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George EL, Jacobs MA, Reitz KM, Massarweh NN, Youk AO, Arya S, Hall DE. Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings. JAMA Surg 2024; 159:501-509. [PMID: 38416481 PMCID: PMC10902781 DOI: 10.1001/jamasurg.2023.8081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/25/2023] [Indexed: 02/29/2024]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking. Objective To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals. Design, Setting, and Participants This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older. Exposures Surgical care in VA or private-sector hospitals. Main Outcomes and Measures Postoperative 30-day mortality and failure to rescue (FTR). Results Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures. Conclusions and Relevance Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Michael A Jacobs
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
| | | | - Nader N Massarweh
- Perioperative and Surgical Care Service, Atlanta Veterans Affairs Healthcare System, Decatur, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - Ada O Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pennsylvania
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Estock JL, Pandalai PK, Johanning JM, Youk AO, Varley PR, Arya S, Massarweh NN, Hall DE. A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty. J Surg Res 2023; 292:130-136. [PMID: 37619497 DOI: 10.1016/j.jss.2023.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/13/2023] [Accepted: 07/12/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers. METHODS We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality. RESULTS Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality. CONCLUSIONS While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.
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Affiliation(s)
- Jamie L Estock
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania.
| | | | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania; Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick R Varley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | | | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburg Healthcare System, University Drive C, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh, Pittsburg, Pennsylvania; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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3
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Estock JL, Schlegel C, Shinall MC, Varley P, Youk AO, Hoehn R, Hall DE. Interpreting the risk analysis index of frailty in the context of surgical oncology. J Surg Oncol 2023; 127:1062-1070. [PMID: 36881022 PMCID: PMC10079577 DOI: 10.1002/jso.27218] [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] [Received: 10/20/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND AND OBJECTIVES The Risk Analysis Index (RAI) accurately predicts adverse postoperative outcomes but the inclusion of cancer status in the RAI has raised two key concerns about its suitability for use in surgical oncology: (1) the potential over classification of cancer patients as frail, and (2) the potential overestimation of postoperative mortality for patients with surgically curable cancers. METHODS We performed a retrospective cohort analysis to assess the RAI's power to appropriately identify frailty and predict postoperative mortality in cancer patients. We assessed discrimination for mortality and calibration across five RAI models-the complete RAI and four variants that removed different cancer-related variables. RESULTS We found that the presence of disseminated cancer was a key variable driving the RAI's power to predict postoperative mortality. The model including only this variable [RAI (disseminated cancer)] was similar to the complete RAI in the overall sample (c = 0.842 vs. 0.840) and outperformed the complete RAI in the cancer subgroup (c = 0.736 vs 0.704, respectively, p < 0.0001, Max R2 = 19.3% vs. 15.1%, respectively). CONCLUSION The RAI demonstrates somewhat less discrimination when applied exclusively to cancer patients, but remains a strong predictor of postoperative mortality, especially in the setting of disseminated cancer.
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Affiliation(s)
- Jamie L Estock
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Cameron Schlegel
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick Varley
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Richard Hoehn
- Department of Surgery, University Hospitals, Cleveland, Ohio, USA
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- GRECC, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Rosland AM, Piette JD, Trivedi R, Lee A, Stoll S, Youk AO, Obrosky DS, Deverts D, Kerr EA, Heisler M. Effectiveness of a Health Coaching Intervention for Patient-Family Dyads to Improve Outcomes Among Adults With Diabetes: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2237960. [PMID: 36374502 PMCID: PMC9664266 DOI: 10.1001/jamanetworkopen.2022.37960] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE More than 75% of US adults with diabetes do not meet treatment goals. More effective support from family and friends ("supporters") may improve diabetes management and outcomes. OBJECTIVE To determine if the Caring Others Increasing Engagement in Patient Aligned Care Teams (CO-IMPACT) intervention improves patient activation, diabetes management, and outcomes compared with standard care. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted from November 2016 to August 2019 among participants recruited from 2 Veterans Health Administration primary care sites. All patient participants were adults aged 30 to 70 years with diabetes who had hemoglobin A1c (HbA1c) levels greater than 8% of total hemoglobin (to convert to proportion of total hemoglobin, multiply by 0.01) or systolic blood pressure (SBP) higher than 150 mm Hg; each participating patient had an adult supporter. Of 1119 recruited, 239 patient-supporter dyads were enrolled between November 2016 and May 2018, randomized 1:1 to receive the CO-IMPACT intervention or standard care, and followed up for 12 to 15 months. Investigators and analysts were blinded to group assignment. INTERVENTIONS Patient-supporter dyads received a health coaching session focused on dyadic information sharing and positive support techniques, then 12 months of biweekly automated monitoring telephone calls to prompt dyadic actions to meet diabetes goals, coaching calls to help dyads prepare for primary care visits, and after-visit summaries. Standard-care dyads received general diabetes education materials only. MAIN OUTCOMES AND MEASURES Intent-to-treat analyses were conducted according to baseline dyad assignment. Primary prespecified outcomes were 12-month changes in Patient Activation Measure-13 (PAM-13) and UK Prospective Diabetes Study (UKPDS) 5-year diabetes-specific cardiac event risk scores. Secondary outcomes included 12-month changes in HbA1c levels, SBP, diabetes self-management behaviors, diabetes distress, diabetes management self-efficacy, and satisfaction with health system support for the involvement of family supporters. Changes in outcome measures between baseline and 12 months were analyzed using linear regression models. RESULTS A total of 239 dyads enrolled; among patient participants, the mean (SD) age was 60 (8.9) years, and 231 (96.7%) were male. The mean (SD) baseline HbA1c level was 8.5% (1.6%) and SBP was 140.2 mm Hg (18.4 mm Hg). A total of 168 patients (70.3%) lived with their enrolled supporter; 229 patients (95.8%) had complete 12-month outcome data. In intention-to-treat analyses vs standard care, CO-IMPACT patients had greater 12-month improvements in PAM-13 scores (intervention effect, 2.60 points; 95% CI, 0.02-5.18 points; P = .048) but nonsignificant differences in UKPDS 5-year cardiac risk (intervention effect, 1.01 points; 95% CI, -0.74 to 2.77 points; P = .26). Patients in the CO-IMPACT arm also had greater 12-month improvements in healthy eating (intervention effect, 0.71 d/wk; 95% CI, 0.20-1.22 d/wk; P = .007), diabetes self-efficacy (intervention effect, 0.40 points; 95% CI, 0.09-0.71 points; P = .01), and satisfaction with health system support for the family supporter participants' involvement (intervention effect, 0.28 points; 95% CI, 0.07-0.49 points; P = .009); however, the 2 arms had similar improvements in HbA1c levels and in other measures. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, the CO-IMPACT intervention successfully engaged patient-supporter dyads and led to improved patient activation and self-efficacy. Physiological outcomes improved similarly in both arms. More intensive direct coaching of supporters, or targeting patients with less preexisting support or fewer diabetes management resources, may have greater impact. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02328326.
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Affiliation(s)
- Ann-Marie Rosland
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John D. Piette
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Ranak Trivedi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
| | - Aaron Lee
- Department of Psychology, University of Mississippi, University
| | - Shelley Stoll
- Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Ada O. Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - D. Scott Obrosky
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Denise Deverts
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eve A. Kerr
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Michele Heisler
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Bulas AM, Li L, Kumar RG, Mazumdar M, Rosso AL, Youk AO, Dams-O'Connor K. Preinjury Health Status of Adults With Traumatic Brain Injury: A Preliminary Matched Case-Control Study. J Head Trauma Rehabil 2022; 37:E186-E195. [PMID: 34145163 PMCID: PMC8671538 DOI: 10.1097/htr.0000000000000703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To discern whether there is evidence that individuals who sustained a traumatic brain injury (TBI) had the greater odds of preexisting health conditions and/or poorer health behaviors than matched controls without TBI. SETTING Brain Injury Inpatient Rehabilitation Unit at Mount Sinai Hospital. Midlife in the United States (MIDUS) control data were collected via random-digit-dialing phone survey. PARTICIPANTS TBI cases were enrolled in the TBI Health Study and met at least 1 of the following 4 injury severity criteria: abnormal computed tomography scan; Glasgow Coma Scale score between 3 and 12; loss of consciousness greater than 30 minutes; or post-TBI amnesia longer than 24 hours. Sixty-two TBI cases and 171 matched MIDUS controls were included in the analyses; controls were excluded if they reported having a history of head injury. DESIGN Matched case-control study. MAIN MEASURES Self-reported measures of depression symptoms, chronic pain, health status, alcohol use, smoking status, abuse of controlled substances, physical activity, physical health composite score, and behavioral health composite score. RESULTS Pre-index injury depression was nearly 4 times higher in TBI cases than in matched controls (OR= 3.98, 95% CI, 1.71-9.27; P = .001). We found no significant differences in the odds of self-reporting 3 or more medical health conditions in year prior to index injury (OR = 1.52; 95% CI, 0.82-2.81; P = .183) or reporting more risky health behaviors (OR = 1.48; 95% CI; 0.75-2.91; P = .254]) in individuals with TBI than in controls. CONCLUSION These preliminary findings suggest that the odds of depression in the year prior to index injury far exceed those reported in matched controls. Further study in larger samples is required to better understand the relative odds of prior health problems in those who sustain a TBI, with a goal of elucidating the implications of preinjury health on post-TBI disease burden.
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Affiliation(s)
- Ashlyn M Bulas
- Departments of Rehabilitation & Human Performance (Ms Bulas, Drs Kumar, and Dams-O'Connor), Institute for Healthcare Delivery Science, Population Health Science and Policy (Drs Li and Mazumdar), and Neurology (Dr Dams-O'Connor), Icahn School of Medicine at Mount Sinai, New York; and Departments of Epidemiology (Dr Rosso), Biostatistics (Dr Youk), University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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DiNardo MM, Greco C, Phares AD, Beyer NM, Youk AO, Obrosky DS, Morone NE, Owen JE, Saba SK, Suss SJ, Siminerio L. Effects of an integrated mindfulness intervention for veterans with diabetes distress: a randomized controlled trial. BMJ Open Diabetes Res Care 2022; 10:10/2/e002631. [PMID: 35346971 PMCID: PMC8961140 DOI: 10.1136/bmjdrc-2021-002631] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/27/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION US military veterans have disproportionately high rates of diabetes and diabetes-related morbidity in addition to being at risk of comorbid stress-related conditions. This study aimed to examine the effects of a technology-supported mindfulness intervention integrated into usual diabetes care and education on psychological and biobehavioral outcomes. RESEARCH DESIGN AND METHODS Veterans (N=132) with type 1 or 2 diabetes participated in this two-arm randomized controlled efficacy trial. The intervention arm received a one-session mindfulness intervention integrated into a pre-existing program of diabetes self-management education and support (DSMES) plus one booster session and 24 weeks of home practice supported by a mobile application. The control arm received one 3-hour comprehensive DSMES group session. The primary outcome was change in diabetes distress (DD). The secondary outcomes were diabetes self-care behaviors, diabetes self-efficacy, post-traumatic stress disorder (PTSD), depression, mindfulness, hemoglobin A1C (HbA1C), body weight, and blood pressure. Assessments were conducted at baseline, 12 weeks, and 24 weeks. Participant satisfaction and engagement in home practice were assessed in the intervention group at 12 and 24 weeks. RESULTS Intention-to-treat group by time analyses showed a statistically significant improvement in DD in both arms without significant intervention effect from baseline to 24 weeks. Examination of distal effects on DD between weeks 12 and 24 showed significantly greater improvement in the intervention arm. Improvement in DD was greater when baseline HbA1C was <8.5%. A significant intervention effect was also shown for general dietary behaviors. The secondary outcomes diabetes self-efficacy, PTSD, depression, and HbA1C significantly improved in both arms without significant intervention effects. Mindfulness and body weight were unchanged in either group. CONCLUSIONS A technology-supported mindfulness intervention integrated with DSMES showed stronger distal effects on DD compared with DSMES control. Examination of longer-term outcomes, underlying mechanisms, and the feasibility of virtual delivery is warranted. TRIAL REGISTRATION NUMBER NCT02928952.
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Affiliation(s)
- Monica M DiNardo
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Carol Greco
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Complementary Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Angela D Phares
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Nicole M Beyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - D Scott Obrosky
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Natalia E Morone
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jason E Owen
- National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Shaddy K Saba
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
| | - Stephen J Suss
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linda Siminerio
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Zupa MF, Piette JD, Stoll SC, Obrosky DS, Boudreaux-Kelly M, Youk AO, Overholt L, Trivedi R, Heisler M, Rosland AM. Patient and supporter factors affecting engagement with diabetes telehealth. Am J Manag Care 2021; 27:409-414. [PMID: 34668669 DOI: 10.37765/ajmc.2021.88758] [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] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To assess what patient, family supporter, and call characteristics predicted whether patients completed automated and coach-provided calls in a telehealth diabetes intervention. STUDY DESIGN A total of 123 adults with type 2 diabetes and high glycated hemoglobin A1c (HbA1c) or blood pressure, enrolled with a family supporter, received automated interactive voice response (IVR) and coach-provided visit preparation calls over 12 months. METHODS Data from baseline surveys and diabetes-related clinical information from patient medical records were entered into multilevel, multivariate regression models of associations between participant and call characteristics with call completion. RESULTS A total of 76.3% of 2784 IVR calls and 75.8% of 367 visit preparation calls were completed. For IVR calls, patients with recent call-triggered provider alerts had higher odds of call completion (adjusted odds ratio [AOR], 3.5; 95% CI, 2.2-5.5); those with depressive symptoms (AOR, 0.4; 95% CI, 0.2-0.9), higher HbA1c (AOR, 0.8; 95% CI, 0.6-0.99), and more months in the study (AOR, 0.9; 95% CI, 0.87-0.94 per month) had lower odds. For visit preparation calls, higher patient activation scores predicted higher call completion (AOR, 1.4; 95% CI, 1.1-1.9); patient college education predicted less call completion (AOR, 0.3; 95% CI, 0.2-0.6). Supporter help taking medications predicted less completion of both call types. Patient age did not predict call completion. CONCLUSIONS Patients of all ages completed telehealth calls at a high rate. Automated IVR calls were completed more often when urgent issues were identified to patients' providers, but less often if patients had high HbA1c or depression. Visit preparation call content should be tailored to patient education level. Family help with medications may identify patients needing additional support to engage with telehealth.
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Affiliation(s)
- Margaret F Zupa
- Department of Medicine, University of Pittsburgh, Falk Medical Bldg, 3601 Fifth Ave, Ste 3B, Pittsburgh, PA 15213.
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Yu YC, Luu HN, Wang R, Thomas CE, Glynn NW, Youk AO, Behari J, Yuan JM. Serum Biomarkers of Iron Status and Risk of Hepatocellular Carcinoma Development in Patients with Nonalcoholic Fatty Liver Disease. Cancer Epidemiol Biomarkers Prev 2021; 31:230-235. [PMID: 34649958 DOI: 10.1158/1055-9965.epi-21-0754] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/27/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) has become a major contributor to the rising incidence of hepatocellular carcinoma (HCC) in the United States and other developed countries. Iron, an essential metal primarily stored in hepatocytes, may play a role in the development of NAFLD-related HCC. Epidemiologic data on iron overload without hemochromatosis in relation to HCC are sparse. This study aimed to examine the associations between serum biomarkers of iron and the risk of HCC in patients with NAFLD. METHODS We identified 18,569 patients with NAFLD using the University of Pittsburgh Medical Center electronic health records from 2004 through 2018. After an average 4.34 years of follow-up, 244 patients developed HCC. Cox proportional hazard regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) of HCC incidence associated with elevated levels of iron biomarkers with adjustment for age, sex, race, body mass index, history of diabetes, and tobacco smoking. RESULTS The HRs (95% CIs) of HCC for clinically defined elevation of serum iron and transferrin saturation were 2.91 (1.34-6.30) and 2.02 (1.22-3.32), respectively, compared with their respective normal range. No statistically significant association was observed for total iron-binding capacity or serum ferritin with HCC risk. CONCLUSIONS Elevated levels of serum iron and transferrin saturation were significantly associated with increased risk of HCC among patients with NAFLD without hemochromatosis or other major underlying causes of chronic liver diseases. IMPACT Clinical surveillance of serum iron level may be a potential strategy to identify patients with NAFLD who are at high risk for HCC.
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Affiliation(s)
- Yi-Chuan Yu
- Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hung N Luu
- Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Renwei Wang
- Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Claire E Thomas
- Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nancy W Glynn
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ada O Youk
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jaideep Behari
- Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jian-Min Yuan
- Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania. .,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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9
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Vina ER, Youk AO, Quinones C, Kwoh CK, Ibrahim SA, Hausmann LRM. Use of Complementary and Alternative Therapy for Knee Osteoarthritis: Race and Gender Variations. ACR Open Rheumatol 2021; 3:660-667. [PMID: 34535982 PMCID: PMC8449036 DOI: 10.1002/acr2.11307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate race and gender variations in complementary and alternative medicine (CAM) use for knee osteoarthritis (OA) (unadjusted and adjusted for demographic and clinical factors). Methods A secondary analysis of cross‐sectional data was conducted. The sample included Veterans Affairs patients 50 years of age or older with symptomatic knee OA. Current use of various CAM therapies was assessed at baseline. Logistic regression models were used to compare race and gender differences in the use of specific CAMs. Results The sample included 517 participants (52.2% identified as African American [AA]; 27.1% identified as female). After adjusting for demographic and clinical factors, AA participants, compared with white participants, were less likely to use joint supplements (odds ratio [OR]: 0.53; 95% confidence interval [CI], 0.31‐0.90]); yoga, tai chi, or pilates (OR: 0.39; 95% CI: 0.19‐0.77); and chiropractic care (OR: 0.51; 95% CI: 0.26‐1.00). However, they were more likely to participate in spiritual activities (OR: 2.02; 95% CI: 1.39‐2.94). Women, compared with men, were more likely to use herbs (OR: 2.42; 95% CI: 1.41‐4.14); yoga, tai chi, or pilates (OR: 2.09; 95% CI: 1.04‐4.19); acupuncture, acupressure, or massage (OR: 2.45; 95% CI: 1.28‐4.67); and spiritual activities (OR: 1.68; 95% CI: 1.09‐2.60). The interactive effects of race and gender were significant in the use of herbs (P = 0.008); yoga, tai chi, or pilates (P = 0.011); acupuncture, acupressure or massage (P = 0.038); and spiritual activities (P < 0.001). Conclusion There are race and gender differences in the use of various CAMs for OA. As benefits and limitations of CAM therapies vary, clinicians must be aware of these differences.
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Affiliation(s)
- Ernest R Vina
- College of Medicine and University of Arizona Arthritis Center, University of Arizona, Tucson
| | - Ada O Youk
- Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cristian Quinones
- College of Medicine and University of Arizona Arthritis Center, University of Arizona, Tucson
| | - C Kent Kwoh
- College of Medicine and University of Arizona Arthritis Center, University of Arizona, Tucson
| | | | - Leslie R M Hausmann
- Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania
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10
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Boyer TL, Youk AO, Haas AP, Brown GR, Shipherd JC, Kauth MR, Jasuja GK, Blosnich JR. Suicide, Homicide, and All-Cause Mortality Among Transgender and Cisgender Patients in the Veterans Health Administration. LGBT Health 2021; 8:173-180. [PMID: 33544021 DOI: 10.1089/lgbt.2020.0235] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: This study examines the differences in suicide, homicide, and all-cause mortality between transgender and cisgender Veterans Health Administration (VHA) patients. Methods: VHA electronic medical record data from October 1, 1999 to December 31, 2016 were used to create a sample of transgender and cisgender patients (n = 32,441). Cox proportional hazard regression was used to evaluate differences in survival time (date of birth to death date/study end). Death data were from the National Death Index. Results: Transgender patients had more than twofold greater hazard of suicide than cisgender patients (adjusted hazard ratio [aHR] = 2.77, 95% confidence interval [CI] = 1.88-4.09), especially among younger (18-39 years) (aHR = 3.35, 95% CI = 1.30-8.60) and older (≥65 years) patients (aHR = 9.48, 95% CI = 3.88-23.19). Alternatively, transgender patients had an overall lower hazard of all-cause mortality (aHR = 0.90, 95% CI = 0.84-0.97) compared with cisgender patients, which was driven by patients 40-64 years old (aHR = 0.78, 95% CI = 0.72-0.86) and reversed by those 65 years and older (aHR = 1.17, 95% CI = 1.03-1.33). Conclusion: Transgender patients' hazard of suicide mortality was significantly greater than that of cisgender VHA patients.
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Affiliation(s)
- Taylor L Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ann P Haas
- Department of Health Sciences, Lehman College, City University of New York, Bronx, New York, USA
| | - George R Brown
- Mountain Home VA Medical Center, Johnson City, Tennessee, USA.,Department of Psychiatry and Behavioral Sciences, East Tennessee State University, Johnson City, Tennessee, USA
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia, USA.,National Center for Post-traumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michael R Kauth
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia, USA.,South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Psychiatry, Baylor College of Medicine, Houston, Texas, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, Massachusetts, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - John R Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
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11
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Paul P, Hammer A, Rositch AF, Burke AE, Viscidi RP, Silver MI, Campos N, Youk AO, Gravitt PE. Rates of New Human Papillomavirus Detection and Loss of Detection in Middle-aged Women by Recent and Past Sexual Behavior. J Infect Dis 2020; 223:1423-1432. [PMID: 32870982 DOI: 10.1093/infdis/jiaa557] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 05/07/2020] [Accepted: 08/27/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Understanding the source of newly detected human papillomavirus (HPV) in middle-aged women is important to inform preventive strategies, such as screening and HPV vaccination. METHODS We conducted a prospective cohort study in Baltimore, Maryland. Women aged 35-60 years underwent HPV testing and completed health and sexual behavior questionnaires every 6 months over a 2-year period. New detection/loss of detection rates were calculated and adjusted hazard ratios were used to identify risk factors for new detection. RESULTS The new and loss of detection analyses included 731 women, and 104 positive for high-risk HPV. The rate of new high-risk HPV detection was 5.0 per 1000 woman-months. Reporting a new sex partner was associated with higher detection rates (adjusted hazard ratio, 8.1; 95% confidence interval, 3.5-18.6), but accounted only for 19.4% of all new detections. Among monogamous and sexually abstinent women, new detection was higher in women reporting ≥5 lifetime sexual partners than in those reporting <5 (adjusted hazard ratio, 2.2; 95% confidence interval, 1.2-4.2). CONCLUSION Although women remain at risk of HPV acquisition from new sex partners as they age, our results suggest that most new detections in middle-aged women reflect recurrence of previously acquired HPV.
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Affiliation(s)
- Proma Paul
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anne Hammer
- Department of Obstetrics and Gynecology, Regional Hospital West Jutland, Herning, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Raphael P Viscidi
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michelle I Silver
- Division of Public Health Sciences, Washington University School of Medicine, St Louis, Missouri, USA
| | - Nicole Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ada O Youk
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine Baltimore, Maryland, USA
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12
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Krishnan Pandalai P, Michael Johanning J, Youk AO, Varley PR, Arya S, Nabile Massarweh N, Hall DE. Biomarkers Added to RAI Frailty Screening: Improved Discrimination but Worth the Cost? J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.057] [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: 11/30/2022]
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13
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Frederick AN, Pardo AD, Schmiedt CW, Hinson WD, Youk AO, Urie BK. Outcomes for dogs with functional thyroid tumors treated by surgical excision alone. J Am Vet Med Assoc 2020; 256:444-448. [PMID: 31999523 DOI: 10.2460/javma.256.4.444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe clinical findings and survival times for dogs with functional thyroid tumors treated with surgery alone and investigate potential prognostic factors for outcome in these patients. ANIMALS 27 client-owned dogs. PROCEDURES Medical records of 9 institutions were reviewed to identify dogs with hyperthyroidism secondary to thyroid neoplasia that were treated with surgery alone between 2005 and 2015. Data collected included signalment, hematologic and physical examination findings, tumor staging results, time from diagnosis to treatment, surgical procedure performed, histologic findings, evidence of recurrence or metastatic disease, and date of death or last follow-up. Median survival time and 1-, 2-, and 3-year survival rates were assessed by Kaplan-Meier analysis. Associations between variables of interest and the outcome of death were assessed with Cox proportional hazards models. RESULTS Dogs from 8 institutions met inclusion criteria. Median age at diagnosis was 10 years (range, 8 to 13 years). Golden Retrievers and Labrador Retrievers were commonly represented (5 dogs each). Polyuria with polydipsia (15/27 [56%]) and weight loss (12 [44%]) were the most common clinical signs; 2 dogs without clinical signs had hyperthyroidism identified by routine hematologic analysis. One dog had metastatic disease at the time of diagnosis. Most tumors (23/27 [85%]) were malignant. Estimated median survival time was 1,072 days. No significant prognostic factors were identified. CONCLUSIONS AND CLINICAL RELEVANCE Dogs with resectable functional thyroid tumors had a good prognosis with surgical excision alone. Survival times for these dogs were similar to those in previous studies that included dogs with nonfunctional thyroid tumors.
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14
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Folb BL, Klem ML, Youk AO, Dahm JJ, He M, Ketchum AM, Wessel CB, Hartman LM. Continuing education for systematic reviews: a prospective longitudinal assessment of a workshop for librarians. J Med Libr Assoc 2020; 108:36-46. [PMID: 31897050 PMCID: PMC6919982 DOI: 10.5195/jmla.2020.492] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/01/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE This prospective, longitudinal study explored the impact of a continuing education class on librarians' knowledge levels about and professional involvement with systematic reviews. Barriers to systematic review participation and the presence of formal systematic review services in libraries were also measured. METHODS Participants completed web-based surveys at three points in time: pre-class, post-class, and six-months' follow-up. Descriptive statistics were calculated for demographics and survey questions. Linear mixed effects models assessed knowledge score changes over time. RESULTS Of 160 class attendees, 140 (88%) completed the pre-class survey. Of those 140, 123 (88%) completed the post-class survey, and 103 (74%) completed the follow-up survey. There was a significant increase (p<0.00001) from pre-class to post-class in knowledge test scores, and this increase was maintained at follow-up. At post-class, 69% or more of participants intended to promote peer review of searches, seek peer review of their searches, search for grey literature, read or follow published guidelines on conduct and documentation of systematic reviews, and ask for authorship on a systematic review. Among librarians who completed a systematic review between post-class and follow-up, 73% consulted published guidelines, 52% searched grey literature, 48% sought peer review, 57% asked for authorship, and 70% received authorship. CONCLUSIONS Attendance at this continuing education class was associated with positive changes in knowledge about systematic reviews and in librarians' systematic review-related professional practices. This suggests that in-depth professional development classes can help librarians develop skills that are needed to meet library patrons' changing service needs.
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Affiliation(s)
- Barbara L Folb
- Librarian Emeritus, Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA,
| | - Mary L Klem
- Research and Instruction Librarian and Liaison to the School of Nursing, Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA,
| | - Ada O Youk
- Associate Professor, Graduate School of Public Health, Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA,
| | - Julia J Dahm
- Coordinator of Technology Integration Services, Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA,
| | - Meiqi He
- Data Analyst, Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA,
| | - Andrea M Ketchum
- Research and Instruction Librarian and Scholarly Communication Liaison, Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA,
| | - Charles B Wessel
- Head of Research Initiative, Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA,
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15
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Christ JP, Anderson JR, Youk AO. Modified cranial closing wedge ostectomy in 25 dogs. Vet Surg 2018; 47:683-691. [DOI: 10.1111/vsu.12912] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 10/16/2017] [Accepted: 10/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Jeffrey P. Christ
- Pittsburgh Veterinary Specialty and Emergency Center; Pittsburgh Pennsylvania
| | | | - Ada O. Youk
- Department of Biostatistics; University of Pittsburgh; Pittsburgh Pennsylvania
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16
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Agimi Y, Albert SM, Youk AO, Documet PI, Steiner CA. Mandatory Physician Reporting of At-Risk Drivers: The Older Driver Example. Gerontologist 2018; 58:578-587. [PMID: 28069887 PMCID: PMC6281322 DOI: 10.1093/geront/gnw209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/23/2016] [Indexed: 11/14/2022] Open
Abstract
Purpose of the Study In a number of states, physicians are mandated by state law to report at-risk drivers to licensing authorities. Often these patients are older adult drivers who may exhibit unsafe driving behaviors, have functional/cognitive impairments, or are diagnosed with conditions such as Alzheimer's disease and/or seizure disorders. The hypothesis that mandatory physician reporting laws reduce the rate of crash-related hospitalizations among older adult drivers was tested. Design and Methods Using retrospective data (2004-2009), this study identified 176,066 older driver crash-related hospitalizations, from the State Inpatient Databases. Three age-specific negative binomial generalized estimating equation models were used to estimate the effect of physician reporting laws on state's incidence rate of crash-related hospitalizations among older drivers. Results No evidence was found for an independent association between mandatory physician reporting laws and a lower crash hospitalization rate among any of the age groups examined. The main predictor of interest, mandatory physician reporting, failed to explain any significant variation in crash hospitalization rates, when adjusting for other state-specific laws and characteristics. Vision testing at in-person license renewal was a significant predictor of lower crash hospitalization rate, ranging from incidence rate ratio of 0.77 (95% confidence interval 0.62-0.94) among 60- to 64-year olds to 0.83 (95% confidence interval 0.67-0.97) among 80- to 84-year olds. Implications Physician reporting laws and age-based licensing requirements are often at odds with older driver's need to maintain independence. This study examines this balance and finds no evidence of the benefits of mandatory physician reporting requirements on driver crash hospitalizations, suggesting that physician mandates do not yet yield significant older driver safety benefits, possibly to the detriment of older driver's well-being and independence.
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Affiliation(s)
- Yll Agimi
- Information Innovators Inc., Silver Spring, Maryland
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences, Graduate School of
Public Health, Pennsylvania
| | - Ada O Youk
- Department of Biostatistics, Graduate School of Public Health, University of
Pittsburgh, Pennsylvania
| | - Patricia I Documet
- Department of Behavioral and Community Health Sciences, Graduate School of
Public Health, Pennsylvania
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17
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Agimi Y, Albert SM, Youk AO, Documet PI, Steiner CA. Dementia and motor vehicle crash hospitalizations: Role of physician reporting laws. Neurology 2018; 90:e808-e813. [PMID: 29386271 PMCID: PMC10681054 DOI: 10.1212/wnl.0000000000005022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 05/29/2017] [Accepted: 12/01/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the effect of physician reporting laws and state licensing requirements on crash hospitalizations among drivers with dementia. METHODS A study of drivers hospitalized because of vehicle crashes, identified from the State Inpatient Databases of the Agency for Healthcare Research and Quality. Multivariable logistic regression was used to examine the effect of mandatory physician reporting of at-risk drivers and state licensing requirement on the prevalence of dementia among hospitalized drivers. RESULTS Physician reporting laws, mandated or legally protected, were not associated with a lower likelihood of dementia among crash hospitalized drivers. Hospitalized drivers aged 60 to 69 years in states with in-person renewal laws were 37% to 38% less likely to have dementia than drivers in other states and 23% to 28% less likely in states with vision testing at in-person renewal. Road testing was associated with lower dementia prevalence among hospitalized drivers aged 80 years and older. CONCLUSION Vision testing at in-person renewal and in-person renewal requirements were significantly related with a lower prevalence of dementia in hospitalized older adults among drivers aged 60 to 69 years. Road testing was significantly associated with a lower proportion of dementia among hospitalized drivers aged 80 years and older. Mandatory physician driver reporting laws lacked any independent association with prevalence of dementia among hospitalized drivers.
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Affiliation(s)
- Yll Agimi
- From Salient CRGT Inc. (Y.A.), Health Services, Silver Spring, MD; Departments of Behavioral and Community Health Sciences (S.M.A., P.I.D.) and Biostatistics (A.O.Y.), University of Pittsburgh, PA; Kaiser Permanente-Denver (C.A.S.), Institute for Health Research, CO; Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality (C.A.S.), DHHS, Rockville, MD.
| | - Steven M Albert
- From Salient CRGT Inc. (Y.A.), Health Services, Silver Spring, MD; Departments of Behavioral and Community Health Sciences (S.M.A., P.I.D.) and Biostatistics (A.O.Y.), University of Pittsburgh, PA; Kaiser Permanente-Denver (C.A.S.), Institute for Health Research, CO; Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality (C.A.S.), DHHS, Rockville, MD
| | - Ada O Youk
- From Salient CRGT Inc. (Y.A.), Health Services, Silver Spring, MD; Departments of Behavioral and Community Health Sciences (S.M.A., P.I.D.) and Biostatistics (A.O.Y.), University of Pittsburgh, PA; Kaiser Permanente-Denver (C.A.S.), Institute for Health Research, CO; Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality (C.A.S.), DHHS, Rockville, MD
| | - Patricia I Documet
- From Salient CRGT Inc. (Y.A.), Health Services, Silver Spring, MD; Departments of Behavioral and Community Health Sciences (S.M.A., P.I.D.) and Biostatistics (A.O.Y.), University of Pittsburgh, PA; Kaiser Permanente-Denver (C.A.S.), Institute for Health Research, CO; Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality (C.A.S.), DHHS, Rockville, MD
| | - Claudia A Steiner
- From Salient CRGT Inc. (Y.A.), Health Services, Silver Spring, MD; Departments of Behavioral and Community Health Sciences (S.M.A., P.I.D.) and Biostatistics (A.O.Y.), University of Pittsburgh, PA; Kaiser Permanente-Denver (C.A.S.), Institute for Health Research, CO; Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality (C.A.S.), DHHS, Rockville, MD
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18
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Bramoweth AD, Germain A, Youk AO, Rodriguez KL, Chinman MJ. A hybrid type I trial to increase Veterans' access to insomnia care: study protocol for a randomized controlled trial. Trials 2018; 19:73. [PMID: 29373993 PMCID: PMC5787269 DOI: 10.1186/s13063-017-2437-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 12/29/2017] [Indexed: 11/10/2022] Open
Abstract
Background Chronic insomnia is among the most reported complaints of Veterans and military personnel referred for mental health services. It is highly comorbid with medical and psychiatric disorders, and is associated with significantly increased healthcare utilization and costs. Evidence-based psychotherapy, namely Cognitive Behavioral Therapy for Insomnia (CBTI), is an effective treatment and recommended over prescription sleep medications. While CBTI is part of a nationwide rollout in the Veterans Health Administration to train hundreds of providers, access to treatment is still limited for many Veterans due to limited treatment availability, low patient and provider knowledge about treatment options, and Veteran barriers such as distance and travel, work schedules, and childcare. Uptake of a briefer, more primary-care-friendly treatment into routine clinical care in Veterans Affairs (VA) primary care settings, where insomnia is typically first recognized and diagnosed, may effectively and efficiently increase access to effective insomnia interventions and help decrease the risks and burdens related to chronic insomnia. Methods This hybrid type I trial is composed of two aims. The first preliminarily tests the clinical non-inferiority of Brief Behavioral Treatment for Insomnia (BBTI) versus the current “gold standard” treatment, CBTI. The second is a qualitative needs assessment, guided by the Consolidated Framework for Implementation Research (CFIR), to identify potential factors that may affect successful implementation and integration of behavioral treatments for insomnia in the primary care setting. To identify potential implementation factors, individual interviews are conducted with the Veterans who participate in the clinical trial, as well as VA primary care providers and nursing staff. Discussion It is increasingly important to better understand barriers to, and facilitators of, implementing insomnia interventions in order to ensure that Veterans have the best access to care. Furthermore, it is important to evaluate the potential for new avenues of treatment delivery, like BBTI in the primary care setting, which can benefit Veterans who may not have adequate access to specialty mental health providers trained in CBTI. Trial registration ClinicalTrials.gov, ID: NCT02724800. Registered on 31 March 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2437-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adam D Bramoweth
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA. .,Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA.
| | - Anne Germain
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew J Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA.,Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA.,RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, 15213, PA, USA
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19
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Buhule OD, Wahed AS, Youk AO. Bayesian hierarchical joint modeling of repeatedly measured continuous and ordinal markers of disease severity: Application to Ugandan diabetes data. Stat Med 2017; 36:4677-4691. [PMID: 28833382 DOI: 10.1002/sim.7444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 06/27/2017] [Accepted: 07/27/2017] [Indexed: 11/12/2022]
Abstract
Modeling of correlated biomarkers jointly has been shown to improve the efficiency of parameter estimates, leading to better clinical decisions. In this paper, we employ a joint modeling approach to a unique diabetes dataset, where blood glucose (continuous) and urine glucose (ordinal) measures of disease severity for diabetes are known to be correlated. The postulated joint model assumes that the outcomes are from distributions that are in the exponential family and hence modeled as multivariate generalized linear mixed effects model associated through correlated and/or shared random effects. The Markov chain Monte Carlo Bayesian approach is used to approximate posterior distribution and draw inference on the parameters. This proposed methodology provides a flexible framework to account for the hierarchical structure of the highly unbalanced data as well as the association between the 2 outcomes. The results indicate improved efficiency of parameter estimates when blood glucose and urine glucose are modeled jointly. Moreover, the simulation studies show that estimates obtained from the joint model are consistently less biased and more efficient than those in the separate models.
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Affiliation(s)
- O D Buhule
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - A S Wahed
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - A O Youk
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA 15261, USA
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20
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Zhao Q, Zmuda JM, Kuipers AL, Bunker CH, Patrick AL, Youk AO, Miljkovic I. Muscle Attenuation Is Associated With Newly Developed Hypertension in Men of African Ancestry. Hypertension 2017; 69:957-963. [PMID: 28264917 DOI: 10.1161/hypertensionaha.116.08415] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/04/2016] [Accepted: 02/05/2017] [Indexed: 12/25/2022]
Abstract
Increased ectopic adipose tissue infiltration in skeletal muscle is associated with insulin resistance and diabetes mellitus. We evaluated whether change in skeletal muscle adiposity predicts subsequent development of hypertension in men of African ancestry, a population sample understudied in previous studies. In the Tobago Health Study, a prospective longitudinal study among men of African ancestry (age range 40-91 years), calf intermuscular adipose tissue, and skeletal muscle attenuation were measured with computed tomography. Hypertension was defined as a systolic blood pressure ≥140 mm Hg, or a diastolic blood pressure ≥90 mm Hg, or receiving antihypertensive medications. Logistic regression was performed with adjustment for age, insulin resistance, baseline and 6-year change in body mass index, baseline and 6-year change in waist circumference, and other potential confounding factors. Among 746 normotensive men at baseline, 321 (43%) developed hypertension during the mean 6.2 years of follow-up. Decreased skeletal muscle attenuation was associated with newly developed hypertension after adjustment for baseline and 6-year change of body mass index (odds ratio [95% confidence interval] per SD, 1.3 [1.0-1.6]) or baseline and 6-year change of waist circumference (odds ratio [95% confidence interval] per SD, 1.3 [1.0-1.6]). No association was observed between increased intermuscular adipose tissue and hypertension. Our novel findings show that decreased muscle attenuation is associated with newly developed hypertension among men of African ancestry, independent of general and central adiposity and insulin resistance. Further studies are needed to adjust for inflammation, visceral and other ectopic adipose tissue depots, and to confirm our findings in other population samples.
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Affiliation(s)
- Qian Zhao
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (Q.Z., J.M.Z., A.L.K., C.H.B., I.M.); Tobago Health Studies Office, Scarborough, Trinidad & Tobago (A.L.P.); and Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA (A.O.Y.)
| | - Joseph M Zmuda
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (Q.Z., J.M.Z., A.L.K., C.H.B., I.M.); Tobago Health Studies Office, Scarborough, Trinidad & Tobago (A.L.P.); and Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA (A.O.Y.)
| | - Allison L Kuipers
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (Q.Z., J.M.Z., A.L.K., C.H.B., I.M.); Tobago Health Studies Office, Scarborough, Trinidad & Tobago (A.L.P.); and Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA (A.O.Y.)
| | - Clareann H Bunker
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (Q.Z., J.M.Z., A.L.K., C.H.B., I.M.); Tobago Health Studies Office, Scarborough, Trinidad & Tobago (A.L.P.); and Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA (A.O.Y.)
| | - Alan L Patrick
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (Q.Z., J.M.Z., A.L.K., C.H.B., I.M.); Tobago Health Studies Office, Scarborough, Trinidad & Tobago (A.L.P.); and Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA (A.O.Y.)
| | - Ada O Youk
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (Q.Z., J.M.Z., A.L.K., C.H.B., I.M.); Tobago Health Studies Office, Scarborough, Trinidad & Tobago (A.L.P.); and Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA (A.O.Y.)
| | - Iva Miljkovic
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (Q.Z., J.M.Z., A.L.K., C.H.B., I.M.); Tobago Health Studies Office, Scarborough, Trinidad & Tobago (A.L.P.); and Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA (A.O.Y.)
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Zhao Q, Zmuda JM, Kuipers AL, Jonnalagadda P, Bunker CH, Patrick AL, Youk AO, Miljkovic I. Greater skeletal muscle fat infiltration is associated with higher all-cause mortality among men of African ancestry. Age Ageing 2016; 45:529-34. [PMID: 27076522 DOI: 10.1093/ageing/afw062] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 02/16/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND fat infiltration within and around skeletal muscle (i.e. myosteatosis) increases with ageing, is greater in African versus European ancestry men and is associated with poor health. Myosteatosis studies of mortality are lacking, particularly among African ancestry populations. METHODS in the Tobago Health study, a prospective longitudinal study, we evaluated the association of all-cause mortality with quantitative computed tomography (QCT) measured lower leg myosteatosis (intermuscular fat (IM fat) and muscle density) in 1,652 African ancestry men using Cox proportional hazards models. Date of death was abstracted from death certificates and/or proxy. RESULTS one hundred and twelve deaths occurred during follow-up (mean 5.9 years). In all men (age range 40-91 years), higher all-cause mortality was associated with greater IM fat (HR (95% CI) per SD: 1.29 (1.06-1.57)) and lower muscle density (HR (95% CI) per SD lower: 1.37 (1.08-1.75)) in fully adjusted models. Similar mortality hazard rates were seen in the subset of elderly men (aged ≥65 years) with greater IM fat (1.40 (1.11-1.78) or lower muscle density (1.66 (1.24-2.21)) in fully adjusted models. CONCLUSIONS our study identified a novel, independent association between myosteatosis and all-cause mortality in African ancestry men. Further studies are needed to establish whether this association is independent of other ectopic fat depots and to identify possible biological mechanisms underlying this relationship.
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Affiliation(s)
- Qian Zhao
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Joseph M Zmuda
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Allison L Kuipers
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | - Clareann H Bunker
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Alan L Patrick
- Tobago Health Studies Office, Scarborough, Trinidad and Tobago
| | - Ada O Youk
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Iva Miljkovic
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15213, USA
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22
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Marsh GM, Youk AO, Buchanich JM, Cassidy LD, Lucas LJ, Esmen NA, Gathuru IM. Pharyngeal cancer mortality among chemical plant workers exposed to formaldehyde. Toxicol Ind Health 2016; 18:257-68. [PMID: 14992463 DOI: 10.1191/0748233702th149oa] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objectives: To assess the possible relationship between formaldehyde exposure and mortality risk from pharyngeal cancer (PC), in particular nasopharyngeal cancer (NPC). Methods: Subjects were 7328 workers employed at a plastics-producing plant (1941-1984). Vital status for 98% of the cohort and cause of death for 95% of 2872 deaths were determined. Reconstructed exposures to formaldehyde, particulates and pigment were used to compute several exposure measures. Standardized mortality ratios (SMRs) were computed for several demographic, work history and formaldehyde exposure variables. In a nested case-control study, seven cases of NPC and 15 cases of other PC were matched on race, sex, age and year of birth to four controls from the cohort. Among interviewed subjects, lifetime smoking history was determined using respondents or proxies for all but one control subject. Results: Statistically significant 2.23-fold and fivefold excesses for PC and NPC, respectively, were observed. Fivefold range NPC excesses were observed for both short (B / 1 year) and long-term workers and were concentrated among workers hired during 1947-1956. Only three NPC cases were exposed to formaldehyde for longer than one year, and each had low average intensity of formaldehyde exposure (0.03-0.60 ppm). Only a few exposure measures revealed some evidence of an association with all PC or NPC. For all PC combined, adjustment for smoking and year-of-hire in the case-control study generally corroborated findings from the cohort study. Conclusions: Overall, the pattern of findings suggests that the large, persistent nasopharyngeal and other PC excesses observed among the Wallingford workforce are not associated with formaldehyde exposure, and may reflect the influence of nonoccupational risk factors or occupational risk factors associated with employment outside the Wallingford plant.
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Affiliation(s)
- Gary M Marsh
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Ye L, Youk AO, Sereika SM, Anderson SJ, Burke LE. A three-step estimation procedure using local polynomial smoothing for inconsistently sampled longitudinal data. Stat Med 2016; 35:3613-22. [PMID: 27122363 DOI: 10.1002/sim.6978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 01/12/2016] [Revised: 03/16/2016] [Accepted: 04/04/2016] [Indexed: 11/06/2022]
Abstract
Parametric mixed-effects models are useful in longitudinal data analysis when the sampling frequencies of a response variable and the associated covariates are the same. We propose a three-step estimation procedure using local polynomial smoothing and demonstrate with data where the variables to be assessed are repeatedly sampled with different frequencies within the same time frame. We first insert pseudo data for the less frequently sampled variable based on the observed measurements to create a new dataset. Then standard simple linear regressions are fitted at each time point to obtain raw estimates of the association between dependent and independent variables. Last, local polynomial smoothing is applied to smooth the raw estimates. Rather than use a kernel function to assign weights, only analytical weights that reflect the importance of each raw estimate are used. The standard errors of the raw estimates and the distance between the pseudo data and the observed data are considered as the measure of the importance of the raw estimates. We applied the proposed method to a weight loss clinical trial, and it efficiently estimated the correlation between the inconsistently sampled longitudinal data. Our approach was also evaluated via simulations. The results showed that the proposed method works better when the residual variances of the standard linear regressions are small and the within-subjects correlations are high. Also, using analytic weights instead of kernel function during local polynomial smoothing is important when raw estimates have extreme values, or the association between the dependent and independent variable is nonlinear. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Lei Ye
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15260, U.S.A.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15260, U.S.A
| | - Ada O Youk
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15260, U.S.A
| | - Susan M Sereika
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, 15260, U.S.A
| | - Stewart J Anderson
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15260, U.S.A
| | - Lora E Burke
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, 15260, U.S.A
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Szigethy E, Youk AO, Gonzalez-Heydrich J, Bujoreanu SI, Weisz J, Fairclough D, Ducharme P, Jones N, Lotrich F, Keljo D, Srinath A, Bousvaros A, Kupfer D, DeMaso DR. Effect of 2 psychotherapies on depression and disease activity in pediatric Crohn's disease. Inflamm Bowel Dis 2015; 21:1321-8. [PMID: 25822010 PMCID: PMC4437807 DOI: 10.1097/mib.0000000000000358] [Citation(s) in RCA: 15] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Crohn's disease (CD) is associated with depression. It is unclear if psychosocial interventions offer benefit for depressive symptoms during active CD. In this secondary analysis of a larger study of treating depression in pediatric inflammatory bowel disease, we assessed whether cognitive behavioral therapy (CBT) would differentiate from supportive nondirective therapy in treating depression and disease activity in youth with CD. We also explored whether somatic depressive symptoms showed a different pattern of response in the overall sample and the subset with active inflammatory bowel disease. METHODS Youth with depression and CD (n = 161) were randomized to 3 months of CBT (teaching coping skills) or supportive nondirective therapy (supportive listening). Depressive severity was measured using the Children's Depression Rating Scale-Revised (CDRS-R) with the somatic depressive subtype consisting of those CDRS-R items, which significantly correlated with CD activity. Disease activity was measured by the Pediatric Crohn's disease Activity Index. Given the potential confound of higher dose steroids, subanalyses excluded subjects on >20 mg/d prednisone equivalent (n = 34). RESULTS Total CDRS-R scores in the overall sample significantly decreased over time after both treatments (P < 0.0001). Treatment with CBT was associated with a significantly greater improvement in the Pediatric Crohn's disease Activity Index (P = 0.05) and somatic depressive subtype (P = 0.03) in those with active inflammatory bowel disease (n = 95) compared with supportive nondirective therapy. After excluding those on steroids (n = 34), there was a significant improvement in total CDRS-R (P = 0.03) and in Pediatric Crohn's disease Activity Index (P = 0.03) after CBT. CONCLUSIONS Psychotherapy may be a useful adjunct to treat depression in the context of CD-related inflammation in youth who are not concurrently on higher dose steroids.
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Affiliation(s)
- Eva Szigethy
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ada O. Youk
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - John Weisz
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | - Diane Fairclough
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Peter Ducharme
- Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts
| | - Neil Jones
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Francis Lotrich
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David Keljo
- Department of Pediatric Gastroenterology, Children's Hospital of Pittsburgh UPMC, Pittsburgh, Pennsylvania; and
| | - Arvind Srinath
- Department of Pediatric Gastroenterology, Children's Hospital of Pittsburgh UPMC, Pittsburgh, Pennsylvania; and
| | - Athos Bousvaros
- Department of Pediatric Gastroenterology, Boston Children's Hospital, Boston, Massachusetts
| | - David Kupfer
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David R. DeMaso
- Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts
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Broyles LM, Wieland ME, Confer AL, DiNardo MM, Kraemer KL, Hanusa BH, Youk AO, Gordon AJ, Sevick MA. Alcohol brief intervention for hospitalized veterans with hazardous drinking: protocol for a 3-arm randomized controlled efficacy trial. Addict Sci Clin Pract 2015; 10:13. [PMID: 25968121 PMCID: PMC4480647 DOI: 10.1186/s13722-015-0033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 04/22/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Various hospital accreditation and quality assurance entities in the United States have approved and endorsed performance measures promoting alcohol brief intervention (BI) for hospitalized individuals who screen positive for unhealthy alcohol use, the spectrum of use ranging from hazardous use to alcohol use disorders. These performance measures have been controversial due to the limited and equivocal evidence for the efficacy of BI among hospitalized individuals. The few BI trials conducted with hospital inpatients vary widely in methodological quality. While the majority of these studies indicate limited to no effects of BI in this population, none have been designed to account for the most pervasive methodological issue in BI studies presumed to drive study findings towards the null: assessment reactivity (AR). METHODS/DESIGN This is a three-arm, single-site, randomized controlled trial of BI for hospitalized patients at a large academic medical center affiliated with the U.S. Department of Veterans Affairs who use alcohol at hazardous levels but do not have an alcohol use disorder. Participants are randomized to one of three study conditions. Study Arm 1 receives a three-part alcohol BI. Study Arm 2 receives attention control. To account for potential AR, Study Arm 3 receives AC with limited assessment. Primary outcomes will include the number of standard drinks/week and binge drinking episodes reported in the 30-day period prior to a final measurement visit obtained 6 months after hospital discharge. Additional outcomes will include readiness to change drinking behavior and number of adverse consequences of alcohol use. To assess differences in primary outcomes across the three arms, we will use mixed-effects regression models that account for a patient's repeated measures over the timepoints and clustering within medical units. Intervention implementation will be assessed by: a) review of intervention audio recordings to characterize barriers to intervention fidelity; and b) feasibility of participant recruitment, enrollment, and follow-up. DISCUSSION The results of this methodologically rigorous trial will provide greater justification for or against the use of BI performance measures in the inpatient setting and inform organizational responses to BI-related hospital accreditation and performance measures. TRIAL REGISTRATION NCT01602172.
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Affiliation(s)
- Lauren M Broyles
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA.
- Veterans Integrated Service Network 4 (VISN4) Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
| | - Melissa E Wieland
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
| | - Andrea L Confer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
| | - Monica M DiNardo
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
| | - Kevin L Kraemer
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA.
| | - Barbara H Hanusa
- Veterans Integrated Service Network 4 (VISN4) Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
| | - Ada O Youk
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Adam J Gordon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA.
- Veterans Integrated Service Network 4 (VISN4) Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, University Drive C (151C), Pittsburgh, PA, 15240, USA.
| | - Mary Ann Sevick
- Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, 227 East 30th Street, New York, NY, 10016, USA.
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Xu J, Barinas-Mitchell E, Kuller LH, Youk AO, Catov JM. Maternal hypertension after a low-birth-weight delivery differs by race/ethnicity: evidence from the National Health and Nutrition Examination Survey (NHANES) 1999-2006. PLoS One 2014; 9:e104149. [PMID: 25093324 PMCID: PMC4122444 DOI: 10.1371/journal.pone.0104149] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 07/10/2014] [Indexed: 01/13/2023] Open
Abstract
Studies have suggested an increase in maternal morbidity and mortality due to cardiovascular diseases in women with a prior low-birth-weight (LBW, <2,500 grams) delivery. This study evaluated blood pressure and hypertension in women who reported a prior preterm or small-for-gestational-age (SGA) LBW delivery in the National Health and Nutrition Examination Survey 1999-2006 (n = 6,307). This study also aimed to explore if race/ethnicity, menopause status, and years since last pregnancy modified the above associations. A total of 3,239 white, 1,350 black, and 1,718 Hispanics were assessed. Linear regression models were used to evaluate blood pressure by birth characteristics (preterm-LBW, SGA-LBW, and birthweight ≥2,500). Logistic regression models estimated the odds ratios (OR) of hypertension among women who reported a preterm-LBW or SGA-LBW delivery compared with women who reported an infant with birthweight ≥2,500 at delivery. Overall, there was a positive association between a preterm-LBW delivery and hypertension (adjusted OR = 1.39, 95% confidence interval (CI) 1.02-1.90). Prior SGA-LBW also increased the odds of hypertension, but the estimate did not reach statistical significance (adjusted OR = 1.21, 95% CI 0.76-1.92). Race/ethnicity modified the above associations. Only black women had increased risk of hypertension following SGA-LBW delivery (adjusted OR = 2.09, 95% CI 1.12-3.90). Black women were at marginally increased risk of hypertension after delivery of a preterm-LBW (adjusted OR = 1.49, 95% CI 0.93-2.38). Whites and Hispanics had increased, but not statistically significant, risk of hypertension after a preterm-LBW (whites: adjusted OR = 1.39, 95% CI 0.92-2.10; Hispanics: adjusted OR = 1.22, 95% CI 0.62-2.38). Stratified analysis indicated that the associations were stronger among women who were premenopausal and whose last pregnancy were more recent. The current study suggests that in a representative United States population, women with a history of preterm- or SGA-LBW deliveries have increased odds of hypertension and this risk appears to be higher for black women and younger women.
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Affiliation(s)
- Jia Xu
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Emma Barinas-Mitchell
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Lewis H. Kuller
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Ada O. Youk
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Janet M. Catov
- Departments of OB/GYN and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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Abstract
The objective of this study is unknown if fetal sex and race modify the impact of maternal pre-pregnancy body mass index (BMI), and smoking on fetal growth. The authors studied markers of fetal growth in singleton offspring of 8,801 primiparous, normotensive women, enrolled in the Collaborative Perinatal Project. The authors tested for departures from additivity between sex/race and each predictor. The head-to-chest circumference ratio (HCC) decreased more, while birthweight and ponderal index (PI) increased more for each 1 kg/m(2) increase in pre-pregnancy BMI among term females versus males (P = 0.07, P < 0.01 and P = 0.08, interaction respectively). For term offspring of White compared with Black women, smoking independent of "dose" was associated with larger reductions in growth (165 g vs. 68 g reduction in birthweight, P < 0.01, interaction), greater reduction in fetal placental ratio (P < 0.01, interaction), PI (P < 0.01, interaction), and greater increase in HCC (P = 0.02), respectively. The association of BMI and smoking with fetal size appeared to be reversed in term versus preterm infants. Our study provides evidence that the associations of pre-pregnancy BMI and smoking are not constant across sex and race. This finding may be relevant to sex and race differences in neonatal and long term health outcomes.
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Affiliation(s)
- Simone A Reynolds
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA, 15261, USA,
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Szigethy E, Bujoreanu SI, Youk AO, Weisz J, Benhayon D, Fairclough D, Ducharme P, Gonzalez-Heydrich J, Keljo D, Srinath A, Bousvaros A, Kirshner M, Newara M, Kupfer D, DeMaso DR. Randomized efficacy trial of two psychotherapies for depression in youth with inflammatory bowel disease. J Am Acad Child Adolesc Psychiatry 2014; 53:726-35. [PMID: 24954822 PMCID: PMC4104185 DOI: 10.1016/j.jaac.2014.04.014] [Citation(s) in RCA: 70] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/10/2014] [Accepted: 05/01/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Pediatric inflammatory bowel disease (IBD) is associated with high rates of depression. This study compared the efficacy of cognitive behavioral therapy (CBT) to supportive nondirective therapy (SNDT) in treating youth with comorbid IBD and depression. METHOD Youth (51% female and 49% male; age 9-17 years, mean age 14.3 years) with depression and Crohn's disease (n = 161) or ulcerative colitis (n = 56) were randomly assigned to a 3-month course of CBT or SNDT. The primary outcome was comparative reduction in depressive symptom severity; secondary outcomes were depression remission, increase in depression response, and improved health-related adjustment and IBD activity. RESULTS A total of 178 participants (82%) completed the 3-month intervention. Both psychotherapies resulted in significant reductions in total Children's Depression Rating Scale Revised score (37.3% for CBT and 31.9% for SNDT), but the difference between the 2 treatments was not significant (p = .16). There were large pre-post effect sizes for each treatment (d = 1.31 for CBT and d = 1.30 for SNDT). More than 65% of youth had a complete remission of depression at 3 months, with no difference between CBT and SNDT (67.8% and 63.2%, respectively). Compared to SNDT, CBT was associated with a greater reduction in IBD activity (p = .04) but no greater improvement on the Clinical Global Assessment Scale (p = .06) and health-related quality of life (IMPACT-III scale) (p = .07). CONCLUSION This is the first randomized controlled study to suggest improvements in depression severity, global functioning, quality of life, and disease activity in a physically ill pediatric cohort treated with psychotherapy. Clinical trial registration information-Reducing Depressive Symptoms in Physically Ill Youth; http://clinical trials.gov; NCT00534911.
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Ramos-Rivers C, Regueiro M, Vargas EJ, Szigethy E, Schoen RE, Dunn M, Watson AR, Schwartz M, Swoger J, Baidoo L, Barrie A, Dudekula A, Youk AO, Binion DG. Association between telephone activity and features of patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2014; 12:986-94.e1. [PMID: 24262938 PMCID: PMC4031304 DOI: 10.1016/j.cgh.2013.11.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [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: 09/12/2013] [Revised: 10/22/2013] [Accepted: 11/06/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Telephone communication is common between healthcare providers and patients with inflammatory bowel disease (IBD). We analyzed telephone activity at an IBD care center to identify disease and patient characteristics associated with high levels of telephone activity and determine if call volume could identify individuals at risk for future visits to the emergency department (ED) or hospitalization. METHODS We performed a prospective observational study in which we categorized telephone calls received by nursing staff over 2 years at a tertiary care IBD clinic (2475 patients in 2009 and 3118 in 2010). We analyzed data on 21,979 ingoing and outgoing calls in 2009 and 32,667 calls in 2010 and assessed associations between clinical factors and logged telephone encounters, and between patterns of telephone encounters and future visits to the ED or hospitalization. RESULTS Telephone encounters occurred twice as frequently as office visits; 15% of the patients generated >10 telephone encounters per year and were responsible for half of all telephone encounters. A higher percentage of these high telephone encounter (HTE) patients were female, had Crohn's disease, received steroid treatment, had increased levels of C-reactive protein and rates of erythrocyte sedimentation, had psychiatric comorbidities, and had chronic abdominal pain than patients with lower telephone encounters. The HTE patients were also more frequently seen in the ED or hospitalized over the same time period and in subsequent years. Forty-two percent of patients with >8 telephone encounters within 30 days were seen in the ED or hospitalized within the subsequent 12 months. CONCLUSIONS Based on an analysis of telephone records at an IBD clinic, 15% of patients account for half of all calls. These HTE patients are a heterogeneous group with refractory disease who are likely to visit the ED or be hospitalized.
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Affiliation(s)
- Claudia Ramos-Rivers
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Miguel Regueiro
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Eric J. Vargas
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Eva Szigethy
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Michael Dunn
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Andrew R. Watson
- Division of Colorectal Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Marc Schwartz
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Jason Swoger
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Leonard Baidoo
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Arthur Barrie
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Anwar Dudekula
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Ada O. Youk
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15213
| | - David G. Binion
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
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Abstract
BACKGROUND Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis. AIMS We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH). METHODS Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children's Hospital of Pittsburgh. RESULTS Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8%) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy. CONCLUSIONS A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.
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Affiliation(s)
- Arvind I. Srinath
- Division of Pediatric Gastroenterology, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Ada O. Youk
- Department of Biostatistics, University of Pittsburgh, 4200 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Klaus Bielefeldt
- Division of Gastroenterology, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Hausmann LRM, Parks A, Youk AO, Kwoh CK. Reduction of bodily pain in response to an online positive activities intervention. J Pain 2014; 15:560-7. [PMID: 24568751 DOI: 10.1016/j.jpain.2014.02.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 01/24/2014] [Accepted: 02/09/2014] [Indexed: 11/24/2022]
Abstract
UNLABELLED Inducing temporary positive states reduces pain and increases pain tolerance in laboratory studies. We tested whether completing positive activities in one's daily life produces long-term reductions in self-reported bodily pain in a randomized controlled trial of an online positive activities intervention. Participants recruited via the Web were randomly assigned to complete 0, 2, 4, or 6 positive activities administered online over a 6-week period. Follow-up assessments were collected at the end of 6 weeks and at 1, 3, and 6 months postintervention. We used linear mixed effects models to examine whether the intervention reduced pain over time among those who had a score <67 on the bodily pain subscale of the Short Form-36 at baseline (N = 417; pain scores range from 0 to 100; higher scores indicate less pain). Mean pain scores improved from baseline to 6 months in the 2-activity (55.7 to 67.4), 4-activity (54.2 to 71.0), and 6-activity (50.9 to 67.9) groups. Improvements were significantly greater (P < .05) in the 4-activity and 6-activity groups than in the 0-activity control group (54.1 to 62.2) in unadjusted and adjusted models. This study suggests that positive activities administered online can reduce bodily pain in adults with at least mild to moderate baseline pain. PERSPECTIVE This study demonstrates that teaching people simple positive activities can decrease reported levels of bodily pain; moreover, these activities can be administered over the internet, a potential avenue for broadly disseminating health interventions at relatively low costs and with high sustainability.
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Affiliation(s)
- Leslie R M Hausmann
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Acacia Parks
- Department of Psychology, Hiram College, Hiram, Ohio
| | - Ada O Youk
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - C Kent Kwoh
- Division of Rheumatology and University of Arizona Arthritis Center, University of Arizona, Tucson, Arizona
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Troy JD, Grandis JR, Youk AO, Diergaarde B, Romkes M, Weissfeld JL. Childhood passive smoke exposure is associated with adult head and neck cancer. Cancer Epidemiol 2013; 37:417-23. [PMID: 23619143 PMCID: PMC3706460 DOI: 10.1016/j.canep.2013.03.011] [Citation(s) in RCA: 14] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 03/17/2013] [Accepted: 03/23/2013] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Passive smoke is carcinogenic but its association with head and neck squamous cell carcinoma (HNSCC) is uncertain. METHODS We conducted a case-control study of childhood passive smoke exposure (CPSE) and HNSCC in 858 cases and 806 frequency-matched controls using an interviewer-administered questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were estimated with logistic regression controlling for adult smoking in the total study population, and in never-smokers only (184 cases and 415 controls). CPSE was also studied in oropharyngeal separately from other HNSCC using polytomous logistic regression. RESULTS CPSE was associated with HNSCC (OR, 1.28; 95% CI, 1.01-1.63) after controlling for adult smoking and other factors. This association was similar in magnitude, although not statistically significant, among subjects who never smoked as adults (OR, 1.19, 95% CI, 0.80-1.76). CPSE was associated more strongly with oropharyngeal cancer (a HNSCC subtype commonly associated with human papillomavirus (HPV) infection) than with HNSCC at non-oropharyngeal sites (OR, 2.02; 95% CI, 1.01-4.06, N=52 cases vs. OR, 1.04; 95% CI, 0.68-1.60, N=132 cases; P-for-heterogeneity=0.08). CONCLUSIONS Data from this large US-based case control study suggest a role for CPSE in HNSCC etiology.
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Affiliation(s)
- Jesse D Troy
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15232, USA.
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Marsh GM, Youk AO, Buchanich JM, Xu H, Downing S, Kennedy KJ, Esmen NA, Hancock RP, Lacey SE, Fleissner ML. Long-Term Health Experience of Jet Engine Manufacturing Workers. J Occup Environ Med 2013; 55:654-75. [DOI: 10.1097/jom.0b013e3182749c4a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [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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Youk AO, Buchanich JM, Fryzek J, Cunningham M, Marsh GM. An ecological study of cancer mortality rates in high altitude counties of the United States. High Alt Med Biol 2012; 13:98-104. [PMID: 22724612 DOI: 10.1089/ham.2011.1051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
To test the hypothesis that sustained, increased hemoglobin levels as measured by residence in high altitudes lead to an increase of malignant cancer deaths, we performed an assessment of U.S. cancer mortality rates for people residing in high altitude counties compared with those in counties with altitudes close to sea level. This included a graphical analysis of mortality rates for all cancers, female breast cancer, respiratory system cancer (RSC) and non-Hodgkin lymphoma (NHL), computation of standardized mortality ratios (SMRs) and Poisson regression modeling. Overall, our ecological evaluation showed statistically significantly reduced SMRs and rate ratios (RRs) for high altitude residents compared to sea level residents. For the causes of death categories examined, we found no evidence that persons residing in high altitude counties are at an elevated risk of cancer mortality compared with persons living close to sea level. Our results corroborate previous altitude studies of cancer mortality.
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Affiliation(s)
- Ada O Youk
- Center for Occupational Biostatistics and Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Reynolds SA, Roberts JM, Bodnar LM, Haggerty CL, Youk AO, Catov JM. Newborns of Preeclamptic Women Show Evidence of Sex-Specific Disparity in Fetal Growth. ACTA ACUST UNITED AC 2012; 9:424-35. [DOI: 10.1016/j.genm.2012.10.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/29/2012] [Accepted: 10/31/2012] [Indexed: 01/08/2023]
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Kurta ML, Moysich KB, Weissfeld JL, Youk AO, Bunker CH, Edwards RP, Modugno F, Ness RB, Diergaarde B. Use of fertility drugs and risk of ovarian cancer: results from a U.S.-based case-control study. Cancer Epidemiol Biomarkers Prev 2012; 21:1282-92. [PMID: 22707710 DOI: 10.1158/1055-9965.epi-12-0426] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Previous studies examining associations between use of fertility drugs and ovarian cancer risk have provided conflicting results. We used data from a large case-control study to determine whether fertility drug use significantly impacts ovarian cancer risk when taking into account parity, gravidity, and cause of infertility. METHODS Data from the Hormones and Ovarian Cancer Prediction (HOPE) study were used (902 cases, 1,802 controls). Medical and reproductive histories were collected via in-person interviews. Logistic regression was used to calculate ORs and 95% confidence intervals (CI). Models were adjusted for age, race, education, age at menarche, parity, oral contraceptive use, breastfeeding, talc use, tubal ligation, and family history of breast/ovarian cancer. RESULTS Ever use of fertility drugs was not significantly associated with ovarian cancer within the total HOPE population (OR, 0.93; 95% CI, 0.65-1.35) or among women who reported seeking medical attention for infertility (OR, 0.87; 95% CI, 0.54-1.40). We did observe a statistically significant increased risk of ovarian cancer for ever use of fertility drugs among women who, despite seeking medical attention for problems getting pregnant, remained nulligravid (OR, 3.13; 95% CI, 1.01-9.67). CONCLUSIONS These results provide further evidence that fertility drug use does not significantly contribute to ovarian cancer risk among the majority of women; however, women who despite infertility evaluation and fertility drug use remain nulligravid, may have an elevated risk for ovarian cancer. IMPACT Our results suggest that fertility drug use does not significantly contribute to overall risk of ovarian cancer when adjusting for known confounding factors.
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Affiliation(s)
- Michelle L Kurta
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Barbour KE, Boudreau R, Danielson ME, Youk AO, Wactawski-Wende J, Greep NC, LaCroix AZ, Jackson RD, Wallace RB, Bauer DC, Allison MA, Cauley JA. Inflammatory markers and the risk of hip fracture: the Women's Health Initiative. J Bone Miner Res 2012; 27:1167-76. [PMID: 22392817 PMCID: PMC3361578 DOI: 10.1002/jbmr.1559] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cytokines play a major role in bone remodeling in vitro and in animal models, with evidence supporting the involvement of inflammatory markers in the pathogenesis of osteoporosis. However, less is known about the longitudinal association of inflammatory markers with hip fracture. We tested whether high receptor levels of proinflammatory cytokines are associated with an increased risk of hip fracture in older women. We used a nested case-control study design from the Women's Health Initiative Observational Study (WHI-OS) and selected 400 cases with physician-adjudicated incident hip fractures and 400 controls matched on age, race, and date of blood draw. Participants were chosen from 39,795 postmenopausal women without previous hip fractures, not using estrogens or other bone-active therapies. Incident hip fractures (median follow-up 7.1 years) were verified by review of radiographs and confirmed by blinded central adjudicators. Hip fractures with a pathological cause were excluded. In multivariable models, the risk of hip fracture for subjects with the highest levels of inflammatory markers (quartile 4) compared with those with lower levels (quartiles 1, 2, and 3) was 1.43 (95% confidence interval [CI], 0.98-2.07) for interleukin-6 (IL-6) soluble receptor (SR), 1.40 (95% CI, 0.97-2.03) for tumor necrosis factor (TNF) SR1, and 1.56 (95% CI, 1.09-2.22) for TNF SR2. In subjects with all three markers in the highest quartile, the risk ratio of fracture was 2.76 (95% CI, 1.22-6.25) in comparison with subjects with 0 or 1 elevated marker(s) (p trend = 0.018). Elevated levels of inflammatory markers for all three cytokine-soluble receptors were associated with an increased risk of hip fractures in older women. Future clinical trials should test whether interventions to decrease inflammatory marker levels reduces hip fractures.
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Affiliation(s)
- Kamil E Barbour
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
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Marsh GM, Youk AO, Roggli VL. Letter to the editor in response to Finkelstein et al. (2012). Inhal Toxicol 2012. [DOI: 10.3109/08958378.2012.663996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Gary M. Marsh
- Department of Biostatistics, Graduate School of Public Health, Center for Occupational Biostatistics and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ada O. Youk
- Department of Biostatistics, Graduate School of Public Health, Center for Occupational Biostatistics and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Victor L. Roggli
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
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Han YY, Youk AO, Sasser H, Talbott EO. Cancer incidence among residents of the Three Mile Island accident area: 1982-1995. Environ Res 2011; 111:1230-1235. [PMID: 21855866 DOI: 10.1016/j.envres.2011.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 05/05/2011] [Accepted: 08/04/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND The Pennsylvania Department of Health established a registry of the Three Mile Island (TMI) nuclear power plant accident in 1979. Over 93% of the population present on the day of the accident within a 5-mile radius was enrolled and interviewed. We used the registry to investigate the potential cancer risk from low-dose radiation exposure among the TMI population. METHODS Cancer incidence data among the TMI cohort were available from 1982 to 1995. Because more than 97% of the population were white and few cancer cases were reported for those younger than 18 years of age, we included whites of age 18 years and older (10,446 men and 11,048 women) for further analyses. Cox regression models were used to estimate the relative risk (RR) per 0.1 mSv and 95% confident interval (CI) of cancer by radiation-related exposures. The cancers of interest were all malignant neoplasms, cancer of bronchus, trachea, and lung, cancer of lymphatic and hematopoietic tissues, leukemia, and female breast. RESULTS Among men and women, there was no evidence of an increased risk for all malignant neoplasms among the TMI cohort exposed to higher maximum and likely γ radiation (RR=1.00, 95% CI=0.97, 1.01 and RR=0.99, 95% CI=0.94, 1.03, respectively) after adjusting for age, gender, education, smoking, and background radiation. Elevation in risk was noted for cancer of the bronchus, trachea, and lung in relation to higher background radiation exposure (RR=1.45, 95% CI=1.02-2.05 at 8.0-8.8 μR/h compared to 5.2-7.2 μR/h). An increased risk of leukemia was found among men exposed to higher maximum and likely γ radiation related to TMI exposure during the ten days following the accident (RR=1.15, 95% CI=1.04, 1.29 and RR=1.36, 95% CI=1.08, 1.71, respectively). This relationship was not found in women. CONCLUSION Increased cancer risks from low-level radiation exposure within the TMI cohort were small and mostly statistically non-significant. However, additional follow-up on this population is warranted, especially to explore the increased risk of leukemia found in men.
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Affiliation(s)
- Yueh-Ying Han
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Marsh GM, Youk AO, Roggli VL. Asbestos fiber concentrations in the lungs of brake repair workers: commercial amphiboles levels are predictive of chrysotile levels. Inhal Toxicol 2011; 23:681-8. [DOI: 10.3109/08958378.2011.580472] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Marsh GM, Buchanich JM, Youk AO. Fiber glass exposure and human respiratory system cancer risk: Lack of evidence persists since 2001 IARC re-evaluation. Regul Toxicol Pharmacol 2011; 60:84-92. [DOI: 10.1016/j.yrtph.2011.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 02/15/2011] [Accepted: 02/16/2011] [Indexed: 11/30/2022]
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Smith HA, Markovic N, Matthews AK, Danielson ME, Kalro BN, Youk AO, Talbott EO. A Comparison of Polycystic Ovary Syndrome and Related Factors Between Lesbian and Heterosexual Women. Womens Health Issues 2011; 21:191-8. [DOI: 10.1016/j.whi.2010.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 10/31/2010] [Accepted: 11/01/2010] [Indexed: 11/29/2022]
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Talbott EO, Xu X, Youk AO, Rager JR, Stragand JA, Malek AM. Risk of leukemia as a result of community exposure to gasoline vapors: a follow-up study. Environ Res 2011; 111:597-602. [PMID: 21453914 DOI: 10.1016/j.envres.2011.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 03/09/2011] [Accepted: 03/15/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To assess the temporal and spatial relationship of risk for total leukemia and AML (acute myelogenous leukemia) among community residents of an area in northeastern (NE) Pennsylvania (PA) affected by the Tranguch Gasoline Spill which occurred in the early 1990s. METHODS Standardized incidence ratios (SIR) were calculated for total leukemia and AML among 625 residents affected by the gasoline spill in relation to both PA and local county cancer incidence rates. The risk of total leukemia and AML among the gasoline exposed population was evaluated for the period prior to the spill, 1985-1989; during the time surrounding the spill, 1990-1994; and for a period subsequent to the spill, 1995-2001. RESULTS The incidence of total leukemia and AML was significantly elevated subsequent to the spill for the entire period 1990-2001 and was highest for the period 1995-2001, whether comparison was made to PA or local county leukemia rates. Based on comparison to PA rates, the SIRs for total leukemia and AML were 7.69 (95% CI=1.58-22.46) and 11.54 (95% CI=2.38-33.69) for the 1995-2001 period, respectively. Prior to the spill, 1985-1989, and during the period of the spill, 1990-1994, no cases of leukemia were identified among the affected residents. CONCLUSIONS These results suggest a possible association between chronic low level benzene exposure and increased risk of leukemia among residents of the Tranguch Spill Site in NE PA. Our study provides additional support to the growing body of evidence implicating low level benzene exposure and cancer risk. We recommend that other communities contaminated with gasoline vapor through leaking underground storage vessels be monitored for elevated risk of leukemia.
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Affiliation(s)
- Evelyn O Talbott
- University of Pittsburgh, Graduate School of Public Health, Departments of Epidemiology, Pittsburgh, PA 15261, USA.
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Buchanich JM, Youk AO, Marsh GM, Kennedy KJ, Lacey SE, Hancock RP, Esmen NA, Cunningham MA, Leiberman FS, Fleissner ML. Long-term health experience of jet engine manufacturing workers: V. Issues with the analysis of non-malignant central nervous system neoplasms. J Registry Manag 2011; 38:115-119. [PMID: 22223053] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE We attempted to examine non-malignant central nervous system (CNS) neoplasms incidence rates for workers at 8 jet engine manufacturing facilities in Connecticut. The objective of this manuscript is to describe difficulties encountered regarding these analyses to aid future studies. METHODS We traced the cohort for incident cases of CNS neoplasms in states where 95% of deaths in the total cohort occurred. We used external and internal analyses in an attempt to obtain the true risk of non-malignant CNS in the cohort. Because these analyses were limited by data constraints, we conducted sensitivity analyses, including using state driver's license data to adjust person-year stop dates to help minimize underascertainment and more accurately determine cohort risk estimates. RESULTS We identified 3 unanticipated challenges: case identification, determination of population-based cancer incidence rates, and handling of case underascertainment. These factors precluded an accurate assessment of non-malignant CNS neoplasm incidence risks in this occupational epidemiology study. CONCLUSIONS The relatively recent (2004) mandate of capturing non-malignant CNS tumor data at the state level means that, in time, it may be possible to conduct external analyses of these data. Meanwhile, similar occupational epidemiology studies may be limited to descriptive analysis of the non-malignant CNS case characteristics.
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Marsh GM, Youk AO, Morfeld P, Collins JJ, Symons JM. Incomplete follow-up in the National Cancer Institute's formaldehyde worker study and the impact on subsequent reanalyses and causal evaluations. Regul Toxicol Pharmacol 2010; 58:233-6. [PMID: 20553990 DOI: 10.1016/j.yrtph.2010.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 06/02/2010] [Accepted: 06/03/2010] [Indexed: 11/29/2022]
Abstract
Three of us (G.M., A.Y., and P.M.) performed reanalyses of the National Cancer Institute cohort study on nasopharyngeal cancer (NPC) risk among formaldehyde exposed workers (Hauptmann et al., 2004). Both reanalyses (Marsh and Youk, 2005; Marsh et al., 2007) were published in this journal. However, the mortality follow-up performed by the NCI working group reported in two publications by Hauptmann et al. (2003, 2004) was later stated to be incomplete (Beane Freeman et al., 2009a,b). This incomplete follow-up may impact the validity of the results of our reanalyses. At this time, corrected estimates for solid cancer mortality risks including NPC as reported in Hauptmann et al. (2004) have not been provided as an erratum by the authors or reported anywhere else to our knowledge. We would like to inform readers about these issues and ask for a prompt corrigendum of the 2004 publication by the NCI working group since this study has played such a prominent role in causal evaluations.
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Affiliation(s)
- Gary M Marsh
- Center for Occupational Biostatistics and Epidemiology and Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Marsh GM, Buchanich JM, Youk AO, Cunningham MA, Lieberman FS, Kennedy KJ, Lacey SE, Hancock RP, Esmen NA, Fleissner ML. Long-Term Health Experience of Jet Engine Manufacturing Workers: III. Incidence of Malignant Central Nervous System Neoplasms. Neuroepidemiology 2010; 35:123-41. [DOI: 10.1159/000310348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 03/01/2010] [Indexed: 11/19/2022] Open
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Marsh GM, Esmen NA, Buchanich JM, Youk AO. Mortality patterns among workers exposed to arsenic, cadmium, and other substances in a copper smelter. Am J Ind Med 2009; 52:633-44. [PMID: 19533624 DOI: 10.1002/ajim.20714] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate the long-term mortality experience of workers exposed to arsenic, cadmium, and other substances at a copper mine and smelter in Copperhill, Tennessee studied earlier as part of an industry-wide study. METHODS Subjects were 2,422 male workers employed three or more years in the smelter or mill between 1/1/46 until the plant strike and scale-down of operations in April 1996. Vital status was determined through 2000 for 99.4% of subjects and cause of death for 91.3% of 878 deaths. Historical exposures were estimated for lead, SO(2), arsenic, cadmium, dust, and cobalt. We computed standardized mortality ratios (SMRs) based on U.S. and local county rates and modeled internal relative risks (RRs). RESULTS We observed overall deficits in deaths based on national and local county comparisons from all causes, all cancers and most of the cause of death categories examined. We found limited evidence of increasing mortality risks from cerebrovascular disease with increasing duration and cumulative arsenic exposure, but no evidence of an exposure-response relationship for cadmium exposure and bronchitis. CONCLUSIONS Our limited evidence of an association between inhaled arsenic exposure and CVD is an exploratory finding not observed in other epidemiology studies of more highly exposed occupational populations. Possible alternative explanations include chance alone and uncontrolled confounding or effect modification by co-exposures or other factors correlated with arsenic exposure and unique to the Copperhill facility.
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Affiliation(s)
- Gary M Marsh
- Department of Biostatistics, Center for Occupational Biostatistics and Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania PA15261, USA.
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Buchanich JM, Youk AO, Marsh GM, Bornemann Z, Lacey SE, Kennedy KJ, Hancock RP, Esmen NA, Lieberman FS. Methodological issues in a retrospective cancer incidence study. Am J Epidemiol 2009; 170:112-9. [PMID: 19414497 DOI: 10.1093/aje/kwp091] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The authors traced incidence of central nervous system cancer in a large occupational cohort of jet engine manufacturing workers from 1976 to 2004 in the 24 US states that comprised 95% of the cohort deaths. The cohort of approximately 224,000 employees was matched with cancer registry data; all central nervous system cancer matches were requested with their diagnostic data. This paper highlights the obstacles encountered while conducting this retrospective cancer incidence study. The authors spent approximately 700 hours completing applications and obtaining the cohort matches. Approximately 70% of the cases were identified in the state in which the facility of interest is located. In addition to the large amount of time involved, identified issues include complicated approval processes, high costs, temporal differences among the registries, and registry agency difficulty in performing the matching. Several states do not allow individual-level data to be used for research purposes. Researchers can gain important cancer incidence information by matching retrospective cohorts to multiple state cancer registries. However, they should carefully weigh the time and costs required and plan accordingly. Despite some serious obstacles, many of which are potentially resolvable, cancer incidence studies of retrospective cohorts using multiple cancer registries are feasible.
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Affiliation(s)
- Jeanine M Buchanich
- Center for Occupational Biostatistics and Epidemiology, Department of Biostatistics, University of Pittsburgh, Pennsylvania 15261, USA.
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Marsh GM, Youk AO, Buchanich JM, Erdal S, Esmen NA. Work in the metal industry and nasopharyngeal cancer mortality among formaldehyde-exposed workers. Regul Toxicol Pharmacol 2007; 48:308-19. [PMID: 17544557 DOI: 10.1016/j.yrtph.2007.04.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [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: 02/10/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate further the possibility that the large nasopharyngeal cancer (NPC) mortality excess among a cohort of formaldehyde-exposed workers may be related to occupational factors external to the study plant. METHODS Subjects were 7345 workers employed at a plastics-producing plant (1941-1984) in Wallingford, Connecticut evaluated independently as part of a National Cancer Institute cohort study. Vital status for 98% of the cohort and cause of death for 95% of 2872 deaths were determined through 2003. Reconstructed worker exposures to formaldehyde were used to compute unlagged and lagged exposure measures. We computed standardized mortality ratios (SMRs) based on US and local county rates. In a nested case-control study we evaluated mortality risks from NPC and from all other pharyngeal cancers combined (AOPC) in relation to formaldehyde exposure while accounting for potential confounding or effect modification by smoking or external (non-Wallingford) employment. Job applications, Connecticut commercial city directories and a previous survey were used to assign subjects to three external job groups. RESULTS We observed no new deaths from NPC and one additional AOPC death (pharynx unspecified) yielding, respectively, SMRs of 4.43 (7 deaths, 95% CI=1.78-9.13) and 1.71 (16 deaths, 95% CI=1.01-2.72). Five of seven NPC cases worked in silver smithing (including brass plating and other jobs related to silver or brass) or other metal work (including steel working and welding), and this type of work was relatively rare in the remaining study population (OR=14.41, 95% CI=1.08-82.1). For AOPC, we found a moderate increase in risk for other metal work (OR=1.40, 95% CI=.31-5.1). Interaction models suggested that NPC and AOPC risks were not elevated in subjects exposed only to formaldehyde. CONCLUSIONS The results of our nested case-control study suggest that the large nasopharyngeal cancer mortality excess in the Wallingford cohort may not be due to formaldehyde exposure, but rather reflects the influence of external employment in the ferrous and non-ferrous metal industries of the local area that entailed possible exposures to several suspected risk factors for upper respiratory system cancer (e.g., sulfuric acid mists, mineral acid, metal dusts and heat). Our findings may also help to explain why the associations with formaldehyde and nasopharyngeal cancer reported in the 1994 update of the 10-plant NCI formaldehyde cohort study were unique to the Wallingford plant (Plant 1 in NCI study). Further updates of the NCI formaldehyde cohort study should include co-exposure data on silver smithing and other metal work for all study plants to help explain the unique findings for nasopharyngeal cancer in Plant 1 compared with the other nine plants.
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Affiliation(s)
- Gary M Marsh
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Marsh GM, Youk AO, Buchanich JM, Cunningham M, Esmen NA, Hall TA, Phillips ML. Mortality patterns among industrial workers exposed to chloroprene and other substances. Chem Biol Interact 2007; 166:285-300. [PMID: 16999943 DOI: 10.1016/j.cbi.2006.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We conducted an historical cohort study to investigate the mortality experience of industrial workers potentially exposed to chloroprene (CD) and other substances, including vinyl chloride (VC), with emphasis on cancer mortality, including respiratory system (RSC) and liver. In 1999, the International Agency for Research on Cancer (IARC) classified CD as a possible carcinogen (Group 2B); VC was classified in 1987 as a known human carcinogen (Group 1). Subjects were 12,430 workers ever employed at one of two U.S. industrial sites (Louisville, KY (n=5507) and Pontchartrain, LA (n=1357)) or two European sites (Maydown, Northern Ireland (n=4849) and Grenoble, France (n=717)), with earliest CD production dates ranging from 1942 (L) to 1969 (P). Two sites (L and M) synthesized CD with the acetylene process that produced VC exposures. We determined vital status through 2000 for 95% of subjects and cause of death for 95% of the deaths. Historical exposures for individual workers were estimated quantitatively for CD and VC. Workers ever exposed to CD ranged from 92.3% (M) to 100% (G); to VC from 5.5% (M) to 22.7% (L). We computed standardized mortality ratios (SMRs) (using national and regional standard populations) in relation to selected demographic, work history and exposure factors. We used worker pay type (white or blue collar) as a rough surrogate for lifetime smoking history. For the combined cohort, SMRs (95% CIs) for all causes combined, all cancers combined, RSC and liver cancer were, respectively, 0.72 (0.69-0.74), 0.73 (0.68-0.78), 0.75 (0.67-0.84) and 0.72 (0.43-1.13). Site-specific (L, M, P and G, respectively) SMRs were: for all cancers combined: 0.75 (0.69-0.80), 0.68 (0.56-0.80), 0.68 (0.47-0.95) and 0.59 (0.36-0.91); for RSC: 0.75 (0.66-0.85), 0.79 (0.58-1.05), 0.62 (0.32-1.09) and 0.85 (0.41-1.56); for liver cancer: 0.90 (0.53-1.44) (17 deaths), 0.24 (0.01-1.34) (1 death), 0.0 (0-2.39) (no deaths) and 0.56 (0.01-3.12) (1 death). Among all workers ever exposed to CD, SMRs were: for all cancers combined: 0.71 (0.66-0.76); for RSC: 0.75 (0.67-0.84); for liver cancer: 0.71 (0.42-1.14). We also observed no increased mortality risks among cohort subgroups defined by race, gender, worker pay type, worker service type (short/long term), time period, year of hire, age at hire, duration of employment, the time since first employment, and CD or VC exposure status (never/ever exposed). In summary, our study has many strengths and is the most definitive study of the human carcinogenic potential of exposure to CD conducted to date. We conclude that persons exposed to chloroprene or vinyl chloride at the levels encountered in the four study sites did not have elevated risks of mortality from any of the causes of death examined, including all cancers combined and lung and liver cancer, the cancer sites of a priori interest. This conclusion is corroborated by our detailed analyses of mortality in relation to qualitative and quantitative exposures to CD and VC at each of the four study sites, reported in our companion paper (Marsh et al., submitted for publication).
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Affiliation(s)
- Gary M Marsh
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261, USA.
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