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Winters N, Schnitzer ME, Campbell JR, Ripley S, Winston C, Savic R, Ahmad N, Bisson G, Dheda K, Esmail A, Gegia M, Monedero I, Dalcolmo MP, Rodrigues D, Singla R, Yim JJ, Menzies D. Identifying patients with multidrug-resistant tuberculosis who may benefit from shorter durations of treatment. PLoS One 2023; 18:e0292106. [PMID: 37797071 PMCID: PMC10553332 DOI: 10.1371/journal.pone.0292106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/13/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Studying treatment duration for rifampicin-resistant and multidrug-resistant tuberculosis (MDR/RR-TB) using observational data is methodologically challenging. We aim to present a hypothesis generating approach to identify factors associated with shorter duration of treatment. STUDY DESIGN AND SETTING We conducted an individual patient data meta-analysis among MDR/RR-TB patients restricted to only those with successful treatment outcomes. Using multivariable linear regression, we estimated associations and their 95% confidence intervals (CI) between the outcome of individual deviation in treatment duration (in months) from the mean duration of their treatment site and patient characteristics, drug resistance, and treatments used. RESULTS Overall, 6702 patients with successful treatment outcomes from 84 treatment sites were included. We found that factors commonly associated with poor treatment outcomes were also associated with longer treatment durations, relative to the site mean duration. Use of bedaquiline was associated with a 0.51 (95% CI: 0.15, 0.87) month decrease in duration of treatment, which was consistent across subgroups, while MDR/RR-TB with fluoroquinolone resistance was associated with 0.78 (95% CI: 0.36, 1.21) months increase. CONCLUSION We describe a method to assess associations between clinical factors and treatment duration in observational studies of MDR/RR-TB patients, that may help identify patients who can benefit from shorter treatment.
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Affiliation(s)
- Nicholas Winters
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Mireille E. Schnitzer
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montreal, Canada
| | - Jonathon R. Campbell
- Department of Medicine & Department of Global and Public Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
- McGill International TB Centre, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Susannah Ripley
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Carla Winston
- US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Rada Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, United States of America
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
| | - Nafees Ahmad
- Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Gregory Bisson
- Department of Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Ali Esmail
- Centre for Lung Infection and Immunity, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Medea Gegia
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | - Ignacio Monedero
- TB-HIV Department, International Union against Tuberculosis and Lung Diseases, Paris, France
| | | | | | - Rupak Singla
- National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - Jae-Joon Yim
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dick Menzies
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
- McGill International TB Centre, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Canada
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Carr W, Kurbatova E, Starks A, Goswami N, Allen L, Winston C. Interim Guidance: 4-Month Rifapentine-Moxifloxacin Regimen for the Treatment of Drug-Susceptible Pulmonary Tuberculosis - United States, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:285-289. [PMID: 35202353 DOI: 10.15585/mmwr.mm7108a1] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
On May 5, 2021, CDC's Tuberculosis Trials Consortium and the National Institutes of Health (NIH)-sponsored AIDS Clinical Trials Group (ACTG) published results from a randomized controlled trial indicating that a 4-month regimen containing rifapentine (RPT), moxifloxacin (MOX), isoniazid (INH), and pyrazinamide (PZA) was as effective as the standard 6-month regimen for tuberculosis (TB) treatment (1). On the basis of these findings, CDC recommends the 4-month regimen as a treatment option for U.S. patients aged ≥12 years with drug-susceptible pulmonary TB and provides implementation considerations for this treatment regimen.
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Affiliation(s)
- Wendy Carr
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Ekaterina Kurbatova
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Angela Starks
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Neela Goswami
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Leeanna Allen
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
| | - Carla Winston
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
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Ludwig A, Lucero-Obusan C, Schirmer P, Winston C, Holodniy M. Acute cardiac injury events ≤30 days after laboratory-confirmed influenza virus infection among U.S. veterans, 2010-2012. BMC Cardiovasc Disord 2015; 15:109. [PMID: 26423142 PMCID: PMC4589211 DOI: 10.1186/s12872-015-0095-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 09/14/2015] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Cardiac injury is a known potential complication of influenza infection. Because U.S. veterans cared for at the U.S. Department of Veterans Affairs are older and have more cardiovascular disease (CVD) risk factors than the general U.S. population, veterans are at risk for cardiac complications of influenza infection. We investigated biomarkers of cardiac injury characteristics and associated cardiac events among veterans who received cardiac biomarker testing ≤30 days after laboratory-confirmed influenza virus infection. METHODS Laboratory-confirmed influenza cases among veterans cared for at U.S. Department of Veterans Affairs' facilities for October 2010-December 2012 were identified using electronic medical records (EMRs). Influenza confirmation was based on respiratory specimen viral culture or antigen or nucleic acid detection. Acute cardiac injury (ACI) was defined as an elevated cardiac biomarker (troponin I or creatinine kinase isoenzyme MB) >99 % of the upper reference limit occurring ≤30 days after influenza specimen collection. EMRs were reviewed for demographics, CVD history and risk factors, and ACI-associated cardiac events. RESULTS Among 38,197 patients with influenza testing results, 4,469 (12 %) had a positive result; 600 of those patients had cardiac biomarker testing performed ≤30 days after influenza testing, and 143 (24 %) had one or more elevated cardiac biomarkers. Among these 143, median age was 73 years (range 44-98 years), and 98 (69 %) were non-Hispanic white. All patients had one or more CVD risk factors, and 98 (69 %) had a history of CVD. Eighty-six percent of ACI-associated events occurred within 3 days of influenza specimen collection date. Seventy patients (49 %) had documented or probable acute myocardial infarction, 8 (6 %) acute congestive heart failure, 6 (4 %) myocarditis, and 4 (3 %) atrial fibrillation. Eleven (8 %) had non-cardiac explanations for elevated cardiac biomarkers, and 44 (31 %) had no documented explanation. Sixty-eight (48 %) patients had received influenza vaccination during the related influenza season. CONCLUSION Among veterans with laboratory-confirmed influenza infection and cardiac biomarker testing ≤30 days after influenza testing, approximately 25 % had evidence of ACI, the majority within 3 days. Approximately half were myocardial infarctions. Our findings emphasize the importance of considering ACI associated with influenza infection among patients at high risk, including this older population with prevalent CVD risk factors.
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Affiliation(s)
- Alison Ludwig
- Centers for Disease Control and Prevention, assigned to Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA. .,Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA.
| | - Cynthia Lucero-Obusan
- Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA.
| | - Patricia Schirmer
- Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA.
| | - Carla Winston
- Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA.
| | - Mark Holodniy
- Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA. .,Division of Infectious Diseases and Geographic Medicine, Stanford University, Palo Alto, CA, 94303, USA.
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Perti T, Schirmer P, Winston C, Weiss E, Cavanaugh J, Lucero-Obusan C, Holodniy M. 1690Opportunities for Improved Detection and Treatment of Latent Tuberculosis Infection Among Veterans — Western United States, January 2010–July 2013. Open Forum Infect Dis 2014. [PMCID: PMC5782134 DOI: 10.1093/ofid/ofu052.1236] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tara Perti
- Office of Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, CA
- Epidemiology Workforce Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Patricia Schirmer
- Office of Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, CA
| | - Carla Winston
- Office of Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, CA
| | - Edward Weiss
- Epidemiology Workforce Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Joseph Cavanaugh
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA
| | - Cynthia Lucero-Obusan
- Office of Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, CA
| | - Mark Holodniy
- Office of Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, CA
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Hajj C, Huguet F, Wu A, Shi W, Zhang Z, O'Reilly E, Winston C, Reidy D, Ho A, Allen P, Goodman K. Chemotherapy and Intensity Modulated Radiation Therapy for Locally Advanced Pancreatic Cancer Achieves Prolonged Survival. Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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6
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Burkom HS, Elbert Y, Winston C, Pavlin J, Lucero-Obusan C, Holodniy M. Coverage and Timeliness of Combined Military and Veteran Surveillance Systems. Online J Public Health Inform 2013. [PMCID: PMC3692883] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Objective Introduction Methods Results Conclusions
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Affiliation(s)
- Howard S. Burkom
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA
| | - Yevgeniy Elbert
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA
| | | | - Julie Pavlin
- Armed Forces Health Surveillance Center, Silver Spring, MD, USA,Julie Pavlin, E-mail:
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7
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Schirmer P, Winston C, Ryono R, Lucero-Obusan C, Oda G, Holodniy M. Does Antimicrobial Prescription Data Improve Influenza Surveillance in VA? Online J Public Health Inform 2013. [PMCID: PMC3692879] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Antimicrobial prescriptions are a new data source available to the Veterans Health Administration (VHA) biosurveillance program. Little is known about whether antiviral or antibacterial prescription data correlates with influenza ICD-9-CM coded encounters. We therefore evaluated the utility and timeliness of antiviral and antibacterial utilization for influenza surveillance. Methods Antiviral (oseltamivir, zanamivir) and antibacterial (azithromycin) outpatient (OP) prescriptions and OP ESSENCE coded respiratory syndrome, influenza-like-illness (ILI) or influenza-specific ICD-9-CM coded visits were analyzed covering the 2010–2011 and 2011–2012 influenza seasons (July 1, 2010–July 31, 2012) for 152 VA medical centers and 971 outpatient clinics using VA Corporate Data Warehouse and ESSENCE biosurveillance tool. Correlation analysis and peak comparisons were performed. Results For this time period, there were 2,880,415 respiratory, 1,578,421 ILI, and 5,158 influenza-specific coded visits. For both influenza seasons, respiratory and ILI visits peaked at weeks 1–2 whereas influenza-specific visits had two peaks between weeks 37–40 and weeks 6–11 (See Figure 1 and 2). The total number of prescriptions was 631,272 azithromycin; 8,362 oseltamivir; and 88 zanamivir (See Figure 2). Spearman rank correlation coefficients for daily antiviral prescriptions and influenza-coded visits were (0.70); ILI visits (0.64), and respiratory illness visits (0.62), respectively; and for azithromycin prescriptions 0.77, 0.98, and 0.97 respectively. Oseltamivir and zanamivir prescriptions only increased in 2010–2011 starting with week 51 and peaking week 6 and in 2011–2012 starting with week 8 and peaking week 14. However, azithromycin prescriptions tracked better across the entire influenza season (peaking at weeks 1–2 for both influenza seasons). Conclusions VA outpatient prescription data indicated that significantly more ILI and respiratory syndrome visits occurred compared to antiviral prescriptions dispensed with marginal temporal correlation between visits and antiviral prescriptions. Reasons for this finding require further investigation. Although we did not chart review the visit code and antimicrobial prescription in individual records, possible factors may be related to later presentation of cases, perceived lack of efficacy of antivirals, or insufficient coding of influenza. Thus, antiviral prescription data provided minimal additional information for influenza trend monitoring in VA although may still be useful a marker of more severe illness. Interestingly, azithromycin use tracked better with the onset and peaks of the influenza season. Further investigation is also needed to determine whether patients with influenza-specific coded encounters were also prescribed azithromycin and why relatively few encounters were coded with an influenza-specific code.
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Affiliation(s)
- Patricia Schirmer
- Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA, USA;,Patricia Schirmer, E-mail:
| | - Carla Winston
- Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA, USA
| | - Russell Ryono
- Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA, USA
| | - Cynthia Lucero-Obusan
- Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA, USA
| | - Gina Oda
- Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA, USA
| | - Mark Holodniy
- Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA, USA;,Stanford University, Division of Infectious Diseases and Geographic Medicine, Palo Alto, CA, USA
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Vinnard C, Winston C, Wileyto EP, MacGregor RR, Bisson G. O2-1.1 Multidrug resistant tuberculous meningitis in the United States, 1993-2005. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976a.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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9
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O'Reilly EM, Jarnagin WR, Brennan MF, Winston C, Tang LH, Capanu M, Schattner M, Chen LY, DeMatteo RP, DiMaio CJ, D'Angelica MI, Kurtz RC, Klimstra DS, Lowery MA, Coit DG, Reidy DL, Allen PJ. Phase II single-arm, single-institution trial of neoadjuvant gemcitabine and oxaliplatin treatment (NT) in patients (pts) with resectable pancreas adenocarcinoma (PC). J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.4065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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De Staercke C, Lally C, Austin H, Winston C, Dowling N, Williams B, Hooper WC. The lack of association between four point mutations in the promoter region of the toll-like 4 receptor gene and myocardial infarction. Thromb Res 2007; 119:105-10. [PMID: 16469362 DOI: 10.1016/j.thromres.2005.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Revised: 11/19/2005] [Accepted: 12/16/2005] [Indexed: 11/24/2022]
Abstract
The toll-like receptor 4 gene product (TLR4) has been implicated in the pathogen recognition response mechanism because it plays a central role in the transcriptional activation of the host defense system. Activation of TLR4 initiates an intracellular signaling cascade, via the adapter protein MyD88 (myeloid differentiation factor 88), which leads to the activation of NF-kappaB transcriptional factor, and ultimately to the induction of a pro-inflammatory response. This inflammatory response has been increasingly associated with atherosclerosis. Recent analyses on two polymorphisms of TLR4, which affect the extracellular domain of the receptor, have been shown to give rise to an attenuated innate immune defense which may contribute to disease susceptibility. We have investigated the significance of four new substitutions found by re-sequencing in the 5'-proximal promoter region of the TLR4 gene in a case-control study of acute myocardial infarction. Our results found no statistically significant association between these genetic variants and MI.
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Affiliation(s)
- Christine De Staercke
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Zhou F, Kyaw M, Shefer A, Martin S, Winston C, Nuorti P. Impact of Pneumococcal Conjugate Vaccine On Pneumonia in Young Children, 1997-2003. Am J Epidemiol 2006. [DOI: 10.1093/aje/163.suppl_11.s156-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bardenheier B, Wortley P, Winston C, Washington ML, Lindley M. 013: Using Cluster Analysis to Examine Patterns of Knowledge, Attitudes, and Practices Related to Influenza Immunization Among Older Adults: Results of the Racial and Ethnic Adult Disparities in Immunization Initiative (Readii) Survey, 2004. Am J Epidemiol 2005. [DOI: 10.1093/aje/161.supplement_1.s4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- B Bardenheier
- Centers for Disease Control and Prevention, Atlanta, GA 30333
| | - P Wortley
- Centers for Disease Control and Prevention, Atlanta, GA 30333
| | - C Winston
- Centers for Disease Control and Prevention, Atlanta, GA 30333
| | - M L Washington
- Centers for Disease Control and Prevention, Atlanta, GA 30333
| | - M Lindley
- Centers for Disease Control and Prevention, Atlanta, GA 30333
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Hassan SA, Hlatky MA, Boothroyd DB, Winston C, Mark DB, Brooks MM, Eagle KA. Outcomes of noncardiac surgery after coronary bypass surgery or coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI). Am J Med 2001; 110:260-6. [PMID: 11239843 DOI: 10.1016/s0002-9343(00)00717-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Previous studies have shown that coronary artery bypass surgery reduces the risk of cardiac complications after noncardiac surgery. Whether coronary angioplasty provides equivalent protection is not known. SUBJECTS AND METHODS Patients were randomly assigned to undergo cardiac artery bypass surgery or angioplasty as part of the Bypass Angioplasty Revascularization Investigation trial. All subsequent noncardiac surgeries during a mean (+/- SD) follow-up of 7.7 years were recorded among participants in the ancillary Study of Economics and Quality of Life. Rates of mortality and nonfatal myocardial infarction, length of stay, and hospital costs were compared by the original randomized assignment. RESULTS A total of 501 patients had noncardiac surgery at a median of 29 months after their most recent coronary revascularization procedure. Mortality and nonfatal myocardial infarction within 30 days of the first noncardiac surgery occurred in 4 of the 250 of the surgery-assigned patients and in 4 of the 251 of the angioplasty-assigned patients (P = 1.0). There were no significant differences in the mean length of hospital stay (6.3 +/- 6.7 versus 6.2 +/- 6.8 days; P = 0.47) or hospital cost ($8,920 +/- $11,511 versus $7,785 +/- $7,643; P = 0.33) between the surgery and angioplasty groups. Similar results were obtained when subsequent noncardiac procedures were included in the analysis. CONCLUSION Rates of myocardial infarction and death after noncardiac surgery are similarly low after contemporary bypass surgery or angioplasty in patients with multivessel coronary artery disease.
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Affiliation(s)
- S A Hassan
- Henry Ford Hospital, Detroit, Michigan, USA
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14
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Yock CA, Boothroyd DB, Owens DK, Winston C, Hlatky MA. Projected long-term costs of coronary stenting in multivessel coronary disease based on the experience of the Bypass Angioplasty Revascularization Investigation (BARI). Am Heart J 2000; 140:556-64. [PMID: 11011328 DOI: 10.1067/mhj.2000.109915] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Stents are now used in the majority of percutaneous coronary revascularization procedures. It is not clear whether the higher initial cost of stenting is later repaid by reducing costly complications and repeat revascularization procedures, especially for patients with multivessel disease. METHODS To project the long-term costs of using coronary stents, angioplasty, or bypass surgery to treat patients with multivessel coronary artery disease, we developed a decision model based on the outcomes documented in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial of coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). We studied 2 clinical strategies: provisional stenting of suboptimal PTCA results and primary stenting of all angiographically eligible lesions. The cost of CABG was also updated to reflect contemporary practice. RESULTS Provisional stenting had lower projected costs over a 4-year period than either traditional PTCA (-$1742, or -3.4%) or contemporary CABG (-$832, or -1.7%), mostly because of reductions in emergency CABG after PTCA. In contrast, primary stenting had higher projected costs over a 4-year period than either PTCA (+$333, or +0. 7%) or contemporary CABG (+$1243, or +2.5%), mainly because of the higher initial procedure costs. These results were not substantially altered when we systematically varied the key parameters of the models in 1-way and 2-way sensitivity analyses. CONCLUSIONS A primary stenting strategy in patients with multivessel disease has higher projected long-term costs than CABG. In contrast, a provisional stenting strategy in multivessel disease has lower projected costs than either PTCA or CABG.
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Affiliation(s)
- C A Yock
- Department of Health Research and Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Hlatky MA, Boothroyd DB, Brooks MM, Winston C, Rosen A, Rogers WJ, Reeder GS, Smith HC, Ryan TJ, Pitt B, Whitlow PL, Wiens RD, Mark DB. Clinical correlates of the initial and long-term cost of coronary bypass surgery and coronary angioplasty. Am Heart J 1999; 138:376-83. [PMID: 10426855 DOI: 10.1016/s0002-8703(99)70128-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medical costs vary substantially among patients. Understanding the baseline factors that predict subsequent cost may allow better selection of therapy for individual patients. Understanding the postprocedure events that increase cost should help to improve efficiency and effectiveness of coronary revascularization. METHODS Data on 4-year costs were collected from patients randomly assigned to coronary angioplasty or bypass surgery as part of the BARI (Bypass Angioplasty Revascularization Investigation) trial. Regression models first examined factors known at the time of randomization that prospectively predicted initial procedure cost and long-term cost. Subsequent models tested the value of postrandomization events as explanatory variables for cost. RESULTS The independent baseline predictors of higher initial percutaneous transluminal coronary angioplasty cost included 3-vessel disease (+12%) and acute presentations (+22%), whereas the independent predictors of higher initial coronary artery bypass grafting cost included the number of comorbid conditions (+5% per condition) and female sex (+7%). The independent baseline predictors of 4-year cost included heart failure (+26%), diabetes (+22%), comorbidity (+10%), and angioplasty assignment in patients with 2-vessel disease (-15%). Postrandomization models showed higher initial and long-term costs were strongly correlated with the number of repeat revascularization procedures (+30% to +128%) and the occurrence of clinical complications (+8% to +131%). CONCLUSIONS Two-vessel disease identifies patients likely to have lower costs after angioplasty, whereas heart failure, comorbid conditions, and diabetes identify patients likely to accrue higher costs after either angioplasty or bypass surgery. Long-term costs can be potentially reduced by interventions that decrease procedural complications or reduce the need for repeat revascularization.
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Affiliation(s)
- M A Hlatky
- Department of Health Research and Policy, Stanford University School of Medicine, HRP Redwood Bldg, Room 150, Stanford, 94305-5405, USA.
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16
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Hlatky MA, Boothroyd D, Horine S, Winston C, Brooks MM, Rogers W, Pitt B, Reeder G, Ryan T, Smith H, Whitlow P, Wiens R, Mark DB. Employment after coronary angioplasty or coronary bypass surgery in patients employed at the time of revascularization. Ann Intern Med 1998; 129:543-7. [PMID: 9758574 DOI: 10.7326/0003-4819-129-7-199810010-00006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients who undergo coronary angioplasty have a shorter convalescence than those who undergo coronary bypass surgery. This may improve subsequent employment. OBJECTIVE To compare employment patterns after coronary angioplasty or surgery. DESIGN Multicenter, randomized clinical trial. SETTING Seven tertiary care hospitals. PATIENTS 409 employed patients with multivessel coronary artery disease. INTERVENTION Coronary bypass surgery or balloon angioplasty. MEASUREMENTS Time to return to work and time spent working during 4 years of follow-up. RESULTS Patients who underwent angioplasty returned to work 6 weeks sooner than patients who underwent coronary bypass surgery (P < 0.001), but long-term employment did not differ significantly (P > 0.2). Long-term employment was significantly lower among patients who were 60 to 64 years of age (P < 0.001), those who worked less than full-time at study entry (P < 0.001), and those who had less formal education (P = 0.005). Patients with only one source of health insurance were more likely to continue working (P = 0.005). CONCLUSIONS Faster recovery after angioplasty speeds return to work but does not improve long-term employment, which is primarily associated with nonmedical factors.
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Affiliation(s)
- M A Hlatky
- Stanford University School of Medicine, California 94305-5405, USA.
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Jacobs AK, Kelsey SF, Brooks MM, Faxon DP, Chaitman BR, Bittner V, Mock MB, Weiner BH, Dean L, Winston C, Drew L, Sopko G. Better outcome for women compared with men undergoing coronary revascularization: a report from the bypass angioplasty revascularization investigation (BARI). Circulation 1998; 98:1279-85. [PMID: 9751675 DOI: 10.1161/01.cir.98.13.1279] [Citation(s) in RCA: 178] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Numerous studies have shown that women undergoing coronary revascularization procedures do so at a higher risk for an adverse outcome compared with men. However, the impact of advances in technology and improvements in techniques on in-hospital and long-term outcome after revascularization in women is unclear. METHODS AND RESULTS We evaluated 1829 patients with symptomatic multivessel coronary disease randomized to CABG or PTCA in the Bypass Angioplasty Revascularization Investigation (BARI), of whom 27% were women. As expected, women were older (64.0 versus 60.5 years), with more congestive heart failure (14% versus 7%), hypertension (68% versus 42%), treated diabetes mellitus (31% versus 15%), and unstable angina (67% versus 61%) than men but had similar preservation of left ventricular function and extent of multivessel disease. Women assigned to surgery received the same number of total grafts but fewer internal mammary artery grafts (72% versus 85%, P<0. 01), and those assigned to angioplasty had more intended lesions (76% versus 71%, P<0.01) successfully dilated than men. At an average of 5.4 years' follow-up, crude mortality rates were similar in women (12.8%) and men (12.0%). The Cox regression model adjusting for baseline differences revealed that women had a significantly lower risk of death (relative risk, 0.60; 95% CI, 0.43 to 0.84; P=0. 003) but not a significantly lower risk of death plus myocardial infarction (relative risk, 0.84; 95% CI, 0.66 to 1.07; P=0.16) than men. CONCLUSIONS Although the unadjusted mortality rate suggests that women and men undergoing CABG and PTCA have a similar 5-year mortality, women have higher risk profiles; consequently, contrary to previous reports, female sex is an independent predictor of improved 5-year survival after we control for multiple risk factors.
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Affiliation(s)
- A K Jacobs
- Evans Memorial Department of Clinical Research and the Section of Cardiology, Department of Medicine, Boston Medical Center, Boston, MA, USA.
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Hlatky MA, Bacon C, Boothroyd D, Mahanna E, Reves JG, Newman MF, Johnstone I, Winston C, Brooks MM, Rosen AD, Mark DB, Pitt B, Rogers W, Ryan T, Wiens R, Blumenthal JA. Cognitive function 5 years after randomization to coronary angioplasty or coronary artery bypass graft surgery. Circulation 1997; 96:II-11-4; discussion II-15. [PMID: 9386068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Coronary bypass surgery often leads to short-term cognitive dysfunction, whereas coronary angioplasty does not. Perioperative cognitive dysfunction usually resolves, although a subgroup of surgical patients may continue to exhibit long-term cognitive dysfunction. The purpose of this study was to compare cognitive function 5 years after randomization to a strategy of either initial coronary surgery or initial angioplasty. METHODS AND RESULTS Five centers in the Bypass Angioplasty Revascularization Investigation participated in this ancillary study. Patients with multivessel coronary disease randomized to angioplasty or surgery were eligible at the time of their 5-year clinic visit. A battery of five measures previously shown to be sensitive to perioperative changes in cognitive function was administered, including the Logical and Figural Memory Scales from the Wechsler Memory Scale, the Digit Symbol and Digit Span subtests from the Wechsler Adult Intelligence Scale, and Part B of the Reitan Trail Making Test. The 125 study patients were generally similar to the 133 patients who were eligible but did not participate, although study participants were significantly younger (P=.003). The 64 patients randomly assigned to angioplasty had baseline characteristics similar to those of 61 patients randomly assigned to surgery. Cognitive function scores were not significantly different between angioplasty or surgery patients in an intention-to-treat analysis (P=.57). There also was no difference in cognitive function scores when the data were analyzed according to whether the patient had ever undergone bypass surgery (P=.59). CONCLUSIONS Long-term cognitive function is similar after coronary bypass surgery and coronary angioplasty in the majority of patients.
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Affiliation(s)
- M A Hlatky
- Stanford University School of Medicine, Calif 94305-5092, USA.
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Abildgaard CF, Winston C. Newborn hemoglobinopathy screening. West J Med 1990; 153:651. [PMID: 2293477 PMCID: PMC1002651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
An assessment of the effects of airline deregulation on travelers and carriers indicates that deregulation has provided travelers and carriers with $14.9 billion of annual benefits (1988 dollars). Airport congestion, airline safety, airline bankruptcy, and mergers are also analyzed and found in most cases to have reduced benefits. But, these costs should not be attributed to deregulation per se, but to failures by the government to pursue appropriate policies in these areas. Pursuit of policies that promote airline competition and efficient use of airport capacity would significantly increase the benefits from deregulation and would provide valuable guidance for other industries undergoing the transition to deregulation.
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Goeddel DV, Yansura DG, Winston C, Caruthers MH. Studies on gene control regions. VII. Effect of 5-bromuracil-substituted lac operators on the lac operator-lac repressor interaction. J Mol Biol 1978; 123:661-87. [PMID: 691058 DOI: 10.1016/0022-2836(78)90211-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Affiliation(s)
| | - R. Mackey
- The Women's Hospital Crown Street Sydney
| | - C. Winston
- The Women's Hospital Crown Street Sydney
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