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Shah SC, Camargo MC, Lamm M, Bustamante R, Roumie CL, Wilson O, Halvorson AE, Greevy R, Liu L, Gupta S, Demb J. Impact of Helicobacter pylori Infection and Treatment on Colorectal Cancer in a Large, Nationwide Cohort. J Clin Oncol 2024:JCO2300703. [PMID: 38427927 DOI: 10.1200/jco.23.00703] [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] [Received: 03/29/2023] [Revised: 11/04/2023] [Accepted: 12/18/2023] [Indexed: 03/03/2024] Open
Abstract
PURPOSE Helicobacter pylori is the most common cause of infection-associated cancer worldwide. We aimed to evaluate the impact of H. pylori infection and treatment on colorectal cancer (CRC) incidence and mortality. PATIENTS US Veterans who completed H. pylori testing between 1999 and 2018. METHODS We conducted a retrospective cohort analysis among adults within the Veterans Health Administration who completed testing for H. pylori. The primary exposures were (1) H. pylori test result (positive/negative) and (2) H. pylori treatment (untreated/treated) among H. pylori-positive individuals. The primary outcomes were CRC incidence and mortality. Follow-up started at the first H. pylori testing and continued until the earliest of incident or fatal CRC, non-CRC death, or December 31, 2019. RESULTS Among 812,736 individuals tested for H. pylori, 205,178 (25.2%) tested positive. Being H. pylori-positive versus H. pylori-negative was associated with higher CRC incidence and mortality. H. pylori treatment versus no treatment was associated with lower CRC incidence and mortality (absolute risk reduction 0.23%-0.35%) through 15-year follow-up. Being H. pylori-positive versus H. pylori-negative was associated with an 18% (adjusted hazard ratio [adjusted HR], 1.18 [95% CI, 1.12 to 1.24]) and 12% (adjusted HR, 1.12 [95% CI, 1.03 to 1.21]) higher incident and fatal CRC risk, respectively. Individuals with untreated versus treated H. pylori infection had 23% (adjusted HR, 1.23 [95% CI, 1.13 to 1.34]) and 40% (adjusted HR, 1.40 [95% CI, 1.24 to 1.58]) higher incident and fatal CRC risk, respectively. The results were more pronounced in the analysis restricted to individuals with nonserologic testing. CONCLUSION H. pylori positivity may be associated with small but statistically significant higher CRC incidence and mortality; untreated individuals, especially those with confirmed active infection, appear to be most at risk.
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Affiliation(s)
- Shailja C Shah
- Division of Gastroenterology, VA San Diego Healthcare System, San Diego, CA
- Division of Gastroenterology, University of California, San Diego, San Diego, CA
| | - M Constanza Camargo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Mark Lamm
- Division of Gastroenterology, VA San Diego Healthcare System, San Diego, CA
| | - Ranier Bustamante
- Division of Gastroenterology, VA San Diego Healthcare System, San Diego, CA
- Division of Gastroenterology, University of California, San Diego, San Diego, CA
| | - Christianne L Roumie
- Department of Medicine, VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, VA Geriatrics Research Education and Clinical Center (GRECC), VA Tennessee Valley Health System, Nashville, TN
| | - Otis Wilson
- Department of Medicine, VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, TN
| | - Alese E Halvorson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Robert Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Lin Liu
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, CA
| | - Samir Gupta
- Division of Gastroenterology, VA San Diego Healthcare System, San Diego, CA
- Division of Gastroenterology, University of California, San Diego, San Diego, CA
| | - Joshua Demb
- Division of Gastroenterology, University of California, San Diego, San Diego, CA
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Shah SC, Halvorson AE, Lee D, Bustamante R, McBay B, Gupta R, Denton J, Dorn C, Wilson O, Peek R, Gupta S, Liu L, Hung A, Greevy R, Roumie CL. Helicobacter pylori Burden in the United States According to Individual Demographics and Geography: A Nationwide Analysis of the Veterans Healthcare System. Clin Gastroenterol Hepatol 2024; 22:42-50.e26. [PMID: 37245717 DOI: 10.1016/j.cgh.2023.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/22/2023] [Accepted: 05/13/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND & AIMS There are no contemporary large-scale studies evaluating the burden of Helicobacter pylori in the United States according to detailed demographics. The primary objective was to evaluate H pylori positivity in a large national healthcare system according to individual demographics and geography. METHODS We conducted a nationwide retrospective analysis of adults in the Veterans Health Administration who completed H pylori testing between 1999 and 2018. The primary outcome was H pylori positivity overall, as well as according to zip code-level geography, race, ethnicity, age, sex, and time period. RESULTS Among 913,328 individuals (mean, 58.1 years; 90.2% male) included between 1999 and 2018, H pylori was diagnosed in 25.8%. Positivity was highest in non-Hispanic black (median, 40.2%; 95% confidence interval [CI], 40.0%-40.5%) and Hispanic (36.7%; 95% CI, 36.4%-37.1%) individuals and lowest in non-Hispanic white individuals (20.1%; 95% CI, 20.0%-20.2%). Although H pylori positivity declined in all racial and ethnic groups over the timeframe, the disproportionate burden of H pylori in non-Hispanic black and Hispanic compared with non-Hispanic white individuals persisted. Approximately 4.7% of the variation in H pylori positivity was explained by demographics, with race and ethnicity accounting for the vast majority. CONCLUSIONS The burden of H pylori is substantial in the United States among veterans. These data should (1) motivate research aimed at better understanding why marked demographic differences in H pylori burden persist so that mitigating interventions may be implemented and (2) guide resource allocation to optimize H pylori testing and eradication in high-risk groups.
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Affiliation(s)
- Shailja C Shah
- Gastroenterology Section, Jennifer Moreno Department of Veterans Affairs Medical Center, San Diego, California; Division of Gastroenterology, University of California, San Diego, La Jolla, California.
| | - Alese E Halvorson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Lee
- Division of Gastroenterology, University of Maryland Medical Center, Baltimore, Maryland
| | - Ranier Bustamante
- Department of Biostatistics, University of California, San Diego, La Jolla, California
| | - Brandon McBay
- Department of Public Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Rohan Gupta
- College of Medicine, State University of New York Upstate Medical University, Syracuse, New York
| | - Jason Denton
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chad Dorn
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Otis Wilson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee; Clinical Services Research and Development, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Richard Peek
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samir Gupta
- Gastroenterology Section, Jennifer Moreno Department of Veterans Affairs Medical Center, San Diego, California; Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - Lin Liu
- Department of Biostatistics, University of California, San Diego, La Jolla, California
| | - Adriana Hung
- Clinical Services Research and Development, VA Tennessee Valley Healthcare System, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee; Clinical Services Research and Development, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Christianne L Roumie
- Clinical Services Research and Development, VA Tennessee Valley Healthcare System, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; VA Geriatrics Research Education and Clinical Center (GRECC), VA Tennessee Valley Health System, Nashville, Tennessee
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Canakis A, Lee A, Halvorson AE, Noto JM, Peek RM, Wilson O, Hung A, Roumie CL, Greevy R, Shah SC. Bile Acid Sequestrant Use and Gastric Cancer: A National Retrospective Cohort Analysis. Clin Transl Gastroenterol 2023; 14:e00596. [PMID: 37606521 PMCID: PMC10749703 DOI: 10.14309/ctg.0000000000000596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION Bile acids have been implicated in gastric carcinogenesis. We hypothesized that bile acid sequestrant medication (BAM) use is associated with a lower gastric cancer (GC) incidence. METHODS We assembled a cohort of veterans receiving longitudinal care within the Veterans Health Administration between 2000 and 2020 who completed testing for Helicobacterpylori . The index date was the date of completed H. pylori testing. The primary exposure was the number of filled BAM prescription(s) in the 5 years before the index date. The primary outcome was incident GC, stratified by anatomic subsite. Follow-up began at the index date and ended at the earliest of GC, death, after 2 years of follow-up, or the study end (May 31, 2020). We used Kaplan-Meier curves to visualize differences in GC incidence by exposure group and multivariable Cox proportional hazards models to estimate the association between BAM exposure and anatomic site-specific GC. RESULTS Among 417,239 individuals (89% male, mean age 54 years, 63% non-Hispanic White), 4,916 (1.2%) filled at least one BAM prescription, 2,623 of whom filled ≥4. Compared with unexposed individuals, those with ≥4 BAM fills before entry had a lower incidence (adjusted hazard ratio 0.71; 95% confidence interval, 0.37-1.36) of GC, but confidence intervals were wide. Results were consistent irrespective of GC anatomic site. DISCUSSION BAMs may have a protective effect against both cardia and noncardia GC. Further research and external validation are needed to confirm these findings.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Amy Lee
- University of California San Diego School of Medicine, San Diego, California, USA
| | - Alese E. Halvorson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jennifer M. Noto
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - Richard M. Peek
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville Tennessee, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - Otis Wilson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, Tennessee, USA
| | - Adriana Hung
- VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - Christianne L. Roumie
- VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville Tennessee, USA
- VA Geriatrics Research Education and Clinical Center (GRECC), VA Tennessee Valley Health System, Nashville, Tennessee, USA
| | - Robert Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - Shailja C. Shah
- Gastroenterology Section, VA San Diego Healthcare System, San Diego, California, USA
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
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Horton TG, Richardson TL, Hackstadt AJ, Halvorson AE, Hung AM, Greevy R, Roumie CL. Validation of an algorithm to identify fractures among patients within the Veterans Health Administration. Pharmacoepidemiol Drug Saf 2023; 32:1290-1298. [PMID: 37363939 PMCID: PMC10543449 DOI: 10.1002/pds.5662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 06/09/2023] [Accepted: 06/23/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE To validate an algorithm that identifies fractures using billing codes from the International Classification of Diseases Ninth Revision (ICD-9) and Tenth Revision (ICD-10) for inpatient, outpatient, and emergency department visits in a population of patients. METHODS We identified and reviewed a random sample of 543 encounters for adults receiving care within a single Veterans Health Administration healthcare system and had a first fracture episode between 2010 and 2019. To determine if an encounter represented a true incident fracture, we performed chart abstraction and assessed the type of fracture and mechanism. We calculated the positive predictive value (PPV) for the overall algorithm and each component diagnosis code along with 95% confidence intervals. Inverse probabilities of selection sampling weights were used to reflect the underlying study population. RESULTS The algorithm had an initial PPV of 73.5% (confidence interval [CI] 69.5, 77.1), with low performance when weighted to reflect the full population (PPV 66.3% [CI 58.8, 73.1]). The modified algorithm was restricted to diagnosis codes with PPVs > 50% and outpatient codes were restricted to the first outpatient position, with the exception of one high performing code. The resulting unweighted PPV improved to 90.1% (CI 86.2, 93.0) and weighted PPV of 91.3% (CI 86.8, 94.4). A confirmation sample demonstrated verified performance with PPV of 87.3% (76.0, 93.7). PPVs by location of care (inpatient, emergency department and outpatient) remained greater than 85% in the modified algorithm. CONCLUSIONS The modified algorithm, which included primary billing codes for inpatient, outpatient, and emergency department visits, demonstrated excellent PPV for identification of fractures among a cohort of patients within the Veterans Health Administration system.
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Affiliation(s)
- Thomas G. Horton
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tadarro L. Richardson
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amber J. Hackstadt
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Alese E. Halvorson
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Adriana M. Hung
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert Greevy
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Christianne L. Roumie
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
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Richardson TL, Halvorson AE, Hackstadt AJ, Hung AM, Greevy R, Grijalva CG, Elasy TA, Roumie CL. Primary Occurrence of Cardiovascular Events After Adding Sodium-Glucose Cotransporter-2 Inhibitors or Glucagon-like Peptide-1 Receptor Agonists Compared With Dipeptidyl Peptidase-4 Inhibitors: A Cohort Study in Veterans With Diabetes. Ann Intern Med 2023; 176:751-760. [PMID: 37155984 PMCID: PMC10367222 DOI: 10.7326/m22-2751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND The effectiveness of glucagon-like peptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) in preventing major adverse cardiac events (MACE) is uncertain for those without preexisting cardiovascular disease. OBJECTIVE To test the hypothesis that MACE incidence was lower with the addition of GLP1RA or SGLT2i compared with dipeptidyl peptidase-4 inhibitors (DPP4i) for primary cardiovascular prevention. DESIGN Retrospective cohort study of U.S. veterans from 2001 to 2019. SETTING Veterans aged 18 years or older receiving care from the Veterans Health Administration, with data linkage to Medicare, Medicaid, and the National Death Index. PATIENTS Veterans adding GLP1RA, SGLT2i, or DPP4i onto metformin, sulfonylurea, or insulin treatment alone or in combination. Episodes were stratified by history of cardiovascular disease. MEASUREMENTS Study outcomes were MACE (acute myocardial infarction, stroke, or cardiovascular death) and heart failure (HF) hospitalization. Cox models compared the outcome between medication groups using pairwise comparisons in a weighted cohort adjusted for covariates. RESULTS The cohort included 28 759 GLP1RA versus 28 628 DPP4i weighted pairs and 21 200 SGLT2i versus 21 170 DPP4i weighted pairs. Median age was 67 years, and diabetes duration was 8.5 years. Glucagon-like peptide-1 receptor agonists were associated with lower MACE and HF versus DPP4i (adjusted hazard ratio [aHR], 0.82 [95% CI, 0.72 to 0.94]), yielding an adjusted risk difference (aRD) of 3.2 events (CI, 1.1 to 5.0) per 1000 person-years. Sodium-glucose cotransporter-2 inhibitors were not associated with MACE and HF (aHR, 0.91 [CI, 0.78 to 1.08]; aRD, 1.28 [-1.12 to 3.32]) compared with DPP4i. LIMITATION Residual confounding; use of DPP4i, GLP1RA, and SGLT2i as first-line therapies were not examined. CONCLUSION The addition of GLP1RA was associated with primary reductions of MACE and HF hospitalization compared with DPP4i use; SGLT2i addition was not associated with primary MACE prevention. PRIMARY FUNDING SOURCE VA Clinical Science Research and Development and supported in part by the Centers for Diabetes Translation Research.
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Affiliation(s)
- Tadarro L. Richardson
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alese E. Halvorson
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Amber J. Hackstadt
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Adriana M. Hung
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert Greevy
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Carlos G. Grijalva
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Tom A. Elasy
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Christianne L. Roumie
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
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Shah SC, Canakis A, Halvorson AE, Dorn C, Wilson O, Denton J, Hauger R, Hunt C, Suzuki A, Matheny ME, Siew E, Hung A, Greevy RA, Roumie CL. Associations Between Gastrointestinal Symptoms and COVID-19 Severity Outcomes Based on a Propensity Score-Weighted Analysis of a Nationwide Cohort. Gastro Hep Adv 2022; 1:977-984. [PMID: 35966642 PMCID: PMC9357443 DOI: 10.1016/j.gastha.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/30/2022] [Indexed: 01/25/2023]
Abstract
Background and Aims Gastrointestinal (GI) symptoms are well-recognized manifestations of coronavirus disease 2019 (COVID-19). Our primary objective was to evaluate the association between GI symptoms and COVID-19 severity. Methods In this nationwide cohort of US veterans, we evaluated GI symptoms (nausea/vomiting/diarrhea) reported 30 days before and including the date of positive SARS-CoV-2 testing (March 1, 2020, to February 20, 2021). All patients had ≥1 year of prior baseline data and ≥60 days follow-up relative to the test date. We used propensity score (PS)-weighting to balance covariates in patients with vs without GI symptoms. The primary composite outcome was severe COVID-19, defined as hospital admission, intensive care unit admission, mechanical ventilation, or death within 60 days of positive testing. Results Of 218,045 SARS-CoV-2 positive patients, 29,257 (13.4%) had GI symptoms. After PS weighting, all covariates were balanced. In the PS-weighted cohort, patients with vs without GI symptoms had severe COVID-19 more often (29.0% vs 17.1%; P < .001). When restricted to hospitalized patients (14.9%; n=32,430), patients with GI symptoms had similar frequencies of intensive care unit admission and mechanical ventilation compared with patients without symptoms. There was a significant age interaction; among hospitalized patients aged ≥70 years, lower COVID-19-associated mortality was observed in patients with vs without GI symptoms, even after accounting for COVID-19-specific medical treatments. Conclusion In the largest integrated US health care system, SARS-CoV-2-positive patients with GI symptoms experienced severe COVID-19 outcomes more often than those without symptoms. Additional research on COVID-19-associated GI symptoms may inform preventive efforts and interventions to reduce severe COVID-19.
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Key Words
- BMI, body mass index
- CDW, Corporate Data Warehouse
- COVID-19
- COVID-19, coronavirus disease 2019
- Epidemiology
- GI, gastrointestinal
- ICD, International Classification of Diseases
- ICU, intensive care unit
- Infectious diseases
- OMOP, Observational Medical Outcomes Partnership
- OR, odds ratios
- Outcomes
- PCR, polymerase chain reaction
- PS, propensity score
- RAASi, renin-angiotensin-aldosterone system inhibitors
- SARS-CoV-2
- SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
- SD, standard deviation
- SDR, Shared Data Resource
- SMD, standardized mean differences
- VHA, Veterans Health Administration
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Affiliation(s)
- Shailja C Shah
- Gastroenterology Section, VA San Diego, San Diego, California
- Division of Gastroenterology, University of California, San Diego, San Diego, California
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Alese E Halvorson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chad Dorn
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Otis Wilson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason Denton
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard Hauger
- Department of Psychiatry, University of California San Diego, La Jolla, California
- Center of Excellence for Stress and Mental Health, San Diego, California
| | - Christine Hunt
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina
- Gastroenterology Section, Durham VA Health Care System, Durham, North Carolina
| | - Ayako Suzuki
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina
- Gastroenterology Section, Durham VA Health Care System, Durham, North Carolina
| | - Michael E Matheny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System, Health Services Research and Development, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward Siew
- VA Tennessee Valley Healthcare System, Health Services Research and Development, Nashville, Tennessee
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adriana Hung
- VA Tennessee Valley Healthcare System, Health Services Research and Development, Nashville, Tennessee
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, Tennessee
| | - Christianne L Roumie
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, Tennessee
- VA Geriatrics Research Education and Clinical Center (GRECC), VA Tennessee Valley Health System, Nashville, Tennessee
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Shah SC, Halvorson AE, McBay B, Dorn C, Wilson O, Denton J, Tuteja S, Chang KM, Cho K, Hauger RL, Suzuki A, Hunt CM, Siew E, Matheny ME, Hung A, Greevy RA, Roumie CL. Proton-pump inhibitor use is not associated with severe COVID-19-related outcomes: a propensity score-weighted analysis of a national veteran cohort. Gut 2022; 71:1447-1450. [PMID: 34663578 PMCID: PMC9013721 DOI: 10.1136/gutjnl-2021-325701] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Shailja C. Shah
- Gastroenterology Section, VA San Diego Healthcare System, San Diego, CA,Division of Gastroenterology, University of California, San Diego, San Diego, CA,Corresponding Author: Shailja C Shah, MD MPH, 3350 La Jolla Village Drive, 3-South (GI Section), Mail Code 111D, San Diego, CA 92161, Phone: 619-854-9550 / Fax: None,
| | - Alese E. Halvorson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Brandon McBay
- Department of Public Health, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Chad Dorn
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Otis Wilson
- The Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Jason Denton
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Sony Tuteja
- The Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Kyong-Mi Chang
- The Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Kelly Cho
- VA Boston Healthcare System & Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Richard L. Hauger
- Department of Psychiatry, University of California San Diego, La Jolla, CA,Center of Excellence for Stress & Mental Health, VA San Diego Healthcare System, San Diego, CA
| | - Ayako Suzuki
- Division of Gastroenterology, Duke University Medical Center, Durham, NC,Gastroenterology Section, Durham VA Health Care System, Durham, NC
| | - Christine M. Hunt
- Division of Gastroenterology, Duke University Medical Center, Durham, NC,Gastroenterology Section, Durham VA Health Care System, Durham, NC
| | - Edward Siew
- Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, TN,VA Tennessee Valley, Health Services Research and Development
| | - Michael E. Matheny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN,Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, TN,VA Tennessee Valley, Health Services Research and Development
| | - Adriana Hung
- Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, TN,VA Tennessee Valley, Clinical Services Research and Development
| | - Robert A. Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN,VA Tennessee Valley, Clinical Services Research and Development
| | - Christianne L. Roumie
- VA Tennessee Valley, Clinical Services Research and Development,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN,VA Geriatrics Research Education and Clinical Center (GRECC), VA Tennessee Valley Health System, Nashville, TN
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Letterie MC, Patrick SW, Halvorson AE, Dupont WD, Carroll KN, Zickafoose JS, Williams SE. Factors Associated With Parental COVID-19 Vaccination Acceptance. Clin Pediatr (Phila) 2022; 61:393-401. [PMID: 35350918 DOI: 10.1177/00099228221084829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As the coronavirus pandemic continues to impact families and children, understanding parental attitudes and likely acceptance of the COVID-19 vaccine is essential. We conducted a statewide survey with a representative sample of parents in Tennessee focused on COVID-19 and influenza vaccine acceptance and perspectives. Data from 1066 parents were analyzed using weighted survey methods to generalize results to the state of Tennessee. About 53% of parents reported a likelihood to vaccinate their children against COVID-19, and 45% were likely to vaccinate their child against COVID-19 and influenza. Female parents were less likely to vaccinate their children against COVID-19, but the strongest predictor of likely COVID-19 vaccine acceptance was influenza vaccine acceptance (adjusted odds ratio = 5.46; 95% confidence interval: 3.20-9.30). Parental acceptance of COVID-19 vaccines for children is closely tied to influenza vaccine acceptance. Public health approaches to maximize vaccine uptake could focus on children who have not been receiving influenza vaccines.
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Affiliation(s)
- Mia C Letterie
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.,Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, TN, USA
| | - Alese E Halvorson
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William D Dupont
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kecia N Carroll
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph S Zickafoose
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Mathematica, Nashville, TN, USA
| | - Sarah E Williams
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Noto JM, Piazuelo MB, Shah SC, Romero-Gallo J, Hart JL, Di C, Carmichael JD, Delgado AG, Halvorson AE, Greevy RA, Wroblewski LE, Sharma A, Newton AB, Allaman MM, Wilson KT, Washington MK, Calcutt MW, Schey KL, Cummings BP, Flynn CR, Zackular JP, Peek RM. Iron deficiency linked to altered bile acid metabolism promotes Helicobacter pylori-induced inflammation-driven gastric carcinogenesis. J Clin Invest 2022; 132:e147822. [PMID: 35316215 PMCID: PMC9106351 DOI: 10.1172/jci147822] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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: 01/19/2021] [Accepted: 03/16/2022] [Indexed: 12/24/2022] Open
Abstract
Gastric carcinogenesis is mediated by complex interactions among Helicobacter pylori, host, and environmental factors. Here, we demonstrate that H. pylori augmented gastric injury in INS-GAS mice under iron-deficient conditions. Mechanistically, these phenotypes were not driven by alterations in the gastric microbiota; however, discovery-based and targeted metabolomics revealed that bile acids were significantly altered in H. pylori-infected mice with iron deficiency, with significant upregulation of deoxycholic acid (DCA), a carcinogenic bile acid. The severity of gastric injury was further augmented when H. pylori-infected mice were treated with DCA, and, in vitro, DCA increased translocation of the H. pylori oncoprotein CagA into host cells. Conversely, bile acid sequestration attenuated H. pylori-induced injury under conditions of iron deficiency. To translate these findings to human populations, we evaluated the association between bile acid sequestrant use and gastric cancer risk in a large human cohort. Among 416,885 individuals, a significant dose-dependent reduction in risk was associated with cumulative bile acid sequestrant use. Further, expression of the bile acid receptor transmembrane G protein-coupled bile acid receptor 5 (TGR5) paralleled the severity of carcinogenic lesions in humans. These data demonstrate that increased H. pylori-induced injury within the context of iron deficiency is tightly linked to altered bile acid metabolism, which may promote gastric carcinogenesis.
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Affiliation(s)
- Jennifer M Noto
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - M Blanca Piazuelo
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shailja C Shah
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Judith Romero-Gallo
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Chao Di
- Division of Protective Immunity, and
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James D Carmichael
- Department of Biochemistry, Mass Spectrometry Research Center Laboratory, Vanderbilt University, Nashville, Tennessee, USA
| | - Alberto G Delgado
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alese E Halvorson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lydia E Wroblewski
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ayushi Sharma
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | | | - Margaret M Allaman
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keith T Wilson
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - M Kay Washington
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - M Wade Calcutt
- Department of Biochemistry, Mass Spectrometry Research Center Laboratory, Vanderbilt University, Nashville, Tennessee, USA
| | - Kevin L Schey
- Department of Biochemistry, Mass Spectrometry Research Center Laboratory, Vanderbilt University, Nashville, Tennessee, USA
| | - Bethany P Cummings
- Department of Surgery, University of California, Davis, Davis, California, USA
| | - Charles R Flynn
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joseph P Zackular
- Division of Protective Immunity, and
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard M Peek
- Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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10
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Shah SC, Shah S, Halvorson AE, Hung A, Greevy RA, Roumie CL. Helicobacter pylori eradication therapy is not associated with increased risk of cardiovascular mortality, based on a national cohort study. Gastro Hep Adv 2022; 1:25-28. [PMID: 35253008 PMCID: PMC8889490 DOI: 10.1016/j.gastha.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Shailja C. Shah
- Gastroenterology Section, VA San Diego Healthcare System, San Diego, CA,Division of Gastroenterology, University of California, San Diego, San Diego, CA,Corresponding Author: Shailja C Shah, MD MPH, 3350 La Jolla Village Drive, VA San Diego Healthcare System, 3-South (GI Section), Mail Code 111D, San Diego, CA 92161, Phone: 619-854-9550,
| | - Sunish Shah
- Antimicrobial Management Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA,Department of Pharmacy Services, Yale New Haven Health System, New Haven, Connecticut, USA
| | - Alese E. Halvorson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Adriana Hung
- VA Tennessee Valley, Clinical Sciences Research and Development,Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Robert A. Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN,VA Tennessee Valley, Clinical Sciences Research and Development
| | - Christianne L. Roumie
- VA Tennessee Valley, Clinical Sciences Research and Development,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN,VA Geriatrics Research Education and Clinical Center (GRECC), VA Tennessee Valley Health System, Nashville, TN
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11
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Osmundson SS, Halvorson AE, Graves KN, Wang C, Bruehl S, Grijalva C, France D, Mokshagundam S, Hartmann K, Harrell FE. Development and Validation of a Model to Predict Post-Discharge Opioid Use after Cesarean Birth. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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12
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Schiff DM, Halvorson AE, Dupont W, Davis MM, Patrick SW. Impact of stigmatizing language describing opioid-exposed mother infant dyads: A randomized case vignette study. Subst Abus 2022; 43:551-555. [PMID: 34586979 PMCID: PMC9644408 DOI: 10.1080/08897077.2021.1975866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Existing literature suggests that using stigmatizing language may promote negative attitudes and result in more punitive views toward individuals with addiction. It is unclear how the commonly used colloquial terms to describe opioid-exposed mother infant dyads impacts public opinion of pregnant women with opioid use disorder (OUD). We sought to examine the extent to which language such as "opioid addict" and "born addicted" influences the perception of pregnant women with OUD. Methods: We conducted a randomized case-based vignette study using a population-weighted sample of parents living in Tennessee, varying in the language used to describe an opioid-exposed mother infant dyad. Participant demographics, views on opioid prescribing, and opinions on criminal justice and child welfare responses following delivery were obtained. Ordinal logistic regression was used to examine the association between vignette type and punitive responses. Results: Eleven hundred participants completed the survey. Overall, 30.6% felt the mother should be arrested and 68.6% felt the mother should lose custody of her infant. There was insufficient evidence to suggest a difference in punitive response selection based on the vignette language (p = 0.27). In the adjusted model, the odds of answering a more punitive response among parents who received non-stigmatizing language was 0.8 (95% CI 0.59-1.08) compared to parents who received stigmatizing language in the vignette. Conclusions: Many parents hold punitive views toward mothers receiving OUD treatment that was not altered by using less value-laden language. Broader stigma-reduction interventions may be more effective.
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Affiliation(s)
- Davida M. Schiff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Alese E. Halvorson
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA;,Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - William Dupont
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA;,Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Matthew M. Davis
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen W. Patrick
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA;,Departments of Pediatrics and Mildred Stahlman Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA;,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
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13
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Cronin RM, Halvorson AE, Springer C, Feng X, Sulieman L, Loperena-Cortes R, Mayo K, Carroll RJ, Chen Q, Ahmedani BK, Karnes J, Korf B, O’Donnell CJ, Qian J, Ramirez AH. Comparison of family health history in surveys vs electronic health record data mapped to the observational medical outcomes partnership data model in the All of Us Research Program. J Am Med Inform Assoc 2021; 28:695-703. [PMID: 33404595 PMCID: PMC7973437 DOI: 10.1093/jamia/ocaa315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/15/2020] [Accepted: 11/14/2020] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Family health history is important to clinical care and precision medicine. Prior studies show gaps in data collected from patient surveys and electronic health records (EHRs). The All of Us Research Program collects family history from participants via surveys and EHRs. This Demonstration Project aims to evaluate availability of family health history information within the publicly available data from All of Us and to characterize the data from both sources. MATERIALS AND METHODS Surveys were completed by participants on an electronic portal. EHR data was mapped to the Observational Medical Outcomes Partnership data model. We used descriptive statistics to perform exploratory analysis of the data, including evaluating a list of medically actionable genetic disorders. We performed a subanalysis on participants who had both survey and EHR data. RESULTS There were 54 872 participants with family history data. Of those, 26% had EHR data only, 63% had survey only, and 10.5% had data from both sources. There were 35 217 participants with reported family history of a medically actionable genetic disorder (9% from EHR only, 89% from surveys, and 2% from both). In the subanalysis, we found inconsistencies between the surveys and EHRs. More details came from surveys. When both mentioned a similar disease, the source of truth was unclear. CONCLUSIONS Compiling data from both surveys and EHR can provide a more comprehensive source for family health history, but informatics challenges and opportunities exist. Access to more complete understanding of a person's family health history may provide opportunities for precision medicine.
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Affiliation(s)
- Robert M Cronin
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Alese E Halvorson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cassie Springer
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Xiaoke Feng
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lina Sulieman
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Roxana Loperena-Cortes
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey Mayo
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert J Carroll
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Qingxia Chen
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Jason Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tuscon, Arizona, USA
| | - Bruce Korf
- Department of Genetics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christopher J O’Donnell
- Department of Medicine, Veterans Administration Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jun Qian
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrea H Ramirez
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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14
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Byrd JC, Ruppert AS, Heerema NA, Halvorson AE, Hoke E, Smith MR, Godwin JE, Couban S, Fehniger TA, Thirman MJ, Tallman MS, Appelbaum FR, Stone RM, Robinson S, Chang JE, Mandrekar SJ, Larson RA. Lenalidomide consolidation benefits patients with CLL receiving chemoimmunotherapy: results for CALGB 10404 (Alliance). Blood Adv 2018; 2:1705-1718. [PMID: 30030269 PMCID: PMC6058242 DOI: 10.1182/bloodadvances.2017015396] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/28/2018] [Indexed: 02/07/2023] Open
Abstract
Prior to novel targeted agents for chronic lymphocytic leukemia (CLL), the best chemoimmunotherapy regimen in patients with non-del(11q) disease was unclear. The role of lenalidomide was also not defined. This phase 2 study randomized 342 untreated patients with non-del(11q) CLL requiring therapy to fludarabine plus rituximab (FR; n = 123), FR plus lenalidomide consolidation (FR+L; n = 109), or FR plus cyclophosphamide (FCR; n = 110) and compared 2-year progression-free survival (PFS) rates of each to the historical control rate with FC (60%). Patients with del(11q) in at least 20% of pretreatment cells continued with FCR (n = 27) or were reassigned to FCR+L (n = 31) and excluded from the primary analysis. Among non-del(11q) patients, 2-year PFS rates were 64% (90% confidence interval [CI], 57-71; FR), 72% (90% CI, 65-79; FR+L), and 74% (90% CI, 66-80; FCR); FR+L and FCR had rates significantly greater than historical control. Median PFS was significantly shorter with FR compared with FR+L (P = .04) and FCR (P < .001): 43 (95% CI, 33-50), 61 (95% CI, 45-71), and 97 (95% CI, 61 to not reached) months, respectively. Median follow-up was 73 months and median overall survival (OS) was only reached with FCR (101 months; 95% CI, 96 to not reached). With FR+L, the risk of death decreased over time and was lower than with FR at later time points (P = .01), but not significantly different from FCR (P = .21). Future studies incorporating short courses of lenalidomide into other novel treatment regimens are justified.
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Affiliation(s)
| | - Amy S Ruppert
- Division of Hematology
- Alliance Statistics and Data Center, and
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, OH
| | | | - Eva Hoke
- Alliance Statistics and Data Center, Duke University, Durham, NC
| | - Mitchell R Smith
- Department of Medical Oncology and Hematology, George Washington University Cancer Center, Washington, DC
| | | | | | - Todd A Fehniger
- Division of Oncology, Washington University School of Medicine, St. Louis, MO
| | - Michael J Thirman
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, IL
| | | | | | - Richard M Stone
- Dana-Farber/Partners CancerCare, Harvard Cancer Center, Boston, MA; and
| | - Sue Robinson
- QEII Health Sciences Centre, Halifax, NS, Canada
| | - Julie E Chang
- Department of Medicine, University of Wisconsin, Madison, WI
| | | | - Richard A Larson
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, IL
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15
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Abeykoon JP, Paludo J, King RL, Ansell SM, Gertz MA, LaPlant BR, Halvorson AE, Gonsalves WI, Dingli D, Fang H, Rajkumar SV, Lacy MQ, He R, Kourelis T, Reeder CB, Novak AJ, McPhail ED, Viswanatha DS, Witzig TE, Go RS, Habermann TM, Buadi FK, Dispenzieri A, Leung N, Lin Y, Thompson CA, Hayman SR, Kyle RA, Kumar SK, Kapoor P. MYD88 mutation status does not impact overall survival in Waldenström macroglobulinemia. Am J Hematol 2018; 93:187-194. [PMID: 29080258 DOI: 10.1002/ajh.24955] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 12/22/2022]
Abstract
Waldenström macroglobulinemia (WM) is an immunoglobulin M-associated lymphoma, with majority of cases demonstrating MYD88 locus alteration, most commonly, MYD88L265P . Owing to low prevalence of the wild-type (WT) MYD88 genotype in WM, clinically relevant data in this patient population are sparse, with one study showing nearly a 10-fold increased risk of mortality in this subgroup compared to patients with MYD88L265P mutation. We studied a large cohort of patients with MYD88L265P and MYD88WT WM, evaluated at Mayo Clinic, Rochester, between 1995 and 2016, to specifically assess the impact of these genotypes on clinical course. Of 557 patients, MYD88L265P mutation status, as determined by allele-specific polymerase chain reaction, was known in 219, and 174 (79%) of those exhibited MYD88L265P , 157 of 174 patients had active disease. Of 45 (21%) patients with MYD88WT genotype, 44 had active disease. The estimated median follow-up was 7.0 years; median overall survival was 10.2 years (95% CI: 8.4-16.5) for MYD88L265P versus 13.9 years (95% CI: 6.4-29.3) for the MYD88WT (P = 0.86). The time-to-next therapy from frontline treatment and the presenting features were similar in the two patient populations. For patients with smoldering WM at diagnosis, the median time-to-progression to active disease was 2.8 years (95% CI: 2.2-3.8) in the MYD88L265P cohort and 1.9 years (95% CI: 0.7-3.1) in the MYD88WT cohort (P = 0.21). The frequency of transformation to high-grade lymphoma, or the development of therapy-elated myelodysplastic syndrome was higher in the MYD88WT cohort (16% versus 4% in the MYD88L265P , P = 0.009). In conclusion, MYD88L265P mutation does not appear to be a determinant of outcome, and its presence may not be a disease-defining feature in WM. Our findings warrant external validation, preferably through prospective studies.
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16
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Paludo J, Mikhael JR, LaPlant BR, Halvorson AE, Kumar S, Gertz MA, Hayman SR, Buadi FK, Dispenzieri A, Lust JA, Kapoor P, Leung N, Russell SJ, Dingli D, Go RS, Lin Y, Gonsalves WI, Fonseca R, Bergsagel PL, Roy V, Sher T, Chanan-Khan AA, Ailawadhi S, Stewart AK, Reeder CB, Richardson PG, Rajkumar SV, Lacy MQ. Pomalidomide, bortezomib, and dexamethasone for patients with relapsed lenalidomide-refractory multiple myeloma. Blood 2017; 130:1198-1204. [PMID: 28684537 PMCID: PMC5606008 DOI: 10.1182/blood-2017-05-782961] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [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: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 01/09/2023] Open
Abstract
This phase 1/2 trial evaluated the maximum tolerated doses, safety, and efficacy of pomalidomide, bortezomib, and dexamethasone (PVD) combination in patients with relapsed lenalidomide-refractory multiple myeloma (MM). In phase 1, dose level 1 consisted of pomalidomide (4 mg by mouth on days 1 to 21), IV or subcutaneous bortezomib (1.0 mg/m2 on days 1, 8, 15, and 22), and dexamethasone (40 mg by mouth on days 1, 8, 15, and 22) given every 28 days. Bortezomib was increased to 1.3 mg/m2 for dose level 2 and adopted in the phase 2 expansion cohort. We describe the results of 50 patients. Objective response rate was 86% (95% confidence interval [CI], 73-94) among all evaluable patients (stringent complete response, 12%; complete response, 10%; very good partial response, 28%; and partial response, 36%) and 100% among high-risk patients. Within a median follow-up of 42 months, 20% remain progression free, 66% are alive, and 4% remain on treatment. Median progression-free survival was 13.7 months (95% CI, 9.6-17.7). The most common toxicities were neutropenia (96%), leukopenia (84%), thrombocytopenia (82%), anemia (74%), and fatigue (72%); however, the majority of these were grade 1 or 2. The most common grade ≥3 toxicities included neutropenia (70%), leukopenia (36%), and lymphopenia (20%). Deep vein thrombosis occurred in 5 patients. In conclusion, PVD is a highly effective combination in lenalidomide-refractory MM patients. Weekly administration of bortezomib enhanced tolerability and convenience. Toxicities are manageable, mostly consisting of mild cytopenias with no significant neuropathy. This trial was registered at www.clinicaltrials.gov as #NCT01212952.
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Affiliation(s)
- Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Betsy R LaPlant
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Alese E Halvorson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | | | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | - Vivek Roy
- Mayo Clinic Florida, Jacksonville, FL; and
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17
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Ruppert AS, Byrd JC, Heerema NA, Smith MR, Godwin JE, Couban S, Fehniger TA, Thirman M, Halvorson AE, Tallman MS, Appelbaum FR, Stone RM, Robinson S, Chang JE, Mandrekar SJ, Larson RA. A genetic risk-stratified, randomized phase 2 intergroup study of fludarabine/antibody combinations in symptomatic, untreated chronic lymphocytic leukemia (CLL): Results from Cancer and Leukemia Group B (CALGB) 10404 (Alliance). J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.7503] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7503 Background: Prior to use of novel targeted agents for CLL, debate existed regarding the best chemoimmunotherapy regimen to build upon in patients (pts) with non-del(11q) disease. The role of lenalidomide (L) was also not defined. CALGB 10404 was a randomized phase 2 study addressing these questions. Methods: Pts with untreated CLL requiring therapy were randomized to treatment with fludarabine + rituximab (FR), FR + 6 monthly consolidative treatments of L (5 mg days 1-21/28 x 1 then 10 mg days 1-21/28 x 5) (FR+L), or FR + cyclophosphamide (FCR). Based on pretreatment central interphase cytogenetic screening, pts with del(11q22.3) in at least 20% of cells were excluded from the primary analysis, testing whether 2-year progression-free survival (PFS) rate was improved in non-del(11q) pts within each arm. A target accrual of 103 non-del(11q) pts per arm provided at least 84% power to detect an increase in 2-year PFS rate from 60% to 73%; the critical value was 69% using a single stage design and type I error rate of 4%. Results: A total of 342 non-del(11q) CLL pts were randomized to treatment with FR (n = 123), FR+L (n = 109), or FCR (n = 110). Baseline characteristics were similar across arms. Two-year PFS rates with exact 90% CIs were 64% (57-71%) (FR), 71% (63-78%) (FR+L), and 74% (66-80%) (FCR). Median PFS was significantly shorter with FR compared to FR+L (p = 0.03) and FCR (p < 0.01): 43 (95% CI: 33-50), 66 (95% CI: 45-not reached), and 78 (95% CI: 58-not reached) months respectively. Median overall survival (OS) has not been reached for any arm. OS at 1, 2, and 3 years was similar across arms, although there was a plateau in OS with no events beyond 41 months in the FR+L arm, different from FR/FCR where events continued to occur. The most common adverse events were cytopenias and infections. Conclusions: FR+L and FCR met the protocol defined primary endpoint. FR+L extended PFS relative to FR and a plateau in survival differentiated this arm from the FR/FCR arms. Future studies comparing FR+L to FCR or incorporating L into other novel treatment regimens are justified. Support: U10CA180821, U10CA180882, Celgene. Clinical trial information: NCT00602459.
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Affiliation(s)
| | - John C. Byrd
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Nyla A. Heerema
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | - Stephen Couban
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | | | | | - Martin S. Tallman
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Sue Robinson
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
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