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Bolden DM, Wogu AF, Peterson PN, Ross EG, Hogan SE, Matsushita K, Criqui MH, Allison M. Association between Statin use and Incident Peripheral Artery Disease According to Race, Age, and Presence of Depression in the Multi-Ethnic Study of Atherosclerosis. Ann Vasc Surg 2024; 102:160-171. [PMID: 38309426 PMCID: PMC10997470 DOI: 10.1016/j.avsg.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 02/05/2024]
Abstract
BACKGROUND Peripheral artery disease (PAD) is associated with high morbidity and mortality and has been commonly described as a coronary heart disease equivalent. Statin medications are recommended for primary prevention of atherosclerotic cardiovascular disease (CVD) among other indications. Therefore, understanding the longitudinal relationship of incident PAD is necessary to inform future research on how to prevent the disease. Depression complicates CVD patients' ability to properly adhere to their medications, yet the effect of depression on the relationship between statin use and incident PAD is understudied. People with PAD have a higher incidence of depressive symptoms than people without PAD. Black American and Hispanic populations are disproportionately affected by both PAD and depression yet research on the modifying effect of either race or depression on the relationship between statin use and onset of PAD is minimal. While statin utilization is highest for ages 75-84 years, there is minimal evidence of favorable risk-benefit balance. Consequently, in this project, we examined the relationship between statin use and incident PAD and whether this relationship is modified by race/ethnicity, depressive symptoms, or age. METHODS We used data on participants from the Multi-Ethnic Study of Atherosclerosis from visit 1 (2000) through study visit 6 (2020) who had three separate measurements of the ankle-brachial index (ABI) taken at visit 1, visit 3, and visit 5. Incident PAD was defined as 1) incident lower extremity amputation or revascularization or 2) ABI less than 0.90 coupled with ABI decrease greater than 0.15 over the follow-up period. Statin use was noted on the study visit prior to incident PAD diagnosis while depressive symptoms were measured at exam 1, visit 3, and visit 5. Propensity score matching was implemented to create balance between the participants in the two treatment groups, that is, statin-treated and statin-untreated groups, to reduce the problem of confounding by indication. Propensity scores were calculated using multivariate logistic regression model to estimate the probability of receiving statin treatment. We used Cox proportional hazards regression to investigate the relationship between time-dependent statin use as well as other risk factors with incident PAD, overall and stratified by 1) race, 2) depression status, and 3) age. RESULTS A total of 4,210 participants were included in the final matched analytic cohort. There were 810 incident cases (19.3%) of PAD that occurred over an average (mean) of 11.3 years (SD = 5.7) of follow-up time. In the statin-treated group, and with an average follow-up time of 12.5 years (SD = 5.6), there were 281 cases (13.4%) of incident PAD with the average follow-up time of 10.1 years (SD = 5.5), whereas in the statin-untreated group, there were 531 cases (25.2%) (P < 0.001). Results demonstrate a lower risk of PAD event in the statin-treated group compared to the untreated group (hazard ratio [HR] = 0.45, 95% confidence interval [CI]: 0.33-0.62) over the span of 18.5 years. The interactions between 1) depression and 2) race with statin use for incident PAD were not significant. However, other risk factors which were significant included Black American race that had approximately 30% lower hazard of PAD compared to non-Hispanic White (HR = 0.70, 95% CI: 0.58-0.84); age-stratified models were also fitted, and stain use was still a significant treatment factor for ages 45-54 (HR = 0.45, 95% CI: 0.33-0.63), 55-64 (HR = 0.61, 95% CI: 0.46-0.79), and 65-74 years (HR = 0.61, 95% CI: 0.48-0.78) but not for ages 75-84 years. CONCLUSIONS Statin use was associated with a decreased risk of incident PAD for those under the age of 75 years. Neither race nor depression significantly modified the relationship between statin use and incident PAD; however, the risk of incident PAD was lower among Black Americans. These findings highlight that the benefit of statin may wane for those over the age of 75 years. Findings also suggest that statin use may not be compromised in those living with depression.
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Affiliation(s)
- Demetria M Bolden
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Adane F Wogu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Division of Cardiology, Denver Health Medical Center, Denver, CO
| | - Elsie G Ross
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Shea E Hogan
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Division of Cardiology, Denver Health Medical Center, Denver, CO
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael H Criqui
- Department of Family Medicine, School of Medicine, University of California San Diego, San Diego, CA
| | - Matthew Allison
- Department of Family Medicine, School of Medicine, University of California San Diego, San Diego, CA
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2
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Mould-Millman NK, Wogu AF, Fosdick BK, Dixon JM, Beaty BL, Bhaumik S, Lategan HJ, Stassen W, Schauer SG, Steyn E, Verster J, Wylie C, de Vries S, Jamison M, Kohlbrenner M, Mayet M, Hodsdon L, Wagner L, Snyders LO, Doubell K, Lourens D, Bebarta VS. Association of freeze-dried plasma with 24-h mortality among trauma patients at risk for hemorrhage. Transfusion 2024; 64 Suppl 2:S155-S166. [PMID: 38501905 DOI: 10.1111/trf.17792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Blood products form the cornerstone of contemporary hemorrhage control but are limited resources. Freeze-dried plasma (FDP), which contains coagulation factors, is a promising adjunct in hemostatic resuscitation. We explore the association between FDP alone or in combination with other blood products on 24-h mortality. STUDY DESIGN AND METHODS This is a secondary data analysis from a cross-sectional prospective observational multicenter study of adult trauma patients in the Western Cape of South Africa. We compare mortality among trauma patients at risk of hemorrhage in three treatment groups: Blood Products only, FDP + Blood Products, and FDP only. We apply inverse probability of treatment weighting and fit a multivariable Cox proportional hazards model to assess the hazard of 24-h mortality. RESULTS Four hundred and forty-eight patients were included, and 55 (12.2%) died within 24 h of hospital arrival. Compared to the Blood Products only group, we found no difference in 24-h mortality for the FDP + Blood Product group (p = .40) and a lower hazard of death for the FDP only group (hazard = 0.38; 95% CI, 0.15-1.00; p = .05). However, sensitivity analyses showed no difference in 24-h mortality across treatments in subgroups with moderate and severe shock, early blood product administration, and accounting for immortal time bias. CONCLUSION We found insufficient evidence to conclude there is a difference in relative 24-h mortality among trauma patients at risk for hemorrhage who received FDP alone, blood products alone, or blood products with FDP. There may be an adjunctive role for FDP in hemorrhagic shock resuscitation in settings with significantly restricted access to blood products.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adane F Wogu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Bailey K Fosdick
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Julia M Dixon
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Smitha Bhaumik
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hendrick J Lategan
- Division of Surgery, Department of Surgical Sciences, Stellenbosch University, Cape Town, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven G Schauer
- Department of Anesthesia, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Elmin Steyn
- Division of Surgery, Department of Surgical Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janette Verster
- Division of Forensic Medicine, Department of Pathology, Stellenbosch University, Cape Town, South Africa
| | - Craig Wylie
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Shaheem de Vries
- Collaborative for Emergency Care in Africa, Cape Town, South Africa
| | - Maria Jamison
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Maria Kohlbrenner
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mohammed Mayet
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Lesley Hodsdon
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Leigh Wagner
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - L' Oreal Snyders
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Karlien Doubell
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Denise Lourens
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Roberts SC, Jolley SE, Beaty LE, Aggarwal NR, Bennett TD, Carlson NE, Fish LE, Kwan BM, Russell S, Wogu AF, Wynia MA, Ginde AA. Association between monoclonal antibody therapy, vaccination, and longer-term symptom resolution after acute COVID-19. J Med Virol 2024; 96:e29541. [PMID: 38516779 PMCID: PMC10963040 DOI: 10.1002/jmv.29541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/20/2024] [Accepted: 03/06/2024] [Indexed: 03/23/2024]
Abstract
Effective therapies for reducing post-acute sequelae of COVID-19 (PASC) symptoms are lacking. Evaluate the association between monoclonal antibody (mAb) treatment or COVID-19 vaccination with symptom recovery in COVID-19 participants. The longitudinal survey-based cohort study was conducted from April 2021 to January 2022 across a multihospital Colorado health system. Adults ≥18 years with a positive SARS-CoV-2 test were included. Primary exposures were mAb treatment and COVID-19 vaccination. The primary outcome was time to symptom resolution after SARS-CoV-2 positive test date. The secondary outcome was hospitalization within 28 days of a positive SARS-CoV-2 test. Analysis included 1612 participants, 539 mAb treated, and 486 with ≥2 vaccinations. Time to symptom resolution was similar between mAb treated versus untreated patients (adjusted hazard ratio (aHR): 0.90, 95% CI: 0.77-1.04). Time to symptom resolution was shorter for patients who received ≥2 vaccinations compared to those unvaccinated (aHR: 1.56, 95% CI: 1.31-1.88). 28-day hospitalization risk was lower for patients receiving mAb therapy (adjusted odds ratio [aOR]: 0.31, 95% CI: 0.19-0.50) and ≥2 vaccinations (aOR: 0.33, 95% CI: 0.20-0.55), compared with untreated or unvaccinated status. Analysis included 1612 participants, 539 mAb treated, and 486 with ≥2 vaccinations. Time to symptom resolution was similar between mAb treated versus untreated patients (adjusted hazard ratio (aHR): 0.90, 95% CI: 0.77-1.04). Time to symptom resolution was shorter for patients who received ≥2 vaccinations compared to those unvaccinated (aHR: 1.56, 95% CI: 1.31-1.88). 28-day hospitalization risk was lower for patients receiving mAb therapy (adjusted odds ratio [aOR]: 0.31, 95% CI: 0.19-0.50) and ≥2 vaccinations (aOR: 0.33, 95% CI: 0.20-0.55), compared with untreated or unvaccinated status. COVID-19 vaccination, but not mAb therapy, was associated with a shorter time to symptom resolution. Both were associated with lower 28-day hospitalization.
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Affiliation(s)
- Samantha C Roberts
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Sarah E Jolley
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Laurel E Beaty
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Neil R Aggarwal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tellen D Bennett
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nichole E Carlson
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lindsey E Fish
- Division of General Internal Medicine, Denver Health and Hospital, Denver, Colorado, USA
| | - Bethany M Kwan
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Seth Russell
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Adane F Wogu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Matthew A Wynia
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Wendel SK, Wogu AF, Carlson NE, Beaty L, Bennett TD, Bookman K, Mayer DA, Michael SM, Molina KC, Peers JL, Russell S, Zane RD, Ginde AA. Effectiveness of subcutaneous monoclonal antibody treatment in emergency department outpatients with COVID-19. J Am Coll Emerg Physicians Open 2024; 5:e13116. [PMID: 38384380 PMCID: PMC10879902 DOI: 10.1002/emp2.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/28/2023] [Accepted: 01/19/2024] [Indexed: 02/23/2024] Open
Abstract
Objectives To evaluate whether subcutaneous neutralizing monoclonal antibody (mAb) treatment given in the emergency department (ED) setting was associated with reduced hospitalizations, mortality, and severity of disease when compared to nontreatment among mAb-eligible patients with coronavirus disease 2019 (COVID-19). Methods This retrospective observational cohort study of ED patients utilized a propensity score-matched analysis to compare patients who received subcutaneous casirivimab and imdevimab mAb to nontreated COVID-19 control patients in November-December 2021. The primary outcome was all-cause hospitalization within 28 days, and secondary outcomes were 90-day hospitalization, 28- and 90-day mortality, and ED length of stay (LOS). Results Of 1340 patients included in the analysis, 490 received subcutaneous casirivimab and imdevimab, and 850 did not received them. There was no difference observed for 28-day hospitalization (8.4% vs. 10.6%; adjusted odds ratio [aOR] 0.79, 95% confidence intervals [CI] 0.53-1.17) or 90-day hospitalization (11.6% vs. 12.5%; aOR 0.93, 95% CI 0.65-1.31). However, mortality at both the 28-day and 90-day timepoints was substantially lower in the treated group (28-day 0.6% vs. 3.1%; aOR 0.18, 95% CI 0.08-0.41; 90-day 0.6% vs. 3.9%; aOR 0.14, 95% CI 0.06-0.36). Among hospitalized patients, treated patients had shorter hospital LOS (5.7 vs. 11.4 days; adjusted rate ratio [aRR] 0.47, 95% CI 0.33-0.69), shorter intensive care unit LOS (3.8 vs. 10.2 days; aRR 0.22, 95% CI 0.14-0.35), and the severity of hospitalization was lower (aOR 0.45, 95% CI 0.21-0.97) compared to untreated. Conclusions Among ED patients who presented for symptomatic COVID-19 during the Delta variant phase, ED subcutaneous casirivimab/imdevimab treatment was not associated with a decrease in hospitalizations. However, treatment was associated with lower mortality at 28 and 90 days, hospital LOS, and overall severity of illness.
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Affiliation(s)
- Sarah K. Wendel
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Emergency MedicineUniversity of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | - Adane F. Wogu
- Department of Biostatistics and InformaticsColorado School of Public HealthAuroraColoradoUSA
| | - Nichole E. Carlson
- Department of Biostatistics and InformaticsColorado School of Public HealthAuroraColoradoUSA
| | - Laurel Beaty
- Department of Biostatistics and InformaticsColorado School of Public HealthAuroraColoradoUSA
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and PediatricsUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Kelly Bookman
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - David A. Mayer
- Department of Biostatistics and InformaticsColorado School of Public HealthAuroraColoradoUSA
| | - Sean M. Michael
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Kyle C. Molina
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Jennifer L. Peers
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Seth Russell
- Departments of Biomedical Informatics and PediatricsUniversity of Colorado School of MedicineAuroraColoradoUSA
- Colorado Clinical and Translational Sciences InstituteUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Richard D. Zane
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Adit A. Ginde
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
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5
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Wogu AF, Li H, Zhao S, Nichols HB, Cai J. Additive subdistribution hazards regression for competing risks data in case-cohort studies. Biometrics 2023; 79:3010-3022. [PMID: 36606409 PMCID: PMC10676749 DOI: 10.1111/biom.13821] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023]
Abstract
In survival data analysis, a competing risk is an event whose occurrence precludes or alters the chance of the occurrence of the primary event of interest. In large cohort studies with long-term follow-up, there are often competing risks. Further, if the event of interest is rare in such large studies, the case-cohort study design is widely used to reduce the cost and achieve the same efficiency as a cohort study. The conventional additive hazards modeling for competing risks data in case-cohort studies involves the cause-specific hazard function, under which direct assessment of covariate effects on the cumulative incidence function, or the subdistribution, is not possible. In this paper, we consider an additive hazard model for the subdistribution of a competing risk in case-cohort studies. We propose estimating equations based on inverse probability weighting methods for the estimation of the model parameters. Consistency and asymptotic normality of the proposed estimators are established. The performance of the proposed methods in finite samples is examined through simulation studies and the proposed approach is applied to a case-cohort dataset from the Sister Study.
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Affiliation(s)
- Adane F. Wogu
- Department of Biostatistics & Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Haolin Li
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shanshan Zhao
- Biostatistics & Computational Biology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Hazel B. Nichols
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jianwen Cai
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Wynia MK, Beaty LE, Bennett TD, Carlson NE, Davis CB, Kwan BM, Mayer DA, Ong TC, Russell S, Steele JD, Stocker HR, Wogu AF, Zane RD, Sokol RJ, Ginde AA. Real-World Evidence of Neutralizing Monoclonal Antibodies for Preventing Hospitalization and Mortality in COVID-19 Outpatients. Chest 2023; 163:1061-1070. [PMID: 36441040 PMCID: PMC9613796 DOI: 10.1016/j.chest.2022.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/22/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Neutralizing monoclonal antibodies (mAbs) were authorized for the treatment of COVID-19 outpatients based on clinical trials completed early in the pandemic, which were underpowered for mortality and subgroup analyses. Real-world data studies are promising for further assessing rapidly deployed therapeutics. RESEARCH QUESTION Did mAb treatment prevent progression to severe disease and death across pandemic phases and based on risk factors, including prior vaccination status? STUDY DESIGN AND METHODS This observational cohort study included nonhospitalized adult patients with SARS-CoV-2 infection from November 2020 to October 2021 using electronic health records from a statewide health system plus state-level vaccine and mortality data. Using propensity matching, we selected approximately 2.5 patients not receiving mAbs for each patient who received mAb treatment under emergency use authorization. The primary outcome was 28-day hospitalization; secondary outcomes included mortality and hospitalization severity. RESULTS Of 36,077 patients with SARS-CoV-2 infection, 2,675 receiving mAbs were matched to 6,677 patients not receiving mAbs. Compared with mAb-untreated patients, mAb-treated patients had lower all-cause hospitalization (4.0% vs 7.7%; adjusted OR, 0.48; 95% CI, 0.38-0.60) and all-cause mortality (0.1% vs 0.9%; adjusted OR, 0.11; 95% CI, 0.03-0.29) to day 28; differences persisted to day 90. Among hospitalized patients, mAb-treated patients had shorter hospital length of stay (5.8 vs 8.5 days) and lower risk of mechanical ventilation (4.6% vs 16.6%). Results were similar for preventing hospitalizations during the Delta variant phase (adjusted OR, 0.35; 95% CI, 0.25-0.50) and across subgroups. Number-needed-to-treat (NNT) to prevent hospitalization was lower for subgroups with higher baseline risk of hospitalization; for example, multiple comorbidities (NNT = 17) and not fully vaccinated (NNT = 24) vs no comorbidities (NNT = 88) and fully vaccinated (NNT = 81). INTERPRETATION Real-world data revealed a strong association between receipt of mAbs and reduced hospitalization and deaths among COVID-19 outpatients across pandemic phases. Real-world data studies should be used to guide practice and policy decisions, including allocation of scarce resources.
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Affiliation(s)
- Matthew K Wynia
- Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora, CO; Department of Health Systems Management and Policy, Colorado School of Public Health, Aurora, CO; Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Laurel E Beaty
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Tellen D Bennett
- Colorado Clinical and Translational Sciences Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO; Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Nichole E Carlson
- Colorado Clinical and Translational Sciences Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Christopher B Davis
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Bethany M Kwan
- Colorado Clinical and Translational Sciences Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
| | - David A Mayer
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Toan C Ong
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Seth Russell
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | - Heather R Stocker
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Adane F Wogu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Richard D Zane
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ronald J Sokol
- Colorado Clinical and Translational Sciences Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO; Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Adit A Ginde
- Colorado Clinical and Translational Sciences Institute, University of Colorado, Anschutz Medical Campus, Aurora, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
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Kaizer AM, Belli HM, Ma Z, Nicklawsky AG, Roberts SC, Wild J, Wogu AF, Xiao M, Sabo RT. Recent innovations in adaptive trial designs: A review of design opportunities in translational research. J Clin Transl Sci 2023; 7:e125. [PMID: 37313381 PMCID: PMC10260347 DOI: 10.1017/cts.2023.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/29/2023] [Accepted: 04/17/2023] [Indexed: 06/15/2023] Open
Abstract
Clinical trials are constantly evolving in the context of increasingly complex research questions and potentially limited resources. In this review article, we discuss the emergence of "adaptive" clinical trials that allow for the preplanned modification of an ongoing clinical trial based on the accumulating evidence with application across translational research. These modifications may include terminating a trial before completion due to futility or efficacy, re-estimating the needed sample size to ensure adequate power, enriching the target population enrolled in the study, selecting across multiple treatment arms, revising allocation ratios used for randomization, or selecting the most appropriate endpoint. Emerging topics related to borrowing information from historic or supplemental data sources, sequential multiple assignment randomized trials (SMART), master protocol and seamless designs, and phase I dose-finding studies are also presented. Each design element includes a brief overview with an accompanying case study to illustrate the design method in practice. We close with brief discussions relating to the statistical considerations for these contemporary designs.
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Affiliation(s)
- Alexander M. Kaizer
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hayley M. Belli
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Zhongyang Ma
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Andrew G. Nicklawsky
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Samantha C. Roberts
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jessica Wild
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Adane F. Wogu
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mengli Xiao
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Roy T. Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
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Aggarwal NR, Beaty LE, Bennett TD, Carlson NE, Davis CB, Kwan BM, Mayer DA, Ong TC, Russell S, Steele J, Wogu AF, Wynia MK, Zane RD, Ginde AA. Real-World Evidence of the Neutralizing Monoclonal Antibody Sotrovimab for Preventing Hospitalization and Mortality in COVID-19 Outpatients. J Infect Dis 2022; 226:2129-2136. [PMID: 35576581 PMCID: PMC10205600 DOI: 10.1093/infdis/jiac206] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [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: 03/21/2022] [Revised: 05/03/2022] [Accepted: 05/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND It is not known whether sotrovimab, a neutralizing monoclonal antibody (mAb) treatment authorized for early symptomatic coronavirus disease 2019 (COVID-19) patients, is also effective in preventing the progression of severe disease and mortality following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta variant infection. METHODS In an observational cohort study of nonhospitalized adult patients with SARS-CoV-2 infection, 1 October 2021-11 December 2021, using electronic health records from a statewide health system plus state-level vaccine and mortality data, we used propensity matching to select 3 patients not receiving mAbs for each patient who received outpatient sotrovimab treatment. The primary outcome was 28-day hospitalization; secondary outcomes included mortality and severity of hospitalization. RESULTS Of 10 036 patients with SARS-CoV-2 infection, 522 receiving sotrovimab were matched to 1563 not receiving mAbs. Compared to mAb-untreated patients, sotrovimab treatment was associated with a 63% decrease in the odds of all-cause hospitalization (raw rate 2.1% vs 5.7%; adjusted odds ratio [aOR], 0.37; 95% confidence interval [CI], .19-.66) and an 89% decrease in the odds of all-cause 28-day mortality (raw rate 0% vs 1.0%; aOR, 0.11; 95% CI, .0-.79), and may reduce respiratory disease severity among those hospitalized. CONCLUSIONS Real-world evidence demonstrated sotrovimab effectiveness in reducing hospitalization and all-cause 28-day mortality among COVID-19 outpatients during the Delta variant phase.
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Affiliation(s)
- Neil R Aggarwal
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Laurel E Beaty
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Tellen D Bennett
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nichole E Carlson
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher B Davis
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Bethany M Kwan
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David A Mayer
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Toan C Ong
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Seth Russell
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeffrey Steele
- Research Informatics, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Adane F Wogu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Matthew K Wynia
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Center for Bioethics and Humanities, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Health Systems Management and Policy, Colorado School of Public Health, Aurora, Colorado, USA
| | - Richard D Zane
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Douin DJ, Wogu AF, Beaty LE, Carlson NE, Bennett TD, Aggarwal NR, Mayer DA, Ong TC, Russell S, Steele J, Peers JL, Molina KC, Wynia MK, Ginde AA. Association between treatment failure and hospitalization after receipt of neutralizing monoclonal antibody treatment for COVID-19 outpatients. BMC Infect Dis 2022; 22:818. [PMID: 36344927 PMCID: PMC9639288 DOI: 10.1186/s12879-022-07819-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Neutralizing monoclonal antibodies (mAbs) are highly effective in reducing hospitalization and mortality among early symptomatic COVID-19 patients in clinical trials and real-world data. While resistance to some mAbs has since emerged among new variants, characteristics associated with treatment failure of mAbs remain unknown. METHODS This multicenter, observational cohort study included patients with COVID-19 who received mAb treatment between November 20, 2020, and December 9, 2021. We utilized electronic health records from a statewide health system plus state-level vaccine and mortality data. The primary outcome was mAb treatment failure, defined as hospitalization or death within 28 days of a positive SARS-CoV-2 test. RESULTS COVID-19 mAb was administered to 7406 patients. Hospitalization within 28 days of positive SARS-CoV-2 test occurred in 258 (3.5%) of all patients who received mAb treatment. Ten patients (0.1%) died within 28 days, and all but one were hospitalized prior to death. Characteristics associated with treatment failure included having two or more comorbidities excluding obesity and immunocompromised status (adjusted odds ratio [OR] 3.71, 95% confidence interval [CI] 2.52-5.56), lack of SARS-CoV-2 vaccination (OR 2.73, 95% CI 2.01-3.77), non-Hispanic black race/ethnicity (OR 2.21, 95% CI 1.20-3.82), obesity (OR 1.79, 95% CI 1.36-2.34), one comorbidity (OR 1.68, 95% CI 1.11-2.57), age ≥ 65 years (OR 1.62, 95% CI 1.13-2.35), and male sex (OR 1.56, 95% CI 1.21-2.02). Immunocompromised status (none, mild, or moderate/severe), pandemic phase, and type of mAb received were not associated with treatment failure (all p > 0.05). CONCLUSIONS Comorbidities, lack of prior SARS-CoV-2 vaccination, non-Hispanic black race/ethnicity, obesity, age ≥ 65 years, and male sex are associated with treatment failure of mAbs.
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Affiliation(s)
- David J. Douin
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 E. 17th Avenue, B-215, Aurora, CO 80045 USA
| | - Adane F. Wogu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO USA
| | - Laurel E. Beaty
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO USA
| | - Nichole E. Carlson
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO USA
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Tellen D. Bennett
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO USA
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Neil R. Aggarwal
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - David A. Mayer
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO USA
| | - Toan C. Ong
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Seth Russell
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Jeffrey Steele
- Research Informatics, Children’s Hospital Colorado, Aurora, CO USA
| | - Jennifer L. Peers
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Kyle C. Molina
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO USA
- University of Colorado School of Pharmacy and Pharmaceutical Sciences, Aurora, CO USA
| | - Matthew K. Wynia
- Section of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Adit A. Ginde
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO USA
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Wynia MK, Beaty LE, Bennett TD, Carlson NE, Davis CB, Kwan BM, Mayer DA, Ong TC, Russell S, Steele J, Stocker HR, Wogu AF, Zane RD, Sokol RJ, Ginde AA. Real World Evidence of Neutralizing Monoclonal Antibodies for Preventing Hospitalization and Mortality in COVID-19 Outpatients. medRxiv 2022:2022.01.09.22268963. [PMID: 35043117 PMCID: PMC8764726 DOI: 10.1101/2022.01.09.22268963] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neutralizing monoclonal antibodies (mAbs) are authorized for early symptomatic COVID-19 patients. Whether mAbs are effective against the SARS-CoV-2 Delta variant, among vaccinated patients, or for prevention of mortality remains unknown. OBJECTIVE To evaluate the effectiveness of mAb treatment in preventing progression to severe disease during the Delta phase of the pandemic and based on key baseline risk factors. DESIGN SETTING AND PATIENTS Observational cohort study of non-hospitalized adult patients with SARS-CoV-2 infection from November 2020-October 2021, using electronic health records from a statewide health system plus state-level vaccine and mortality data. Using propensity matching, we selected approximately 2.5 patients not receiving mAbs for each patient who received mAbs. EXPOSURE Neutralizing mAb treatment under emergency use authorization. MAIN OUTCOMES The primary outcome was 28-day hospitalization; secondary outcomes included mortality and severity of hospitalization. RESULTS Of 36,077 patients with SARS-CoV-2 infection, 2,675 receiving mAbs were matched to 6,677 not receiving mAbs. Compared to mAb-untreated patients, mAb-treated patients had lower all-cause hospitalization (4.0% vs 7.7%; adjusted OR 0.48, 95%CI 0.38-0.60) and all-cause mortality (0.1% vs. 0.9%; adjusted OR 0.11, 95%CI 0.03-0.29) to day 28; differences persisted to day 90. Among hospitalized patients, mAb-treated patients had shorter hospital length of stay (5.8 vs. 8.5 days) and lower risk of mechanical ventilation (4.6% vs. 16.6%). Relative effectiveness was similar in preventing hospitalizations during the Delta variant phase (adjusted OR 0.35, 95%CI 0.25-0.50) and across subgroups. Lower number-needed-to-treat (NNT) to prevent hospitalization were observed for subgroups with higher baseline risk of hospitalization (e.g., multiple comorbidities (NNT=17) and not fully vaccinated (NNT=24) vs. no comorbidities (NNT=88) and fully vaccinated (NNT=81). CONCLUSION Real-world evidence demonstrated mAb effectiveness in reducing hospitalization among COVID-19 outpatients, including during the Delta variant phase, and conferred an overall 89% reduction in 28-day mortality. Early outpatient treatment with mAbs should be prioritized, especially for individuals with highest risk for hospitalization.
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Ataga KI, Elsherif L, Wichlan D, Wogu AF, Matsui N, Pawlinski R, Cai J, Key NS. A pilot study of the effect of rivaroxaban in sickle cell anemia. Transfusion 2021; 61:1694-1698. [PMID: 33660875 DOI: 10.1111/trf.16343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The contribution of coagulation activation to the pathogenesis of sickle cell disease (SCD) remains incompletely defined. We evaluated the efficacy and safety of rivaroxaban, an oral direct factor Xa inhibitor, in subjects with sickle cell anemia. MATERIALS AND METHODS In this pilot, single-center, randomized, double-blind, placebo-controlled, crossover study, eligible subjects with sickle cell anemia received rivaroxaban or placebo. The effect of rivaroxaban on coagulation activation, endothelial activation, inflammation, and microvascular blood flow was evaluated. RESULTS Fourteen patients (HbSS - 14; females - 9) with mean age of 38 ± 10.6 years were randomized to receive rivaroxaban 20 mg daily or placebo for 4 weeks and, following a 2-week washout phase, were "crossed-over" to the treatment arm opposite to which they were initially assigned. Mean adherence to treatment with rivaroxaban, assessed by pill counts, was 85.6% in the first treatment period and 93.6% in the second period. Treatment with rivaroxaban resulted in a decrease from baseline of thrombin-antithrombin complex versus placebo (-34.4 ug/L [95% CI: -69.4, 0.53] vs. 0.35 ug/L [95% CI: -3.8, 4.5], p = .08), but the difference was not statistically significant. No significant differences were observed in changes from baseline of D-dimer, inflammatory, and endothelial activation markers or measures of microvascular blood flow. Rivaroxaban was well tolerated. CONCLUSIONS Rivaroxaban was safe but did not significantly decrease coagulation activation, endothelial activation, or inflammation. Rivaroxaban did not improve microvascular blood flow. Adequately powered studies are required to further evaluate the efficacy of rivaroxaban in SCD. Clinicaltrials.gov Identifier: NCT02072668.
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Affiliation(s)
- Kenneth I Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Scienter Center, Memphis, Tennessee, USA
| | - Laila Elsherif
- Center for Sickle Cell Disease, University of Tennessee Health Scienter Center, Memphis, Tennessee, USA
| | - David Wichlan
- Division of Hematology and Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adane F Wogu
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Neil Matsui
- Vanguard Therapeutics, Inc., Half Moon Bay, California, USA
| | - Rafal Pawlinski
- Division of Hematology and Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jianwen Cai
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nigel S Key
- Division of Hematology and Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
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Ataga KI, Wichlan D, Elsherif L, Derebail VK, Wogu AF, Maitra P, Cai J, Caughey MC, Pollock DM, Pollock JS, Archer DR, Hinderliter AL. A pilot study of the effect of atorvastatin on endothelial function and albuminuria in sickle cell disease. Am J Hematol 2019; 94:E299-E301. [PMID: 31407373 DOI: 10.1002/ajh.25614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/02/2019] [Accepted: 08/07/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Kenneth I Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Scienter Center, Memphis, Tennessee
| | - David Wichlan
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Laila Elsherif
- Center for Sickle Cell Disease, University of Tennessee Health Scienter Center, Memphis, Tennessee
| | - Vimal K Derebail
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina
| | - Adane F Wogu
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Poulami Maitra
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Jianwen Cai
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Melissa C Caughey
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina
| | - David M Pollock
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer S Pollock
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - David R Archer
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Alan L Hinderliter
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina
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Wogu AF, Loffredo CA, Bebu I, Luta G. Mediation analysis of gestational age, congenital heart defects, and infant birth-weight. BMC Res Notes 2014; 7:926. [PMID: 25515761 PMCID: PMC4320577 DOI: 10.1186/1756-0500-7-926] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [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: 10/16/2014] [Accepted: 12/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this study we assessed the mediation role of the gestational age on the effect of the infant's congenital heart defects (CHD) on birth-weight. METHODS We used secondary data from the Baltimore-Washington Infant Study (1981-1989). Mediation analysis was employed to investigate whether gestational age acted as a mediator of the association between CHD and reduced birth-weight. We estimated the mediated effect, the mediation proportion, and their corresponding 95% confidence intervals (CI) using several methods. RESULTS There were 3362 CHD cases and 3564 controls in the dataset with mean birth-weight of 3071 (SD = 729) and 3353 (SD = 603) grams, respectively; the mean gestational age was 38.9 (SD = 2.7) and 39.6 (SD = 2.2) weeks, respectively. After adjusting for covariates, the estimated mediated effect by gestational age was 113.5 grams (95% CI, 92.4-134.2) and the mediation proportion was 40.7% (95% CI, 34.7%-46.6%), using the bootstrap approach. CONCLUSIONS Gestational age may account for about 41% of the overall effect of heart defects on reduced infant birth-weight. Improved prenatal care and other public health efforts that promote full term delivery, particularly targeting high-risk families and mothers known to be carrying a fetus with CHD, may therefore be expected to improve the birth-weight of these infants and their long term health.
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Affiliation(s)
| | - Christopher A Loffredo
- Departments of Oncology and of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, 3800 Reservoir Rd, NW, Washington, DC 20057, USA.
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Culakova E, Thota R, Poniewierski MS, Kuderer NM, Wogu AF, Dale DC, Crawford J, Lyman GH. Patterns of chemotherapy-associated toxicity and supportive care in US oncology practice: a nationwide prospective cohort study. Cancer Med 2014; 3:434-44. [PMID: 24706592 PMCID: PMC3987093 DOI: 10.1002/cam4.200] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [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: 10/28/2013] [Revised: 12/13/2013] [Accepted: 12/30/2013] [Indexed: 01/16/2023] Open
Abstract
Neutropenic complications remain an important dose-limiting toxicity of cancer chemotherapy-associated with considerable morbidity, mortality, and cost. Risk of the initial neutropenic event is greatest during the first cycle. The purpose of this study was to better understand timing of neutropenic events in relation to delivered chemotherapy dose intensity and utilization of supportive care during cancer treatment. A prospective cohort study of adult patients with solid tumors or lymphoma initiating chemotherapy was conducted at 115 randomly selected US practice sites between 2002 and 2006. Chemotherapy-associated toxicities were captured in up to four treatment cycles including severe neutropenia, febrile neutropenia, and infection. Documented interventions included colony-stimulating factor (CSF), antibiotics use, and reductions in chemotherapy relative dose intensity (RDI). A total of 3638 patients with breast (39.7%), lung (23.7%), colorectal (13.6%), ovarian (8.3%) cancers, or lymphoma (14.7%) were eligible for this analysis. The majority of neutropenic and infection events occurred in the first cycle. A significant inverse relationship was observed between reductions in neutropenic and infectious events and increased utilization of measures to reduce these complications in subsequent cycles. More than 60% of patients with stage IV solid tumors underwent reductions in RDI. Patients with lymphoma and stage I–III solid tumors had less dose reductions while receiving more prophylactic CSFs. Approximately, 15% of patients received prophylactic antibiotics. While the risk of neutropenic complications remains greatest during the initial cycle of chemotherapy, subsequently instituted clinical measures in efforts to reduce the risk of these events vary with cancer type and stage.
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Lyman GH, Culakova E, Poniewierski MS, Wogu AF, Barry W, Ginsburg GS, Marcom PK, Ready N, Abernethy A, Geradts J, Hwang S, Kuderer NM. Abstract P3-06-07: Ki67 as a Predictive Marker of Response to Neoadjuvant Chemotherapy in Patients with Early-Stage Breast Cancer (ESBC): A Systematic Review and Evidence Summary. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p3-06-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Immunohistochemical (IHC) assessment of the proportion of cells staining for the KI67 nuclear antigen is being increasing utilized in the management of patients with early-stage breast cancer (ESBC). A comprehensive systematic review and evidence synthesis of biomarkers potentially predictive of response to systemic therapy was initiated as a part of an NCI-funded comparative effectiveness research program.
Methods: Studies of chemotherapy response prediction based on baseline IHC assessment of Ki67 in patients with ESBC receiving neoadjuvant systemic therapy were identified. Response was specified as pathologic complete response (pCR) or clinical response (ClinR). Assay predictive performance for response was assessed on the basis of sensitivity, specificity, predictive value and predictive odds ratio (POR±95%CLs) utilizing mixed effects models. Study results were fitted in an ROC analysis based on the method of DerSimonian and Laird. Publication bias was evaluated on the basis of funnel plot asymmetry assessed by Egger's regression intercept and Begg and Mazumdar's rank correlation.
Results: Of 469 potentially eligible studies, dual blind full text review identified 42 eligible studies reporting 44 independent cohorts with 6,716 patients (21–979). While Ki67 cutpoints varied considerably, they were most commonly between 10%–30% (median 20%, range 1–50%). The analysis prsented here is limited to the 30 studies of ESBC patients (N = 3,343) receiving neoadjuvant therapy of which 14 reported fewer than 100 patients. The proportion of patients with elevated Ki67 across studies ranged from 0.20–0.92 (median = 0.54). Sensitivity and specificity for treatment response in patients with high vs. low baseline Ki67 was 0.65 [0.61, 0.68] and 0.52 [0.50, 0.54], respectively. Estimated response rates across studies in patients with high vs. low Ki67 were 31% [29%, 34%] and 19% [17%, 21%], respectively. The estimated POR for response across studies was 2.82 [2.14, 3.72; P < .001].
POR was significantly greater in studies of anthracycline-based [3.0] than non-anthracycline regimens [0.92](Pinteraction = .043) and of cyclophosphamide-based [3.41] compared to non-cyclophosphamide regimens [2.00](P interaction=.039) but was not associated with treatment based on other drug classes. Although Ki67 predictive performance was not significantly associated with the cutpoint utilized or the proportion of patients with ER or PR+, Her2+, or high grade tumors across studies, analysis based on individual patient data is needed to assess performance in specific clinical subgroups. No significant publication bias was found.
Conclusions: A compelling need exists for larger studies with greater methodologic rigor and standardization to assess the clinical validity of Ki67 in ESBC as well its clinical utility in guiding neoadjuvant treatment decisions compared to the use of conventional predictive markers.
Funding: NCI: RC2CA14041-01
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-06-07.
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Culakova E, Poniewierski MS, Wogu AF, Kuderer NM, Crawford J, Dale DC, Lyman GH. Abstract P1-15-04: The relationship of relative dose intensity and supportive care to febrile neutropenia rates in patients with early stage breast cancer receiving chemotherapy: a prospective cohort study of chemotherapy-associated toxicity. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p1-15-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Febrile neutropenia (FN) represents a major dose-limiting toxicity of cancer chemotherapy resulting in considerable morbidity, mortality, and cost. Patients have the highest risk of the initial neutropenic event in cycle 1 when most patients receive full dose chemotherapy. This study evaluates time course of neutropenic events in patients receiving chemotherapy for early-stage breast cancer (ESBC) and supportive care interventions that modify FN risk in ESBC patients treated in actual oncology practice.
Methods: A prospective cohort study of adult cancer patients with solid tumors or lymphoma starting a chemotherapy regimen was conducted at 115 U.S. sites. Toxicities associated with chemotherapy were recorded in up to 4 cycles including severe neutropenia (SN), FN, and infection. Documented clinical interventions included reductions in chemotherapy relative dose intensity (RDI), the use of colony-stimulating factors (CSFs), and antibiotics.
Results: A total of 1202 ESBC patients starting chemotherapy were analyzed, of which 1154, 1099, and 896 reached the midcycle of cycles 2, 3, and 4, respectively. While the majority of neutropenic and infection events occurred in cycle 1, decreasing rates of FN and infection in later cycles correlated with increasing reductions in dose intensity and increased use of CSFs and antibiotics.
The overall risk of FN in all patients combined was 16.3 %. It reached 21.1% for patients who started with planned RDI≥85% and without primary CSF prophylaxis. There was no significant difference in FN rates by menopausal status or hormone receptors.
Conclusions: While the risk of neutropenic complications is highest during the first cycle of chemotherapy, reductions in neutropenic events during subsequent cycles are associated with reduced chemotherapy dose intensity or increased use of supportive care measures. Nevertheless, the cumulative risk of neutropenic events remains high in ESBC patients receiving full dose chemotherapy without prophylactic measures overall and across menopausal and hormone receptor subgroups.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-15-04.
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Affiliation(s)
- E Culakova
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - MS Poniewierski
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - AF Wogu
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - NM Kuderer
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - J Crawford
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - DC Dale
- Duke University, Durham, NC; University of Washington, Seattle, WA
| | - GH Lyman
- Duke University, Durham, NC; University of Washington, Seattle, WA
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