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Suen AO, Cenzer I, Iyer AS, Witt LJ, Smith AK, Kotwal A. The National Prevalence of Supplemental Oxygen Use in Persons with Chronic Obstructive Pulmonary Disease: A Comparison of Claims-based and Self-reported Supplemental Oxygen Use. Ann Am Thorac Soc 2024; 21:838-840. [PMID: 38330174 DOI: 10.1513/annalsats.202311-949rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/08/2023] [Accepted: 02/08/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Angela O Suen
- University of California, San Francisco San Francisco, California
| | - Irena Cenzer
- University of California, San Francisco San Francisco, California
| | - Anand S Iyer
- University of Alabama at Birmingham Birmingham, Alabama
| | - Leah J Witt
- University of California, San Francisco San Francisco, California
| | | | - Ashwin Kotwal
- University of California, San Francisco San Francisco, California
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Byun JY, Wells R, Bechthold AC, Coffee-Dunning J, Armstrong M, Taylor R, O'Hare L, Dransfield MT, Brown CJ, Vance DE, Odom JN, Bakitas M, Iyer AS. Project EPIC (Empowering People to Independence in COPD): Study protocol for a hybrid effectiveness-implementation pilot randomized controlled trial of telephonic, geriatrics-palliative care nurse-coaching in older adults with COPD and their family caregivers. Contemp Clin Trials 2024; 140:107487. [PMID: 38458558 PMCID: PMC11065558 DOI: 10.1016/j.cct.2024.107487] [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: 12/10/2023] [Revised: 02/25/2024] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND EPIC (Empowering People to Independence in COPD) is a geriatric-palliative care telephonic, nurse coach intervention informed by Baltes' Theory of Successful Aging and adapted from the ENABLE (Educate, Nurture, Advise, Before Life Ends) intervention. EPIC, focused on improving independence, mobility, well-being, and COPD symptoms, has undergone formative and summative evaluation for adults with COPD. METHODS The primary study aim is to assess the refined EPIC intervention's feasibility and acceptability via a pilot hybrid effectiveness-implementation randomized control trial in community-dwelling older adults with moderate to severe COPD and their family caregivers. The secondary aim is to explore the impact of EPIC on patient and caregiver outcomes. Older adults with COPD and their family caregivers (target N = 60 dyads) will be randomized to EPIC (intervention) or usual COPD care (control). EPIC includes six patient and four family caregiver weekly, telephone-based nurse coach sessions using a manualized curriculum (Charting Your Course), plus three monthly follow-up calls. Feasibility will be measured as completion of EPIC intervention and trial components (e.g., recruitment, retention, data collection). Acceptability will be evaluated using satisfaction surveys and post-study feedback interviews. A blinded data collector will assess exploratory outcomes (e.g., Life-Space mobility, quality of life, caregiver burden, emotional symptoms, loneliness, cognitive impairment, functional status, healthcare utilization) at baseline, 12, and 24 weeks. DISCUSSION This intervention fills a gap in addressing the geriatrics and palliative care needs and equity for adults with COPD and their family caregivers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05040386.
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Affiliation(s)
- Jun Y Byun
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Avery C Bechthold
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Jazmine Coffee-Dunning
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Margaret Armstrong
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Richard Taylor
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Lanier O'Hare
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America; Division of Pulmonary, Allergy and Critical Care, University of Alabama at Birmingham Pulmonary Division, THT│ 1900 University Blvd, Birmingham, AL 35294, United States of America.
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care, University of Alabama at Birmingham Pulmonary Division, THT│ 1900 University Blvd, Birmingham, AL 35294, United States of America.
| | - Cynthia J Brown
- Department of Internal Medicine, Louisiana State University Health Sciences Center, 2021 Perdido St, New Orleans, LA 70112, United States of America.
| | - David E Vance
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - J Nicholas Odom
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Anand S Iyer
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, United States of America; Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, United States of America; Division of Pulmonary, Allergy and Critical Care, University of Alabama at Birmingham Pulmonary Division, THT│ 1900 University Blvd, Birmingham, AL 35294, United States of America; Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, United States of America.
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Yohannes AM, Iyer AS, Clay C, Cochran L, Chen X, Lombardi DA, Bhatt SP. Post Hoc Analysis of Lung Function Improvement and Patient-Reported Outcomes With Revefenacin in Adults With Moderate-to-Very Severe COPD and Comorbid Anxiety or Depression. Chronic Obstr Pulm Dis 2024; 11:196-205. [PMID: 38241514 DOI: 10.15326/jcopdf.2023.0465] [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] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
Background Revefenacin, a once-daily, nebulized, long-acting muscarinic antagonist approved in the United States for the maintenance of chronic obstructive pulmonary disease (COPD), significantly improves lung function and quality of life versus placebo in patients with moderate-to-very severe COPD. Comorbid anxiety and/or depression may alter patients' symptom perception and response to bronchodilators. The impact of revefenacin in patients with COPD with comorbid anxiety and/or depression has not been previously investigated. Methods This post hoc subgroup analysis examined data from two 12-week, randomized, phase 3 trials in patients with moderate-to-very severe COPD with the following self-reported subgroups: anxiety only (A), depression only (D), anxiety and depression (+A/+D), and neither anxiety nor depression (-A/-D). We assessed change from baseline in trough forced expiratory volume in 1 second (FEV1) at Day 85 and health status by the St George's Respiratory Questionnaire (SGRQ) and COPD Assessment Test (CAT). Results Of 812 patients, 90 (11%), 110 (14%), 141 (17%), and 471 (58%) had A, D, +A/+D, and -A/-D respectively. In revefenacin versus placebo, trough FEV1 significantly improved from baseline at Day 85 across all subgroups as well as the SGRQ and CAT scores in patients with A, +A/+D, and -A/-D. Revefenacin was well tolerated regardless of A/D status, with a minimal incidence of treatment-emergent antimuscarinic adverse events across subgroups. Conclusion In this analysis, revefenacin versus placebo significantly improved health outcomes in patients with moderate-to-very severe COPD with A, +A/+D, and -A/-D, but not in patients with D. The safety profile of revefenacin was not affected by comorbid anxiety/depression status.
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Affiliation(s)
- Abebaw M Yohannes
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, United States
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, and Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, and Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Candice Clay
- Theravance Biopharma US, Inc., South San Francisco, California, United States
| | - Lauren Cochran
- Theravance Biopharma US, Inc., South San Francisco, California, United States
| | - Xianyi Chen
- Theravance Biopharma US, Inc., South San Francisco, California, United States
| | - David A Lombardi
- Theravance Biopharma US, Inc., South San Francisco, California, United States
| | - Surya P Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, and Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, United States
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Byun JY, Chapman Lambert C, Fazeli PL, Iyer AS, Batey DS, Vance DE. Symptomatology and Quality of Life of Older People With HIV and Comorbid Chronic Obstructive Pulmonary Diseases From an HIV Clinic in Birmingham, Alabama. J Assoc Nurses AIDS Care 2024:00001782-990000000-00094. [PMID: 38319887 DOI: 10.1097/jnc.0000000000000452] [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: 02/08/2024]
Abstract
ABSTRACT Psychological symptomatology and quality of life (QoL) have been studied in older people with HIV (PWH) and those with chronic obstructive pulmonary disease (COPD), respectively, but there is a dearth of studies in older PWH with COPD. Our study compared depressive symptoms, anxiety, and QoL between older PWH with and without COPD using data from an HIV clinic in Birmingham, Alabama, from January 2018 to February 2020. Data on depressive symptoms (Patient Health Questionnaire-9), anxiety (Patient Health Questionnaire-5 Anxiety), and QoL (EuroQoL-5 Dimension) were analyzed. Among 690 PWH aged 50 years or older, 102 individuals (14.8%) had COPD. Significant differences were found between the two groups in depressive symptoms and components of QoL (e.g., mobility, self-care, usual activities, and pain/discomfort), but not in anxiety and general health. Experiencing COPD may worsen depressive symptomatology and QoL in older PWH, highlighting the need for tailored health care and research for this population.
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Affiliation(s)
- Jun Y Byun
- Jun Y. Byun, PhD, MSN, is a Postdoctoral Fellow, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Crystal Chapman Lambert, PhD, MSPH, CRNP, FNP-BC, ACRN, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pariya L. Fazeli, PhD, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Anand S. Iyer, MD, MSPH, is an Assistant Professor in the Division of Pulmonary, Allergy, and Critical Care Medicine and the School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- D. Scott Batey, PhD, MSW, is an Associate Professor, School of Social Work, Tulane University, New Orleans, Louisiana, USA
- David E. Vance, PhD, MGS, is a Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Crystal Chapman Lambert
- Jun Y. Byun, PhD, MSN, is a Postdoctoral Fellow, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Crystal Chapman Lambert, PhD, MSPH, CRNP, FNP-BC, ACRN, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pariya L. Fazeli, PhD, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Anand S. Iyer, MD, MSPH, is an Assistant Professor in the Division of Pulmonary, Allergy, and Critical Care Medicine and the School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- D. Scott Batey, PhD, MSW, is an Associate Professor, School of Social Work, Tulane University, New Orleans, Louisiana, USA
- David E. Vance, PhD, MGS, is a Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Pariya L Fazeli
- Jun Y. Byun, PhD, MSN, is a Postdoctoral Fellow, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Crystal Chapman Lambert, PhD, MSPH, CRNP, FNP-BC, ACRN, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pariya L. Fazeli, PhD, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Anand S. Iyer, MD, MSPH, is an Assistant Professor in the Division of Pulmonary, Allergy, and Critical Care Medicine and the School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- D. Scott Batey, PhD, MSW, is an Associate Professor, School of Social Work, Tulane University, New Orleans, Louisiana, USA
- David E. Vance, PhD, MGS, is a Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anand S Iyer
- Jun Y. Byun, PhD, MSN, is a Postdoctoral Fellow, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Crystal Chapman Lambert, PhD, MSPH, CRNP, FNP-BC, ACRN, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pariya L. Fazeli, PhD, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Anand S. Iyer, MD, MSPH, is an Assistant Professor in the Division of Pulmonary, Allergy, and Critical Care Medicine and the School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- D. Scott Batey, PhD, MSW, is an Associate Professor, School of Social Work, Tulane University, New Orleans, Louisiana, USA
- David E. Vance, PhD, MGS, is a Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - D Scott Batey
- Jun Y. Byun, PhD, MSN, is a Postdoctoral Fellow, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Crystal Chapman Lambert, PhD, MSPH, CRNP, FNP-BC, ACRN, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pariya L. Fazeli, PhD, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Anand S. Iyer, MD, MSPH, is an Assistant Professor in the Division of Pulmonary, Allergy, and Critical Care Medicine and the School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- D. Scott Batey, PhD, MSW, is an Associate Professor, School of Social Work, Tulane University, New Orleans, Louisiana, USA
- David E. Vance, PhD, MGS, is a Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David E Vance
- Jun Y. Byun, PhD, MSN, is a Postdoctoral Fellow, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Crystal Chapman Lambert, PhD, MSPH, CRNP, FNP-BC, ACRN, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Pariya L. Fazeli, PhD, is an Associate Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Anand S. Iyer, MD, MSPH, is an Assistant Professor in the Division of Pulmonary, Allergy, and Critical Care Medicine and the School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
- D. Scott Batey, PhD, MSW, is an Associate Professor, School of Social Work, Tulane University, New Orleans, Louisiana, USA
- David E. Vance, PhD, MGS, is a Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Yohannes AM, Iyer AS, Hoth KF, Dransfield MT. Cognitive behavioural therapy sessions approach ineffective for anxiety and depression in COPD: is the door closed for good? Eur Respir J 2024; 63:2301857. [PMID: 38176705 DOI: 10.1183/13993003.01857-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Abebaw Mengistu Yohannes
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Lung Health Center, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Lung Health Center, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Suen AO, Iyer AS, Cenzer I, Farrand E, White DB, Singer J, Sudore R, Kotwal A. National Prevalence of Social Isolation and Loneliness in Adults with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2023; 20:1709-1717. [PMID: 37463307 PMCID: PMC10704233 DOI: 10.1513/annalsats.202304-288oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023] Open
Abstract
Rationale: Social isolation and loneliness are gaining recognition for their role in health outcomes, yet they have not been defined in people with chronic obstructive pulmonary disease (COPD). Objective: To determine the national prevalence of and characteristics associated with social isolation and loneliness in people with COPD. Methods: This is a cross-sectional study of community-dwelling adults aged ⩾50 years in the nationally representative HRS (Health and Retirement Study) (2016-2018). Participants self-reported COPD and supplemental oxygen use and were categorized into three groups: 1) no COPD; 2) COPD; and 3) COPD on oxygen. Social isolation was defined using a nine-item scale indicating minimal household contacts, social network interaction, and community engagement. Loneliness was measured using the 3-Item UCLA Loneliness Scale. Multivariable logistic regression defined prevalence and associated characteristics for both. Results: Participants (n = 10,384) were on average 68 years old (standard deviation, ±10.5), 54% female, 10% Black, 11% self-reported COPD, and 2% self-reported supplemental oxygen. Overall, 12% were socially isolated, 12% lonely, and 3% both socially isolated and lonely. People with COPD had a higher adjusted prevalence of social isolation (no COPD: 11%; COPD: 16%; COPD on oxygen: 20%; P < 0.05) and loneliness (no COPD: 11%; COPD: 18%; COPD on oxygen: 22%; P < 0.001). In those with COPD, characteristics associated with social isolation (P < 0.05) included sex (men: 22%; women: 13%), non-Hispanic White ethnicity (White: 19%; Black: 7%), low net worth (<$6,000: 32%; $81,001-$239,000: 10%), depression (depression: 24%; no depression: 14%), having difficulty with one or more activities of daily living (one or more difficulty: 22%; no difficulty: 14%), and current cigarette use (current: 24%; never: 13%). Characteristics associated with loneliness (P < 0.05) included younger age (50-64 yr: 22%; 75-84 yr: 12%), being single (single: 32%; married: 12%), depression (depression: 36%; no depression: 13%), having difficulty with one or more activities of daily living (one or more difficulty: 29%; no difficulty: 15%), diabetes (diabetes: 26%; no diabetes: 17%), and heart disease (heart disease 23%; no heart disease: 17%). Conclusions: Nearly one in six adults with COPD experience social isolation, and one in five experience loneliness, with almost twice the prevalence among those on supplemental oxygen compared with the general population. Demographic and clinical characteristics identify those at highest risk to guide clinical and policy interventions.
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Affiliation(s)
- Angela O. Suen
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | - Anand S. Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Palliative and Supportive Care, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Irena Cenzer
- Division of Geriatrics, and
- Division of Palliative Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Erica Farrand
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | - Douglas B. White
- Program on Ethics and Decision Making in Critical Illness, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Rebecca Sudore
- Division of Geriatrics, and
- Division of Palliative Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ashwin Kotwal
- Division of Geriatrics, and
- Division of Palliative Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
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Leiter RE, Bischoff KE, Carey EC, Gelfand SL, Iyer AS, Jain N, Kramer NM, Lally K, Landzberg MJ, Lever N, Newport K, O'Donnell A, Patel A, Sciacca KR, Snaman JM, Tulsky JA, Rosa WE, Lakin JR. Top Ten Tips Palliative Care Clinicians Should Know About Delivering Specialty-Aligned Palliative Care. J Palliat Med 2023; 26:1401-1407. [PMID: 37001173 DOI: 10.1089/jpm.2023.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Specialty-aligned palliative care (SAPC) refers to interprofessional palliative care (PC) that is delivered to a specific population of patients in close partnership with other primary or specialty clinicians. As evolving PC models address physical, psychosocial, and spiritual suffering across illnesses and settings, PC clinicians must acquire advanced knowledge of disease-specific symptoms, common treatments, and complications that impact prognosis and outcomes. The tips provided in this article draw on the experience and knowledge of interprofessional PC and other specialist clinicians from diverse institutions across the United States who have developed and studied SAPC services across different disease groups. Recommendations include focusing on approaching specialty team partnerships with humility, curiosity, and diplomacy; focusing on patient populations where PC needs are great; clarifying how work and responsibilities will be divided between PC and other clinicians to the extent possible; using consults as opportunities for bidirectional learning; and adapting workflows and schedules to meet specialty team needs while managing expectations and setting limits as appropriate. Furthermore, to provide effective SAPC, PC clinicians must learn about the specific symptoms, prognoses, and common treatments of the patients they are serving. They must also build trusting relationships and maintain open communication with patients and referring clinicians to ensure integrated and aligned PC delivery.
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Affiliation(s)
- Richard E Leiter
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Elise C Carey
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samantha L Gelfand
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nelia Jain
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Neha M Kramer
- Department of Neurology and Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Kate Lally
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael J Landzberg
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Natasha Lever
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kristina Newport
- Section of Palliative Medicine, Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Arden O'Donnell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Kate R Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jennifer M Snaman
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - James A Tulsky
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Iyer AS. Is Levetiracetam a Superior Anti-Seizure Medication in Pediatric Status Epilepticus? Indian Pediatr 2023; 60:517-518. [PMID: 37209049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- Anand S Iyer
- Pediatric Neurologist, Apollo Hospitals International Ltd, Ahmedabad, Gujarat.
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Sheth F, Shah J, Jain D, Shah S, Patel H, Patel K, Solanki DI, Iyer AS, Menghani B, Mhatre P, Mehta S, Bajaj S, Patel V, Pandya M, Dhami D, Patel D, Sheth J, Sheth H. Comparative yield of molecular diagnostic algorithms for autism spectrum disorder diagnosis in India: evidence supporting whole exome sequencing as first tier test. BMC Neurol 2023; 23:292. [PMID: 37543562 PMCID: PMC10403833 DOI: 10.1186/s12883-023-03341-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/21/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Autism spectrum disorder (ASD) affects 1 in 100 children globally with a rapidly increasing prevalence. To the best of our knowledge, no data exists on the genetic architecture of ASD in India. This study aimed to identify the genetic architecture of ASD in India and to assess the use of whole exome sequencing (WES) as a first-tier test instead of chromosomal microarray (CMA) for genetic diagnosis. METHODS Between 2020 and 2022, 101 patient-parent trios of Indian origin diagnosed with ASD according to the Diagnostic and Statistical Manual, 5th edition, were recruited. All probands underwent a sequential genetic testing pathway consisting of karyotyping, Fragile-X testing (in male probands only), CMA and WES. Candidate variant validation and parental segregation analysis was performed using orthogonal methods. RESULTS Of 101 trios, no probands were identified with a gross chromosomal anomaly or Fragile-X. Three (2.9%) and 30 (29.7%) trios received a confirmed genetic diagnosis from CMA and WES, respectively. Amongst diagnosis from WES, SNVs were detected in 27 cases (90%) and CNVs in 3 cases (10%), including the 3 CNVs detected from CMA. Segregation analysis showed 66.6% (n = 3 for CNVs and n = 17 for SNVs) and 16.6% (n = 5) of the cases had de novo and recessive variants respectively, which is in concordance with the distribution of variant types and mode of inheritance observed in ASD patients of non-Hispanic white/ European ethnicity. MECP2 gene was the most recurrently mutated gene (n = 6; 20%) in the present cohort. Majority of the affected genes identified in the study cohort are involved in synaptic formation, transcription and its regulation, ubiquitination and chromatin remodeling. CONCLUSIONS Our study suggests de novo variants as a major cause of ASD in the Indian population, with Rett syndrome as the most commonly detected disorder. Furthermore, we provide evidence of a significant difference in the diagnostic yield between CMA (3%) and WES (30%) which supports the implementation of WES as a first-tier test for genetic diagnosis of ASD in India.
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Affiliation(s)
- Frenny Sheth
- FRIGE's Institute of Human Genetics, Ahmedabad, India.
| | - Jhanvi Shah
- FRIGE's Institute of Human Genetics, Ahmedabad, India
| | - Deepika Jain
- Shishu Child Development and Early Intervention Centre, Ahmedabad, India
| | - Siddharth Shah
- Royal Institute of Child Neurosciences, Ahmedabad, India
| | | | - Ketan Patel
- Specialty Homeopathic Clinic, Ahmedabad, India
| | | | | | - Bhargavi Menghani
- Children's Institute for Development and Advancement Centre, Vadodara, India
| | - Priti Mhatre
- Tender Kinds Centre for Child Development, Navi Mumbai, India
| | - Sanjiv Mehta
- Royal Institute of Child Neurosciences, Ahmedabad, India
| | | | - Vishal Patel
- Little Brain Pediatric Neurocare Centre, Vadodara, India
| | | | - Deepak Dhami
- Axon Child Neurology and Epilepsy Centre, Rajkot, India
| | - Darshan Patel
- Charotar Institute of Paramedical Sciences, Charotar University of Science and Technology, Changa, India
| | - Jayesh Sheth
- FRIGE's Institute of Human Genetics, Ahmedabad, India
| | - Harsh Sheth
- FRIGE's Institute of Human Genetics, Ahmedabad, India.
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10
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Maddocks M, Brighton LJ, Alison JA, Ter Beek L, Bhatt SP, Brummel NE, Burtin C, Cesari M, Evans RA, Ferrante LE, Flores-Flores O, Franssen FME, Garvey C, Harrison SL, Iyer AS, Lahouse L, Lareau S, Lee AL, Man WDC, Marengoni A, McAuley HJC, Rozenberg D, Singer JP, Spruit MA, Osadnik CR. Rehabilitation for People with Respiratory Disease and Frailty: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:767-780. [PMID: 37261787 PMCID: PMC10257033 DOI: 10.1513/annalsats.202302-129st] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
People with respiratory disease have increased risk of developing frailty, which is associated with worse health outcomes. There is growing evidence of the role of rehabilitation in managing frailty in people with respiratory disease. However, several challenges remain regarding optimal methods of identifying frailty and delivering rehabilitation for this population. The aims of this American Thoracic Society workshop were to outline key definitions and concepts around rehabilitation for people with respiratory disease and frailty, synthesize available evidence, and explore how programs may be adapted to align to the needs and experiences of this population. Across two half-day virtual workshops, 20 professionals from diverse disciplines, professions, and countries discussed key developments and identified opportunities for future research, with additional input via online correspondence. Participants highlighted a "frailty rehabilitation paradox" whereby pulmonary rehabilitation can effectively reduce frailty, but programs are challenging for some individuals with frailty to complete. Frailty should not limit access to rehabilitation; instead, the identification of frailty should prompt comprehensive assessment and tailored support, including onward referral for additional specialist input. Exercise prescriptions that explicitly consider symptom burden and comorbidities, integration of additional geriatric or palliative care expertise, and/or preemptive planning for disruptions to participation may support engagement and outcomes. To identify and measure frailty in people with respiratory disease, tools should be selected on the basis of sensitivity, specificity, responsiveness, and feasibility for their intended purpose. Research is required to expand understanding beyond the physical dimensions of frailty and to explore the merits and limitations of telerehabilitation or home-based pulmonary rehabilitation for people with chronic respiratory disease and frailty.
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11
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Brighton LJ, Lareau S, Maddocks M, Osadnik C, Lahousse L, Lee A, Allison J, Singer J, Rozenberg D, Man WD, Ferrante L, Spruit MA, Burtin C, Harrison SL, Iyer AS. What is Frailty? Am J Respir Crit Care Med 2023; 207:P5-P6. [PMID: 37260228 PMCID: PMC10263127 DOI: 10.1164/rccm.207i11p5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
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12
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Iyer AS, Wells RD, Dionne-Odom JN, Bechthold AC, Armstrong M, Byun JY, O'Hare L, Taylor R, Ford S, Coffee-Dunning J, Dransfield MT, Brown CJ, Bakitas MA. Project EPIC (Early Palliative Care In COPD): A Formative and Summative Evaluation of the EPIC Telehealth Intervention. J Pain Symptom Manage 2023; 65:335-347.e3. [PMID: 36496113 PMCID: PMC10023469 DOI: 10.1016/j.jpainsymman.2022.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
CONTEXT Early, concurrent palliative care interventions in chronic obstructive pulmonary disease (COPD) are limited. Project EPIC (Early Palliative Care In COPD) is a multiphase mixed methods study working to fill this gap. OBJECTIVES To conduct a formative and summative evaluation of EPIC, a telephonic nurse coach-led early palliative care intervention for COPD adapted from the ENABLE© intervention in cancer. METHODS Phase I Formative Evaluation: Patients with moderate-to-very-severe COPD, family caregivers, and pulmonary and palliative care clinicians rated the acceptability and feasibility of EPIC (≥4 out of five on a Likert-scale survey). Phase II Summative Evaluation: Patients and family caregivers in Phase I participated in a pilot of the three month EPIC prototype to evaluate intervention and data collection feasibility (≥70% completion) and to seek qualitative feedback. RESULTS Phase I Formative Evaluation: Patients (n=10), family caregivers (n=10), pulmonary clinicians (n=6), and palliative care clinicians (n=6) found EPIC acceptable and feasible to support adaptation, while priority early palliative care needs in COPD from our prior research mapped well to the EPIC prototype. Phase II Summative Evaluation: Patients (n=5; ages 49-72, 40% moderate COPD, 40% Black) and their family caregivers (n=5; ages 51-73, 40% Black) completed 100% of EPIC prototype components, including weekly telephone sessions, a one month follow-up call, Advance Directive, palliative care clinic attendance, and 95% of monthly phone data collection sessions. Feedback from participants about EPIC was all positive. CONCLUSION EPIC was acceptable and feasible in patients with COPD and their family caregivers. Larger feasibility and effectiveness trials are warranted.
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Affiliation(s)
- Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine (A.S.I., L.O.H., M.T.D.), University of Alabama at Birmingham, Birmingham, Alabama; Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama.
| | - Rachel D Wells
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - J Nicholas Dionne-Odom
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - Avery C Bechthold
- School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - Margaret Armstrong
- School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - Jun Yeong Byun
- School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - Lanier O'Hare
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine (A.S.I., L.O.H., M.T.D.), University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard Taylor
- School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephanie Ford
- School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - Jazmine Coffee-Dunning
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine (A.S.I., L.O.H., M.T.D.), University of Alabama at Birmingham, Birmingham, Alabama; Birmingham Veterans Affairs Medical Center (M.T.D.), Birmingham, Alabama
| | - Cynthia J Brown
- Department of Internal Medicine(C.J.B.), Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Marie A Bakitas
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing (A.S.I., R.D.W., J.N.D., J.C., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama
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13
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Sullivan DR, Iyer AS, Reinke LF. Collaborative Primary Palliative Care in Serious Illness: A Pragmatic Path Forward. Ann Am Thorac Soc 2023; 20:358-360. [PMID: 36342447 PMCID: PMC9993156 DOI: 10.1513/annalsats.202206-556vp] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 06/27/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Donald R. Sullivan
- Division of Pulmonary, Allergy, and Critical Care Medicine and
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Anand S. Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine and
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, and
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Lynn F. Reinke
- College of Nursing, University of Utah, Salt Lake City, Utah
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14
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Adviento BA, Regan EA, Make BJ, Han MK, Foreman MG, Iyer AS, Bhatt SP, Kim V, Bon J, Soler X, Kinney GL, Hanania NA, Lowe KE, Holm KE, Yohannes AM, Shinozaki G, Hoth KF, Fiedorowicz JG. Clinical Markers Associated With Risk of Suicide or Drug Overdose Among Individuals With Smoking Exposure: A Longitudinal Follow-up Study of the COPDGene Cohort. Chest 2023; 163:292-302. [PMID: 36167120 PMCID: PMC10083129 DOI: 10.1016/j.chest.2022.09.022] [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: 02/17/2022] [Revised: 08/11/2022] [Accepted: 09/03/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Studies have shown that COPD and smoking are associated with increased suicide risk. To date, there are no prospective studies examining suicide risk among individuals with smoking exposure along a spectrum of pulmonary diseases ranging from normal spirometry to severe COPD. RESEARCH QUESTION Which clinical variables predict death by suicide or overdose of indeterminate intent in a large cohort of individuals with smoking exposure within the Genetic Epidemiology of COPD (COPDGene) study? STUDY DESIGN AND METHODS We studied data from 9,930 participants involved in COPDGene, a multisite, prospective cohort study of individuals with smoking exposure. Primary cause of adjudicated deaths was identified by using death certificates, family reports, and medical records. Time to death by suicide/overdose was examined as the primary outcome in Cox regression models including age, sex, race, BMI, pack-years, current smoking status, airflow limitation (FEV1 % predicted), dyspnea (modified Medical Research Council scale score ≥ 2), 6-min walk distance, supplemental oxygen use, and severe exacerbations in the prior year with time-varying covariates and other causes of death as a competing risk. RESULTS The cohort was 47% female and 33% Black (67% White); they had a mean ± SD age of 59.6 ± 9.0 years and a mean FEV1 % predicted of 76.1 ± 25.5. Sixty-three individuals died by suicide/overdose. Factors associated with risk of suicide/overdose were current smoking (hazard ratio [HR], 6.44; 95% CI, 2.64-15.67), use of sedative/hypnotics (HR, 2.33; 95% CI, 1.24-4.38), and dyspnea (HR, 2.23; 95% CI, 1.34-3.70). Lower risk was associated with older age (per-decade HR, 0.45; 95% CI, 0.31-0.67), higher BMI (HR, 0.95; 95% CI, 0.91-0.99), and African-American race (HR, 0.41; 95% CI, 0.23-0.74). Severity of airflow limitation (FEV % predicted) was not associated with suicide risk. INTERPRETATION In this well-characterized cohort of individuals with smoking exposure with and without COPD, risk factors for suicide/overdose were identified that emphasize the subjective experience of illness over objective assessments of lung function.
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Affiliation(s)
- Brigid A Adviento
- Department of Psychiatry, University of Iowa, Iowa City, IA; Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Elizabeth A Regan
- Division of Rheumatology, Department of Medicine, National Jewish Health, Denver, CO
| | - Barry J Make
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Marilyn G Foreman
- Pulmonary and Critical Care Medicine Division, Morehouse School of Medicine, Atlanta, GA
| | - Anand S Iyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Victor Kim
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Jessica Bon
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Xavier Soler
- Department of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA
| | - Gregory L Kinney
- Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Katherine E Lowe
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Kristen E Holm
- Division of Neurology and Behavioral Health, National Jewish Health, Denver, CO; Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Aurora, CO
| | | | - Gen Shinozaki
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA
| | - Karin F Hoth
- Department of Psychiatry, University of Iowa, Iowa City, IA; Iowa Neuroscience Institute, University of Iowa, Iowa City, IA.
| | - Jess G Fiedorowicz
- Ottawa Hospital, Ottawa Hospital Research Institute, and University of Ottawa, Ottawa, Ontario, Canada
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Weiss JR, Serdenes R, Madtha U, Zhao H, Kim V, Lopez-Pastrana J, Eakin MN, O'Toole J, Cooper CB, Woodruff P, Kanner RE, Krishnan JA, Iyer AS, Couper D, Morrison MF. Association Among Chronic Obstructive Pulmonary Disease Severity, Exacerbation Risk, and Anxiety and Depression Symptoms in the SPIROMICS Cohort. J Acad Consult Liaison Psychiatry 2023; 64:45-57. [PMID: 35948252 DOI: 10.1016/j.jaclp.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/22/2022] [Accepted: 07/29/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common, progressive lung disease that often manifests with psychiatric symptoms. Despite this, patients with COPD are not routinely screened for anxiety and depression, which substantially contribute to COPD-related morbidity. OBJECTIVE To determine the relationship among COPD symptom severity, exacerbation risk, and clinically significant anxiety and depression symptoms in ever smokers with COPD. METHODS We used baseline data from the Subpopulations and Intermediate Outcome Measures In COPD Study (SPIROMICS) cohort to examine ever smokers with COPD across Global Initiative for Obstructive Lung Disease (GOLD) disease severity groups. Multivariable logistic regression models were used to calculate odds ratios for clinically significant anxiety and depression for each GOLD group, which was compared to the control group of ever smokers without COPD. Odds ratios were adjusted for subject demographics, medical comorbidities, and substance use covariates, and comparisons were completed using 2-tailed tests. RESULTS Of the 2664 subjects studied, 784 (29.4%) had clinically significant anxiety, and 497 (18.7%) had clinically significant depression. In the multivariable analysis, high pulmonary symptom groups, groups B and D, had increased adjusted odds of clinically significant anxiety (group B: adjusted odds ratios [AOR] 1.28, P = 0.03; group D: AOR 1.95, P < 0.0001) and depression (group B: AOR 2.09, P < 0.0001; group D: AOR 3.04, P < 0.0001). GOLD group D, the group with high pulmonary symptoms and high COPD exacerbation risk, had the greatest risk of both anxiety and depression among the GOLD groups. CONCLUSIONS High COPD symptom severity, even in the absence of elevated COPD exacerbation risk, is associated with clinically significant anxiety and depression. Our separate analyses of anxiety and depression symptoms in a large, multisite, national cohort are unique within the literature and have important treatment implications for COPD patients. Our findings also highlight the utility of screening patients with high COPD symptom severity for anxiety and depression.
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Affiliation(s)
- Jacob R Weiss
- Department of Psychiatry and Behavioral Science, Temple University Hospital, Philadelphia, PA.
| | - Ryan Serdenes
- Department of Psychiatry and Behavioral Science, Temple University Hospital, Philadelphia, PA
| | - Uchechukwu Madtha
- Department of Psychiatry and Behavioral Science, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Huaqing Zhao
- Department of Biomedical Education and Data Science, Lewis Katz School of Medicine, Philadelphia, PA
| | - Victor Kim
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA
| | - Jahaira Lopez-Pastrana
- Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jacqueline O'Toole
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher B Cooper
- Departments of Medicine and Physiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Prescott Woodruff
- Division of Pulmonary, Critical Care and Sleep, University of California San Francisco, San Francisco, CA
| | - Richard E Kanner
- Division of Pulmonary and Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - Jerry A Krishnan
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL
| | - Anand S Iyer
- Lung Health Center, Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - David Couper
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mary F Morrison
- Department of Psychiatry and Behavioral Science, Temple University Hospital, Philadelphia, PA
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16
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Sullivan DR, Iyer AS, Enguidanos S, Cox CE, Farquhar M, Janssen DJA, Lindell KO, Mularski RA, Smallwood N, Turnbull AE, Wilkinson AM, Courtright KR, Maddocks M, McPherson ML, Thornton JD, Campbell ML, Fasolino TK, Fogelman PM, Gershon L, Gershon T, Hartog C, Luther J, Meier DE, Nelson JE, Rabinowitz E, Rushton CH, Sloan DH, Kross EK, Reinke LF. Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement. Am J Respir Crit Care Med 2022; 206:e44-e69. [PMID: 36112774 PMCID: PMC9799127 DOI: 10.1164/rccm.202207-1262st] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.
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Krishnan JK, Ancy KM, Oromendia C, Hoffman KL, Easthausen I, Leidy NK, Han MK, Bowler RP, Christenson SA, Couper DJ, Criner GJ, Curtis JL, Dransfield MT, Hansel NN, Iyer AS, Paine III R, Peters SP, Wedzicha JA, Woodruff PG, Ballman KV, Martinez FJ. Characterizing COPD Symptom Variability in the Stable State Utilizing the Evaluating Respiratory Symptoms in COPD Instrument. Chronic Obstr Pulm Dis 2022; 9:195-208. [PMID: 35403414 PMCID: PMC9166327 DOI: 10.15326/jcopdf.2021.0263] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 06/14/2023]
Abstract
RATIONALE It has been suggested that patients with chronic obstructive pulmonary disease (COPD) experience considerable daily respiratory symptom fluctuation. A standardized measure is needed to quantify and understand the implications of day-to-day symptom variability. OBJECTIVES To compare standard deviation with other statistical measures of symptom variability and identify characteristics of individuals with higher symptom variability. METHODS Individuals in the SubPopulations and InteRmediate Outcome Measures In COPD Study (SPIROMICS) Exacerbations sub-study completed an Evaluating Respiratory Symptoms in COPD (E-RS) daily questionnaire. We calculated within-subject standard deviation (WS-SD) for each patient at week 0 and correlated this with measurements obtained 4 weeks later using Pearson's r and Bland Altman plots. Median WS-SD value dichotomized participants into higher versus lower variability groups. Association between WS-SD and exacerbation risk during 4 follow-up weeks was explored. MEASUREMENTS AND MAIN RESULTS Diary completion rates were sufficient in 140 (68%) of 205 sub-study participants. Reproducibility (r) of the WS-SD metric from baseline to week 4 was 0.32. Higher variability participants had higher St George's Respiratory Questionnaire (SGRQ) scores (47.3 ± 20.3 versus 39.6 ± 21.5, p=.04) than lower variability participants. Exploratory analyses found no relationship between symptom variability and health care resource utilization-defined exacerbations. CONCLUSIONS WS-SD of the E-RS can be used as a measure of symptom variability in studies of patients with COPD. Patients with higher variability have worse health-related quality of life. WS-SD should be further validated as a measure to understand the implications of symptom variability.
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Affiliation(s)
- Jamuna K. Krishnan
- Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, New York, United States
- *Co-first authors, both authors contributed equally to the work
| | - Kayley M. Ancy
- Department of Medicine, Weill Cornell Medicine, New York, New York, United States
- *Co-first authors, both authors contributed equally to the work
| | - Clara Oromendia
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, United States
| | - Katherine L. Hoffman
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, United States
| | - Imaani Easthausen
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, United States
| | | | - MeiLan K. Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Russell P. Bowler
- Department of Medicine, National Jewish Medical and Research Center, Denver, Colorado, United States
| | - Stephanie A. Christenson
- Pulmonary and Critical Care, University of California San Francisco, San Francisco, California, United States
| | - David J. Couper
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Gerard J. Criner
- Pulmonary and Critical Care Medicine, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Jeffrey L. Curtis
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, Michigan, United States
- Medical Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Mark T. Dransfield
- Pulmonary, Allergy and Critical Care, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Nadia N. Hansel
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore Maryland, United States
| | - Anand S. Iyer
- Pulmonary, Allergy and Critical Care, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Robert Paine III
- Division of Pulmonary and Critical Care Medicine, Department of Veterans Affairs Medical Center, University of Utah, Salt Lake City, Utah, United States
| | - Stephen P. Peters
- Section on Pulmonary, Critical Care, Allergy and Immunological Diseases, Wake Forest School of Medicine Medical Center, Winston-Salem, North Carolina, United States
| | | | - Prescott G. Woodruff
- Pulmonary and Critical Care, University of California San Francisco, San Francisco, California, United States
| | - Karla V. Ballman
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, United States
| | - Fernando J. Martinez
- Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, New York, United States
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Affiliation(s)
- Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Cynthia J Brown
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans
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19
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Iyer AS, Parekh TM, O’Toole J, Bhatt SP, Eakin MN, Krishnan JA, Yohannes AM, Woodruff PG, Cooper CB, Kanner RE, Hanania NA, Dransfield MT, Regan EA, Hoth KF, Kim V. Clinically Significant and Comorbid Anxiety and Depression Symptoms Predict Severe Respiratory Exacerbations in Smokers: A Post Hoc Analysis of the COPDGene and SPIROMICS Cohorts. Ann Am Thorac Soc 2022; 19:143-146. [PMID: 34343034 PMCID: PMC9797036 DOI: 10.1513/annalsats.202103-240rl] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Anand S. Iyer
- University of Alabama at
BirminghamBirmingham, Alabama
| | | | | | | | | | | | | | | | | | | | | | - Mark T. Dransfield
- University of Alabama at
BirminghamBirmingham, Alabama
- Birmingham Veterans Affairs Medical
CenterBirmingham, Alabama
| | | | | | - Victor Kim
- Temple UniversityPhiladelphia,
Pennsylvania
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20
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Centor RM, Iyer AS. Web Exclusive. Annals On Call - COPD: What Clinicians Need to Know-Part 2. Ann Intern Med 2021; 174:OC1. [PMID: 34339233 DOI: 10.7326/a20-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Robert M Centor
- Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)
| | - Anand S Iyer
- University of Alabama at Birmingham, Birmingham, Alabama (A.S.I.)
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21
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Schlögl M, Iyer AS, Riese F, Blum D, O'Hare L, Kulkarni T, Pautex S, Schildmann J, Swetz KM, Kumar P, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Oncology, Dementia, Frailty, and Pulmonary Diseases. J Palliat Med 2021; 24:1391-1397. [PMID: 34264746 DOI: 10.1089/jpm.2021.0327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Prognostication has been described as "Medicine's Lost Art." Taken with diagnosis and treatment, prognostication is the third leg on which medical care rests. As research leads to additional beneficial treatments for vexing conditions like cancer, dementia, and lung disease, prognostication becomes even more difficult. This article, written by a group of palliative care clinicians with backgrounds in geriatrics, pulmonology, and oncology, aims to offer a useful framework for consideration of prognosis in these conditions. This article will serve as the first in a three-part series on prognostication in adults and children.
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Affiliation(s)
- Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Medicine, Center for Outcomes and Effectiveness Research and Education, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Florian Riese
- University Research Priority Program "Dynamics of Healthy Aging," University of Zurich, Zurich, Switzerland
| | - David Blum
- Department of Radiation Oncology, Competence Center for Palliative Care, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lanier O'Hare
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tejaswini Kulkarni
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sophie Pautex
- Division of Palliative Medicine, Department of Geriatrics and Rehabilitation, University of Geneva, University Hospital Geneva, Geneva, Switzerland
| | - Jan Schildmann
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University, Halle-Wittenberg, Germany
| | - Keith M Swetz
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Pallavi Kumar
- Division of Hematology Oncology, Department of Medicine, Ruth and Raymond Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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22
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Centor RM, Iyer AS. Web Exclusive. Annals On Call - COPD: What Clinicians Need to Know-Part 1. Ann Intern Med 2021; 174:OC1. [PMID: 34297607 DOI: 10.7326/a20-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Robert M Centor
- Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)
| | - Anand S Iyer
- University of Alabama at Birmingham, Birmingham, Alabama (A.S.I.)
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23
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Iyer AS, Cross SH, Dransfield MT, Warraich HJ. Urban-Rural Disparities in Deaths from Chronic Lower Respiratory Disease in the United States. Am J Respir Crit Care Med 2021; 203:769-772. [PMID: 33211972 DOI: 10.1164/rccm.202008-3375le] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Anand S Iyer
- University of Alabama at Birmingham Birmingham, Alabama
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24
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Iyer AS. Noninvasive Ventilation in Seriously Ill Older Adults at the End of Life-The Evidence Remains Elusive. JAMA Intern Med 2021; 181:102-103. [PMID: 33074308 PMCID: PMC8018582 DOI: 10.1001/jamainternmed.2020.5648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham.,Lung Health Center, Department of Medicine, University of Alabama at Birmingham, Birmingham.,Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham
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25
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Iyer AS, Curtis JR, Meier DE. Proactive Integration of Geriatrics and Palliative Care Principles Into Practice for Chronic Obstructive Pulmonary Disease. JAMA Intern Med 2020; 180:815-816. [PMID: 32338726 DOI: 10.1001/jamainternmed.2020.1088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham.,Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Center to Advance Palliative Care, New York, New York
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26
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Iyer AS, Dionne-Odom JN, Khateeb DM, O'Hare L, Tucker RO, Brown CJ, Dransfield MT, Bakitas MA. A Qualitative Study of Pulmonary and Palliative Care Clinician Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease. J Palliat Med 2020; 23:513-526. [PMID: 31657654 PMCID: PMC7104897 DOI: 10.1089/jpm.2019.0355] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Guidelines recommend that pulmonary clinicians involve palliative care in chronic obstructive pulmonary disease (COPD); however, integration before advanced stage, that is, early palliative care, is rare. Objective: To explore and compare pulmonary and palliative care clinician perspectives on barriers, facilitators, and potential referral criteria for early palliative care in COPD. Design: Qualitative descriptive formative evaluation study. Setting/Subjects: Pulmonary and palliative care clinicians at a tertiary academic medical center. Measurements: Transcribed interviews were thematically analyzed by specialty to identify within- and across-specialty perspectives on barriers, facilitators, and referral criteria. Results: Twelve clinicians (n = 6 pulmonary, n = 6 palliative care) participated. Clinicians from both specialties agreed that early palliative care could add value to disease-focused COPD care. Perspectives on many barriers and facilitators were shared between specialties along broad educational, clinical, and operational categories. Pulmonary and palliative care clinicians shared concerns about the misconception that palliative care was synonymous to end-of-life care. Pulmonologists were particularly concerned about the potential risks of opioids and benzodiazepines in COPD. Both specialties stressed the need for clearly defined roles, consensus referral criteria, and novel delivery models. Although no single referral criterion was discussed by all, frequent hospitalizations and emotional symptoms were raised by most across disciplines. Multimorbidity and poor prognosis were discussed only by palliative care clinicians, whereas medication adherence was discussed only by pulmonary clinicians. Conclusions: Pulmonary and palliative care clinicians supported early palliative care in COPD. Continued needs include addressing pulmonologists' misconceptions of palliative care, establishing consensus referral criteria, and implementing novel early palliative care models.
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Affiliation(s)
- Anand S. Iyer
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Center for Outcomes and Effectiveness Research and Education, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - James Nicholas Dionne-Odom
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Dina M. Khateeb
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lanier O'Hare
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rodney O. Tucker
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cynthia J. Brown
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Mark T. Dransfield
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Marie A. Bakitas
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
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27
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Iyer AS, Dionne-Odom JN, Ford SM, Crump Tims SL, Sockwell ED, Ivankova NV, Brown CJ, Tucker RO, Dransfield MT, Bakitas MA. A Formative Evaluation of Patient and Family Caregiver Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease across Disease Severity. Ann Am Thorac Soc 2019; 16:1024-1033. [PMID: 31039003 PMCID: PMC6774751 DOI: 10.1513/annalsats.201902-112oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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: 02/04/2019] [Accepted: 04/29/2019] [Indexed: 12/20/2022] Open
Abstract
Rationale: Little direction exists on how to integrate early palliative care in chronic obstructive pulmonary disease (COPD).Objectives: We sought to identify patient and family caregiver early palliative care needs across stages of COPD severity.Methods: As part of the Medical Research Council Framework developmental phase for intervention development, we conducted a formative evaluation of patients with moderate to very severe COPD (forced expiratory volume in 1 s [FEV1]/FVC < 70% and FEV1 < 80%-predicted) and their family caregivers. Validated surveys on quality of life, anxiety and depressive symptoms, and social isolation quantified symptom severity. Semi-structured interviews were analyzed for major themes on early palliative care and needs in patients and family caregivers and across COPD severity stages.Results: Patients (n = 10) were a mean (±SD) age of 60.4 (±7.5) years, 50% African American, and 70% male, with 30% having moderate COPD, 30% severe COPD, and 40% very severe COPD. Family caregivers (n = 10) were a mean age of 58.3 (±8.7) years, 40% African American, and 10% male. Overall, 30% (n = 6) of participants had poor quality of life, 45% (n = 9) had moderate-severe anxiety symptoms, 25% (n = 5) had moderate-severe depressive symptoms, and 40% (n = 8) reported social isolation. Only 30% had heard of palliative care, and most participants had misconceptions that palliative care was end-of-life care. All participants responded positively to a standardized description of early palliative care and were receptive to its integration as early as moderate stage. Five broad themes of early palliative care needs emerged: 1) coping with COPD; 2) emotional symptoms; 3) respiratory symptoms; 4) illness understanding; and 5) prognostic awareness. Coping with COPD and emotional symptoms were commonly shared early palliative care needs. Patients with very severe COPD and their family caregivers prioritized illness understanding and prognostic awareness compared with those with moderate-severe COPD.Conclusions: Patients with moderate to very severe COPD and their family caregivers found early palliative care acceptable and felt it should be integrated before end-stage. Of the five broad themes of early palliative care needs, coping with COPD and emotional symptoms were the highest priority, followed by respiratory symptoms, illness understanding, and prognostic awareness.
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Affiliation(s)
- Anand S. Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine
- Health Services, Outcomes, and Effectiveness Research Training Program
- Lung Health Center
| | - J. Nicholas Dionne-Odom
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine
- School of Nursing, and
| | - Stephanie M. Ford
- Lung Health Center
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine
| | - Sheri L. Crump Tims
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine
- School of Nursing, and
| | - Elizabeth D. Sockwell
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine
- School of Nursing, and
| | - Nataliya V. Ivankova
- School of Nursing, and
- School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Cynthia J. Brown
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Rodney O. Tucker
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine
| | - Mark T. Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine
- Lung Health Center
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Marie A. Bakitas
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine
- School of Nursing, and
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Iyer AS, Holm KE, Bhatt SP, Kim V, Kinney GL, Wamboldt FS, Jacobs MR, Regan EA, Armstrong HF, Lowe KE, Martinez CH, Dransfield MT, Foreman MG, Shinozaki G, Hanania NA, Wise RA, Make BJ, Hoth KF. Symptoms of anxiety and depression and use of anxiolytic-hypnotics and antidepressants in current and former smokers with and without COPD - A cross sectional analysis of the COPDGene cohort. J Psychosom Res 2019; 118:18-26. [PMID: 30782350 PMCID: PMC6383809 DOI: 10.1016/j.jpsychores.2019.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 07/20/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the frequency of anxiety/depressive symptoms and use of anxiolytic-hypnotics/antidepressants in smokers with and without COPD and to identify characteristics associated with having unmedicated symptoms. METHODS Cross-sectional analysis of ambulatory, current/former smokers ≥10 pack years enrolled in the COPDGene study. We measured anxiety/depressive symptoms using the Hospital Anxiety and Depression Scale (subscales ≥8), recorded anxiolytic-hypnotic/antidepressant use, and defined unmedicated symptoms as elevated anxiety/depressive symptoms and not on medications. Regression analysis identified characteristics associated with having unmedicated symptoms. KEY RESULTS Of 5331 current/former smokers (45% with and 55% without COPD), 1332 (25.0%) had anxiety/depressive symptoms. Anxiety symptoms were similar in frequency in smokers with and without COPD (19.7% overall), while depressive symptoms were most frequent in severe-very severe COPD at 20.7% (13.1% overall). In the entire cohort, 1135 (21.2%) were on medications. Anxiolytic-hypnotic use was highest in severe-very severe COPD (range 7.6%-12.0%), while antidepressant use showed no significant variation in smokers with and without COPD (range 14.7%-17.1%). Overall, 881 (66% of those with symptoms) had unmedicated symptoms, which was associated with African American race (adjusted OR 2.95, 95% CI 2.25-3.87), male gender (adjusted OR 1.93, 95% CI 1.57-2.36), no health insurance (adjusted OR 2.38, 95% CI 1.30-4.35), severe-very severe COPD (adjusted OR 1.48, 95% CI 1.04-2.11), and higher respiratory symptoms/exacerbation history (adjusted OR 2.21, 95% CI 1.62-3.02). CONCLUSIONS Significant unmet mental health care needs exist in current and former smokers with and without COPD. One in five have unmedicated symptoms, identified by key demographic and clinical characteristics. PRIMARY FUNDING SOURCE National Institutes of Health and The COPD Foundation.
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Affiliation(s)
- Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Health Services, Outcomes, and Effectiveness Research Training Program, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Kristen E Holm
- Department of Medicine, National Jewish Health, Denver, CO, USA; Department of Community and Behavioral Health, Colorado School of Public Health, Aurora, CO, USA
| | - Surya P Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Victor Kim
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine Philadelphia, PA, USA
| | - Gregory L Kinney
- Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Frederick S Wamboldt
- Department of Medicine, National Jewish Health, Denver, CO, USA; Department of Psychiatry, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, CO, USA
| | - Michael R Jacobs
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine Philadelphia, PA, USA
| | - Elizabeth A Regan
- Department of Medicine, National Jewish Health, Denver, CO, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Hilary F Armstrong
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Katherine E Lowe
- Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Carlos H Martinez
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Marilyn G Foreman
- Division of Pulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Gen Shinozaki
- Department of Psychiatry, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Nicola A Hanania
- Division of Pulmonary/Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Barry J Make
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Karin F Hoth
- Department of Psychiatry, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Department of Pulmonary, Critical Care, and Sleep Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
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29
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Iyer AS, Benzo RP, Bakitas MA. Easing the Tension Between Palliative Care and Intensive Care in Chronic Obstructive Pulmonary Disease. J Palliat Care 2018; 33:123-124. [PMID: 29902961 DOI: 10.1177/0825859718782505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anand S Iyer
- 1 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,2 Health Services, Outcomes, and Effectiveness Research Training Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roberto P Benzo
- 3 Division of Pulmonary and Critical Care Medicine, Mindful Breathing Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Marie A Bakitas
- 4 Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,5 School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
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30
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Lowe KE, Make BJ, Crapo JD, Kinney GL, Hokanson JE, Kim V, Iyer AS, Bhatt SP, Hoth KF, Holm KE, Wise R, DeMeo D, Foreman MG, Stone TJ, Regan EA. Association of low income with pulmonary disease progression in smokers with and without chronic obstructive pulmonary disease. ERJ Open Res 2018; 4:00069-2018. [PMID: 30443555 PMCID: PMC6230816 DOI: 10.1183/23120541.00069-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/11/2018] [Indexed: 11/09/2022] Open
Abstract
Low socioeconomic status has been associated with chronic obstructive pulmonary disease (COPD) but little is known about its impact on disease progression. We assessed the association of income to symptoms, pulmonary disease severity and progression in smokers with and without COPD. The COPDGene cohort of 4826 smokers who reported annual income in phase 2 was analysed. Those who reported annual income <USD 15 000 per year were “low-income” and the remainder “higher income”. Baseline demographics, symptoms, computed tomography (CT) imaging, and 5-year change in spirometry and CT metrics were characterised by group. The low income group was younger (55.7 versus 61.7, p<0.0001), had more current smokers (73% versus 36%, p<0.0001), higher rates of severe exacerbations (13% versus 7%, p<0.0001), more chronic bronchitis (22% versus 14%, p<0.0001), reduced access to preventative care and lower quality of life, but less emphysema (4.7% versus 6.2%, p<0.0001). After 5 years the low-income group had more smoking-related disease progression, without significant change in exacerbations or symptoms, than higher-income subjects. Low income was an independent predictor of decreasing forced expiratory volume in 1 s (FEV1) (p=0.001) and increased airway disease (p=0.007) after adjusting for baseline FEV1, age, sex, race, exposures and current smoking. Income disparity beyond the effects of race and current smoking is an important factor for disease progression. Worldwide, poverty and its consequences: associated respiratory exposures, limited healthcare access, and inadequate education about smoking risks, may exacerbate chronic lung disease. Income is a factor in predicting pulmonary disease progression in smokers with and without COPD; those with lower income experience faster progression and worse symptomshttp://ow.ly/1SSe30lU1cX
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Affiliation(s)
| | - Barry J Make
- Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - James D Crapo
- Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Gregory L Kinney
- Dept of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - John E Hokanson
- Dept of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Victor Kim
- Dept of Thoracic Medicine and Surgery, Temple University, Philadelphia, PA, USA
| | - Anand S Iyer
- Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Surya P Bhatt
- Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Karin F Hoth
- Dept of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Kristen E Holm
- Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Robert Wise
- Dept of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dawn DeMeo
- Dept of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Elizabeth A Regan
- Dept of Medicine, National Jewish Health, Denver, CO, USA.,Dept of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
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Iyer AS, Wells JM, Bhatt SP, Kirkpatrick DP, Sawyer P, Brown CJ, Allman RM, Bakitas MA, Dransfield MT. Life-Space mobility and clinical outcomes in COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:2731-2738. [PMID: 30233163 PMCID: PMC6130264 DOI: 10.2147/copd.s170887] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [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] [Indexed: 12/27/2022] Open
Abstract
Background Social isolation is a common experience in patients with COPD but is not captured by existing patient-reported outcomes, and its association with clinical outcomes is unknown. Methods We prospectively enrolled adults with stable COPD who completed the University of Alabama at Birmingham Life Space Assessment (LSA) (range: 0–120, restricted Life-Space mobility: ≤60 and a marker of social isolation in older adults); six-minute walk test (6MWT), and the University of California at San Diego Shortness of Breath Questionnaire, COPD Assessment Test, and Hospital Anxiety and Depression Scale. The occurrence of severe exacerbations (emergency room visit or hospitalization) was recorded by review of the electronic record up to 1 year after enrollment. We determined associations between Life-Space mobility and clinical outcomes using regression analyses. Results Fifty subjects had a mean ± SD %-predicted FEV1 of 42.9±15.5, and 23 (46%) had restricted Life-Space mobility. After adjusting for age, gender, %-predicted FEV1, comorbidity count, inhaled corticosteroid/long-acting beta2-agonist use, and prior cardiopulmonary rehabilitation, subjects with restricted Life-Space had an increased risk for severe exacerbations (adjusted incidence rate ratio 4.65, 95% CI 1.19–18.23, P=0.03). LSA scores were associated with 6MWD (R=0.50, P<0.001), dyspnea (R=−0.58, P<0.001), quality of life (R=−0.34, P=0.02), and depressive symptoms (R=−0.39, P=0.005). Conclusion Restricted Life-Space mobility predicts severe exacerbations and is associated with reduced exercise tolerance, more severe dyspnea, reduced quality of life, and greater depressive symptoms.
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Affiliation(s)
- Anand S Iyer
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, .,Health Services, Outcomes, and Effectiveness Research Training Program, University of Alabama at Birmingham, Birmingham, AL, USA, .,Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA,
| | - James M Wells
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, .,Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA, .,Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Surya P Bhatt
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, .,Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA,
| | - deNay P Kirkpatrick
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, .,Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA,
| | - Patricia Sawyer
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Cynthia J Brown
- Veterans Affairs Medical Center, Birmingham, AL, USA.,Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard M Allman
- Department of Medicine, George Washington University School of Medicine, Washington, DC, USA
| | - Marie A Bakitas
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Medicine, Center for Palliative and Supportive Care, Division of Geriatrics, Gerontology, and Palliative Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark T Dransfield
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA, .,Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA, .,Veterans Affairs Medical Center, Birmingham, AL, USA
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Iyer AS, Dransfield MT. The "Obesity Paradox" in Chronic Obstructive Pulmonary Disease: Can It Be Resolved? Ann Am Thorac Soc 2018; 15:158-159. [PMID: 29388820 PMCID: PMC5822407 DOI: 10.1513/annalsats.201711-901ed] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 11/20/2022] Open
Affiliation(s)
- Anand S. Iyer
- Division of Pulmonary Allergy, and Critical Care Medicine
- Health Services, Outcomes, and Effectiveness Research Training Program, and
- Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Mark T. Dransfield
- Division of Pulmonary Allergy, and Critical Care Medicine
- Health Services, Outcomes, and Effectiveness Research Training Program, and
- Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama; and
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
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Parekh TM, Bhatt SP, Westfall AO, Wells JM, Kirkpatrick D, Iyer AS, Mugavero M, Willig JH, Dransfield MT. Implications of DRG Classification in a Bundled Payment Initiative for COPD. Am J Accountable Care 2017; 5:12-18. [PMID: 29623307 PMCID: PMC5881946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Institutions participating in the Medicare Bundled Payments for Care Improvement (BPCI) initiative invest significantly in efforts to reduce readmissions and costs for patients who are included in the program. Eligibility for the BPCI initiative is determined by diagnosis-related group (DRG) classification. The implications of this methodology for chronic diseases are not known. We hypothesized that patients included in a BPCI initiative for chronic obstructive pulmonary disease (COPD) would have less severe illness and decreased hospital utilization compared with those excluded from the bundled payment initiative. STUDY DESIGN Retrospective observational study. METHODS We sought to determine the clinical characteristics and outcomes of Medicare patients admitted to the University of Alabama at Birmingham Hospital with acute exacerbations of COPD between 2012 and 2014 who were included and excluded in a BPCI initiative. Patients were included in the analysis if they were discharged with a COPD DRG or with a non-COPD DRG but with an International Classification of Diseases, Ninth Revision code for COPD exacerbation. RESULTS Six hundred and ninety-eight unique patients were discharged for an acute exacerbation of COPD; 239 (34.2%) were not classified into a COPD DRG and thus were excluded from the BPCI initiative. These patients were more likely to have intensive care unit (ICU) admissions (63.2% vs 4.4%, respectively; P <.001) and require noninvasive (46.9% vs 6.5%; P <.001) and invasive mechanical ventilation (41.4% vs 0.7%; P <.001) during their hospitalization than those in the initiative. They also had a longer ICU length of stay (5.2 vs 1.8 days; P = .011), longer hospital length of stay (10.3 days vs 3.9 days; P <.001), higher in-hospital mortality (14.6% vs 0.7%; P <.001), and greater hospitalization costs (median = $13,677 [interquartile range = $7489-$23,054] vs $4281 [$2718-$6537]; P <.001). CONCLUSIONS The use of DRGs to identify patients with COPD for inclusion in the BPCI initiative led to the exclusion of more than one-third of patients with acute exacerbations who had more severe illness and worse outcomes and who may benefit most from the additional interventions provided by the initiative.
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Affiliation(s)
- Trisha M Parekh
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Surya P Bhatt
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Andrew O Westfall
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - James M Wells
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Denay Kirkpatrick
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Anand S Iyer
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Michael Mugavero
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - James H Willig
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Mark T Dransfield
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
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Iyer AS, Bakitas M. Early Palliative Care in Advanced Illness: Do Right by Mama. JAMA Intern Med 2017; 177:761-762. [PMID: 28418511 DOI: 10.1001/jamainternmed.2017.0764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Alabama at Birmingham, Birmingham2Health Services, Outcomes, and Effectiveness Research Training Program, University of Alabama at Birmingham, Birmingham
| | - Marie Bakitas
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham4School of Nursing, University of Alabama at Birmingham, Birmingham
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Affiliation(s)
- Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Veterans Affairs Medical Center, Birmingham, AL, USA.
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Wells JM, Iyer AS, Rahaghi FN, Bhatt SP, Gupta H, Denney TS, Lloyd SG, Dell'Italia LJ, Nath H, Estepar RSJ, Washko GR, Dransfield MT. Pulmonary artery enlargement is associated with right ventricular dysfunction and loss of blood volume in small pulmonary vessels in chronic obstructive pulmonary disease. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002546. [PMID: 25855668 DOI: 10.1161/circimaging.114.002546] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [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: 11/16/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease causes significant morbidity and concomitant pulmonary vascular disease and cardiac dysfunction are associated with poor prognosis. Computed tomography-detected relative pulmonary artery (PA) enlargement defined as a PA to ascending aorta diameter ratio >1 (PA:A>1) is a marker for pulmonary hypertension and predicts chronic obstructive pulmonary disease exacerbations. However, little is known about the relationship between the PA:A ratio, pulmonary blood volume, and cardiac function. METHODS AND RESULTS A single-center prospective cohort study of patients with chronic obstructive pulmonary disease was conducted. Clinical characteristics and computed tomography metrics, including the PA:A and pulmonary blood vessel volume, were measured. Ventricular functions, volumes, and dimensions were measured by cine cardiac MRI with 3-dimensional analysis. Linear regression examined the relationships between clinical characteristics, computed tomography and cardiac MRI metrics, and 6-minute walk distance. Twenty-four patients were evaluated and those with PA:A>1 had higher right ventricular (RV) end-diastolic and end-systolic volume indices accompanied by lower RV ejection fraction (52±7% versus 60±9%; P=0.04). The PA:A correlated inversely with total intraparenchymal pulmonary blood vessel volume and the volume of distal vessels with a cross-sectional area of <5 mm(2). Lower forced expiratory volume, PA:A>1, and hyperinflation correlated with reduced RV ejection fraction. Both PA diameter and reduced RV ejection fraction were independently associated with reduced 6-minute walk distance. CONCLUSIONS The loss of blood volume in distal pulmonary vessels is associated with PA enlargement on computed tomography. Cardiac MRI detects early RV dysfunction and remodeling in nonsevere chronic obstructive pulmonary disease patients with a PA:A>1. Both RV dysfunction and PA enlargement are independently associated with reduced walk distance. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00608764.
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Affiliation(s)
- J Michael Wells
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.).
| | - Anand S Iyer
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Farbod N Rahaghi
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Surya P Bhatt
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Himanshu Gupta
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Thomas S Denney
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Steven G Lloyd
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Louis J Dell'Italia
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Hrudaya Nath
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Raul San Jose Estepar
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - George R Washko
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
| | - Mark T Dransfield
- From the Birmingham VA Medical Center, AL (J.M.W., H.G., S.G.L., L.J.D., M.T.D.); Department of Medicine (J.M.W., A.S.I., S.P.B., H.G., S.G.L., L.J.D., M.T.D.), Division of Pulmonary, Allergy, and Critical Care, Lung Health Center (J.M.W., S.P.B., M.T.D.), Division of Cardiovascular Disease (H.G., S.G.L., L.J.D.), and Department of Radiology (H.N.), University of Alabama at Birmingham; Division of Pulmonary and Critical Care Medicine (F.N.R., G.R.W.) and Department of Radiology, Harvard Medical School (R.S.J.E.), Brigham and Women's Hospital, Boston, MA; and Department of Electrical and Computer Engineering, Auburn University, AL (T.S.D.)
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Iyer AS, Wells JM, Vishin S, Bhatt SP, Wille KM, Dransfield MT. CT scan-measured pulmonary artery to aorta ratio and echocardiography for detecting pulmonary hypertension in severe COPD. Chest 2014; 145:824-832. [PMID: 24114440 DOI: 10.1378/chest.13-1422] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND COPD is associated with significant morbidity primarily driven by acute exacerbations. Relative pulmonary artery (PA) enlargement, defined as a PA to ascending aorta (A) diameter ratio greater than one (PA:A>1) identifies patients at increased risk for exacerbations. However, little is known about the correlation between PA:A, echocardiography, and invasive hemodynamics in COPD. METHODS A retrospective observational study of patients with severe COPD being evaluated for lung transplantation at a single center between 2007 and 2011 was conducted. Clinical characteristics, CT scans, echocardiograms, and right-sided heart catheterizations were reviewed. The PA diameter at the bifurcation and A diameter from the same CT image were measured. Linear and logistic regression were used to examine the relationships between PA:A ratio by CT scan and PA systolic pressure (PASP) by echocardiogram with invasive hemodynamics. Receiver operating characteristic analysis assessed the usefulness of the PA:A ratio and PASP in predicting resting pulmonary hypertension (PH) (mean pulmonary artery pressure [mPAP]>25 mm Hg). RESULTS Sixty patients with a mean predicted FEV1 of 27%±12% were evaluated. CT scan-measured PA:A correlated linearly with mPAP after adjustment for multiple covariates (r=0.30, P=.03), a finding not observed with PASP. In a multivariate logistic model, mPAP was independently associated with PA:A>1 (OR, 1.44; 95% CI, 1.02-2.04; P=.04). PA:A>1 was 73% sensitive and 84% specific for identifying patients with resting PH (area under the curve, 0.83; 95% CI, 0.72-0.93; P<.001), whereas PASP was not useful. CONCLUSIONS A PA:A ratio>1 on CT scan outperforms echocardiography for diagnosing resting PH in patients with severe COPD.
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Affiliation(s)
- Anand S Iyer
- Department of Internal Medicine, University of Alabama at Birmingham
| | - J Michael Wells
- Department of Internal Medicine, University of Alabama at Birmingham; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine and University of Alabama at Birmingham Lung Health Center, University of Alabama at Birmingham; Birmingham Veterans Affairs Medical Center, Birmingham, AL.
| | - Sonia Vishin
- Department of Internal Medicine, University of Alabama at Birmingham; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine and University of Alabama at Birmingham Lung Health Center, University of Alabama at Birmingham
| | - Surya P Bhatt
- Department of Internal Medicine, University of Alabama at Birmingham
| | - Keith M Wille
- Department of Internal Medicine, University of Alabama at Birmingham; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine and University of Alabama at Birmingham Lung Health Center, University of Alabama at Birmingham
| | - Mark T Dransfield
- Department of Internal Medicine, University of Alabama at Birmingham; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine and University of Alabama at Birmingham Lung Health Center, University of Alabama at Birmingham; Birmingham Veterans Affairs Medical Center, Birmingham, AL
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Iyer AS, Ahmed MI, Filippatos GS, Ekundayo OJ, Aban IB, Love TE, Nanda NC, Bakris GL, Fonarow GC, Aronow WS, Ahmed A. Uncontrolled hypertension and increased risk for incident heart failure in older adults with hypertension: findings from a propensity-matched prospective population study. ACTA ACUST UNITED AC 2010; 4:22-31. [PMID: 20374948 DOI: 10.1016/j.jash.2010.02.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Revised: 01/20/2010] [Accepted: 02/02/2010] [Indexed: 11/29/2022]
Abstract
Hypertension is a risk factor for incident heart failure (HF). However, the effect of uncontrolled blood pressure (BP) on incident HF in older adults with hypertension has not been prospectively examined in propensity-matched studies. Of the 5795 Cardiovascular Health Study participants, > or =65 years, 2562 with self-reported physician-diagnosed hypertension had no baseline HF. Of these, 1391 had uncontrolled hypertension, defined as systolic BP (SBP) > or =140 (n = 1373) or diastolic BP > or =90 mm Hg (n = 18). Propensity scores for uncontrolled hypertension, calculated for each participant, were used to assemble a cohort of 1021 pairs of participants with controlled and uncontrolled hypertension who were balanced on 31 baseline characteristics. Centrally adjudicated incident HF developed in 23% and 26% of participants with controlled and uncontrolled hypertension respectively during 13 years of follow-up (matched hazard ratio [HR] when uncontrolled hypertension was compared with controlled hypertension, 1.39; 95% confidence interval [CI], 1.12 to 1.73; P = .003). HRs (95% CI) for incident HF for those with (n = 503) and without (n = 1539) chronic kidney disease (CKD) were 1.73 (95% CI, 1.26 to 2.38; P = .001) and 1.08 (95% CI, 0.87 to 1.34; P = .486) respectively (P for interaction, .012). Compared with participants with controlled hypertension, HRs for incident HF associated with SBP 140 to 159 and > or =160 mm Hg were 1.06 (95% CI, 0.86 to 1.31; P = .572) and 1.58 (95% CI, 1.27 to 1.96; P < .0001), respectively. In community-dwelling older adults with hypertension, those with uncontrolled (versus controlled) BP have increased risk of new-onset HF, which is more pronounced in those with SBP > or =160 mm Hg and with CKD.
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Affiliation(s)
- Anand S Iyer
- University of Alabama at Birmingham, Birmingham, AL, USA
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