traffic analytics. We then conducted chi-square tests to compare potential differences in the proportion of patients opening messages and other evaluation metrics, adjusting for potential confounders. All statistical analyses were performed in SAS (version 9.4; SAS Institute). RESULTS We sent 1686 targeted messages and 1450 blast messages. Message opening was significantly higher with the targeted approach for patients on anticoagulation (723/1156, 62.5% vs 382/668, 57.2%; P=.005) and trended the same in patients off anticoagulation; subsequent website reviews did not differ by messaging approach. More patients off anticoagulation at baseline started anticoagulation with the targeted approach than the blast approach (adjusted percentage 9.3% vs 2.1%; P<.001). CONCLUSIONS Patients were more responsive in terms of message opening and subsequent anticoagulation initiation with the targeted approach.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Chan Medical School, Worcester, MA, United States
- University of Massachusetts Memorial Health Care, Worcester, MA, United States
| | - Parth Patel
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Soumya Chennupati
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Daniel Mbusa
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Hammad Sadiq
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Sanjeev Rampam
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Robert Leung
- University of Massachusetts Chan Medical School, Worcester, MA, United States
- University of Massachusetts Memorial Health Care, Worcester, MA, United States
| | - Megan Miller
- College of Pharmacy, University of Florida, Jacksonville, FL, United States
| | | | - Patrick Fry
- College of Medicine, University of Florida, Jacksonville, FL, United States
| | | | - Christina Catalano
- College of Medicine, University of Florida, Jacksonville, FL, United States
| | - Charles Harrison
- College of Medicine, University of Florida, Jacksonville, FL, United States
| | | | - Sybil Crawford
- University of Massachusetts Chan Medical School, Worcester, MA, United States
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Kapoor A, Patel P, Mbusa D, Pham T, Cicirale C, Tran W, Beavers C, Javed S, Wagner J, Swain D, Crawford S, Darling C, ItoFuKunaga M, McManus D, Mazor K, Gurwitz J. Multicomponent Pharmacist Intervention Did Not Reduce Clinically Important Medication Errors for Ambulatory Patients Initiating Direct Oral Anticoagulants. J Gen Intern Med 2023; 38:3526-3534. [PMID: 37758967 PMCID: PMC10713923 DOI: 10.1007/s11606-023-08315-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/30/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Anticoagulants including direct oral anticoagulants (DOACs) are among the highest-risk medications in the United States. We postulated that routine consultation and follow-up from a clinical pharmacist would reduce clinically important medication errors (CIMEs) among patients beginning or resuming a DOAC in the ambulatory care setting. OBJECTIVE To evaluate the effectiveness of a multicomponent intervention for reducing CIMEs. DESIGN Randomized controlled trial. PARTICIPANTS Ambulatory patients initiating a DOAC or resuming one after a complication. INTERVENTION Pharmacist evaluation and monitoring based on the implementation of a recently published checklist. Key elements included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests. CONTROL Coupons and assistance to increase the affordability of DOACs. MAIN MEASURE Anticoagulant-related CIMEs (Anticoagulant-CIMEs) and non-anticoagulant-related CIMEs over 90 days from DOAC initiation; CIMEs identified through masked assessment process including two physician adjudication of events presented by a pharmacist distinct from intervention pharmacist who reviewed participant electronic medical records and interview data. ANALYSIS Incidence and incidence rate ratio (IRR) of CIMEs (intervention vs. control) using multivariable Poisson regression modeling. KEY RESULTS A total of 561 patients (281 intervention and 280 control patients) contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs (0.95 per 100 person-days). Failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs were the most common anticoagulant-related CIMEs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients (IRR 1.17; 95% CI 0.98-1.42) or non-anticoagulant-related CIMEs (IRR 1.05; 95% CI 0.80-1.37). CONCLUSION A multi-component intervention in which clinical pharmacists implemented an evidence-based DOAC Checklist did not reduce CIMEs. NIH TRIAL NUMBER NCT04068727.
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Affiliation(s)
- Alok Kapoor
- UMass Chan Medical School, Worcester, MA, USA.
- UMass Memorial Medical Center, Worcester, MA, USA.
| | - Parth Patel
- UMass Chan Medical School, Worcester, MA, USA
| | | | - Thu Pham
- UMass Chan Medical School, Worcester, MA, USA
| | - Carrie Cicirale
- Barnes-Jewish Hospital, One Barnes Jewish Hospital Plaza, St. Louis, MO, USA
| | - Wenisa Tran
- UMass Memorial Medical Center, Worcester, MA, USA
| | | | - Saud Javed
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Medical Center, Worcester, MA, USA
| | | | - Dawn Swain
- Bouve College of Health Sciences, Northeastern University , Boston, MA, USA
- Beverly Hospital, Beverly, MA, USA
| | - Sybil Crawford
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Chad Darling
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Medical Center, Worcester, MA, USA
| | - Mayuko ItoFuKunaga
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Medical Center, Worcester, MA, USA
| | - David McManus
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Medical Center, Worcester, MA, USA
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Fleming V, Prasad A, Ge C, Crawford S, Meraj S, Hough CL, Lo B, Carson SS, Steingrub J, White DB, Muehlschlegel S. Prevalence and predictors of shared decision-making in goals-of-care clinician-family meetings for critically ill neurologic patients: a multi-center mixed-methods study. Crit Care 2023; 27:403. [PMID: 37865797 PMCID: PMC10590503 DOI: 10.1186/s13054-023-04693-2] [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: 08/16/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Shared decision-making is a joint process where patients, or their surrogates, and clinicians make health choices based on evidence and preferences. We aimed to determine the extent and predictors of shared decision-making for goals-of-care discussions for critically ill neurological patients, which is crucial for patient-goal-concordant care but currently unknown. METHODS We analyzed 72 audio-recorded routine clinician-family meetings during which goals-of-care were discussed from seven US hospitals. These occurred for 67 patients with 72 surrogates and 29 clinicians; one hospital provided 49/72 (68%) of the recordings. Using a previously validated 10-element shared decision-making instrument, we quantified the extent of shared decision-making in each meeting. We measured clinicians' and surrogates' characteristics and prognostic estimates for the patient's hospital survival and 6-month independent function using post-meeting questionnaires. We calculated clinician-family prognostic discordance, defined as ≥ 20% absolute difference between the clinician's and surrogate's estimates. We applied mixed-effects regression to identify independent associations with greater shared decision-making. RESULTS The median shared decision-making score was 7 (IQR 5-8). Only 6% of meetings contained all 10 shared decision-making elements. The most common elements were "discussing uncertainty"(89%) and "assessing family understanding"(86%); least frequent elements were "assessing the need for input from others"(36%) and "eliciting the context of the decision"(33%). Clinician-family prognostic discordance was present in 60% for hospital survival and 45% for 6-month independent function. Univariate analyses indicated associations between greater shared decision-making and younger clinician age, fewer years in practice, specialty (medical-surgical critical care > internal medicine > neurocritical care > other > trauma surgery), and higher clinician-family prognostic discordance for hospital survival. After adjustment, only higher clinician-family prognostic discordance for hospital survival remained independently associated with greater shared decision-making (p = 0.029). CONCLUSION Fewer than 1 in 10 goals-of-care clinician-family meetings for critically ill neurological patients contained all shared decision-making elements. Our findings highlight gaps in shared decision-making. Interventions promoting shared decision-making for high-stakes decisions in these patients may increase patient-value congruent care; future studies should also examine whether they will affect decision quality and surrogates' health outcomes.
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Affiliation(s)
- Victoria Fleming
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Abhinav Prasad
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Departments of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Connie Ge
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Sybil Crawford
- Tan Chingfen University of Massachusetts Graduate School of Nursing, Worcester, MA, USA
| | - Shazeb Meraj
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Catherine L Hough
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Shannon S Carson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Jay Steingrub
- Division of Pulmonary Medicine and Critical Care Medicine, Department of Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Departments of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Departments of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Phipps 455, Baltimore, MD, 21287, USA.
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Cohn AY, Grant LK, Nathan MD, Wiley A, Abramson M, Harder JA, Crawford S, Klerman EB, Scheer FAJL, Kaiser UB, Rahman SA, Joffe H. Effects of Sleep Fragmentation and Estradiol Decline on Cortisol in a Human Experimental Model of Menopause. J Clin Endocrinol Metab 2023; 108:e1347-e1357. [PMID: 37207451 PMCID: PMC10584010 DOI: 10.1210/clinem/dgad285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/21/2023]
Abstract
CONTEXT Perturbations to the hypothalamic-pituitary-adrenal (HPA) axis have been hypothesized to increase postmenopausal cardiometabolic risk. Although sleep disturbance, a known risk factor for cardiometabolic disease, is prevalent during the menopause transition, it is unknown whether menopause-related sleep disturbance and estradiol decline disturb the HPA axis. OBJECTIVE We examined the effect of experimental fragmentation of sleep and suppression of estradiol as a model of menopause on cortisol levels in healthy young women. METHODS Twenty-two women completed a 5-night inpatient study during the mid-to-late follicular phase (estrogenized). A subset (n = 14) repeated the protocol after gonadotropin-releasing hormone agonist-induced estradiol suppression. Each inpatient study included 2 unfragmented sleep nights followed by 3 experimental sleep fragmentation nights. This study took place with premenopausal women at an academic medical center. Interventions included sleep fragmentation and pharmacological hypoestrogenism, and main outcome measures were serum bedtime cortisol levels and cortisol awakening response (CAR). RESULTS Bedtime cortisol increased 27% (P = .03) and CAR decreased 57% (P = .01) following sleep fragmentation compared to unfragmented sleep. Polysomnographic-derived wake after sleep-onset (WASO) was positively associated with bedtime cortisol levels (P = .047) and negatively associated with CAR (P < .01). Bedtime cortisol levels were 22% lower in the hypoestrogenized state compared to the estrogenized state (P = .02), while CAR was similar in both estradiol conditions (P = .38). CONCLUSION Estradiol suppression and modifiable menopause-related sleep fragmentation both independently perturb HPA axis activity. Sleep fragmentation, commonly seen in menopausal women, may disrupt the HPA axis, which in turn may lead to adverse health effects as women age.
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Affiliation(s)
- Aviva Y Cohn
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School (HMS), Boston, MA 02115, USA
- Women's Hormones and Aging Research Program, Department of Psychiatry, BWH, HMS, Boston, MA 02115, USA
- Connors Center for Women's Health and Gender Biology, BWH, HMS, Boston, MA 02115, USA
| | - Leilah K Grant
- Connors Center for Women's Health and Gender Biology, BWH, HMS, Boston, MA 02115, USA
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, BWH, Boston, MA 02115, USA
- Division of Sleep Medicine, HMS, Boston, MA 02115, USA
| | - Margo D Nathan
- Women's Hormones and Aging Research Program, Department of Psychiatry, BWH, HMS, Boston, MA 02115, USA
| | - Aleta Wiley
- Women's Hormones and Aging Research Program, Department of Psychiatry, BWH, HMS, Boston, MA 02115, USA
- Connors Center for Women's Health and Gender Biology, BWH, HMS, Boston, MA 02115, USA
| | - Mathena Abramson
- Women's Hormones and Aging Research Program, Department of Psychiatry, BWH, HMS, Boston, MA 02115, USA
- Connors Center for Women's Health and Gender Biology, BWH, HMS, Boston, MA 02115, USA
| | - Jessica A Harder
- Women's Hormones and Aging Research Program, Department of Psychiatry, BWH, HMS, Boston, MA 02115, USA
| | - Sybil Crawford
- Tan Chingfen Graduate School of Nursing at UMass Chan Medical School, Worcester, MA 01605, USA
| | - Elizabeth B Klerman
- Connors Center for Women's Health and Gender Biology, BWH, HMS, Boston, MA 02115, USA
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, BWH, Boston, MA 02115, USA
- Division of Sleep Medicine, HMS, Boston, MA 02115, USA
- Department of Neurology, Massachusetts General Hospital, HMS, Boston, MA 02114, USA
| | - Frank A J L Scheer
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, BWH, Boston, MA 02115, USA
- Division of Sleep Medicine, HMS, Boston, MA 02115, USA
| | - Ursula B Kaiser
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School (HMS), Boston, MA 02115, USA
| | - Shadab A Rahman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, BWH, Boston, MA 02115, USA
- Division of Sleep Medicine, HMS, Boston, MA 02115, USA
| | - Hadine Joffe
- Women's Hormones and Aging Research Program, Department of Psychiatry, BWH, HMS, Boston, MA 02115, USA
- Connors Center for Women's Health and Gender Biology, BWH, HMS, Boston, MA 02115, USA
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El Khoudary SR, Chen X, Wang Z, Brooks MM, Orchard T, Crawford S, Janssen I, Everson-Rose SA, McConnell D, Matthews K. Low-density lipoprotein subclasses over the menopausal transition and risk of coronary calcification and carotid atherosclerosis: the SWAN Heart and HDL ancillary studies. Menopause 2023; 30:1006-1013. [PMID: 37738035 PMCID: PMC10539013 DOI: 10.1097/gme.0000000000002245] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
OBJECTIVE Perimenopausal women experience a steep increase in low-density lipoprotein cholesterol (LDL-C) that is related to a higher risk of carotid plaque later in life. Low-density lipoprotein subclasses have been linked to cardiovascular diseases beyond LDL-C, promising a better risk stratification. We aim to characterize changes in LDL subclasses and assess their associations with presence of coronary artery calcium (CAC score ≥10) and carotid intima-media thickness (cIMT) over the menopausal transition (MT) and by menopause stage. METHODS Nuclear magnetic resonance spectroscopy LDL subclasses were measured for a maximum of five time points. Coronary artery calcification and cIMT were measured for a maximum of two time points. LOESS (locally weighted regression with scatter smoothing) plots, linear mixed-effects models, and generalized estimating equations were used for analyses. RESULTS The study included 471 women (baseline: age, 50.2 ± 2.7 years; 79.0% premenopausal/early perimenopausal), of whom 221 had data on CAC or cIMT. Low-density lipoprotein subclasses increased over the MT, whereas intermediate density-lipoprotein particles declined. In adjusted models, higher total LDL particles (LDL-P) and apolipoprotein B were associated with greater CAC prevalence and greater cIMT. Although none of the associations were modified by menopause stage, higher LDL-C, apolipoprotein B, and total LDL-P were associated with greater cIMT during the perimenopause or postmenopause stages, whereas higher LDL-C and small LDL-P were associated with greater CAC prevalence, mainly during perimenopause. CONCLUSIONS During the MT, women experience significant increases in LDL subclasses found to be related to greater cIMT levels and CAC prevalence. Whether these changes could better predict future risk of hard cardiovascular disease events beyond LDL-C remains a research question to address.
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Affiliation(s)
| | - Xirun Chen
- University of Pittsburgh, Pittsburgh, PA
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Goss A, Ge C, Crawford S, Goostrey K, Buddadhumaruk P, Hough CL, Lo B, Carson S, Steingrub J, White DB, Muehlschlegel S. Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study. Neurology 2023; 101:e558-e569. [PMID: 37290972 PMCID: PMC10401677 DOI: 10.1212/wnl.0000000000207462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/13/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition). METHODS We conducted a multicenter cross-sectional mixed-methods study analyzing deidentified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from 7 US centers. Two coders assigned codes for prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survival"; "She'll probably survive") or nonprobabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariate binomial logistic regression to examine independent associations between prognostic language and domain of prognosis. RESULTS We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [interquartile range (IQR) 0-2]), physical function (median 2 [IQR 0-7]), cognition (median 2 [IQR 0-6]), and overall recovery (median 2 [IQR 1-4]). Most statements were nonprobabilistic (316/512 [62%]); 10 of 512 prognostic statements (2%) offered numeric estimates; and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared with statements about cognition, statements about survival (odds ratio [OR] 2.50, 95% CI 1.01-6.18, p = 0.048) and physical function (OR 3.22, 95% 1.77-5.86, p < 0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34, 95% CI 0.17-0.66, p = 0.002). DISCUSSION Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.
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Affiliation(s)
- Adeline Goss
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Connie Ge
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
| | - Sybil Crawford
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Kelsey Goostrey
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Praewpannanrai Buddadhumaruk
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Catherine L Hough
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Bernard Lo
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Shannon Carson
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Jay Steingrub
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Douglas B White
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Susanne Muehlschlegel
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
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8
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Fisher KA, Nguyen N, Fouayzi H, Crawford S, Singh S, Dong M, Wittenberg R, Mazor KM. From COVID-19 Vaccine Hesitancy to Vaccine Acceptance: Results of a Longitudinal Survey. Public Health Rep 2023:333549231176006. [PMID: 37243439 DOI: 10.1177/00333549231176006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVES COVID-19 vaccines are widely available, but uptake is suboptimal. To develop strategies to increase vaccination rates, we sought to (1) characterize adults initially hesitant to be vaccinated for COVID-19 who later received the vaccine and (2) identify factors associated with their vaccination decision. METHODS In January 2021, we conducted an online survey of US adults via Prolific that assessed vaccination intent, COVID-19-related knowledge and attitudes, and demographic characteristics. In May 2021, we recontacted respondents to assess vaccination status and factors influencing their vaccination decision. We used χ2 statistics and t tests to examine associations between respondents' vaccination status and their characteristics, knowledge, and attitudes. We analyzed reasons for vaccination using thematic analysis. RESULTS Of 756 initially vaccine-hesitant respondents, 529 (70.0%) completed the follow-up survey. Nearly half of those initially not sure about vaccination (47.3%, 112 of 237) were vaccinated at follow-up, while 21.2% (62 of 292) of those initially planning not to be vaccinated were vaccinated at follow-up. Of those initially not sure, higher educational attainment, greater knowledge of COVID-19, and a doctor's recommendation were associated with vaccination. Of those initially intending not to be vaccinated, male sex, Democratic political affiliation, receipt of an influenza shot within 5 years, being more worried about COVID-19, and having greater COVID-19 knowledge were associated with increased likelihood of being vaccinated. Of 167 respondents who gave reasons for vaccination, protecting oneself and others (59.9%), practical issues (29.9%), social influences (17.4%), and vaccine safety (13.8%) were the main reasons. CONCLUSION Providing information on the protective value of vaccination, implementing rules that make remaining unvaccinated burdensome, making vaccination easy, and providing social support may influence vaccine-hesitant adults to accept vaccination.
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Affiliation(s)
- Kimberly A Fisher
- Meyers Health Care Institute, a joint endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Ngoc Nguyen
- Meyers Health Care Institute, a joint endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Hassan Fouayzi
- Meyers Health Care Institute, a joint endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Sybil Crawford
- Meyers Health Care Institute, a joint endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Sonal Singh
- Meyers Health Care Institute, a joint endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
- Department of Family and Community Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - May Dong
- T.H. Chan School of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Ruth Wittenberg
- Meyers Health Care Institute, a joint endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Kathleen M Mazor
- Meyers Health Care Institute, a joint endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
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9
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Qi M, Brooks MM, Janssen I, McConnell D, Barinas-Mitchell E, Derby C, Karlamangla A, Crawford S, Orchard T, Billheimer J, El Khoudary SR. Abstract P504: Prospective Associations of Midlife C3, C4 and Their Changes Since Midlife With Future Cognitive Performance: The Study of Women’s Health Across the Nation HDL Ancillary Study. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Objective:
Almost two-thirds of Americans over 65 with Alzheimer’s disease (AD) are women. The menopause transition is characterized by a systemic inflammatory state which increases atherosclerosis risk predisposing to dementia. Complement system was inappropriately activated in the brain of AD patients, which may contribute to local inflammation correlated with cognitive dysfunction. Complement factor 3 (C3) and 4 (C4) are the most clinically used complement components. Increased serum C3 and the presence of C4 null genes producing less C4 are risk factors of cardiovascular disease (CVD), indicating the necessity of analyzing the ratio of C3 and C4. Since serum C3 and C4 markedly increase over the menopause transition, we aimed to assess the associations of midlife C3, C4, and C3/C4 ratio and their changes since midlife with future cognitive function in women.
Design:
Repeated measures of serum C3, C4, and measures of working memory (digit span backward test), processing speed (symbol digit modality test), episodic memory immediate and delayed recall (East Boston memory test) were evaluated among midlife women traversing menopause. Mixed effect models were applied to assess the associations.
Results:
We included 305 women (706 observations) with mean age of 51 (SD=3) and 72% of them being pre- or perimenopausal at baseline. C3 and C4 were measured a median of 1.07 (Q1: 0.94, Q3: 1.81) years before cognitive performance assessment. In final models, higher C4 measured at midlife (baseline) was associated with better future episodic memory levels, and higher midlife C3/C4 ratio was associated with worse future episodic memory (
Table
). Changes in the complement factors were not associated with cognitive measures.
Conclusion:
Among women, higher midlife C4 and lower midlife C3/C4 ratio, but not changes in C4 or C3/C4 ratio since midlife, were associated with better future episodic memory levels. Midlife complement protein levels could be early markers of cognitive impairment known to be linked with CVD.
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Affiliation(s)
- Meiyuzhen Qi
- Univ of Pittsburgh Graduate Sch of Public Health, Pittsburgh, PA
| | - Maria M Brooks
- Univ of Pittsburgh Graduate Sch of Public Health, Pittsburgh, PA
| | | | | | | | - Carol Derby
- Albert Einstein College of Medicine, Bronx, NY
| | - Arun Karlamangla
- Univ of California Los Angeles David Geffen Sch of Medicine, Los Angeles, CA
| | | | - Trevor Orchard
- Univ of Pittsburgh Graduate Sch of Public Health, pittsburgh, PA
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10
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Wilson AS, Pham T, Mbusa D, Patel P, Chennupati S, Crawford S, Kapoor A. Pharmacist-led, checklist intervention did not improve adherence in ambulatory patients starting/resuming DOACs. J Am Pharm Assoc (2003) 2023; 63:878-884.e3. [PMID: 36966089 DOI: 10.1016/j.japh.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/18/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND High adherence to direct-acting oral anticoagulant (DOAC) is critical to treat and prevent thromboembolic disease. The Anticoagulation Forum recently endorsed a checklist (DOAC checklist) that recommends care processes that may improve adherence. OBJECTIVES This study aimed to determine whether checklist-driven care from a clinical pharmacist improves adherence in ambulatory patients starting a DOAC or resuming it after a setback. METHODS This study included ambulatory patients starting a DOAC or resuming it after setback (thromboembolic event or bleeding) in an ambulatory setting. Settings included office, emergency department, and short-stay hospital visit. Following the DOAC checklist, a clinical pharmacist verified DOAC appropriateness, instructed dose de-escalation, educated through 3 tele-visits, fielded hotline calls, and handed off to a continuity provider after 3 months. Intervention and control patients received coupons and help with completing manufacturer-based medication assistance applications. Using pharmacy dispense records, our group measured medication possession ratio (MPR) at 90 days (primary outcome) and proportion of days covered (PDC) at 90 days and MPR and PDC at 180 and 365 days (secondary outcomes). Given skewing, our team analyzed adherence as < 80%, 80%-89%, and 90% or more and conducted ordered logistic regression. RESULTS Of 561 patients randomized, 427 had sufficient records to analyze. Adherence was high with only 41 patients (9.6%) having MPR less than 80% at 90 days. There was no difference in adherence between intervention and control patients for primary outcome (odds ratio 0.94 [95% CI 0.60-1.49]) or secondary outcomes. CONCLUSION Our checklist-driven intervention did not appreciably improve adherence beyond that seen in control patients treated with usual care (plus coupons and medication assistance we provided to all patients) in ambulatory patients starting or resuming DOACs, although it should be noted that high levels of adherence in both study groups were noted. Given high adherence, reassessing the DOAC checklist outside of a traditional trial may be more fruitful.
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11
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Pham T, Patel P, Mbusa D, Kapoor A, Crawford S, Sadiq H, Rampam S, Wagner J, Gurwitz JH, Mazor KM. Impact of a pharmacist intervention on DOAC knowledge and satisfaction in ambulatory patients. J Thromb Thrombolysis 2023; 55:346-354. [PMID: 36510110 DOI: 10.1007/s11239-022-02743-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/14/2022]
Abstract
Patient education of high-risk medications such as direct oral anticoagulants (DOACs) is limited in ambulatory care settings. Clinical pharmacists are uniquely equipped to educate patients about DOACS but seldom interact with patients in those settings where patient education and satisfaction are often overlooked. Recently, the Anticoagulation Forum endorsed a checklist (DOAC Checklist) to guide and educate patients initiating or resuming DOACs. We assessed the impact on knowledge and satisfaction of an intervention framed around the checklist. Randomized clinical trial. Ambulatory patients starting a DOAC or resuming one after setback (bleeding, stroke, or transient ischemic attack) in an ambulatory setting (office, emergency department, or short stay hospitalization). Three educational clinical pharmacist tele-visits, hotline access to the pharmacist, and coordination with continuity providers in 3 months. Patient knowledge scores from a 15-item DOAC-related questionnaire and satisfaction scores from an abbreviated version of the Duke Anticoagulation Satisfaction Survey (DASS). Of 561 randomized patients, 436 completed our follow-up surveys. Knowledge scores were similar for the 233 intervention patients vs. 203 control patients (63.7% vs 62.2% correct). Satisfaction scores on the 7-point Likert scale were virtually identical (6.24 and 6.22). Our pharmacist-led intervention framed around the DOAC checklist had little impact on knowledge and satisfaction. Delays between intervention end and completion of the follow-up questionnaires may have obscured benefits experienced earlier. More intensive education or strategies other than telephone-based consultation may be required to produce sustained knowledge.TRN: NCT04068727 retrospectively registered on August 22, 2019.
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Affiliation(s)
- Thu Pham
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
| | - Parth Patel
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
| | - Daniel Mbusa
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA.
| | - Sybil Crawford
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
| | - Hammad Sadiq
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
| | - Sanjeev Rampam
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
| | - Joann Wagner
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
| | - Jerry H Gurwitz
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
- Reliant Medical Group, Worcester, MA, USA
| | - Kathleen M Mazor
- Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Ave North - S6-750, Worcester, MA, 01605, USA
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12
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Khan SY, Snitman A, Habrawi Z, Crawford S, Melkus MW, Layeequr Rahman R. The Role of Cryoablation in Breast Cancer Beyond the Oncologic Control: COST and Breast-Q Patient-Reported Outcomes. Ann Surg Oncol 2023; 30:1029-1037. [PMID: 36171531 DOI: 10.1245/s10434-022-12570-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/28/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cryoablation has been established as a minimally invasive alternative to resection of early-stage breast cancer; however, there are no data on the cost and impact on patients' financial, psychosocial, sexual, physical, and cosmetic outcomes utilizing this approach. This study compares cost-effectiveness and patient-reported quality-of-life factors in cryoablation versus resection. METHODS Women with early-stage, low-risk infiltrating ductal carcinomas ≤ 1.5 cm underwent cryoablation or resection. Adjuvant therapy was provided according to tumor board recommendations. Direct and indirect costs were tracked for both groups. Financial toxicity and well-being outcome were measured by administering the Comprehensive Score of Financial Toxicity (COST) and BREAST-Q surveys, respectively, at 6-month follow-up. RESULTS Of the 34 eligible patients, 14 (41.1%) consented for cryoablation and 20 (58.8%) underwent resection. The median (centile) (range) follow-up was 35.0 (21.3) (15-50) months for cryoablation vs. 25 (20.8) (17-50) months for resection [p = 0.6479]. Mean (standard deviation) cost of care for cryoablation versus resection was $2221.70 (615.70) versus $16,896.50 (1332.40) [p < 0.0001], and median financial well-being scores for the cryoablation versus resection groups were 38.0 (34.5, 40.0) versus 10 (5.3, 14.0) [p < 0.0001]. Poor financial well-being was directly correlated with the cost of care [p < 0.0001]. Median psychosocial well-being scores were similar across both groups, however the cryoablation group had higher scores for physical [100 (100, 100) vs. 89 (79, 100); p = 0.0141], sexual [100 (91, 100) vs. 91 (87.5, 91); p = 0.0079], and cosmetic [100 (100, 100) vs. 88 (88, 100); p = 0.0171] outcomes. CONCLUSION Cryoablation offers a cost-effective and quality-of-life advantage compared with resection for early-stage, low-risk breast cancer.
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Affiliation(s)
- Sonia Y Khan
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Breast Center of Excellence, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Annie Snitman
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Zaina Habrawi
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Breast Center of Excellence, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sybil Crawford
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Michael W Melkus
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Breast Center of Excellence, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rakhshanda Layeequr Rahman
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
- Breast Center of Excellence, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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13
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Santoro N, Flyckt R, Davis A, Finkelstein J, Crawford S, Sun F, Derby C, Morrison A, Sluss P, Zhang H. Anti-Müllerian Hormone Level Decline in Patients Undergoing Hysterectomy With and Without Oophorectomy Compared With Natural Menopause. Obstet Gynecol 2023; 141:331-340. [PMID: 36649324 PMCID: PMC9858351 DOI: 10.1097/aog.0000000000005049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/07/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the relationship between hysterectomy with and without ovarian conservation and the onset of ovarian failure using anti-müllerian hormone (AMH) levels and imputed final menstrual period (FMP). METHODS A total of 1,428 women with an observed FMP and 232 women who underwent hysterectomy (159 with bilateral salpingo-oophorectomy [BSO], 13 with one ovary conserved, and 60 with both ovaries conserved) and who had serial AMH measurements were included from SWAN (The Study of Women's Health Across the Nation), a multi-ethnic, multi-site, community-based study. Anti-müllerian hormone levels were sampled annually with at least one presurgery or pre-FMP measurement at least one postsurgery or post-FMP measurement. Surgery-related differences in patterns of AMH levels with respect to surgery date or FMP were estimated using piecewise linear mixed modeling; differences in age at first undetectable AMH level were estimated using survival analyses. RESULTS Patients with conservation of one or both ovaries or natural menopause demonstrated similar patterns of decline in AMH levels when anchored to surgery or FMP. Patients with hysterectomy (all types) had a later counterfactual FMP (52.9±0.2 SEM) compared with the observed FMP in those with natural menopause (52.1±0.1 years, P =.002). Those undergoing BSO had an immediate reduction in AMH level to undetectable after surgery. CONCLUSION Hysterectomy does not lead to a more rapid decline in AMH levels postoperatively compared with natural menopause. Patients undergoing BSO have a rapid loss of AMH, consistent with complete removal of the ovaries. These data suggest that hysterectomy as currently performed does not compromise ovarian reserve.
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Affiliation(s)
- Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - Rebecca Flyckt
- Division of Reproductive Endocrinology, Case Western Reserve University, Cleveland, Ohio 44106
| | - Anne Davis
- current address: IVI RMA Global, San Diego, California 92121
| | - Joel Finkelstein
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts 02114
| | - Sybil Crawford
- Department of Medicine, UMass Chan Medical School, Worcester, Massachusetts 01605
| | - Fangbai Sun
- Department of Statistics and Data Science, Yale University School of Medicine, New Haven Connecticut 06511
| | - Carol Derby
- Departments of Neurology and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York 10461
| | | | - Patrick Sluss
- Department of Clinical Pathology, Massachusetts General Hospital, Boston, Massachusetts 01224
| | - Heping Zhang
- Department of Statistics and Data Science, Yale University School of Medicine, New Haven Connecticut 06511
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14
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Khan SY, Snitman A, Habrawi Z, Crawford S, Melkus MW, Layeequr Rahman R. ASO Visual Abstract: The Role of Cryoablation in Breast Cancer Beyond the Oncologic Control: COST and Breast-Q Patient Reported Outcomes. Ann Surg Oncol 2023; 30:1040-1041. [PMID: 36183017 DOI: 10.1245/s10434-022-12610-0] [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: 01/10/2023]
Affiliation(s)
- Sonia Y Khan
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Texas Tech University Health Sciences Center, Breast Center of Excellence, Lubbock, TX, USA
| | - Annie Snitman
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Zaina Habrawi
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Texas Tech University Health Sciences Center, Breast Center of Excellence, Lubbock, TX, USA
| | - Sybil Crawford
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Michael W Melkus
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Texas Tech University Health Sciences Center, Breast Center of Excellence, Lubbock, TX, USA
| | - Rakhshanda Layeequr Rahman
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
- Texas Tech University Health Sciences Center, Breast Center of Excellence, Lubbock, TX, USA.
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15
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El Khoudary SR, Chen X, Qi M, Derby CA, Brooks MM, Thurston RC, Janssen I, Crawford S, Lee JS, Jackson EA, Chae CU, McConnell D, Matthews KA. The independent associations of anti-Müllerian hormone and estradiol levels over the menopause transition with lipids/lipoproteins: The Study of Women's health Across the Nation. J Clin Lipidol 2023; 17:157-167. [PMID: 36517413 PMCID: PMC9974763 DOI: 10.1016/j.jacl.2022.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The menopause transition (MT) is linked to adverse changes in lipids/lipoproteins. However, the related contributions of anti-Müllerian hormone (AMH) and estradiol (E2) are not clear. OBJECTIVE To evaluate the independent associations of premenopausal AMH and E2 levels and their changes with lipids/lipoproteins levels [total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), apolipoprotein B (apoB) and apolipoprotein A-1 (apoA-1)] over the MT. METHODS SWAN participants who transitioned to menopause without exogenous hormone use, hysterectomy, or bilateral oophorectomy with data available on both exposure and outcomes when they were premenopausal until the 1st visit postmenopausal were studied. RESULTS The study included 1,440 women (baseline-age:mean±SD=47.4±2.6) with data available from up to 9 visits (1997-2013). Lower premenopausal levels and greater declines in AMH were independently associated with greater TC and HDL-C, whereas lower premenopausal levels and greater declines in E2 were independently associated with greater TG and apo B and lower HDL-C. Greater declines in AMH were independently associated with greater apoA-1, and greater declines in E2 were independently associated with greater TC and LDL-C. CONCLUSIONS AMH and E2 and their changes over the MT relate differently to lipids/lipoproteins profile in women during midlife. Lower premenopausal and/or greater declines in E2 over the MT were associated with an atherogenic lipid/lipoprotein profile. On the other hand, lower premenopausal AMH and/or greater declines in AMH over the MT were linked to higher apo A-1 and HDL-C; the later found previously to be related to a greater atherosclerotic risk after menopause.
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Affiliation(s)
- Samar R El Khoudary
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Clinical and Translational Science Institute, 4420 Bayard Street, Suite 600, Pittsburgh, PA 15260, United States.
| | - Xirun Chen
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Clinical and Translational Science Institute, 4420 Bayard Street, Suite 600, Pittsburgh, PA 15260, United States
| | - Meiyuzhen Qi
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Clinical and Translational Science Institute, 4420 Bayard Street, Suite 600, Pittsburgh, PA 15260, United States
| | - Carol A Derby
- Albert Einstein College of Medicine Department of Neurology and Department of Epidemiology & Public Health, Bronx, NY, United States
| | - Maria M Brooks
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Clinical and Translational Science Institute, 4420 Bayard Street, Suite 600, Pittsburgh, PA 15260, United States
| | - Rebecca C Thurston
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Clinical and Translational Science Institute, 4420 Bayard Street, Suite 600, Pittsburgh, PA 15260, United States; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Imke Janssen
- Department of Preventive Medicine, Rush University Rush Medical Center, Chicago, IL, United States
| | - Sybil Crawford
- University of Massachusetts Tan Chingfen Graduate School of Nursing at UMass Chan Medical School, Worcester, MA, United States
| | - Jennifer S Lee
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Elizabeth A Jackson
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, United States
| | - Claudia U Chae
- Massachusetts General Hospital, Boston, MA, United States
| | - Daniel McConnell
- University of Michigan Department of Epidemiology, Ann Arbor, MI, United States
| | - Karen A Matthews
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Clinical and Translational Science Institute, 4420 Bayard Street, Suite 600, Pittsburgh, PA 15260, United States; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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16
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Fisher KA, Nguyen N, Fouayzi H, Singh S, Crawford S, Mazor KM. Impact of a physician recommendation on COVID-19 vaccination intent among vaccine hesitant individuals. Patient Educ Couns 2023; 106:107-112. [PMID: 36244947 PMCID: PMC9523946 DOI: 10.1016/j.pec.2022.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To test the impact of varied physician recommendations on COVID-19 vaccine hesitancy. METHODS We conducted a vignette-based experimental survey on Prolific, an online research platform. COVID-19 vaccine hesitant, adult panel members were assigned to one of five messages that varied by recommendation style (participatory vs explicit) and strategy (acknowledgement of concerns; comparison to the flu shot; statement that millions of people have already received it; emphasis on protecting others). Vaccine hesitancy was re-assessed with the question, "Would you get vaccinated at this visit?". RESULTS Of the 752 participants, 60.1% were female, 43.4% Black, 23.6% Latino, and 33.0% White; mean age was 35.6 years. Overall, 33.1% of the initially "not sure" and 13.1% of the initially "no" participants became less hesitant following any recommendation. Among the "not sure" participants, 20.3% of those who received a participatory recommendation became less hesitant compared with 34.3%- 39.5% for the explicit recommendations. The "protect others" message was most effective among initially "no" participants; 19.8% become less hesitant, compared to 8.7% for the participatory recommendation. CONCLUSION A physician recommendation may reduce COVID-19 vaccine hesitancy. PRACTICE IMPLICATIONS An explicit recommendation and "protect others" message appear to be important elements of a physician recommendation for COVID-19 vaccination.
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Affiliation(s)
- Kimberly A Fisher
- Department of Medicine, Division of Health Systems Science, UMass Chan Medical School, Worcester, MA, USA.
| | - Ngoc Nguyen
- Department of Medicine, Division of Health Systems Science, UMass Chan Medical School, Worcester, MA, USA
| | - Hassan Fouayzi
- Department of Medicine, Division of Health Systems Science, UMass Chan Medical School, Worcester, MA, USA
| | - Sonal Singh
- Department of Medicine, Division of Health Systems Science, UMass Chan Medical School, Worcester, MA, USA; Department of Family and Community Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Sybil Crawford
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Kathleen M Mazor
- Department of Medicine, Division of Health Systems Science, UMass Chan Medical School, Worcester, MA, USA
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Trivedi M, Frisard C, Crawford S, Bram J, Geller AC, Pbert L. Impact of COVID-19 on childhood obesity: Data from a paediatric weight management trial. Pediatr Obes 2022; 17:e12959. [PMID: 35876325 PMCID: PMC9350020 DOI: 10.1111/ijpo.12959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/07/2022] [Accepted: 07/01/2022] [Indexed: 11/29/2022]
Abstract
There is growing concern that the coronavirus disease 2019 (COVID-19) pandemic is exacerbating childhood obesity. We sought to examine the effects of the pandemic on weight and weight-related behaviours among children with overweight and obesity participating in an ongoing cluster randomized controlled trial of a paediatric practice-based weight intervention with 2 study arms: nutritionist-delivered coaching telephone calls over 8 weeks with an accompanying workbook on lifestyle changes versus the same workbook in eight mailings without nutritionist coaching calls. In a pooled, secondary analysis of 373 children in central Massachusetts (aged 8-12 years, 29% Latinx, 55% White, 8% Black), the monthly rate of BMI increase more than doubled for those children whose 6-month study visit occurred post-pandemic onset (n = 91) compared to children whose 6-month study visit occurred pre-pandemic onset (n = 282) (0.13 kg/m2 versus 0.05 kg/m2 ; ratio = 2.47, p = 0.02). The post-pandemic onset group also had a significant decrease in activity levels (β -8.18 MVPA minutes/day, p = 0.01). Caloric intake and screen time did not differ between the pre- and post-pandemic onset groups. These findings show that after the start of the pandemic, children with overweight and obesity experienced an increase in weight and decrease in activity levels. This data can inform public health strategies to address pandemic-related effects on childhood obesity.
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Affiliation(s)
- Michelle Trivedi
- Division of Pulmonary Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Christine Frisard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sybil Crawford
- Graduate School of Nursing, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jennifer Bram
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Alan C. Geller
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Lori Pbert
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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Coborn J, de Wit A, Crawford S, Nathan M, Rahman S, Finkelstein L, Wiley A, Joffe H. Disruption of Sleep Continuity During the Perimenopause: Associations with Female Reproductive Hormone Profiles. J Clin Endocrinol Metab 2022; 107:e4144-e4153. [PMID: 35878624 PMCID: PMC9516110 DOI: 10.1210/clinem/dgac447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Nocturnal vasomotor symptoms (nVMS), depressive symptoms (DepSx), and female reproductive hormone changes contribute to perimenopause-associated disruption in sleep continuity. Hormonal changes underlie both nVMS and DepSx. However, their association with sleep continuity parameters resulting in perimenopause-associated sleep disruption remains unclear. OBJECTIVE We aimed to determine the association between female reproductive hormones and perimenopausal sleep discontinuity independent of nVMS and DepSx. METHODS Daily sleep and VMS diaries, and weekly serum assays of female reproductive hormones were obtained for 8 consecutive weeks in 45 perimenopausal women with mild DepSx but no primary sleep disorder. Generalized estimating equations were used to examine associations of estradiol, progesterone, and follicle stimulating hormone (FSH) with mean number of nightly awakenings, wakefulness after sleep onset (WASO) and sleep-onset latency (SOL) adjusting for nVMS and DepSx. RESULTS Sleep disruption was common (median 1.5 awakenings/night, WASO 24.3 and SOL 20.0 minutes). More awakenings were associated with estradiol levels in the postmenopausal range (β = 0.14; 95% CI, 0.04 to 0.24; P = 0.007), and higher FSH levels (β [1-unit increase] = 0.12; 95% CI, 0.02 to 0.22; P = 0.02), but not with progesterone (β [1-unit increase] = -0.02; 95% CI, -0.06 to 0.01; P = 0.20) in adjusted models. Female reproductive hormones were not associated with WASO or SOL. CONCLUSION Associations of more awakenings with lower estradiol and higher FSH levels provide support for a perimenopause-associated sleep discontinuity condition that is linked with female reproductive hormone changes, independent of nVMS and DepSx.
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Affiliation(s)
| | | | - Sybil Crawford
- Tan Chingfen Graduate School of Nursing at UMass Chan Medical School, Worcester, MA, 01605, United States
| | - Margo Nathan
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 02115, United States
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 02115, United States
| | - Shadab Rahman
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 02115, United States
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, MA, 02115, United States
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, 02115, United States
| | - Lauren Finkelstein
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 02115, United States
| | - Aleta Wiley
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 02115, United States
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 02115, United States
| | - Hadine Joffe
- Correspondence: Hadine Joffe, MD MSc, Brigham and Women’s Hospital, Thorn 1117, 75 Francis St, Boston MA 02115-6106, USA.
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19
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Sadiq H, Rampam S, Patel J, Crawford S, Walz M, Kapoor A. Preoperative walking intervention did not appear to improve patient-reported postoperative recovery in older adults with frailty traits: Randomized trial. Medicine (Baltimore) 2022; 101:e30689. [PMID: 36197179 PMCID: PMC9509049 DOI: 10.1097/md.0000000000030689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To assess the impact of a preoperative walking intervention on improving postoperative recovery in at-risk frail older adult patients. STUDY TYPE Unblinded, randomized controlled trial which assigned patients to intervention versus control. POPULATION Patients aged 60+ scheduled for surgery 3-8 weeks from randomization scoring 4+ on the Edmonton Frail Scale. INTERVENTION Preoperative walking enhanced by goal setting with an activity monitor and telephonic coaching. MAIN OUTCOMES Quality of Recovery 9-item instrument total score and a modified version of the Abdominal Surgery Impact Scale total score. RESULTS A total of 83 patients were analyzed. Postoperative recovery scores were similar in intervention vs control - Quality of Recovery-9 item instrument total score 14.1 vs. 14.1 (P = .94) and modified Abdominal and Surgery Impact Scale total score 82.8 vs. 79.2 (P = .93). Few intervention patients met their daily step count goals. Despite this, intervention patients improved average daily step counts significantly. CONCLUSIONS Preoperative walking bolstered with activity monitor and remote coaching did not appear to lead to improved postoperative recovery in older adults with frailty traits. Further research is necessary to see if a similar intervention in specific surgery types or a more intense version of the intervention can improve recovery.
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Affiliation(s)
| | | | - Jay Patel
- UMass Chan Medical School, Worcester, MA, USA
| | | | - Matthias Walz
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Health, Worcester, MA USA
| | - Alok Kapoor
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Health, Worcester, MA USA
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20
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O'Donoghue J, Luther J, Hoque S, Mizrahi R, Spano M, Frisard C, Garg A, Crawford S, Byatt N, Lemon SC, Rosal M, Pbert L, Trivedi M. Strategies to improve the recruitment and retention of underserved children and families in clinical trials: A case example of a school-supervised asthma therapy pilot. Contemp Clin Trials 2022; 120:106884. [PMID: 35995130 PMCID: PMC9489677 DOI: 10.1016/j.cct.2022.106884] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/24/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Due to underrepresentation of racial/ethnic minority and low-income groups in clinical studies, there is a call to improve the recruitment and retention of these populations in research. Pilot studies can test recruitment and retention practices for better inclusion of medically underserved children and families in subsequent clinical trials. We examined this using a school-based asthma intervention, in preparation for a larger clinical trial in which our goal is to include an underserved study population. METHODS We recruited children with poorly controlled asthma in a two-site pilot cluster randomized controlled trial of school-supervised asthma therapy versus enhanced usual care (receipt of an educational asthma workbook). We sought a study population with a high percentage of children and families from racial/ethnic minority and low-income groups. The primary outcome of the pilot trial was recruitment/retention over 12 months. Strategies used to facilitate recruitment/retention of this study population included engaging pre-trial multi-level stakeholders, selecting trial sites with high percentages of underserved children and families, training diverse medical providers to recruit participants, conducting remote trial assessments, and providing multi-lingual study materials. RESULTS Twenty-six children [42.3% female, 11.5% Black, 30.8% Multiracial (Black & other), 76.9% Hispanic, and 92.3% with family income below $40,000] and their caregivers were enrolled in the study, which represents 55.3% of those initially referred by their provider, with 96.2%, 92.3%, and 96.2% retention at 3-, 6-, and 12-month follow-up, respectively. CONCLUSION Targeted strategies facilitated the inclusion of a medically underserved population of children and families in our pilot study, prior to expanding to a larger trial.
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Affiliation(s)
- Julia O'Donoghue
- Division of Pulmonology, Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, United States of America.
| | - Janki Luther
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Shushmita Hoque
- Division of Pulmonology, Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Raphael Mizrahi
- Division of Pulmonology, Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Michelle Spano
- Division of Pulmonology, Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Christine Frisard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Arvin Garg
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Sybil Crawford
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Nancy Byatt
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Stephenie C Lemon
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Milagros Rosal
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Lori Pbert
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
| | - Michelle Trivedi
- Division of Pulmonology, Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, United States of America; Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States of America
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21
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Fitzpatrick M, Sadiq H, Rampam S, Araia A, Miller M, Vargas KR, Fry P, Smith AM, Lowe MM, Catalano C, Harrison C, Catanzaro J, Crawford S, McManus D, Kapoor A. Preventing preventable strokes: A study protocol to push guideline-driven atrial fibrillation patient education via patient portal. Cardiovascular Digital Health Journal 2022; 3:241-246. [PMID: 36310680 PMCID: PMC9596318 DOI: 10.1016/j.cvdhj.2022.07.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background The main approach to preventing stroke in patients with atrial fibrillation (AF) is anticoagulation (AC), but only about 60% of at-risk individuals are on AC. Patient-facing electronic health record–based interventions have produced mixed results. Little is known about the impact of health portal–based messaging on AC use. Objective The purpose of this study was describe a protocol we will use to measure the association between AC use and patient portal message opening. We also will measure patient attitudes toward education materials housed on a professional society Web site. Methods We will send portal messages to patients aged ≥18 years with AF 1 week before an office/teleconference visit with a primary care or cardiology provider. The message will be customized for 3 groups of patients: those on AC; those at elevated risk but off AC; and those not currently at risk but may be at risk in the future. Within the message, we will embed a link to UpBeat.org, a Web site of the Heart Rhythm Society containing patient educational materials. We also will embed a link to a survey. Among other things, the survey will request patients to rate their attitude toward the Heart Rhythm Society Web pages. To measure the effectiveness of the intervention, we will track AC use and its association with message opening, adjusting for potential confounders. Conclusion If we detect an increase in AC use correlates with message opening, we will be well positioned to conduct a future comparative effectiveness trial. If patients rate the UpBeat.org materials highly, patients from other institutions also may benefit from receiving these materials.
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Affiliation(s)
- Michael Fitzpatrick
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Medicine, University of Massachusetts Memorial Health Care, Worcester, Massachusetts
| | - Hammad Sadiq
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sanjeev Rampam
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Almaz Araia
- Department of Practice Improvement and Policy, Heart Rhythm Society, Washington, District of Columbia
| | - Megan Miller
- Department of Medicinal Chemistry, University of Florida College of Pharmacy, Jacksonville, Florida
| | - Kevin Rivera Vargas
- Department of Medicinal Chemistry, University of Florida College of Pharmacy, Jacksonville, Florida
| | - Patrick Fry
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Anne Marie Smith
- Department of Practice Improvement and Policy, Heart Rhythm Society, Washington, District of Columbia
| | | | - Christina Catalano
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Charles Harrison
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - John Catanzaro
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Sybil Crawford
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Medicine, University of Massachusetts Memorial Health Care, Worcester, Massachusetts
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Medicine, University of Massachusetts Memorial Health Care, Worcester, Massachusetts
- Address reprint requests and correspondence: Dr Alok Kapoor, Biotech One, Suite 100, University of Massachusetts Medical School, 365 Plantation St, Worcester, MA 01605.
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22
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Rampam S, Sadiq H, Patel J, Meyer D, Uy K, Yates J, Schanzer A, Movahedi B, Lindberg J, Crawford S, Gurwitz J, Mazor K, Stefan M, White D, Walz M, Kapoor A. Supervised preoperative walking on increasing early postoperative stamina and mobility in older adults with frailty traits: A pilot and feasibility study. Health Sci Rep 2022; 5:e738. [PMID: 35873397 PMCID: PMC9301296 DOI: 10.1002/hsr2.738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 12/18/2022] Open
Abstract
Background and Aims Frail older adults are more than twice as likely to experience postoperative complications. Preoperative exercise may better prepare these patients through improved stamina and mobility experienced in the days following surgery. We measured the impact of a walking intervention using an activity tracker and coaching on postoperative stamina, and mobility in older adults with frailty traits. Methods We included patients aged 60+ and scoring 4+ on the Edmonton Frailty Scale. We then randomized patients to intervention versus control stratified by anticipated hospital stay (1 night vs. 2+ night) and baseline stamina (i.e., 6-min walk distance [6MWD]). Intervention patients received an activity tracker and linked smart phone. An athletic trainer (AT) prescribed a daily step count goal and titrated this up after checking in with patients during weekly telephone calls. Controls received general walking recommendations. We then measured postoperative 6MWD 1-3 days after surgery. We also assessed postoperative mobility by measuring steps walked the day after surgery using a thigh-worn monitor. Because many patients could not walk postoperatively, we compared intervention-control difference in both 6MWD and steps using Wilcoxon rank testing and Tobit and ordinal logistic regression adjusting for several patient characteristics. Results We randomized 104 eligible patients; 80 patients remained for final analysis. There was no difference in intervention versus control postoperative 6MWD (median 72 vs. 74 m Wilcoxon p = 0.54) or postoperative steps taken (median 128 vs. 51 steps Wilcoxon p = 0.76). Analysis adjusting for patient characteristics was consistent with these findings. Conclusion Our intervention consisting of goal setting with an activity tracker and telephonic coaching by an AT did not appear to improve stamina or mobility measured in the days after surgery. Small sample size limited our ability to examine this impact in subsets defined by surgical specialty or baseline stamina.
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Affiliation(s)
- Sanjeev Rampam
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA
| | - Hammad Sadiq
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA
| | - Jay Patel
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA
| | - David Meyer
- Hospital Medicine UMass Memorial Health Worcester Massachusetts USA.,Department of Surgery UMass Chan Medical School Worcester MA USA
| | - Karl Uy
- Department of Surgery UMass Chan Medical School Worcester MA USA.,Thoracic Surgery UMass Memorial Health Worcester MA USA
| | - Jennifer Yates
- Department of Urology UMass Chan Medical School Worcester MA USA.,Urology UMass Memorial Health Worcester MA USA
| | - Andres Schanzer
- Department of Surgery UMass Chan Medical School Worcester MA USA.,Vascular Surgery UMass Memorial Health Worcester MA USA
| | - Babak Movahedi
- Department of Surgery UMass Chan Medical School Worcester MA USA.,Transplant Surgery UMass Memorial Health Worcester MA USA
| | - James Lindberg
- Department of Surgery UMass Chan Medical School Worcester MA USA.,Surgical Oncology UMass Memorial Health Worcester MA USA
| | - Sybil Crawford
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA
| | - Jerry Gurwitz
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA.,Department of Medicine Meyers Health Care Institute Worcester Massachusetts USA
| | - Kathleen Mazor
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA.,Department of Medicine Meyers Health Care Institute Worcester Massachusetts USA
| | - Mihaela Stefan
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA.,Medicine Baystate Medical Center Springfield Massachusetts USA
| | - Daniel White
- Department of Physical Therapy University of Delaware Newark Delaware USA
| | - Matthias Walz
- Department of Anesthesiology and Perioperative Medicine UMass Chan Medical School Worcester MA USA.,Anesthesiology UMass Memorial Health Worcester MA USA
| | - Alok Kapoor
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA.,Hospital Medicine UMass Memorial Health Worcester Massachusetts USA.,Department of Medicine Meyers Health Care Institute Worcester Massachusetts USA
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23
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Faro JM, Pbert L, Crawford S, Frisard CF, Pendharkar JA, Sadasivam RS, Geller AC, Mazor KM, Ockene JK. U.S. medical students personal health behaviors, attitudes and perceived skills towards weight management counseling. Prev Med Rep 2022; 27:101814. [PMID: 35656208 PMCID: PMC9152782 DOI: 10.1016/j.pmedr.2022.101814] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/28/2022] [Accepted: 04/30/2022] [Indexed: 11/16/2022] Open
Abstract
Physicians' abilities to address obesity in routine care may be affected by their own health behaviors, skills in and attitudes toward weight management counseling (WMC). Gender differences have been noted amongst these factors as well. We examined gender differences in personal health behaviors and predictors of perceived WMC skills and attitudes of medical students enrolled in a WMC trial. Enrollment took place in 2020 and consisted of students from eight U.S. medical schools. Baseline measures included demographics, exercise, and weight management behaviors, WMC attitudes and perceived skills. Descriptive statistics were calculated, and linear mixed models used to assess the effect of personal health behaviors on outcomes of WMC attitudes and perceived skills. Complete data were available for 1145 medical students. More males reported exercising 4 or more days/week (58.6% v. 41.4%), being more likely to monitor their weight (75.6% v. 70.3%) and less likely to intentionally attempt weight loss in the past (50.3% v. 65.3%) compared to females (all p's < 0.05). Exercising 4 or more days per week was positively associated with perceived WMC skills in the adjusted model (β = 0.10, CI 0.06 to 0.14, p < 0.01). Exercise frequency was positively associated with perceived WMC skills, regardless of gender. WMC curriculum may consider focusing on personal health behaviors such as exercise to increase perceived WMC skills.
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Affiliation(s)
- Jamie M. Faro
- University of Massachusetts Chan Medical School, Department of Population and Quantitative Health Sciences, 368 Plantation St., Worcester, MA, United States
- Corresponding author.
| | - Lori Pbert
- University of Massachusetts Chan Medical School, Department of Population and Quantitative Health Sciences, 368 Plantation St., Worcester, MA, United States
| | - Sybil Crawford
- University of Massachusetts Chan Medical School, Department of Population and Quantitative Health Sciences, 368 Plantation St., Worcester, MA, United States
| | - Christine F. Frisard
- University of Massachusetts Chan Medical School, Department of Population and Quantitative Health Sciences, 368 Plantation St., Worcester, MA, United States
| | - Jyothi A. Pendharkar
- University of Massachusetts Chan Medical School, Department of Population and Quantitative Health Sciences, 368 Plantation St., Worcester, MA, United States
| | - Rajani S. Sadasivam
- University of Massachusetts Chan Medical School, Department of Population and Quantitative Health Sciences, 368 Plantation St., Worcester, MA, United States
| | - Alan C. Geller
- Harvard School of Public Health, Department of Social and Behavioral Sciences, 677 Huntington Ave., Cambridge, MA, United States
| | - Kathleen M. Mazor
- Meyers Health Care Institute, University of Massachusetts Medical School, 385 Grove St., Worcester, MA, United States
- University of Massachusetts Chan Medical School, Department of Medicine, 55 N Lake Ave., Worcester, MA, United States
| | - Judith K. Ockene
- University of Massachusetts Chan Medical School, Department of Population and Quantitative Health Sciences, 368 Plantation St., Worcester, MA, United States
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24
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Rahman SA, Nathan MD, Wiley A, Crawford S, Cohn AY, Harder JA, Grant LK, Erickson A, Srivastava A, McCormick K, Bertisch SM, Winkelman JW, Joffe H. A double-blind, randomized, placebo-controlled trial of suvorexant for the treatment of vasomotor symptom-associated insomnia disorder in midlife women. Sleep 2022; 45:6503732. [DOI: 10.1093/sleep/zsac007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 12/01/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study Objectives
The neuropeptide orexin promotes wakefulness, modulates thermoregulation, increases after menopause, and is normalized in women receiving estrogen therapy, suggesting a role for orexin antagonism as a treatment for the vasomotor symptom (VMS)-associated insomnia disorder. We tested the efficacy of the dual orexin receptor antagonist suvorexant for chronic insomnia related to nighttime VMS.
Methods
In a double-blind, placebo-controlled trial, 56 women with chronic insomnia associated with nighttime VMS, Insomnia Severity Index (ISI) scores ≥15, and >30 min of diary-rated wake after sleep-onset (WASO) were randomized to receive oral suvorexant 10–20 mg (n = 27) or placebo (n = 29) nightly for 4 weeks. Analysis of within-person change in ISI was adjusted for baseline ISI and race.
Results
Mean baseline ISI scores were 18.1 (95% CI, 16.8 to 19.4) and 18.3 (95% CI, 17.2 to 19.5) in the suvorexant and placebo groups, respectively (p = .81). The average 4-week ISI within-person decrease from baseline was greater on suvorexant (−8.1 [95% CI, −10.2 to −6.0]) compared to placebo (−5.6 [95% CI, −7.4 to −3.9], p = .04). Compared to placebo, nighttime diary-rated VMS frequency was significantly reduced with suvorexant (p < .01). While diary-rated WASO and total sleep time trended toward improvement on suvorexant, findings were not significant after adjustment for multiple comparisons. Daytime VMS and other sleep-related outcomes did not differ between groups. Suvorexant was well tolerated.
Conclusion
These results suggest that suvorexant is likely a well-tolerated and efficacious treatment for VMS-associated insomnia disorder and reduces nighttime VMS. Antagonism of orexin receptors could provide a novel therapeutic option for midlife women with VMS-associated chronic insomnia.
Clinical Trial Information
Efficacy of Suvorexant in the Treatment of Hot Flash-associated Insomnia, https://clinicaltrials.gov/ct2/show/NCT03034018, ClinicalTrials.gov Identifier: NCT03034018.
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Affiliation(s)
- Shadab A Rahman
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Margo D Nathan
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Aleta Wiley
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sybil Crawford
- Tan Chingfen Graduate School of Nursing, UMASS Chan Medical School, Worcester, MA, USA
| | - Aviva Y Cohn
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica A Harder
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Leilah K Grant
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Athena Erickson
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Akanksha Srivastava
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen McCormick
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Suzanne M Bertisch
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
| | - John W Winkelman
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hadine Joffe
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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25
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Patel J, Sadiq H, Catanzaro J, Crawford S, Wright A, Manning G, Allison J, Mazor K, McManus D, Kapoor A. SUPPORT-AF IV: Supporting use of AC through provider prompting about oral anticoagulation therapy for AF clinical trial study protocol. Cardiovasc Digit Health J 2022; 2:222-230. [PMID: 35265912 PMCID: PMC8890051 DOI: 10.1016/j.cvdhj.2021.06.001] [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] [Indexed: 11/25/2022] Open
Abstract
Background Six million Americans suffer from atrial fibrillation (AF), a heart rhythm abnormality that significantly increases the risk of stroke. AF is responsible for 15% of ischemic strokes, which lead to permanent disability in 60% of cases and death in up to 20%. Anticoagulation (AC) is the mainstay for stroke prevention in patients with AF. Despite guidelines recommending AC for patients, up to half of eligible patients are not on AC. Clinical decision support tools in the electronic health record (EHR) can help bridge the disparity in AC prescription for patients with AF. Objective To enhance and assess the effectiveness of our previous rule-based alert on AC initiation and persistence in a diverse patient population from UMass-Memorial Medical Center and University of Florida at Jacksonville. Methods/Results Using the EHR, we will track AC initiation and persistence. We will interview both patients and providers to determine a measure of satisfaction with AC management. We will track digital crumbs to better understand the alert’s mechanism of effect and further add enhancements. These enhancements will be used to refine the alert and aid in developing an implementation toolkit to facilitate use of the alert at other health systems. Conclusion If the number of AC starts, the likelihood of persisting on AC, and the frequency alert use are found to be higher among intervention vs control providers, we believe such findings will confirm our hypothesis on the effectiveness of our alert.
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Affiliation(s)
- Jay Patel
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hammad Sadiq
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - John Catanzaro
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Sybil Crawford
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Adam Wright
- Department of Biomedical Informatics, University of Vanderbilt School of Medicine, Nashville, Tennessee
| | - Gordon Manning
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,University of Massachusetts Memorial Health Care, Worcester, Massachusetts
| | - Jeroan Allison
- University of Massachusetts Memorial Health Care, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kathleen Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,University of Massachusetts Memorial Health Care, Worcester, Massachusetts.,Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - David McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,University of Massachusetts Memorial Health Care, Worcester, Massachusetts
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,University of Massachusetts Memorial Health Care, Worcester, Massachusetts
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26
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El Khoudary SR, Nasr A, Billheimer J, Brooks MM, McConnell D, Crawford S, Orchard TJ, Rader DJ, Matthews KA. Associations of Endogenous Hormones With HDL Novel Metrics Across the Menopause Transition: The SWAN HDL Study. J Clin Endocrinol Metab 2022; 107:e303-e314. [PMID: 34390340 PMCID: PMC8684446 DOI: 10.1210/clinem/dgab595] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 01/28/2023]
Abstract
CONTEXT Novel metrics of high-density lipoprotein (HDL) (subclasses, lipid content, and function) may improve characterization of the anti-atherogenic features of HDL. In midlife women, changes in these metrics vary by time relative to the final menstrual period (FMP), supporting a contribution of estradiol (E2) and follicle-stimulating hormone (FSH). OBJECTIVE We tested associations of endogenous E2 and FSH with novel HDL metrics and assessed whether these associations varied by time relative to FMP. METHODS This study was a longitudinal analysis from the Study of Women's Health Across the Nation (SWAN) HDL study, using a community-based cohort of 463 women, baseline mean age 50.2 (2.7) years. The main outcome measures were HDL cholesterol efflux capacity (HDL-CEC), HDL phospholipids (HDL-PL), HDL triglycerides (HDL-Tg), HDL particles (HDL-P), HDL size, and HDL cholesterol (HDL-C). RESULTS In multivariable analyses, E2 was positively associated with HDL size, large HDL-P, HDL-CEC, and HDL-Tg, but negatively with medium HDL-P (P values < 0.05). The positive association between E2 and HDL-Tg was stronger 2 years post-FMP than before, (interaction P = 0.031). FSH was positively related to total and medium HDL-P, but negatively to HDL size, large HDL-P, and HDL-CEC per particle (P values < 0.05). Associations of higher FSH with greater total HDL-P and smaller HDL size were only evident at/after menopause (interaction P values < 0.05). CONCLUSION Some of the associations linking E2 and FSH with novel HDL metrics were vulnerable to time relative to menopause onset. Whether a late initiation of hormone therapy relative to menopause could have a detrimental effect on lipid content of HDL particles should be tested in the future.
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Affiliation(s)
- Samar R El Khoudary
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15261, USA
- Correspondence: Samar R. El Khoudary, PhD, MPH, FAHA, Associate Professor of Epidemiology, Clinical and Translational Science Institute, Epidemiology Data Center, 4420 Bayard Street, Suite 600, Pittsburgh, PA, 15260, USA.
| | - Alexis Nasr
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15261, USA
| | - Jeffrey Billheimer
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Maria M Brooks
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15261, USA
| | - Dan McConnell
- Department of Epidemiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sybil Crawford
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Trevor J Orchard
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15261, USA
| | - Daniel J Rader
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Karen A Matthews
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15261, USA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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27
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Kapoor A, Patel J, Chen Z, Crawford S, McManus D, Gurwitz J, Shireman TI, Zhang N. Geriatric conditions do not predict stroke or bleeding in long-term care residents with atrial fibrillation. J Am Geriatr Soc 2021; 70:1218-1227. [PMID: 34902164 DOI: 10.1111/jgs.17605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term care (LTC) providers prescribe anticoagulation (AC) less frequently in residents with atrial fibrillation (AF) and geriatric conditions independent of CHA2 DS2 -VASc stroke risk score. Geriatric conditions include recent fall, activities of daily living dependency, mobility impairment, cognitive impairment, low body mass index, and weight loss. Multiple publications have suggested that patients with geriatric conditions are at increased risk for stroke. Understanding better the risk of stroke and bleeding in residents with AF and geriatric conditions would be valuable to LTC providers for AC decision-making. METHODS AND RESULTS We measured the association of geriatric conditions with composite of stroke/transient ischemic attack (TIA)/systemic embolism and bleeding in residents with AF and elevated stroke risk (CHA2 DS2 -VASc score ≥ 2) living in American LTC facilities in 2015. After merging nursing home assessments (Minimum Data Set) with medication and hospital utilization records, we identified 209,413 eligible residents. Using generalized estimating equations, we found that the incidence of stroke/TIA/systemic embolism ranged from 0.13% to 0.26% over 30 days (1.43%-3.08%/year) in residents off AC with and without geriatric conditions adjusting for other resident characteristics including CHA2 DS2 -VASc score and propensity to receive AC. Similarly, the monthly incidence of bleeding on AC ranged from 0.22% to 0.28% (2.61%-3.31%/year) without increased risk with geriatric conditions. Residents with a CHA2 DS2 -VASc score of ≥7 had a 2.4-fold increased risk of stroke compared with those with score of 2-4 (0.30% vs. 0.12%/month). CONCLUSION Calculating a CHA2 DS2 -VASc score can be helpful in AC decision-making for residents with and without geriatric conditions.
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Affiliation(s)
- Alok Kapoor
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jay Patel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Zhiyong Chen
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Zem Data Science, LLC, North Potomac, Maryland, USA
| | - Sybil Crawford
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - David McManus
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jerry Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice, Center for Gerontology & Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ning Zhang
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Health Policy and Promotion, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
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28
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Kapoor A, Sadiq H, Patel J, Zhang N, Mazor K, Crawford S, Chen Z, Gurwitz J, McManus D, Hanchate A. Disparities in Anticoagulation Use by Race and Ethnicity in Long-Term Care Residents With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e023428. [PMID: 34816732 PMCID: PMC9075411 DOI: 10.1161/jaha.121.023428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alok Kapoor
- University of Massachusetts Medical SchoolWorcesterMA
- University of Massachusetts Memorial Medical CenterWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Hammad Sadiq
- University of Massachusetts Medical SchoolWorcesterMA
| | - Jay Patel
- University of Massachusetts Medical SchoolWorcesterMA
| | - Ning Zhang
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
- Department of Health Policy and PromotionSchool of Public Health and Health SciencesUniversity of Massachusetts AmherstAmherstMA
| | - Kathleen Mazor
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Sybil Crawford
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Zhiyong Chen
- University of Massachusetts Medical SchoolWorcesterMA
- Zem Data Science, LLCNorth PotomacMD
| | - Jerry Gurwitz
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - David McManus
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Amresh Hanchate
- Department of Social Sciences and HealthWake Forest School of MedicineWinston‐SalemNC
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29
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Ko D, Saleeba C, Sadiq H, Crawford S, Paul T, Shi Q, Wang Z, Benjamin EJ, Walkey AJ, Lubitz SA, Kapoor A, McManus D. Secondary Precipitants of Atrial Fibrillation and Anticoagulation Therapy. J Am Heart Assoc 2021; 10:e021746. [PMID: 34668392 PMCID: PMC8751824 DOI: 10.1161/jaha.121.021746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Atrial fibrillation (AF) commonly occurs in the setting of acute conditions. We aimed to identify the acute conditions associated with secondary AF (AF precipitants) including pneumonia/sepsis, pneumothorax, respiratory failure, myocarditis, pericarditis, alcohol intoxication, thyrotoxicosis, cardiothoracic surgery, other surgery in patients with newly diagnosed AF and determine their association with subsequent oral anticoagulant use. Methods and Results We assembled a cohort of patients in the UMass Memorial Healthcare system with a new diagnosis of AF with and without AF precipitants. We used combinations of International Classification of Diseases, Tenth Revision (ICD-10) codes, Current Procedural Terminology codes, laboratory values, imaging reports, and physician notes including discharge summary texts to identify AF precipitants. We then manually reviewed the individual charts to validate presence of AF precipitants. The study sample consisted of 185 patients with and 172 patients without AF precipitants. Pneumonia/sepsis, myocardial infarction, respiratory failure, and cardiothoracic surgery were the most common precipitants identified. In multivariable analyses adjusting for age, sex, patient comorbidities, left atrial enlargement, left ventricular ejection fraction, and antiplatelet use, patients with AF precipitants were less likely to receive subsequent anticoagulation therapy at 30 days after the initial AF diagnosis (odds ratio, 0.31; 95% CI, 0.19-0.52). The association was persistent after excluding men with CHA2DS2-VASc score <2 and women with CHA2DS2-VASc score <3. Conclusions Our study highlights lower usage of oral anticoagulant in secondary AF in contemporary clinical practice.
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Affiliation(s)
- Darae Ko
- Section of Cardiovascular Medicine Boston University School of Medicine Boston MA
| | - Connor Saleeba
- Department of Medicine UMass Medical School Worcester MA
| | - Hammad Sadiq
- Department of Medicine UMass Medical School Worcester MA
| | - Sybil Crawford
- Graduate School of Nursing UMass Medical School Worcester MA
| | - Tenes Paul
- Department of Medicine UMass Medical School Worcester MA
| | - Qiming Shi
- Center for Clinical and Translational Science UMass Medical School Worcester MA
| | - Ziyue Wang
- Department of Medicine UMass Medical School Worcester MA
| | - Emelia J Benjamin
- Section of Cardiovascular Medicine Boston University School of Medicine Boston MA.,Department of Epidemiology Boston University School of Public Health Boston MA
| | - Allan J Walkey
- The Pulmonary Center Boston University School of Medicine Boston MA.,Department of Health Law, Policy, & Management Boston University School of Public Health Boston MA
| | - Steven A Lubitz
- Cardiovascular Research Center and Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | - Alok Kapoor
- Department of Medicine UMass Medical School Worcester MA
| | - David McManus
- Department of Medicine UMass Medical School Worcester MA
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30
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Fisher KA, Nguyen N, Crawford S, Fouayzi H, Singh S, Mazor KM. Preferences for COVID-19 vaccination information and location: Associations with vaccine hesitancy, race and ethnicity. Vaccine 2021; 39:6591-6594. [PMID: 34629210 PMCID: PMC8463309 DOI: 10.1016/j.vaccine.2021.09.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 11/30/2022]
Abstract
This study examined the association between preferences for being informed about the COVID-19 vaccine and where to receive it with vaccination intent and race/ethnicity. We conducted an online survey, oversampling Black and Latino panel members. The 1668 participants were 53.2% female, 34.8% White, 33.3% Black, and 31.8% Latino. Participants who were vaccine hesitant (answered “not sure” or “no” to vaccination intent) were more likely to prefer a conversation with their doctor compared to those who answered “yes” (25.0% and 23.4% vs 7.8%, P < .001, respectively). Among participants who responded “not sure”, 61.8% prefer to be vaccinated at a doctor’s office, compared with 35.2% of those who responded “yes” (P < .001). Preferred location differed by race/ethnicity (P < .001) with 67.6% of Black “not sure” participants preferring a doctor’s office compared to 60.2% of Latino and 54.9% of White “not sure” participants. These findings underscore the need to integrate healthcare providers into COVID-19 vaccination programs.
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Affiliation(s)
- Kimberly A Fisher
- Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States; Meyers Health Care Institute, A Joint Endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, 385 Grove Street, Worcester, MA 01605, United States.
| | - Ngoc Nguyen
- Meyers Health Care Institute, A Joint Endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, 385 Grove Street, Worcester, MA 01605, United States
| | - Sybil Crawford
- Meyers Health Care Institute, A Joint Endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, 385 Grove Street, Worcester, MA 01605, United States; Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States
| | - Hassan Fouayzi
- Meyers Health Care Institute, A Joint Endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, 385 Grove Street, Worcester, MA 01605, United States
| | - Sonal Singh
- Meyers Health Care Institute, A Joint Endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, 385 Grove Street, Worcester, MA 01605, United States; Department of Family Medicine and Community Health, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States
| | - Kathleen M Mazor
- Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States; Meyers Health Care Institute, A Joint Endeavor of the UMass Chan Medical School, Reliant Medical Group, and Fallon Health, 385 Grove Street, Worcester, MA 01605, United States
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31
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Ockene JK, Pbert L, Crawford S, Frisard CF, Pendharkar JA, Sadasivam RS, Faro J, Okuliar C, Eno C, Margo K, Shaw MA, Soleymani T, Stadler DD, Warrier S, White K, Geller AC. Teaching Medical Students to Help Patients Manage Their Weight: Outcomes of an Eight-School Randomized Controlled Trial. J Gen Intern Med 2021; 36:3000-3007. [PMID: 33835315 PMCID: PMC8034040 DOI: 10.1007/s11606-020-06571-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/29/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Given the rising rates of obesity there is a pressing need for medical schools to better prepare students for intervening with patients who have overweight or obesity and for prevention efforts. OBJECTIVE To assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change. DESIGN A pair-matched, group-randomized controlled trial (2015-2020) included students enrolled in eight U.S. medical schools randomized to receive either multi-modal weight management education (MME) or traditional weight management education (TE). SETTING/PARTICIPANTS Students from the class of 2020 (N=1305) were asked to participate in an objective structured clinical examination (OSCE) focused on weight management counseling and complete pre and post surveys. A total of 70.1% of eligible students (N=915) completed the OSCE and 69.3% (N=904) completed both surveys. INTERVENTIONS The MME implemented over three years included a web-based course, a role-play classroom exercise, a web-patient encounter with feedback, and an enhanced clerkship experience with preceptors trained in weight management counseling (WMC). Counseling focused on the 5As (Ask, Advise, Assess, Assist, Arrange) and patient-centeredness. MEASUREMENTS The outcome was student 5As WMC skills assessed using an objective measure, an OSCE, scored using a behavior checklist, and a subjective measure, student self-reported skills for performing the 5As. RESULTS Among MME students who completed two of three WMC components compared to those who completed none, exposure was significantly associated with higher OSCE scores and self-reported 5A skills. LIMITATIONS Variability in medical schools requiring participation in the WMC curriculum. CONCLUSIONS This trial revealed that medical students struggle with delivering weight management counseling to their patients who have overweight or obesity. Medical schools, though restrained in adding curricula, should incorporate should incorporate multiple WMC curricula components early in medical student education to provide knowledge and build confidence for supporting patients in developing individualized plans for weight management. NIH TRIAL REGISTRY NUMBER R01-194787.
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Affiliation(s)
- Judith K Ockene
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Lori Pbert
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Sybil Crawford
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Christine F Frisard
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Jyothi A Pendharkar
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Rajani S Sadasivam
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Jamie Faro
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | | | - Cassie Eno
- Creighton University School of Medicine, Omaha, NE, USA
| | - Katherine Margo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Monica Ann Shaw
- University of Louisville School of Medicine, Louisville, KY, USA
| | - Taraneh Soleymani
- Previously at the University of Alabama, Birmingham, AL and now at Penn State Health, Middletown, PA, USA
| | | | | | | | - Alan C Geller
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Cambridge, MA, USA
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Pendharkar JA, Frisard CF, Geller AC, Pbert L, Crawford S, Guck TP, Stadler DD, Ockene J. Weight management counseling experiences of first year medical students before starting medical school and their self-perceived impact on treating patients with obesity. Prev Med Rep 2021; 23:101411. [PMID: 34150473 PMCID: PMC8193141 DOI: 10.1016/j.pmedr.2021.101411] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 11/19/2022] Open
Abstract
Physicians can play a vital role in counseling patients on overweight and obesity. This secondary analysis examined whether experiences in patient care specific to weight management before starting medical school were associated with students' intentions and confidence to provide weight management counseling (WMC) to patients who have overweight or obesity, and perceived impact as future physicians on patients' motivation to manage weight. First-year medical students (n = 1305) in the entering class of 2020 at eight medical schools nationwide completed questions relating to their prior experiences in patient care and WMC using the 5As. Also assessed were their intentions to treat patients with overweight or obesity, and confidence in counseling patients to help manage their weight. Over half the students (58.3%) who completed the survey had prior experience in patient care and nearly half (47.4%) began medical school with prior WMC experiences. Prior experiences correlated positively with higher confidence in performing WMC and students' intentions to treat patients with overweight or obesity. Given the relatively high rates of exposure to some type of weight management or lifestyle counseling among students before enrolling in medical school, the curriculum could build on established student interest and experience by offering treatment strategies including counseling for patients with overweight and obesity. By making prior experiences advantageous for admission, medical schools could gravitate towards admitting students who have brief but valuable insights about weight management in health care, thus increasing the possibility of filling important gaps.
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Affiliation(s)
- Jyothi A. Pendharkar
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Christine F. Frisard
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Alan C. Geller
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Cambridge, MA, USA
| | - Lori Pbert
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sybil Crawford
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | - Judith Ockene
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Fleming N, Wilson J, Crawford S, Feeney S. A Quality Improvement Initiative to Improve Antibiotic Stewardship at a Federally Qualified Health Center. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhang N, Patel J, Chen Z, Zhou Y, Crawford S, McManus DD, Gurwitz J, Shireman TI, Kapoor A. Geriatric Conditions Are Associated With Decreased Anticoagulation Use in Long-Term Care Residents With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e021293. [PMID: 34387127 PMCID: PMC8475043 DOI: 10.1161/jaha.121.021293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Anticoagulation is the mainstay for stroke prevention in patients with atrial fibrillation, but concerns about bleeding inhibit its use in residents of long‐term care facilities. Risk‐profiling algorithms using comorbid disease information (eg, CHADS2 and ATRIA [Anticoagulation and Risk Factors in Atrial Fibrillation]) have been available for years. In the long‐term care setting, however, providers and residents may place more value on geriatric conditions such as mobility impairment, activities of daily living dependency, cognitive impairment, low body mass index, weight loss, and fall history. Methods and Results Using a retrospective cohort design, we measured the association between geriatric conditions and anticoagulation use and type. After merging nursing home assessments containing information about geriatric conditions (Minimum Data Set 2015) with Medicare Part A 2014 to 2015 claims and prescription claims (Medicare Part D) 2015 to 2016, we identified 228 741 residents with atrial fibrillation and elevated stroke risk (CHA2DS2‐VASc score ≥2) for our main analysis. Recent fall, activities of daily living dependency, moderate and severe cognitive impairment, low body mass index, and unintentional weight loss were all associated with lower anticoagulation use even after adjustment for multiple predictors of stroke and bleeding (odds ratios ranging from 0.51 to 0.91). Residents with recent fall, low body mass index, and unintentional weight loss were more likely to be using a direct oral anticoagulant, although the magnitude of this effect was smaller. Conclusions Geriatric conditions were associated with lower anticoagulation use. Preventing stroke in these residents with potential for further physical and cognitive impairment would appear to be of paramount significance, although the net benefit of anticoagulation in these individuals warrants further research.
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Affiliation(s)
- Ning Zhang
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,Department of Health Policy and Promotion School of Public Health and Health Sciences University of Massachusetts Amherst Amherst MA
| | - Jay Patel
- University of Massachusetts Medical School Worcester MA
| | - Zhiyong Chen
- University of Massachusetts Medical School Worcester MA.,Zem Data Science North Potomac MD
| | - Yanhua Zhou
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Sybil Crawford
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - David D McManus
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Jerry Gurwitz
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice Center for Gerontology & Healthcare Research School of Public Health Brown University Providence RI
| | - Alok Kapoor
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
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Lasley BL, McConnell DS, Crawford S. A Simple Algorithm is Created for Identifying Intermenstrual Intervals Containing an Oscillatory LH Pattern That Associates With Vasomotor Symptoms Using Daily Urinary LH Excretion in the Study of Women’s Health Across the Nation (SWAN). J Endocr Soc 2021. [PMCID: PMC8089939 DOI: 10.1210/jendso/bvab048.1480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: A specific and unique pattern of luteinizing hormone (LH) excretion has been associated with vasomotor symptoms (VMS) in early menopausal women. Described as “oscillations” of LH excretion, this pattern is consistent with secretory “surges” of LH followed by pituitary “fatigue”. This pattern has not been observed in non-VMS intermenstrual intervals and supports the concept that a breakdown in the hypothalamic-pituitary ovarian axis feed-back loops leads to extreme and cyclic variations in gonadotropin hormone releasing hormone (GnRH) secretion that stimulates collateral nerves to alter core body temperature. Regardless of the precise mechanism, the pattern of LH secretion, as transduced in daily urine as oscillations, provides the basis for the development and validation of a VMS algorithm. Objective: The purpose of this study was to create a simple algorithm to identify intermenstrual intervals exhibiting oscillatory LH, to facilitate investigations into its associations with VMS and other symptoms during the menopausal transition (MT). Methods: As part of the Study of Women’s Health Across the Nation (SWAN), participants in the Daily Hormone Substudy (DHS) were asked to provide daily urine samples - from which LH, E1c, and PdG were measured - and complete a daily symptoms diary for one menstrual cycle (up to 50 days). Analyses included 144 participants whose first DHS collection did not meet the Kassam criterion for evidence of luteal activity; of these, 61 were assessed by an expert as having oscillatory LH and 83 as non-oscillatory LH. Proposed algorithm-based classifications regarding oscillatory LH included number of days with LH at least 50% of the collection maximum LH (number of large-LH days) and number of days with LH no more than twice the collection minimum LH (number of small-LH days). Agreement of these 2 criteria with rater-assigned oscillatory LH was assessed using nonparametric t-tests and binomial logistic regression. Associations of these with VMS frequency were assessed using Spearman correlations. Results: The number of large-LH days was strongly associated with oscillatory LH: median (interquartile range) = 13 (7,22) for oscillatory collections versus 4 (2, 11) for non-oscillatory collections (p<.0001) but number of small-LH days was unrelated (p=.98). Percentage of collection days with VMS was significantly correlated with number of large-LH days (Spearman r=.37, p<.0001) but not with number of small-LH days (Spearman r=.03, p>.05); adjustment for total collection length had negligible impact. Conclusion: A simple algorithm using urinary LH profiles can be used to identify intermenstrual collections that likely contain intervals of VMS.
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Gurwitz JH, Kapoor A, Garber L, Mazor KM, Wagner J, Cutrona SL, Singh S, Kanaan AO, Donovan JL, Crawford S, Anzuoni K, Konola TJ, Zhou Y, Field TS. Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:610-618. [PMID: 33646267 PMCID: PMC7922235 DOI: 10.1001/jamainternmed.2020.9285] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The National Action Plan for Adverse Drug Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids. OBJECTIVE To determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older who were discharged from the hospital and prescribed at least 1 high-risk medication. Participants were enrolled into the trial from June 2016 through September 2018. INTERVENTIONS The pharmacist-directed intervention included an in-home assessment by a clinical pharmacist, evidence-based educational resources, communication with the primary care team, and telephone follow-up. Participants in the control group were provided educational materials via mail. MAIN OUTCOMES AND MEASURES The study assessed 2 outcomes over a 45-day posthospital discharge period: (1) adverse drug-related incidents and (2) a subset defined as clinically important medication errors, which included preventable or ameliorable ADEs and potential ADEs (ie, medication-related errors that may not yet have caused injury to a patient, but have the potential to cause future harm if not addressed). Clinically important medication errors were the primary study outcome. RESULTS There were 361 participants (mean [SD] age, 68.7 [9.3] years; 177 women [49.0%]; 319 White [88.4%] and 8 Black individuals [2.2%]). Of these, 180 (49.9%) were randomly assigned to the intervention group and 181 (50.1%) to the control group. Among all participants, 100 (27.7%) experienced 1 or more adverse drug-related incidents, and 65 (18%) experienced 1 or more clinically important medication errors. There were 81 adverse drug-related incidents identified in the intervention group and 72 in the control group. There were 44 clinically important medication errors in the intervention group and 45 in the control group. The intervention did not significantly alter the per-patient rate of adverse drug-related incidents (unadjusted incidence rate ratio, 1.13; 95% CI, 0.83-1.56) or clinically important medication errors (unadjusted incidence rate ratio, 0.99; 95% CI, 0.65-1.49). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention. However, there were study recruitment challenges and lower than expected numbers of events among the study population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02781662.
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Affiliation(s)
- Jerry H Gurwitz
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester.,Reliant Medical Group, Worcester, Massachusetts
| | - Alok Kapoor
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Lawrence Garber
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Reliant Medical Group, Worcester, Massachusetts
| | - Kathleen M Mazor
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Joann Wagner
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Sarah L Cutrona
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts.,Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Sonal Singh
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Abir O Kanaan
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Massachusetts College of Pharmacy and Health Sciences, Worcester
| | - Jennifer L Donovan
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Sybil Crawford
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Kathryn Anzuoni
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Timothy J Konola
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Yanhua Zhou
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester
| | - Terry S Field
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester.,Department of Medicine, University of Massachusetts Medical School, Worcester
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Ashe KM, Geller AC, Pendharkar JA, Pbert L, Crawford S, Clark MA, Frisard CF, Eno CA, Faro J, Ockene JK. Exposure to Weight Management Counseling Among Students at 8 U.S. Medical Schools. Am J Prev Med 2021; 60:711-715. [PMID: 33632652 PMCID: PMC8068621 DOI: 10.1016/j.amepre.2020.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/10/2020] [Accepted: 10/26/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Clinical guidelines support physician intervention consistent with the Ask, Advise, Assess, Assist, Arrange framework for adults who have obesity. However, weight management counseling curricula vary across medical schools. It is unknown how frequently students receive experiences in weight management counseling, such as instruction, observation, and direct experience. METHODS A cross-sectional survey, conducted in 2017, of 730 third-year medical students in 8 U.S. medical schools assessed the frequency of direct patient, observational, and instructional weight management counseling experiences that were reported as summed scores with a range of 0‒18. Analysis was completed in 2017. RESULTS Students reported the least experience with receiving instruction (6.5, SD=3.9), followed by direct patient experience (8.6, SD=4.8) and observational experiences (10.3, SD=5.0). During the preclinical years, 79% of students reported a total of ≤3 hours of combined weight management counseling instruction in the classroom, clinic, doctor's office, or hospital. The majority of the students (59%-76%) reported never receiving skills-based instruction for weight management counseling. Of the Ask, Advise, Assess, Assist, Arrange framework, scores were lowest for assisting the patient to achieve their agreed-upon goals (31%) and arranging follow-up contact (22%). CONCLUSIONS Overall exposure to weight management counseling was less than optimal. Medical school educators can work toward developing a more coordinated approach to weight management counseling.
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Affiliation(s)
- Karen M Ashe
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Alan C Geller
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jyothi A Pendharkar
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Lori Pbert
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sybil Crawford
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Melissa A Clark
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Christine F Frisard
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Cassie A Eno
- School of Medicine, Creighton University, Omaha, Nebraska
| | - Jamie Faro
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Judith K Ockene
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.
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de Wit AE, Giltay EJ, de Boer MK, Nathan M, Wiley A, Crawford S, Joffe H. Predictors of irritability symptoms in mildly depressed perimenopausal women. Psychoneuroendocrinology 2021; 126:105128. [PMID: 33493755 DOI: 10.1016/j.psyneuen.2021.105128] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/15/2020] [Accepted: 01/05/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Irritability is a highly burdensome complaint, commonly, but not universally, linked with depressive symptoms. While increased variability in estradiol has been associated with depressive symptoms during perimenopause, more insight is needed into reproductive hormone dynamics and other factors that predispose perimenopausal women to irritable mood. METHODS Among 50 mildly depressed perimenopausal women (mean (SD) age 48.4 (3.9) years), severity of irritability symptoms (on Symptom Questionnaire Hostility subscale, range 0-23) was assessed weekly for eight weeks, concurrent with potential predictors. Associations between these were examined using generalized estimating equating models. RESULTS Most women (82.0%) reported having moderate to severe irritability at least once. However, the severity of irritability was highly variable from week-to-week (between-subject mean coefficient of variation [CV] 72.9% and within-subject mean CV 63.7%). In multivariate analyses, less variable serum estradiol levels (standardized β within-person CV -0.23 95%CI [-0.32, -0.14], p < 0.001), greater depression severity (0.45 [0.35, 0.56], p < 0.001), younger age (-0.23, [-0.28, -0.09], p < 0.001), and more frequent vasomotor symptoms (0.14 [0.05, 0.23], p = 0.002) were associated with more irritability. Depression severity explained the largest portion of the variance in irritability, but still not more than 20.3%. Neither crude values, weekly change in, or variability of progesterone or FSH levels were associated with irritability. CONCLUSIONS Irritability was highly prevalent among mildly depressed perimenopausal women. In contrast to depressive symptoms, decreased rather than increased variability in estradiol levels was associated with more irritability. This highlights that irritable mood can be disentangled from depressive symptoms in perimenopausal women and might be linked with different estradiol dynamics.
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Affiliation(s)
- Anouk E de Wit
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn 1117, MA 02115, United States.
| | - Erik J Giltay
- Department of Psychiatry, Leiden University Medical Center, 2300 RC B1-P, The Netherlands.
| | - Marrit K de Boer
- Department of Psychiatry, University of Groningen / University Medical Center Groningen, 9700 RB, PO Box 30.001 (CC 43), Groningen, The Netherlands.
| | - Margo Nathan
- Connors Center for Women's Health and Gender Biology / Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn 1117, MA 02115, United States.
| | - Aleta Wiley
- Connors Center for Women's Health and Gender Biology / Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn 1117, MA 02115, United States.
| | - Sybil Crawford
- Dept of Medicine, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Graduate School of Nursing, 55 Lake Avenue North, S1-853, MA 01655, United States.
| | - Hadine Joffe
- Connors Center for Women's Health and Gender Biology / Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn 1117, MA 02115, United States.
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Field TS, Fouayzi H, Crawford S, Kapoor A, Saphirak C, Handler SM, Fisher K, Johnson F, Spenard A, Zhang N, Gurwitz JH. The Association of Nursing Home Characteristics and Quality with Adverse Events After a Hospitalization. J Am Med Dir Assoc 2021; 22:2196-2200. [PMID: 33785310 DOI: 10.1016/j.jamda.2021.02.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND/OBJECTIVES We previously found high rates of adverse events (AEs) for long-stay nursing home residents who return to the facility after a hospitalization. Further evidence about the association of AEs with aspects of the facilities and their quality may support quality improvement efforts directed at reducing risk. DESIGN Prospective cohort analysis. SETTING AND PARTICIPANTS 32 nursing homes in the New England states. A total of 555 long-stay residents contributed 762 returns from hospitalizations. METHODS We measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. We constructed Cox proportional hazards models controlling for individual resident characteristics that were previously found associated with AEs. RESULTS We found no association of AEs with most nursing home characteristics, including 5-star quality ratings and the composite quality score. Associations with individual quality indicators were inconsistent and frequently not monotonic. Several individual quality indicators were associated with AEs; the highest tertile of percentage of residents with depression (4%-25%) had a hazard ratio (HR) of 1.65 [95% confidence interval (CI) 1.16, 2.35] and the highest tertile of the percentage taking antipsychotic medications (18%-35%) had an HR of 1.58 (CI 1.13, 2.21). The percentage of residents needing increased assistance with activities of daily living was statistically significant but not monotonic; the middle tertile (13% to <20%) had an HR of 1.69 (CI 1.16, 2.47). CONCLUSIONS AND IMPLICATIONS AEs occurring during transitions between nursing homes and hospitals are not explained by the characteristics of the facilities or summary quality scores. Development of risk reduction approaches requires assessment of processes and quality beyond the current quality measures.
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Affiliation(s)
- Terry S Field
- University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, Worcester, MA, USA.
| | - Hassan Fouayzi
- University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, Worcester, MA, USA
| | - Sybil Crawford
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Alok Kapoor
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | - Kimberly Fisher
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | - Ning Zhang
- University of Massachusetts, Amherst, MA, USA
| | - Jerry H Gurwitz
- University of Massachusetts Medical School, Worcester, MA, USA; Meyers Primary Care Institute, Worcester, MA, USA
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Sadiq H, Hoque L, Shi Q, Manning G, Crawford S, McManus D, Kapoor A. SUPPORT-AF III: supporting use of AC through provider prompting about oral anticoagulation therapy for AF. J Thromb Thrombolysis 2021; 52:808-816. [PMID: 33694097 DOI: 10.1007/s11239-021-02420-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Accepted: 02/24/2021] [Indexed: 11/30/2022]
Abstract
Only half of atrial fibrillation (AF) patients with elevated stroke risk receive anticoagulation (AC). Electronic health record (EHR) alerts have the potential to close the gap. We designed an outpatient EHR alert (linked to an order set for ordering AC, labs, and specialty referrals) that fired when cardiology and primary care providers (PCPs) saw AF patients not on AC. We assigned all untreated patients seen by cardiology providers and PCPs in the 8 months before and after the alert launch to pre- and post-launch intervention cohorts, respectively. Untreated AF patients seeing other types of providers became controls. We then compared the difference in AC starts between intervention and control patients post-launch to the same difference prelaunch (adjusting for covariates). We measured alert responsiveness as how often patients had at least one encounter with a provider, who interacted with the alert. The adjusted percentage of AC starts for the prelaunch cohort was 20% for intervention patients and 17% for controls (difference = 3%); post-launch, the percentage was 13% for both post-launch intervention and controls (difference = 0%). The difference in difference was - 3% (p value 0.63). For half of patients, at least one provider was responsive to our alert. Reasons for no AC commonly included relative contraindications (e.g. fall, gastrointestinal bleed). Our alert did not increase AC starts but responsiveness to it was high. Increasing AC starts will likely require education surrounding relative contraindications.
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Affiliation(s)
- Hammad Sadiq
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Laboni Hoque
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Qiming Shi
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Gordon Manning
- University of Massachusetts Medical School, Worcester, MA, USA.,UMass Memorial Health Care, Worcester, MA, USA
| | - Sybil Crawford
- University of Massachusetts Medical School, Worcester, MA, USA
| | - David McManus
- University of Massachusetts Medical School, Worcester, MA, USA.,UMass Memorial Health Care, Worcester, MA, USA
| | - Alok Kapoor
- University of Massachusetts Medical School, Worcester, MA, USA. .,UMass Memorial Health Care, Worcester, MA, USA. .,Biotech One, University of Massachusetts Medical School, 365 Plantation Street, Suite 100, Worcester, MA, 01605, USA.
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Pbert L, Trivedi M, Druker S, Bram J, Olendzki B, Crawford S, Frisard C, Andersen V, Waring ME, Clements K, Schneider K, Geller AC. Supporting families of children with overweight and obesity to live healthy lifestyles: Design and rationale for the Fitline cluster randomized controlled pediatric practice-based trial. Contemp Clin Trials 2021; 104:106348. [PMID: 33706002 DOI: 10.1016/j.cct.2021.106348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/04/2021] [Accepted: 03/01/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Over a third of preadolescent children with overweight or obesity. The American Academy of Pediatrics (AAP) recommends pediatric providers help families make changes in eating and activity to improve body mass index (BMI). However, implementation is challenging given limited time and referral sources, and family burden to access in-person weight management programs. PURPOSE To describe the design of a National Heart Blood and Lung Institute sponsored cluster randomized controlled pediatric-based trial evaluating the effectiveness of the Fitline pediatric practice-based referral program to reduce BMI and improve diet and physical activity in children with overweight or obesity. Comparison will be made between brief provider intervention plus referral to (1) eight weekly nutritionist-delivered coaching calls with workbook to help families make AAP-recommended lifestyle changes (Fitline-Coaching), vs. (2) the same workbook in eight mailings without coaching (Fitline-Workbook). METHODS Twenty practices are pair-matched and randomized to one of the two conditions; 494 parents and their children ages 8-12 with a BMI of ≥85th percentile are being recruited. The primary outcome is child BMI; secondary outcomes are child's diet and physical activity at baseline and 6- and 12-months post-baseline. Cost-effectiveness of the two interventions also will be examined. CONCLUSION This is the first randomized controlled trial to examine use of a centrally located telephonic coaching service to support families of children with overweight and obesity in making AAP-recommended lifestyle changes. If effective, the Fitline program will provide an innovative model for widespread dissemination, setting new standards for weight management care in pediatric practice. TRIAL REGISTRATION The ClinicalTrials.gov registration number is NCT03143660.
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Affiliation(s)
- Lori Pbert
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.
| | - Michelle Trivedi
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, United States
| | - Susan Druker
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jennifer Bram
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, United States
| | - Barbara Olendzki
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Sybil Crawford
- Graduate School of Nursing, University of Massachusetts Medical School, Worcester, MA, United States
| | - Christine Frisard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Victoria Andersen
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Karen Clements
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Kristin Schneider
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Alan C Geller
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, United States
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Godzik C, Crawford S, Ryan E. Feasibility of an online cognitive behavioral therapy program to improve insomnia, mood, and quality of life in bereaved adults ages 55 and older. Geriatr Nurs 2020; 42:99-106. [PMID: 33340917 DOI: 10.1016/j.gerinurse.2020.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 04/12/2020] [Revised: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 11/19/2022]
Abstract
The aim of the current study was to assess the feasibility and preliminary efficacy of utilizing an online Cognitive Behavioral Therapy for Insomnia (CBT-I) program in bereaved older adults (ages 55 and older). Participants were randomized to receive either a 6-week online CBT-I program or six weeks of online psychoeducational modules on insomnia and grief. The sample included 30 adults with mild to severe symptoms of insomnia. Results suggest that the study was feasible to conduct, as evidenced by the brief 5-week recruitment time, 87% retention rate, and 100% completion rate of the intervention modules. There were no treatment effects by time difference shown in the study and no significant differences in study outcomes were found between the CBT-I and control groups, as both demonstrated similar improvements in insomnia. However, this study suggests that it is feasible to recruit bereaved older adults for an online educational program and successfully administer an online protocol targeting insomnia and well-being.
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Affiliation(s)
- Cassandra Godzik
- Dartmouth College/Dartmouth Hitchcock Medical Center, Dartmouth Centers for Health and Aging, 46 Centerra Parkway, Box 201, Lebanon, New Hampshire 03766 USA.
| | - Sybil Crawford
- University of Massachusetts Medical School, Graduate School of Nursing, 55 North Lake Avenue, Worcester, Massachusetts, 01655 USA
| | - Elizabeth Ryan
- Veterans Association Boston Healthcare System, 150 South Huntington Avenue, Boston, Massachusetts, 02130 USA
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Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has rapidly instigated a global pandemic. Vaccine development is proceeding at an unprecedented pace. Once available, it will be important to maximize vaccine uptake and coverage. OBJECTIVE To assess intent to be vaccinated against COVID-19 among a representative sample of adults in the United States and identify predictors of and reasons for vaccine hesitancy. DESIGN Cross-sectional survey, fielded from 16 through 20 April 2020. SETTING Representative sample of adults residing in the United States. PARTICIPANTS Approximately 1000 adults drawn from the AmeriSpeak probability-based research panel, covering approximately 97% of the U.S. household population. MEASUREMENTS Intent to be vaccinated against COVID-19 was measured with the question, "When a vaccine for the coronavirus becomes available, will you get vaccinated?" Response options were "yes," "no," and "not sure." Participants who responded "no" or "not sure" were asked to provide a reason. RESULTS A total of 991 AmeriSpeak panel members responded. Overall, 57.6% of participants (n = 571) intended to be vaccinated, 31.6% (n = 313) were not sure, and 10.8% (n = 107) did not intend to be vaccinated. Factors independently associated with vaccine hesitancy (a response of "no" or "not sure") included younger age, Black race, lower educational attainment, and not having received the influenza vaccine in the prior year. Reasons for vaccine hesitancy included vaccine-specific concerns, a need for more information, antivaccine attitudes or beliefs, and a lack of trust. LIMITATIONS Participants' intent to be vaccinated was explored before a vaccine was available and when the pandemic was affecting a narrower swath of the United States. Questions about specific information or factors that might increase vaccination acceptance were not included. The survey response rate was 16.1%. CONCLUSION This national survey, conducted during the coronavirus pandemic, revealed that approximately 3 in 10 adults were not sure they would accept vaccination and 1 in 10 did not intend to be vaccinated against COVID-19. Targeted and multipronged efforts will be needed to increase acceptance of a COVID-19 vaccine when one becomes available. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Kimberly A Fisher
- Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester, Massachusetts (K.A.F., S.C., K.M.M.)
| | | | - Jeremy Walder
- University of Massachusetts Medical School, Worcester, Massachusetts (J.W.)
| | - Sybil Crawford
- Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester, Massachusetts (K.A.F., S.C., K.M.M.)
| | - Hassan Fouayzi
- Meyers Primary Care Institute, Worcester, Massachusetts (S.J.B., H.F.)
| | - Kathleen M Mazor
- Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester, Massachusetts (K.A.F., S.C., K.M.M.)
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Hoque L, Dewolf R, Meyers D, White DK, Mazor KM, Stefan M, Crawford S, Alavi K, Yates J, Maxfield M, Lou F, Uy K, Walz M, Kapoor A. Improving stamina and mobility with preop walking in surgical patients with frailty traits -OASIS IV: randomized clinical trial study protocol. BMC Geriatr 2020; 20:394. [PMID: 33028223 PMCID: PMC7542706 DOI: 10.1186/s12877-020-01799-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022] Open
Abstract
Background Frail older surgical patients face more than a two-fold increase in postoperative complications, including myocardial infarction, deep vein thrombosis, pulmonary embolism, pneumonia, ileus, and others. Many of these complications occur because of postoperative loss of stamina and poor mobility. Preoperative exercise may better prepare these vulnerable patients for surgery. We present the protocol for our ongoing randomized trial to assess the impact of a preoperative walking intervention with remote coaching and pedometer on outcomes of stamina (six-minute walk distance- 6MWD) and mobility (postoperative steps) in older adults with frailty traits. Methods We will be conducting a randomized clinical trial with a total of 120 patients permitting up to a 33% rate of attrition, to reach a final sample size of 80 (with 40 patients for each study arm). We will include patients who are age 60 or higher, score 4 or greater on the Edmonton Frailty Scale assessment, and will be undergoing a surgical operation that requires a 2 or more night hospital stay to be eligible for our trial. Using block randomization stratified on baseline 6MWD, we will assign patients to wear a pedometer. At the end of three baseline days, an athletic trainer (AT) will provide a daily step count goal reflecting a 10–20% increase from baseline. Subsequently, the AT will call weekly to further titrate the goal or calls more frequently if the patient is not meeting the prescribed goal. Controls will receive general walking advice. Our main outcome is change in 6MWD on postoperative day (POD) 2/3 vs. baseline. We will also collect 6MWD approximately 4 weeks after surgery and daily in-hospital steps. Conclusion If changes in a 6MWD and step counts are significantly higher for the intervention group, we believe this will confirm our hypothesis that the intervention leads to decreased loss of stamina and mobility. Once confirmed, we anticipate expanding to multiple centers to assess the interventional impact on clinical endpoints. Trial registration The randomized clinical trial was registered on clinicaltrials.gov under the identifier NCT03892187 on March 27, 2019.
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Affiliation(s)
- Laboni Hoque
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA
| | - Ryan Dewolf
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA
| | - David Meyers
- University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | | | - Kathleen M Mazor
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Mihaela Stefan
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,Baystate Medical Center, Springfield, MA, USA
| | - Sybil Crawford
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA
| | - Karim Alavi
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Jennifer Yates
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Mark Maxfield
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Feiran Lou
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Karl Uy
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Matthias Walz
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Alok Kapoor
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA. .,University of Massachusetts Memorial Health Care, Worcester, MA, USA. .,Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA.
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Layeequr Rahman R, Puckett Y, Habrawi Z, Crawford S. A decade of intraoperative ultrasound guided breast conservation for margin negative resection - Radioactive, and magnetic, and Infrared Oh My…. Am J Surg 2020; 220:1410-1416. [PMID: 32958157 DOI: 10.1016/j.amjsurg.2020.09.008] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/11/2020] [Accepted: 09/03/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The oncologic goal of margin-negative breast conservation requires adequate localization of tumor. Intraoperative ultrasound remains most feasible but under-utilized method to localize the tumor and assess margins. METHODS A prospectively maintained breast cancer database over a decade was queried for margin status in breast cancer patients undergoing breast conservation. Techniques of tumor localization, margin re-excision and closest margins were analyzed. Rate of conversion to mastectomy was determined. RESULTS Of the 945 breast cancer patients treated at a university-based Breast Center of Excellence between January 1, 2009 and December 31, 2018, 149(15.8%) had ductal carcinoma in situ; 712(75.3%) had invasive ductal carcinoma, and 63(6.7%) had invasive lobular carcinoma. Clinical stage distribution was: T1 = 372(39.4%); T2 = 257(27.2%); T3 = 87(9.2%). Five hundred and eighty three (61.7%) patients underwent breast conservation. The median (25th -75th centile) closest margin was 6(2.5, 10.0) mm. Thirty five (6.0%) patients underwent margin re-excision, of which 9(25%) were converted to mastectomy. Tumor localization was achieved with ultrasound in 521(89.4%) patients and with wire localization in 62(10.6%) patients. The median (25th-75th centile) closest margin with wire localization was 5.0(2.0, 8.5) mm versus 5.0 (2.0, 8.0) mm with ultrasound guidance [p = 0.6635]. The re-excision rate with wire localization was 14.5% versus 4.9% with ultrasound guidance [p = 0.0073]. The unadjusted Odds Ratio (95% CI) for margin revision in wire localized group compared with ultrasound was 3.2 (7.14, 1.42) [p = 0.0045]; multivariate adjusted OR (95%) was 4(9.09, 1.7) [p = 0.0013]. CONCLUSIONS Ultrasound guidance for localization of breast cancer remains the most effective option for margin negative breast conservation.
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Affiliation(s)
- Rakhshanda Layeequr Rahman
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Yana Puckett
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Zaina Habrawi
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Sybil Crawford
- University of Massachusetts, Medical School Division of Preventive and Behavioral Medicine, Department of Medicine, 55 Lake Avenue North, Shaw Building Room 228, Worcester, Massachusetts, 01655, USA.
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Greendale GA, Witt-Enderby P, Karlamangla AS, Munmun F, Crawford S, Huang M, Santoro N. Melatonin Patterns and Levels During the Human Menstrual Cycle and After Menopause. J Endocr Soc 2020; 4:bvaa115. [PMID: 33094207 PMCID: PMC7566378 DOI: 10.1210/jendso/bvaa115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/26/2020] [Indexed: 11/19/2022] Open
Abstract
Context Melatonin may play a role in the regulation of the human menstrual cycle and may decline with menopause and/or aging. Objective The objective of this work is to investigate the relations between melatonin and the menstrual cycle, menopause, and aging. Methods This was a cross-sectional and longitudinal analysis of 20 participants from the Study of Women’s Health Across the Nation (SWAN) Daily Hormone Study (DHS). The outcome measure was first-morning urine assay of 6-sulfatoxymelatonin (aMT6s), a gauge of melatonin. For each participant, aMT6s was measured daily during one premenopausal cycle with evidence of luteal activity (ELA) and one postmenopausal collection with no evidence of luteal activity (NELA). Results In addition to the organized patterns of hormone metabolites (estrone conjugates [E1c], and pregnanediol glucuronide [PdG]) and gonadotropins that characterized ovulatory menstrual cycles, there was a late luteal rise in aMT6s. In NELA collections, there was no periodicity of E1c, PdG, gonadotropins, or aMT6s. The strongest predictors of aMT6s levels were PdG values 11 to 12 days prior to aMT6s (β = 1.46, P = .001 and β = 1.44, P = .001, respectively). E1c and gonadotropins were not statistically significantly associated with aMT6s. Mean aMT6s in premenopause was 53.5 ng/mL, greater than the mean of 37.4 ng/mL in postmenopausal samples from the same women (P = .0002). Conclusions This study confirms a late luteal melatonin rise, likely signaled by progesterone, which may influence menstrual cycle pacemaker control. Melatonin declined from premenopause to postmenopause. A high correlation between menopause transition stage and age precludes distinction between the influences of ovarian and chronological aging.
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Affiliation(s)
- Gail A Greendale
- Department of Medicine, Division of Geriatrics, University of California, Los Angeles, Los Angeles, California
| | - Paula Witt-Enderby
- Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania
| | - Arun S Karlamangla
- Department of Medicine, Division of Geriatrics, University of California, Los Angeles, Los Angeles, California
| | - Fahima Munmun
- Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sybil Crawford
- University of Massachusetts Medical School, Graduate School of Nursing, Worcester, Massachusetts
| | - MeiHua Huang
- Department of Medicine, Division of Geriatrics, University of California, Los Angeles, Los Angeles, California
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
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Kapoor A, Field T, Handler S, Fisher K, Saphirak C, Crawford S, Fouayzi H, Johnson F, Spenard A, Zhang N, Gurwitz JH. Characteristics of Long‐Term Care Residents That Predict Adverse Events after Hospitalization. J Am Geriatr Soc 2020; 68:2551-2557. [DOI: 10.1111/jgs.16770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Alok Kapoor
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| | - Terry Field
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| | | | - Kimberly Fisher
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| | | | - Sybil Crawford
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
| | | | | | | | - Ning Zhang
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
- University of Massachusetts Amherst Massachusetts
| | - Jerry H. Gurwitz
- University of Massachusetts Medical School Worcester Massachusetts
- Meyers Primary Care Institute Worcester Massachusetts
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McConnell DS, Lasley BL, Crawford S, Gee NA, Auchus RJ. SAT-022 Adrenal Androgen Production Is Maintained While Ovarian Estrogens Fall Following the Final Menstrual Period in the Study of Women’s Health Across the Nation (SWAN). J Endocr Soc 2020. [PMCID: PMC7208005 DOI: 10.1210/jendso/bvaa046.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to clarify changes in sex steroids at the final menstrual period (FMP). We have shown previously that estradiol (E2) declines substantially in the 4-year period around the FMP, but hypothesize that testosterone (T) declines modestly and adrenal Δ5 androgens dehydroepiandrosterone (DHEA) and androstenediol (Adiol) remain unchanged. Methods: Liquid chromatography tandem mass spectrometry (LC-MS/MS) and immunoassay was used in approximately annual samples collected before and following FMP in 1490 women. We estimated time-related changes in each log-transformed androgen using piecewise linear mixed modeling, with knots (slope changes) at FMP-2 yrs and FMP+2 yrs as seen for E2. These models then were re-estimated for subgroups with different time courses identified using group-based trajectory modeling. Results: In the full sample, T was generally stable, although time course varied by subgroup, with a significant decrease of 5%/year in T in [FMP-2yrs, FMP+2yrs] only in the lowest T women. For DHEA and Adiol, declines were similar across all 3 time segments and across subgroups. Mean circulating androgen concentration declined modestly (P> 0.05) from five years before to five years following FMP. However, when stratified only the lowest 7% of circulating T declined significantly (p< 0.05) in the four years surrounding FMP when mean circulating E2 declined. This trajectory divergence of the lower circulating T suggests a different, non-adrenal source that is decreased at FMP which may be useful in clarifying ovarian versus adrenal testosterone production during the post-menopause. Paired results from samples collected before and following FMP in the same subjects indicate mean circulating E2 is less than 5% of mean circulating T suggesting that a relatively large portion of circulating E2 may be largely a result of peripheral conversion of adrenal androgens. Longitudinal LC-MS/MS analyses of circulating E2 and T indicate that the principal change in sex steroid influence at menopause is largely a decrease and dampening of ovarian and not adrenal steroid production.
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Affiliation(s)
| | | | - Sybil Crawford
- UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL, Worcester, MA, USA
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Santoro NF, Auchus RJ, Greendale G, Lasley BL, McConnell DS, Randolph JF, Martin D, Crawford S. SAT-027 Comparison of Estradiol by Mass Spectrometry Versus Immunoassay in Women Undergoing Menopause: Study of Womens Health Across the Nation (SWAN). J Endocr Soc 2020. [PMCID: PMC7209686 DOI: 10.1210/jendso/bvaa046.446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Serum estradiol (E2) concentrations in midreproductive women are easily measured using a variety of conventional immunoassays (IA). However, when women approach and traverse menopause, E2 eventually drops below levels where IA lacks sufficient sensitivity to accurately measure E2. Liquid chromatography and tandem mass spectrometry (LC/MS/MS) has become the standard method for assessing steroid hormones, especially when circulating concentrations are low. We evaluated the relationship between IA and LC/MS/MS E2 measurements in a cohort of women taken from the Study of Womens Health Across the Nation (SWAN) to assess the degree of agreement between the two methods and to determine the level of E2 at which IA becomes unreliable. Methods: 315 serum samples that had been previously measured for E2 using IA were re-analyzed using LC/MS/MS performed by one of the authors (RA). In this original set, E2 levels that were below the limit of assay detection (LLD, 6 pg/ml) were interpolated as a random number between 0 and the LLD. Agreement between all 315 samples was assessed using both Pearson and Spearman correlation. The analysis was repeated excluding the subset of specimens that were below the lower limit of detection (LLD) for the IA E2 assay (6 pg/ml; N=176), and a third set of correlations was obtained for specimens that measured <15 pg/ml by IA but were above the 6 pg/ml LLD (N=82). Results: The overall dataset (N=315) demonstrated excellent agreement between IA and LC/MS/MS with a Pearson’s r and Spearmans r of 0.98 AND 0.60, respectively. When the subset of 176 samples above the LLD were assessed, Pearson’s r was 0.98 and Spearman’s r was 0.81. In contrast, when specimens measuring 6–15 pg/ml by IA were compared to LC/MS/MS, Pearson’s r was -0.03 and Spearman’s r was 0.09, indicating a complete loss of relationship between the two methods. Conclusions: The IA used by SWAN (England, Clin Chem 2002; 48: 1584) and LC/MS/MS demonstrate excellent correlation for E2 measurements above 15 pg/ml. However, circulating concentrations of E2 below 15 pg/ml were not accurately measured using IA.
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Affiliation(s)
| | | | - Gail Greendale
- University of California at Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | - Sybil Crawford
- UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL, Worcester, MA, USA
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Pettee Gabriel K, Sternfeld B, Colvin AB, Lucas AR, Karvonen-Gutierrez CA, Gold EB, Crawford S, Greendale GA, Avis NE. The impact of breast cancer on physical activity from midlife to early older adulthood and predictors of change post-diagnosis. J Cancer Surviv 2020; 14:545-555. [PMID: 32232722 DOI: 10.1007/s11764-020-00879-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/11/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To examine physical activity (PA) patterns from pre- to post-diagnosis, and compare these changes to women without breast cancer. To determine pre-diagnosis predictors of PA change, post-diagnosis, in breast cancer survivors (BCS). METHODS Data were from 2314 Study of Women's Health Across the Nation (SWAN) participants, average age of 46.4 ± 2.7 years at baseline (1996-1997). In Pink SWAN, 151 women who reported an incident breast cancer diagnosis over 20 years were classified as BCS; the remaining 2163 women were controls. LOESS plots and linear mixed models were used to illustrate and compare PA changes (sports/exercise [primary measure] and total PA) from pre- to post-diagnosis (or corresponding period) in BCS versus controls. Adjusted linear regression models were used to determine pre-diagnosis predictors of at-risk post-diagnosis PA change patterns (consistently low and decreased PA). RESULTS No differences in pre- to post-diagnosis PA (or corresponding period) were observed in BCS versus controls. Among BCS, the odds of at-risk post-diagnosis PA change patterns was 2.50 (95% CI 0.96-6.48) times higher for those who reported sleep problems at ≥ 50% (compared to 0%) of pre-diagnosis visits and 3.49 (95% CI 1.26-9.65) times higher for those who were overweight or obese at all (compared to no) pre-diagnosis visits. No other statistically significant predictors were noted. CONCLUSIONS Age-related declines in PA were not amplified by a breast cancer diagnosis. Given the beneficial role of PA across the cancer control continuum, efforts to increase or maintain adequate PA, post-diagnosis, should be continued. IMPLICATIONS FOR CANCER SURVIVORS While age-related physical activity declines were not amplified breast cancer diagnosis, efforts to identify breast cancer survivors at increased risk for post-diagnosis physical activity declines (or maintenance of low activity) may be a high-yield strategy to improve prognosis and quality of life.
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Affiliation(s)
- Kelley Pettee Gabriel
- Department of Epidemiology, School of Public Health, The University of Alabama at Birmingham, RPHB 217, 1720 2nd Ave S, Birmingham, AL, 35294-0022, USA.
| | - Barbara Sternfeld
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, 94610, USA
| | - Alicia B Colvin
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Alexander R Lucas
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, 23219, USA
| | | | - Ellen B Gold
- Department of Public Health Sciences, Division of Epidemiology, University of California - Davis, Davis, CA, 95817, USA
| | - Sybil Crawford
- Graduate School of Nursing, University of Massachusetts Medical School, Worchester, MA, 01605, USA
| | - Gail A Greendale
- Department of Medicine, Division of Geriatrics, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Nancy E Avis
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
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