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Bramante CT, Beckman KB, Mehta T, Karger AB, Odde DJ, Tignanelli CJ, Buse JB, Johnson DM, Watson RHB, Daniel JJ, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Siegel LK, Klatt NR, Anderson B, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Fricton RD, Lee S, Griffiths G, Pullen MF, Thompson JL, Sherwood NE, Murray TA, Rose MR, Boulware DR, Huling JD. Favorable Antiviral Effect of Metformin on Severe Acute Respiratory Syndrome Coronavirus 2 Viral Load in a Randomized, Placebo-Controlled Clinical Trial of Coronavirus Disease 2019. Clin Infect Dis 2024:ciae159. [PMID: 38690892 DOI: 10.1093/cid/ciae159] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Metformin has antiviral activity against RNA viruses including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The mechanism appears to be suppression of protein translation via targeting the host mechanistic target of rapamycin pathway. In the COVID-OUT randomized trial for outpatient coronavirus disease 2019 (COVID-19), metformin reduced the odds of hospitalizations/death through 28 days by 58%, of emergency department visits/hospitalizations/death through 14 days by 42%, and of long COVID through 10 months by 42%. METHODS COVID-OUT was a 2 × 3 randomized, placebo-controlled, double-blind trial that assessed metformin, fluvoxamine, and ivermectin; 999 participants self-collected anterior nasal swabs on day 1 (n = 945), day 5 (n = 871), and day 10 (n = 775). Viral load was quantified using reverse-transcription quantitative polymerase chain reaction. RESULTS The mean SARS-CoV-2 viral load was reduced 3.6-fold with metformin relative to placebo (-0.56 log10 copies/mL; 95% confidence interval [CI], -1.05 to -.06; P = .027). Those who received metformin were less likely to have a detectable viral load than placebo at day 5 or day 10 (odds ratio [OR], 0.72; 95% CI, .55 to .94). Viral rebound, defined as a higher viral load at day 10 than day 5, was less frequent with metformin (3.28%) than placebo (5.95%; OR, 0.68; 95% CI, .36 to 1.29). The metformin effect was consistent across subgroups and increased over time. Neither ivermectin nor fluvoxamine showed effect over placebo. CONCLUSIONS In this randomized, placebo-controlled trial of outpatient treatment of SARS-CoV-2, metformin significantly reduced SARS-CoV-2 viral load, which may explain the clinical benefits in this trial. Metformin is pleiotropic with other actions that are relevant to COVID-19 pathophysiology. CLINICAL TRIALS REGISTRATION NCT04510194.
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Affiliation(s)
- Carolyn T Bramante
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenneth B Beckman
- Genomics Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tanvi Mehta
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - David J Odde
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Darrell M Johnson
- Genomics Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ray H B Watson
- Genomics Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jerry J Daniel
- Genomics Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - David M Liebovitz
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacinda M Nicklas
- General Internal Medicine, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, Minnesota, USA
| | - Michael A Puskarich
- Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View-University of California, Los Angeles, California, USA
| | - Lianne K Siegel
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Katrina M Hartman
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Via Rao
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Aubrey A Hagen
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah L Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nandini Avula
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neha V Reddy
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Spencer M Erickson
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Regina D Fricton
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Samuel Lee
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Gwendolyn Griffiths
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew F Pullen
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Thomas A Murray
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael R Rose
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jared D Huling
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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An SJ, Smith C, Davis D, Gallaher J, Tignanelli CJ, Charles A. Predictors of Functional Decline Among Critically Ill Surgical Patients: A National Analysis. J Surg Res 2024; 296:209-216. [PMID: 38281356 DOI: 10.1016/j.jss.2023.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Functional decline is associated with critical illness, though this relationship in surgical patients is unclear. This study aims to characterize functional decline after intensive care unit (ICU) admission among surgical patients. METHODS We performed a retrospective analysis of surgical patients admitted to the ICU in the Cerner Acute Physiology and Chronic Health Evaluation database, which includes 236 hospitals, from 2007 to 2017. Patients with and without functional decline were compared. Predictors of decline were modeled. RESULTS A total of 52,838 patients were included; 19,310 (36.5%) experienced a functional decline. Median ages of the decline and nondecline groups were 69 (interquartile range 59-78) and 63 (interquartile range 52-72) years, respectively (P < 0.01). The nondecline group had a larger proportion of males (59.1% versus 55.3% in the decline group, P < 0.01). After controlling for sociodemographic covariates, comorbidities, and disease severity upon ICU admission, patients undergoing pulmonary (odds ratio [OR] 6.54, 95% confidence interval [CI] 2.67-16.02), musculoskeletal (OR 4.13, CI 3.51-4.87), neurological (OR 2.67, CI 2.39-2.98), gastrointestinal (OR 1.61, CI 1.38-1.88), and skin and soft tissue (OR 1.35, CI 1.08-1.68) compared to cardiovascular surgeries had increased odds of decline. CONCLUSIONS More than one in three critically ill surgical patients experienced a functional decline. Pulmonary, musculoskeletal, and neurological procedures conferred the greatest risk. Additional resources should be targeted toward the rehabilitation of these patients.
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Affiliation(s)
- Selena J An
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charlotte Smith
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Dylane Davis
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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King S, Proper J, Siegel LK, Ingraham NE, Tignanelli CJ, Chipman JG, Ho J. Acute Appendicitis Treatment Strategies and Mortality Based on Critical Illness on Admission: An Observational Study. Surg Infect (Larchmt) 2024; 25:56-62. [PMID: 38285892 PMCID: PMC10825276 DOI: 10.1089/sur.2023.249] [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: 01/31/2024] Open
Abstract
Background: Trials have shown non-inferiority of non-operative management (NOM) for appendicitis, although critically ill patients have been often excluded. The purpose of this study is to evaluate surgical versus NOM outcomes in critically ill patients with appendicitis by measuring mortality and hospital length of stay (LOS). Patients and Methods: The Healthcare Cost and Utilization Project's (HCUP) Database was utilized to analyze data from 10 states between 2008 and 2015. All patients with acute appendicitis by International Classification of Diseases, Ninth Revision (ICD-9) codes over the age of 18 were included. Negative binomial and logistic regression were used to determine the association of acute renal failure (ARF), cardiovascular failure (CVF), pulmonary failure (PF), and sepsis by treatment strategy (laparoscopic, open, both, or no surgery) on mortality and hospital LOS. Results: Among 464,123 patients, 67.5%, 23.3%, 8.2%, and 0.8% underwent laparoscopic, open, NOM, or both laparoscopic and open surgery, respectively. Patients who underwent surgery had 58% lower odds of mortality and 34% shorter hospital LOS compared with NOM patients. Patients with ARF, CVF, PF, and sepsis had 102%, 383%, 475%, and 666% higher odds of mortality and a 47%, 46%, 71%, and 163% longer hospital LOS, respectively, compared with patients without these diagnoses on admission. Conclusions: Critical illness on admission increases mortality and hospital LOS. Patients who underwent laparoscopic, and to a lesser extent, open appendectomy had improved mortality compared with those who did not undergo surgery regardless of critical illness status.
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Affiliation(s)
- Samantha King
- Division of Plastic Surgery, University of Washington, Seattle, Washington, USA
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lianne K. Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas E. Ingraham
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnestoa, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeffrey G. Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jason Ho
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
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Silverman GM, Rajamani G, Ingraham NE, Glover JK, Sahoo HS, Usher M, Zhang R, Ikramuddin F, Melnik TE, Melton GB, Tignanelli CJ. A Symptom-Based Natural Language Processing Surveillance Pipeline for Post-COVID-19 Patients. Stud Health Technol Inform 2024; 310:860-864. [PMID: 38269931 DOI: 10.3233/shti231087] [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: 01/26/2024]
Abstract
Post-acute sequelae of SARS CoV-2 (PASC) are a group of conditions in which patients previously infected with COVID-19 experience symptoms weeks/months post-infection. PASC has substantial societal burden, including increased healthcare costs and disabilities. This study presents a natural language processing (NLP) based pipeline for identification of PASC symptoms and demonstrates its ability to estimate the proportion of suspected PASC cases. A manual case review to obtain this estimate indicated our sample incidence of PASC (13%) was representative of the estimated population proportion (95% CI: 19±6.22%). However, the high number of cases classified as indeterminate demonstrates the challenges in classifying PASC even among experienced clinicians. Lastly, this study developed a dashboard to display views of aggregated PASC symptoms and measured its utility using the System Usability Scale. Overall comments related to the dashboard's potential were positive. This pipeline is crucial for monitoring post-COVID-19 patients with potential for use in clinical settings.
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Affiliation(s)
- Greg M Silverman
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | | | - James K Glover
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Himanshu S Sahoo
- Department of Electrical and Computer Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Michael Usher
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Rui Zhang
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Farha Ikramuddin
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Tanya E Melnik
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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5
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Castro-Pearson S, Samorodnitsky S, Yang K, Lotfi-Emran S, Ingraham NE, Bramante C, Jones EK, Greising S, Yu M, Steffen B, Svensson J, Åhlberg E, Österberg B, Wacker D, Guan W, Puskarich M, Smed-Sörensen A, Lusczek E, Safo SE, Tignanelli CJ. Development of a proteomic signature associated with severe disease for patients with COVID-19 using data from 5 multicenter, randomized, controlled, and prospective studies. Sci Rep 2023; 13:20315. [PMID: 37985892 PMCID: PMC10661735 DOI: 10.1038/s41598-023-46343-1] [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: 02/28/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023] Open
Abstract
Significant progress has been made in preventing severe COVID-19 disease through the development of vaccines. However, we still lack a validated baseline predictive biologic signature for the development of more severe disease in both outpatients and inpatients infected with SARS-CoV-2. The objective of this study was to develop and externally validate, via 5 international outpatient and inpatient trials and/or prospective cohort studies, a novel baseline proteomic signature, which predicts the development of moderate or severe (vs mild) disease in patients with COVID-19 from a proteomic analysis of 7000 + proteins. The secondary objective was exploratory, to identify (1) individual baseline protein levels and/or (2) protein level changes within the first 2 weeks of acute infection that are associated with the development of moderate/severe (vs mild) disease. For model development, samples collected from 2 randomized controlled trials were used. Plasma was isolated and the SomaLogic SomaScan platform was used to characterize protein levels for 7301 proteins of interest for all studies. We dichotomized 113 patients as having mild or moderate/severe COVID-19 disease. An elastic net approach was used to develop a predictive proteomic signature. For validation, we applied our signature to data from three independent prospective biomarker studies. We found 4110 proteins measured at baseline that significantly differed between patients with mild COVID-19 and those with moderate/severe COVID-19 after adjusting for multiple hypothesis testing. Baseline protein expression was associated with predicted disease severity with an error rate of 4.7% (AUC = 0.964). We also found that five proteins (Afamin, I-309, NKG2A, PRS57, LIPK) and patient age serve as a signature that separates patients with mild COVID-19 and patients with moderate/severe COVID-19 with an error rate of 1.77% (AUC = 0.9804). This panel was validated using data from 3 external studies with AUCs of 0.764 (Harvard University), 0.696 (University of Colorado), and 0.893 (Karolinska Institutet). In this study we developed and externally validated a baseline COVID-19 proteomic signature associated with disease severity for potential use in both outpatients and inpatients with COVID-19.
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Affiliation(s)
- Sandra Castro-Pearson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sarah Samorodnitsky
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kaifeng Yang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sahar Lotfi-Emran
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Carolyn Bramante
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Emma K Jones
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Sarah Greising
- School of Kinesiology, University of Minnesota, Minneapolis, MN, USA
| | - Meng Yu
- Division of Immunology and Allergy, Department of Medicine Solna, Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Brian Steffen
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Julia Svensson
- Division of Immunology and Allergy, Department of Medicine Solna, Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Eric Åhlberg
- Division of Immunology and Allergy, Department of Medicine Solna, Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Björn Österberg
- Division of Immunology and Allergy, Department of Medicine Solna, Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - David Wacker
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Anna Smed-Sörensen
- Division of Immunology and Allergy, Department of Medicine Solna, Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Elizabeth Lusczek
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Sandra E Safo
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
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Avula N, Kakach D, Tignanelli CJ, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Buse JB, Klatt NR, Anderson B, Karger AB, Hartman KM, Patel B, Fenno SL, Reddy NV, Erickson SM, Boulware DR, Murray TA, Bramante CT. Strategies used for the COVID-OUT decentralized trial of outpatient treatment of SARS-CoV-2. J Clin Transl Sci 2023; 7:e242. [PMID: 38033705 PMCID: PMC10685265 DOI: 10.1017/cts.2023.668] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/20/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
The COVID-19 pandemic accelerated the development of decentralized clinical trials (DCT). DCT's are an important and pragmatic method for assessing health outcomes yet comprise only a minority of clinical trials, and few published methodologies exist. In this report, we detail the operational components of COVID-OUT, a decentralized, multicenter, quadruple-blinded, randomized trial that rapidly delivered study drugs nation-wide. The trial examined three medications (metformin, ivermectin, and fluvoxamine) as outpatient treatment of SARS-CoV-2 for their effectiveness in preventing severe or long COVID-19. Decentralized strategies included HIPAA-compliant electronic screening and consenting, prepacking investigational product to accelerate delivery after randomization, and remotely confirming participant-reported outcomes. Of the 1417 individuals with the intention-to-treat sample, the remote nature of the study caused an additional 94 participants to not take any doses of study drug. Therefore, 1323 participants were in the modified intention-to-treat sample, which was the a priori primary study sample. Only 1.4% of participants were lost to follow-up. Decentralized strategies facilitated the successful completion of the COVID-OUT trial without any in-person contact by expediting intervention delivery, expanding trial access geographically, limiting contagion exposure, and making it easy for participants to complete follow-up visits. Remotely completed consent and follow-up facilitated enrollment.
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Affiliation(s)
- Nandini Avula
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Dustin Kakach
- Investigational Drug Service, Fairview Health Services, University of Minnesota Medical Center, Minneapolis, MN, USA
| | | | - David M. Liebovitz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jacinda M. Nicklas
- Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Kenneth Cohen
- UnitedHealth Group, Optum Health, Minnetonka, MN, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, School of Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Hrishikesh K. Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA, USA
| | - John B. Buse
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Nichole R. Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Amy B. Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M. Hartman
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L. Fenno
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Neha V. Reddy
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Spencer M. Erickson
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - David R. Boulware
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A. Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Carolyn T. Bramante
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
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An SJ, Davis D, Peiffer S, Gallaher J, Tignanelli CJ, Charles A. Arrhythmias in Critically Ill Surgical and Non-surgical Patients: A National Propensity-Matched Study. World J Surg 2023; 47:2668-2675. [PMID: 37524957 DOI: 10.1007/s00268-023-07129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Arrhythmias are common in critically ill patients, though the impact of arrhythmias on surgical patients is not well delineated. We aimed to characterize mortality following arrhythmias in critically ill patients. METHODS We performed a propensity-matched retrospective analysis of intensive care unit (ICU) patients from 2007 to 2017 in the Cerner Acute Physiology and Chronic Health Evaluation database. We compared outcomes between patients with and without arrhythmias and those with and without surgical indications for ICU admission. We also modeled predictors of arrhythmias in surgical patients. RESULTS 467,951 patients were included; 97,958 (20.9%) were surgical patients. Arrhythmias occurred in 1.4% of the study cohorts. Predictors of arrhythmias in surgical patients included a history of cardiovascular disease (odds ratio [OR] 1.35, 95% confidence interval [CI95] 1.11-1.63), respiratory failure (OR 1.48, CI95 1.12-1.96), pneumonia (OR 3.17, CI95 1.98-5.10), higher bicarbonate level (OR 1.03, CI95 1.01-1.05), lower albumin level (OR 0.79, CI95 0.68-0.91), and vasopressor requirement (OR 27.2, CI95 22.0-33.7). After propensity matching, surgical patients with arrhythmias had a 42% mortality risk reduction compared to non-surgical patients (risk ratio [RR] 0.58, CI 95 0.43-0.79). Predicted probabilities of mortality for surgical patients were lower at all ages. CONCLUSIONS Surgical patients with arrhythmias are at lower risk of mortality than non-surgical patients. In this propensity-matched analysis, predictors of arrhythmias in critically ill surgical patients included a history of cardiovascular disease, respiratory complications, increased bicarbonate levels, decreased albumin levels, and vasopressor requirement. These findings highlight the differential effect of arrhythmias on different cohorts of critically ill populations.
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Affiliation(s)
- Selena J An
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA
| | - Dylane Davis
- School of Medicine, University of North Carolina at Chapel Hill, 1001 Bondurant Hall, CB 9535, Chapel Hill, NC, 27599, USA
| | - Sarah Peiffer
- Baylor College of Medicine, 1 Moursund St, Houston, TX, 77030, USA
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, 11-132 Phillips-Wangensteen Bldg., 516 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA.
- Department of Surgery, UNC School of Medicine, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA.
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Yang K, Kang Z, Guan W, Lotfi-Emran S, Mayer ZJ, Guerrero CR, Steffen BT, Puskarich MA, Tignanelli CJ, Lusczek E, Safo SE. Developing A Baseline Metabolomic Signature Associated with COVID-19 Severity: Insights from Prospective Trials Encompassing 13 U.S. Centers. Metabolites 2023; 13:1107. [PMID: 37999202 PMCID: PMC10672920 DOI: 10.3390/metabo13111107] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 11/25/2023] Open
Abstract
Metabolic disease is a significant risk factor for severe COVID-19 infection, but the contributing pathways are not yet fully elucidated. Using data from two randomized controlled trials across 13 U.S. academic centers, our goal was to characterize metabolic features that predict severe COVID-19 and define a novel baseline metabolomic signature. Individuals (n = 133) were dichotomized as having mild or moderate/severe COVID-19 disease based on the WHO ordinal scale. Blood samples were analyzed using the Biocrates platform, providing 630 targeted metabolites for analysis. Resampling techniques and machine learning models were used to determine metabolomic features associated with severe disease. Ingenuity Pathway Analysis (IPA) was used for functional enrichment analysis. To aid in clinical decision making, we created baseline metabolomics signatures of low-correlated molecules. Multivariable logistic regression models were fit to associate these signatures with severe disease on training data. A three-metabolite signature, lysophosphatidylcholine a C17:0, dihydroceramide (d18:0/24:1), and triacylglyceride (20:4_36:4), resulted in the best discrimination performance with an average test AUROC of 0.978 and F1 score of 0.942. Pathways related to amino acids were significantly enriched from the IPA analyses, and the mitogen-activated protein kinase kinase 5 (MAP2K5) was differentially activated between groups. In conclusion, metabolites related to lipid metabolism efficiently discriminated between mild vs. moderate/severe disease. SDMA and GABA demonstrated the potential to discriminate between these two groups as well. The mitogen-activated protein kinase kinase 5 (MAP2K5) regulator is differentially activated between groups, suggesting further investigation as a potential therapeutic pathway.
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Affiliation(s)
- Kaifeng Yang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA (S.E.S.)
| | - Zhiyu Kang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA (S.E.S.)
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA (S.E.S.)
| | - Sahar Lotfi-Emran
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Zachary J. Mayer
- Center for Metabolomics and Proteomics, University of Minnesota, Minneapolis, MN 55455, USA
| | - Candace R. Guerrero
- Center for Metabolomics and Proteomics, University of Minnesota, Minneapolis, MN 55455, USA
| | - Brian T. Steffen
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA (E.L.)
| | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55455, USA
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA (E.L.)
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN 55455, USA
| | - Elizabeth Lusczek
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA (E.L.)
| | - Sandra E. Safo
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA (S.E.S.)
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9
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Fawley JA, Tignanelli CJ, Werner NL, Kasotakis G, Mandell SP, Glass NE, Dries DJ, Costantini TW, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for management of acute respiratory distress syndrome and severe hypoxemia. J Trauma Acute Care Surg 2023; 95:592-602. [PMID: 37314843 PMCID: PMC10545067 DOI: 10.1097/ta.0000000000004046] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023]
Abstract
LEVEL OF EVIDENCE Therapeutic/Care Management: Level V.
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10
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Bramante CT, Buse JB, Liebovitz DM, Nicklas JM, Puskarich MA, Cohen K, Belani HK, Anderson BJ, Huling JD, Tignanelli CJ, Thompson JL, Pullen M, Wirtz EL, Siegel LK, Proper JL, Odde DJ, Klatt NR, Sherwood NE, Lindberg SM, Karger AB, Beckman KB, Erickson SM, Fenno SL, Hartman KM, Rose MR, Mehta T, Patel B, Griffiths G, Bhat NS, Murray TA, Boulware DR. Outpatient treatment of COVID-19 and incidence of post-COVID-19 condition over 10 months (COVID-OUT): a multicentre, randomised, quadruple-blind, parallel-group, phase 3 trial. Lancet Infect Dis 2023; 23:1119-1129. [PMID: 37302406 DOI: 10.1016/s1473-3099(23)00299-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/30/2023] [Accepted: 05/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Post-COVID-19 condition (also known as long COVID) is an emerging chronic illness potentially affecting millions of people. We aimed to evaluate whether outpatient COVID-19 treatment with metformin, ivermectin, or fluvoxamine soon after SARS-CoV-2 infection could reduce the risk of long COVID. METHODS We conducted a decentralised, randomised, quadruple-blind, parallel-group, phase 3 trial (COVID-OUT) at six sites in the USA. We included adults aged 30-85 years with overweight or obesity who had COVID-19 symptoms for fewer than 7 days and a documented SARS-CoV-2 positive PCR or antigen test within 3 days before enrolment. Participants were randomly assigned via 2 × 3 parallel factorial randomisation (1:1:1:1:1:1) to receive metformin plus ivermectin, metformin plus fluvoxamine, metformin plus placebo, ivermectin plus placebo, fluvoxamine plus placebo, or placebo plus placebo. Participants, investigators, care providers, and outcomes assessors were masked to study group assignment. The primary outcome was severe COVID-19 by day 14, and those data have been published previously. Because the trial was delivered remotely nationwide, the a priori primary sample was a modified intention-to-treat sample, meaning that participants who did not receive any dose of study treatment were excluded. Long COVID diagnosis by a medical provider was a prespecified, long-term secondary outcome. This trial is complete and is registered with ClinicalTrials.gov, NCT04510194. FINDINGS Between Dec 30, 2020, and Jan 28, 2022, 6602 people were assessed for eligibility and 1431 were enrolled and randomly assigned. Of 1323 participants who received a dose of study treatment and were included in the modified intention-to-treat population, 1126 consented for long-term follow-up and completed at least one survey after the assessment for long COVID at day 180 (564 received metformin and 562 received matched placebo; a subset of participants in the metformin vs placebo trial were also randomly assigned to receive ivermectin or fluvoxamine). 1074 (95%) of 1126 participants completed at least 9 months of follow-up. 632 (56·1%) of 1126 participants were female and 494 (43·9%) were male; 44 (7·0%) of 632 women were pregnant. The median age was 45 years (IQR 37-54) and median BMI was 29·8 kg/m2 (IQR 27·0-34·2). Overall, 93 (8·3%) of 1126 participants reported receipt of a long COVID diagnosis by day 300. The cumulative incidence of long COVID by day 300 was 6·3% (95% CI 4·2-8·2) in participants who received metformin and 10·4% (7·8-12·9) in those who received identical metformin placebo (hazard ratio [HR] 0·59, 95% CI 0·39-0·89; p=0·012). The metformin beneficial effect was consistent across prespecified subgroups. When metformin was started within 3 days of symptom onset, the HR was 0·37 (95% CI 0·15-0·95). There was no effect on cumulative incidence of long COVID with ivermectin (HR 0·99, 95% CI 0·59-1·64) or fluvoxamine (1·36, 0·78-2·34) compared with placebo. INTERPRETATION Outpatient treatment with metformin reduced long COVID incidence by about 41%, with an absolute reduction of 4·1%, compared with placebo. Metformin has clinical benefits when used as outpatient treatment for COVID-19 and is globally available, low-cost, and safe. FUNDING Parsemus Foundation; Rainwater Charitable Foundation; Fast Grants; UnitedHealth Group Foundation; National Institute of Diabetes, Digestive and Kidney Diseases; National Institutes of Health; and National Center for Advancing Translational Sciences.
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Affiliation(s)
- Carolyn T Bramante
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, NC, USA
| | - David M Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View, University of California, Los Angeles, CA, USA
| | - Blake J Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA; Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Pullen
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer L Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David J Odde
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sarah M Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | | | - Spencer M Erickson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L Fenno
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M Hartman
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Michael R Rose
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanvi Mehta
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Gwendolyn Griffiths
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Neeta S Bhat
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
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11
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Alper BS, Dehnbostel J, Shahin K, Ojha N, Khanna G, Tignanelli CJ. Striking a match between FHIR-based patient data and FHIR-based eligibility criteria. Learn Health Syst 2023; 7:e10368. [PMID: 37860063 PMCID: PMC10582208 DOI: 10.1002/lrh2.10368] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 10/21/2023] Open
Abstract
Inputs and Outputs The Strike-a-Match Function, written in JavaScript version ES6+, accepts the input of two datasets (one dataset defining eligibility criteria for research studies or clinical decision support, and one dataset defining characteristics for an individual patient). It returns an output signaling whether the patient characteristics are a match for the eligibility criteria. Purpose Ultimately, such a system will play a "matchmaker" role in facilitating point-of-care recognition of patient-specific clinical decision support. Specifications The eligibility criteria are defined in HL7 FHIR (version R5) EvidenceVariable Resource JSON structure. The patient characteristics are provided in an FHIR Bundle Resource JSON including one Patient Resource and one or more Observation and Condition Resources which could be obtained from the patient's electronic health record. Application The Strike-a-Match Function determines whether or not the patient is a match to the eligibility criteria and an Eligibility Criteria Matching Software Demonstration interface provides a human-readable display of matching results by criteria for the clinician or patient to consider. This is the first software application, serving as proof of principle, that compares patient characteristics and eligibility criteria with all data exchanged using HL7 FHIR JSON. An Eligibility Criteria Matching Software Library at https://fevir.net/110192 provides a method for sharing functions using the same information model.
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Affiliation(s)
- Brian S. Alper
- Computable Publishing LLCIpswichMassachusettsUSA
- Scientific Knowledge Accelerator FoundationIpswichMassachusettsUSA
| | - Joanne Dehnbostel
- Computable Publishing LLCIpswichMassachusettsUSA
- Scientific Knowledge Accelerator FoundationIpswichMassachusettsUSA
| | - Khalid Shahin
- Computable Publishing LLCIpswichMassachusettsUSA
- Scientific Knowledge Accelerator FoundationIpswichMassachusettsUSA
| | | | - Gopal Khanna
- Medical Industry Leadership Institute, Carlson School of ManagementUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Christopher J. Tignanelli
- Department of SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
- Program for Clinical Artificial Intelligence, UMN Center for Learning Health Systems ScienceMinneapolisMinnesotaUSA
- UMN Center for Quality Outcomes, Discovery and EvaluationMinneapolisMinnesotaUSA
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12
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Tignanelli CJ, Arbabi S, Iskander G, Kralovich K, Scott J, Sangji NF, Hemmila MR. Association of Discontinuing Preinjury Beta-Adrenergic Blockade Medications With Mortality in Severe Blunt Traumatic Brian Injury. Ann Surg Open 2023; 4:e324. [PMID: 37746607 PMCID: PMC10513140 DOI: 10.1097/as9.0000000000000324] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 07/14/2023] [Indexed: 09/26/2023] Open
Abstract
Background Beta-adrenergic receptor blocker (BB) administration has been shown to improve survival after traumatic brain injury (TBI). However, studies to date that observe a benefit did not distinguish between continuation of preinjury BB versus de novo initiation of BB. Objectives To determine the effect of continuation of preinjury BB and de novo initiation of BB on risk-adjusted mortality and complications for patients with TBI. Methods Trauma quality collaborative data (2016-2021) were analyzed. Patients were excluded with hospitalization <48 hours, direct admission, or penetrating injury. Severe TBI was identified as a head abbreviated injury scale (AIS) value of 3 to 5. Patients were placed into 4 groups based on the preinjury BB use and administration of BB during hospitalization. Propensity score matching was used to create 1:1 matched cohorts of patients for comparisons. Odd ratios of mortality accounting for hospital clustering were calculated. A sensitivity analysis was performed excluding patients with AIS >2 injuries in all other body regions to create a cohort of isolated TBI patients. Results A total of 15,153 patients treated at 35 trauma centers were available for analysis. Patients were divided into 4 cohort groupings related to preinjury BB use and postinjury receipt of BB. The odds of mortality was significantly reduced for patients with a TBI on a preinjury BB who had the medication continued in the acute setting (as compared with patients on preinjury BB who did not) (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.54-0.98; P = 0.04). Patients with a TBI who were not on preinjury BB did not benefit from de novo initiation of BB with regard to mortality (OR, 0.83; 95% CI, 0.64-1.08; P = 0.2). In the sensitivity analysis, excluding polytrauma patients, patients on preinjury BB who had BB continued had a reduction in mortality when compared with patients in which BB was stopped following a TBI (OR, 0.65; 95% CI, 0.47-0.91; P = 0.01). Conclusions Continuing BB is associated with reduced odds of mortality in patients with a TBI on preinjury BB. We were unable to demonstrate benefit from instituting beta blockade in patients who are not on a BB preinjury.
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Affiliation(s)
| | - Saman Arbabi
- Department of Surgery, University of Washington, Seattle, WA
| | - Gaby Iskander
- Division of Acute Care Surgery, Spectrum Health, Grand Rapids, MI
| | | | - John Scott
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Mark R. Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI
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13
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Jones EK, Ninkovic I, Bahr M, Dodge S, Doering M, Martin D, Ottosen J, Allen T, Melton GB, Tignanelli CJ. A novel, evidence-based, comprehensive clinical decision support system improves outcomes for patients with traumatic rib fractures. J Trauma Acute Care Surg 2023; 95:161-171. [PMID: 37012630 DOI: 10.1097/ta.0000000000003866] [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] [Indexed: 04/05/2023]
Abstract
BACKGROUND Traumatic rib fractures are associated with high morbidity and mortality. Clinical decision support systems (CDSS) have been shown to improve adherence to evidence-based (EB) practice and improve clinical outcomes. The objective of this study was to investigate if a rib fracture CDSS reduced hospital length of stay (LOS), 90-day and 1-year mortality, unplanned ICU transfer, and the need for mechanical ventilation. The independent association of two process measures, an admission EB order set and a pain-inspiratory-cough score early warning system, with LOS were investigated. METHODS The CDSS was scaled across nine US trauma centers. Following multiple imputation, multivariable regression models were fit to evaluate the association of the CDSS on primary and secondary outcomes. As a sensitivity analysis, propensity score matching was also performed to confirm regression findings. RESULTS Overall, 3,279 patients met inclusion criteria. Rates of EB practices increased following implementation. On risk-adjusted analysis, in-hospital LOS preintervention versus postintervention was unchanged (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 0.97-1.15, p = 0.2) but unplanned transfer to the ICU was reduced (odds ratio, 0.28; 95% CI, 0.09-0.84, p = 0.024), as was 1-year mortality (hazard ratio, 0.6; 95% CI, 0.4-0.89, p = 0.01). Provider utilization of the admission order bundle was 45.3%. Utilization was associated with significantly reduced LOS (IRR, 0.87; 95% CI, 0.77-0.98; p = 0.019). The early warning system triggered on 34.4% of patients; however, was not associated with a significant reduction in hospital LOS (IRR, 0.76; 95% CI, 0.55-1.06; p = 0.1). CONCLUSION A novel, user-centered, comprehensive CDSS improves adherence to EB practice and is associated with a significant reduction in unplanned ICU admissions and possibly mortality, but not hospital LOS. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Emma K Jones
- From the Department of Surgery (E.K.J., D.M., G.B.M., C.J.T.), University of Minnesota; Fairview Health Services IT (I.N., S.D., G.B.M.); Trauma Services (M.B., M.D.), Fairview Health Services, Minneapolis; Department of Surgery (J.O.), Essentia Health, Duluth; Department of Radiology (T.A.), Institute for Health Informatics (G.B.M.), University of Minnesota; Fairview Health Services IT (G.B.M., C.J.T.); Center for Learning Health System Sciences (G.B.M., C.J.T.), University of Minnesota, Minneapolis, Minnesota
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14
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Byrd TF, Southwell B, Ravishankar A, Tran T, Kc A, Phelan T, Melton-Meaux GB, Usher MG, Scheppmann D, Switzer S, Simon G, Tignanelli CJ. Validation of a Proprietary Deterioration Index Model and Performance in Hospitalized Adults. JAMA Netw Open 2023; 6:e2324176. [PMID: 37486632 PMCID: PMC10366696 DOI: 10.1001/jamanetworkopen.2023.24176] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Importance The Deterioration Index (DTI), used by hospitals for predicting patient deterioration, has not been extensively validated externally, raising concerns about performance and equitable predictions. Objective To locally validate DTI performance and assess its potential for bias in predicting patient clinical deterioration. Design, Setting, and Participants This retrospective prognostic study included 13 737 patients admitted to 8 heterogenous Midwestern US hospitals varying in size and type, including academic, community, urban, and rural hospitals. Patients were 18 years or older and admitted between January 1 and May 31, 2021. Exposure DTI predictions made every 15 minutes. Main Outcomes and Measures Deterioration, defined as the occurrence of any of the following while hospitalized: mechanical ventilation, intensive care unit transfer, or death. Performance of the DTI was evaluated using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC). Bias measures were calculated across demographic subgroups. Results A total of 5 143 513 DTI predictions were made for 13 737 patients across 14 834 hospitalizations. Among 13 918 encounters, the mean (SD) age of patients was 60.3 (19.2) years; 7636 (54.9%) were female, 11 345 (81.5%) were White, and 12 392 (89.0%) were of other ethnicity than Hispanic or Latino. The prevalence of deterioration was 10.3% (n = 1436). The DTI produced AUROCs of 0.759 (95% CI, 0.756-0.762) at the observation level and 0.685 (95% CI, 0.671-0.700) at the encounter level. Corresponding AUPRCs were 0.039 (95% CI, 0.037-0.040) at the observation level and 0.248 (95% CI, 0.227-0.273) at the encounter level. Bias measures varied across demographic subgroups and were 14.0% worse for patients identifying as American Indian or Alaska Native and 19.0% worse for those who chose not to disclose their ethnicity. Conclusions and Relevance In this prognostic study, the DTI had modest ability to predict patient deterioration, with varying degrees of performance at the observation and encounter levels and across different demographic groups. Disparate performance across subgroups suggests the need for more transparency in model training data and reinforces the need to locally validate externally developed prediction models.
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Affiliation(s)
- Thomas F Byrd
- Department of Medicine, University of Minnesota, Minneapolis
- Institute for Health Informatics, University of Minnesota, Minneapolis
| | | | | | - Travis Tran
- Department of Medicine, University of Minnesota, Minneapolis
| | - Abhinab Kc
- University of Minnesota Medical School, University of Minnesota, Minneapolis
| | - Tom Phelan
- Fairview Health Services, Minneapolis, Minnesota
| | - Genevieve B Melton-Meaux
- Institute for Health Informatics, University of Minnesota, Minneapolis
- Department of Surgery, University of Minnesota, Minneapolis
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis
| | - Michael G Usher
- Department of Medicine, University of Minnesota, Minneapolis
- Institute for Health Informatics, University of Minnesota, Minneapolis
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis
| | - Daren Scheppmann
- Institute for Health Informatics, University of Minnesota, Minneapolis
| | - Sean Switzer
- Department of Medicine, University of Minnesota, Minneapolis
| | - Gyorgy Simon
- Department of Medicine, University of Minnesota, Minneapolis
- Institute for Health Informatics, University of Minnesota, Minneapolis
| | - Christopher J Tignanelli
- Institute for Health Informatics, University of Minnesota, Minneapolis
- Department of Surgery, University of Minnesota, Minneapolis
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis
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15
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Loftus TJ, Altieri MS, Balch JA, Abbott KL, Choi J, Marwaha JS, Hashimoto DA, Brat GA, Raftopoulos Y, Evans HL, Jackson GP, Walsh DS, Tignanelli CJ. Artificial Intelligence-enabled Decision Support in Surgery: State-of-the-art and Future Directions. Ann Surg 2023; 278:51-58. [PMID: 36942574 DOI: 10.1097/sla.0000000000005853] [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] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To summarize state-of-the-art artificial intelligence-enabled decision support in surgery and to quantify deficiencies in scientific rigor and reporting. BACKGROUND To positively affect surgical care, decision-support models must exceed current reporting guideline requirements by performing external and real-time validation, enrolling adequate sample sizes, reporting model precision, assessing performance across vulnerable populations, and achieving clinical implementation; the degree to which published models meet these criteria is unknown. METHODS Embase, PubMed, and MEDLINE databases were searched from their inception to September 21, 2022 for articles describing artificial intelligence-enabled decision support in surgery that uses preoperative or intraoperative data elements to predict complications within 90 days of surgery. Scientific rigor and reporting criteria were assessed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. RESULTS Sample size ranged from 163-2,882,526, with 8/36 articles (22.2%) featuring sample sizes of less than 2000; 7 of these 8 articles (87.5%) had below-average (<0.83) area under the receiver operating characteristic or accuracy. Overall, 29 articles (80.6%) performed internal validation only, 5 (13.8%) performed external validation, and 2 (5.6%) performed real-time validation. Twenty-three articles (63.9%) reported precision. No articles reported performance across sociodemographic categories. Thirteen articles (36.1%) presented a framework that could be used for clinical implementation; none assessed clinical implementation efficacy. CONCLUSIONS Artificial intelligence-enabled decision support in surgery is limited by reliance on internal validation, small sample sizes that risk overfitting and sacrifice predictive performance, and failure to report confidence intervals, precision, equity analyses, and clinical implementation. Researchers should strive to improve scientific quality.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Maria S Altieri
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Jeff Choi
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Stanford University, Stanford, CA
| | - Jayson S Marwaha
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Beth Israel Deaconess Medical Center
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA
| | - Daniel A Hashimoto
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Pennsylvania Perelman School of Medicine
- General Robotics, Automation, Sensing, and Perception Laboratory, University of Pennsylvania School of Engineering and Applied Science, Philadelphia, PA
| | - Gabriel A Brat
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Beth Israel Deaconess Medical Center
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA
| | - Yannis Raftopoulos
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Weight Management Program, Holyoke Medical Center, Holyoke, MA
| | - Heather L Evans
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Gretchen P Jackson
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Digital, Intuitive Surgical, Sunnyvale, CA; Departments of Pediatric Surgery, Pediatrics, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Danielle S Walsh
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Kentucky, Lexington, KY
| | - Christopher J Tignanelli
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery
- Institute for Health Informatics
- Program for Clinical Artificial Intelligence, Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN
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16
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Di Stefano L, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Bengtson CD, Gadomski A, Geriak M, Puskarich MA, Salathe MA, Schutte AE, Tignanelli CJ, Victory J, Bierer BE, Hanley DF, Freilich DA. Losartan in hospitalized patients with COVID-19 in North America: An individual participant data meta-analysis. Medicine (Baltimore) 2023; 102:e33904. [PMID: 37335665 PMCID: PMC10256351 DOI: 10.1097/md.0000000000033904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/11/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (ARBs) have been hypothesized to benefit patients with COVID-19 via the inhibition of viral entry and other mechanisms. We conducted an individual participant data (IPD) meta-analysis assessing the effect of starting the ARB losartan in recently hospitalized COVID-19 patients. METHODS We searched ClinicalTrials.gov in January 2021 for U.S./Canada-based trials where an angiotensin-converting enzyme inhibitors/ARB was a treatment arm, targeted outcomes could be extrapolated, and data sharing was allowed. Our primary outcome was a 7-point COVID-19 ordinal score measured 13 to 16 days post-enrollment. We analyzed data by fitting multilevel Bayesian ordinal regression models and standardizing the resulting predictions. RESULTS 325 participants (156 losartan vs 169 control) from 4 studies contributed IPD. Three were randomized trials; one used non-randomized concurrent and historical controls. Baseline covariates were reasonably balanced for the randomized trials. All studies evaluated losartan. We found equivocal evidence of a difference in ordinal scores 13-16 days post-enrollment (model-standardized odds ratio [OR] 1.10, 95% credible interval [CrI] 0.76-1.71; adjusted OR 1.15, 95% CrI 0.15-3.59) and no compelling evidence of treatment effect heterogeneity among prespecified subgroups. Losartan had worse effects for those taking corticosteroids at baseline after adjusting for covariates (ratio of adjusted ORs 0.29, 95% CrI 0.08-0.99). Hypotension serious adverse event rates were numerically higher with losartan. CONCLUSIONS In this IPD meta-analysis of hospitalized COVID-19 patients, we found no convincing evidence for the benefit of losartan versus control treatment, but a higher rate of hypotension adverse events with losartan.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, CO
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Charles D. Bengtson
- Department of Internal Medicine, University of Kansas Medical Center, KS City, KS
| | - Anne Gadomski
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
| | | | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthias A. Salathe
- Department of Internal Medicine, University of Kansas Medical Center, KS City, KS
| | - Aletta E. Schutte
- School of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Daniel A. Freilich
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, NY
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17
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Bramante CT, Beckman KB, Mehta T, Karger AB, Odde DJ, Tignanelli CJ, Buse JB, Johnson DM, Watson RHB, Daniel JJ, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Siegel LK, Klatt NR, Anderson B, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Fricton RD, Lee S, Griffiths G, Pullen MF, Thompson JL, Sherwood N, Murray TA, Rose MR, Boulware DR, Huling JD. Metformin reduces SARS-CoV-2 in a Phase 3 Randomized Placebo Controlled Clinical Trial. medRxiv 2023:2023.06.06.23290989. [PMID: 37333243 PMCID: PMC10275003 DOI: 10.1101/2023.06.06.23290989] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Current antiviral treatment options for SARS-CoV-2 infections are not available globally, cannot be used with many medications, and are limited to virus-specific targets.1-3 Biophysical modeling of SARS-CoV-2 replication predicted that protein translation is an especially attractive target for antiviral therapy.4 Literature review identified metformin, widely known as a treatment for diabetes, as a potential suppressor of protein translation via targeting of the host mTor pathway.5 In vitro, metformin has antiviral activity against RNA viruses including SARS-CoV-2.6,7 In the COVID-OUT phase 3, randomized, placebo-controlled trial of outpatient treatment of COVID-19, metformin had a 42% reduction in ER visits/hospitalizations/death through 14 days; a 58% reduction in hospitalizations/death through 28 days, and a 42% reduction in Long COVID through 10 months.8,9 Here we show viral load analysis of specimens collected in the COVID-OUT trial that the mean SARS-CoV-2 viral load was reduced 3.6-fold with metformin relative to placebo (-0.56 log10 copies/mL; 95%CI, -1.05 to -0.06, p=0.027) while there was no virologic effect for ivermectin or fluvoxamine vs placebo. The metformin effect was consistent across subgroups and with emerging data.10,11 Our results demonstrate, consistent with model predictions, that a safe, widely available,12 well-tolerated, and inexpensive oral medication, metformin, can be repurposed to significantly reduce SARS-CoV-2 viral load.
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Affiliation(s)
| | | | - Tanvi Mehta
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - David J Odde
- Department of Biomedical Engineering University of Minnesota, Minneapolis, MN
| | | | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, NC
| | | | - Ray H B Watson
- Genomics Center, University of Minnesota, Minneapolis, MN
| | - Jerry J Daniel
- Genomics Center, University of Minnesota, Minneapolis, MN
| | | | | | | | | | - Hrishikesh K Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Via Rao
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Aubrey A Hagen
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah L Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Nandini Avula
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Neha V Reddy
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | | | | | - Samuel Lee
- General Internal Medicine, Northwestern University, Chicago, IL
| | | | - Matthew F Pullen
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN
| | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Nancy Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Michael R Rose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
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18
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Samorodnitsky S, Castro-Pearson S, Yang K, Lotfi-Emran S, Ingraham NE, Bramante C, Geising S, Jones EK, Wacker D, Puskarich M, Lusczek E, Safo S, Tignanelli CJ. Proteomic pathways associated with developing severe disease for patients with COVID-19: A biologic analysis of data from two multicenter randomized controlled trials encompassing 13 U.S. hospitals. J Crit Care 2023. [PMCID: PMC9930204 DOI: 10.1016/j.jcrc.2022.154203] [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: 02/17/2023]
Affiliation(s)
- Sarah Samorodnitsky
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sandra Castro-Pearson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kaifeng Yang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sahar Lotfi-Emran
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Carolyn Bramante
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sarah Geising
- School of Kinesiology, University of Minnesota, Minneapolis, MN, USA
| | - Emma K. Jones
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - David Wacker
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA,Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Elizabeth Lusczek
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA,Corresponding author
| | - Sandra Safo
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA,Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
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Ingraham NE, Jones EK, King S, Dries J, Phillips M, Loftus T, Evans HL, Melton GB, Tignanelli CJ. Re-Aiming Equity Evaluation in Clinical Decision Support: A Scoping Review of Equity Assessments in Surgical Decision Support Systems. Ann Surg 2023; 277:359-364. [PMID: 35943199 PMCID: PMC9905217 DOI: 10.1097/sla.0000000000005661] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE We critically evaluated the surgical literature to explore the prevalence and describe how equity assessments occur when using clinical decision support systems. BACKGROUND Clinical decision support (CDS) systems are increasingly used to facilitate surgical care delivery. Despite formal recommendations to do so, equity evaluations are not routinely performed on CDS systems and underrepresented populations are at risk of harm and further health disparities. We explored surgical literature to determine frequency and rigor of CDS equity assessments and offer recommendations to improve CDS equity by appending existing frameworks. METHODS We performed a scoping review up to Augus 25, 2021 using PubMed and Google Scholar for the following search terms: clinical decision support, implementation, RE-AIM, Proctor, Proctor's framework, equity, trauma, surgery, surgical. We identified 1415 citations and 229 abstracts met criteria for review. A total of 84 underwent full review after 145 were excluded if they did not assess outcomes of an electronic CDS tool or have a surgical use case. RESULTS Only 6% (5/84) of surgical CDS systems reported equity analyses, suggesting that current methods for optimizing equity in surgical CDS are inadequate. We propose revising the RE-AIM framework to include an Equity element (RE 2 -AIM) specifying that CDS foundational analyses and algorithms are performed or trained on balanced datasets with sociodemographic characteristics that accurately represent the CDS target population and are assessed by sensitivity analyses focused on vulnerable subpopulations. CONCLUSION Current surgical CDS literature reports little with respect to equity. Revising the RE-AIM framework to include an Equity element (RE 2 -AIM) promotes the development and implementation of CDS systems that, at minimum, do not worsen healthcare disparities and possibly improve their generalizability.
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Affiliation(s)
- Nicholas E Ingraham
- Department of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN
| | - Emma K Jones
- Department of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN
| | - Samantha King
- Department of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN
| | - James Dries
- Department of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN
| | - Michael Phillips
- Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tyler Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Heather L Evans
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN
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20
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Johnson RA, Eaton A, Tignanelli CJ, Carrabre KJ, Gerges C, Yang GL, Hemmila MR, Ngwenya LB, Wright JM, Parr AM. Changes in patterns of traumatic brain injury in the Michigan Trauma Quality Improvement Program database early in the COVID-19 pandemic. J Neurosurg 2023; 138:465-475. [PMID: 35901671 DOI: 10.3171/2022.5.jns22244] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/17/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The authors' objective was to investigate the impact of the global COVID-19 pandemic on hospital presentation and process of care for the treatment of traumatic brain injuries (TBIs). Improved understanding of these effects will inform sociopolitical and hospital policies in response to future pandemics. METHODS The Michigan Trauma Quality Improvement Program (MTQIP) database, which contains data from 36 level I and II trauma centers in Michigan and Minnesota, was queried to identify patients who sustained TBI on the basis of head/neck Abbreviated Injury Scale (AIS) codes during the periods of March 13 through July 2 of 2017-2019 (pre-COVID-19 period) and March 13, 2020, through July 2, 2020 (COVID-19 period). Analyses were performed to detect differences in incidence, patient characteristics, injury severity, and outcomes. RESULTS There was an 18% decrease in the rate of encounters with TBI in the first 8 weeks (March 13 through May 7), followed by a 16% increase during the last 8 weeks (May 8 through July 2), of our COVID-19 period compared with the pre-COVID-19 period. Cumulatively, there was no difference in the rates of encounters with TBI between the COVID-19 and pre-COVID-19 periods. Severity of TBI, as measured with maximum AIS score for the head/neck region and Glasgow Coma Scale score, was also similar between periods. During the COVID-19 period, a greater proportion of patients with TBI presented more than a day after sustaining their injuries (p = 0.046). COVID-19 was also associated with a doubling in the decubitus ulcer rate from 1.0% to 2.1% (p = 0.002) and change in the distribution of discharge status (p = 0.01). Multivariable analysis showed no differences in odds of death/hospice discharge, intensive care unit stay of at least a day, or need for a ventilator for at least a day between the COVID-19 and pre-COVID-19 periods. CONCLUSIONS During the early months of the COVID-19 pandemic, the number of patients who presented with TBI was initially lower than in the years 2017-2019 prior to the pandemic. However, there was a subsequent increase in the rate of encounters with TBI, resulting in overall similar rates of TBI between March 13 through July 2 during the COVID-19 period and during the pre-COVID-19 period. The COVID-19 cohort was also associated with negative impacts on time to presentation, rate of decubitus ulcers, and discharge with supervision. Policies in response to future pandemics must consider the resources necessary to care for patients with TBI.
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Affiliation(s)
- Reid A Johnson
- 1University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Anne Eaton
- 2Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Christopher J Tignanelli
- 3Department of Surgery, University of Minnesota, Minneapolis, Minnesota.,4Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota
| | - Kailey J Carrabre
- 1University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Christina Gerges
- 5Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - George L Yang
- 6Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio
| | - Mark R Hemmila
- 7Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan; and
| | - Laura B Ngwenya
- 6Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio
| | - James M Wright
- 5Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ann M Parr
- 8Department of Neurosurgery, Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota
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21
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Ikramuddin F, Melnik T, Ingraham NE, Nguyen N, Siegel L, Usher MG, Tignanelli CJ, Morse L. Predictors of discharge disposition and mortality following hospitalization with SARS-CoV-2 infection. PLoS One 2023; 18:e0283326. [PMID: 37053224 PMCID: PMC10101512 DOI: 10.1371/journal.pone.0283326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/07/2023] [Indexed: 04/14/2023] Open
Abstract
IMPORTANCE The SARS-CoV-2 pandemic has overwhelmed hospital capacity, prioritizing the need to understand factors associated with type of discharge disposition. OBJECTIVE Characterization of disposition associated factors following SARS-CoV-2. DESIGN Retrospective study of SARS-CoV-2 positive patients from March 7th, 2020, to May 4th, 2022, requiring hospitalization. SETTING Midwest academic health-system. PARTICIPANTS Patients above the age 18 years admitted with PCR + SARS-CoV-2. INTERVENTION None. MAIN OUTCOMES Discharge to home versus PAC (inpatient rehabilitation facility (IRF), skilled-nursing facility (SNF), long-term acute care (LTACH)), or died/hospice while hospitalized (DH). RESULTS We identified 62,279 SARS-CoV-2 PCR+ patients; 6,248 required hospitalizations, of whom 4611(73.8%) were discharged home, 985 (15.8%) to PAC and 652 (10.4%) died in hospital (DH). Patients discharged to PAC had a higher median age (75.7 years, IQR: 65.6-85.1) compared to those discharged home (57.0 years, IQR: 38.2-69.9), and had longer mean length of stay (LOS) 14.7 days, SD: 14.0) compared to discharge home (5.8 days, SD: 5.9). Older age (RRR:1.04, 95% CI:1.041-1.055), and higher Elixhauser comorbidity index [EI] (RRR:1.19, 95% CI:1.168-1.218) were associated with higher rate of discharge to PAC versus home. Older age (RRR:1.069, 95% CI:1.060-1.077) and higher EI (RRR:1.09, 95% CI:1.071-1.126) were associated with more frequent DH versus home. Blacks, Asians, and Hispanics were less likely to be discharged to PAC (RRR, 0.64 CI 0.47-0.88), (RRR 0.48 CI 0.34-0.67) and (RRR 0.586 CI 0.352-0.975). Having alpha variant was associated with less frequent PAC discharge versus home (RRR 0.589 CI 0.444-780). The relative risks for DH were lower with a higher platelet count 0.998 (CI 0.99-0.99) and albumin levels 0.342 (CI 0.26-0.45), and higher with increased CRP (RRR 1.006 CI 1.004-1.007) and D-Dimer (RRR 1.070 CI 1.039-1.101). Increased albumin had lower risk to PAC discharge (RRR 0.630 CI 0.497-0.798. An increase in D-Dimer (RRR1.033 CI 1.002-1.064) and CRP (RRR1.002 CI1.001-1.004) was associated with higher risk of PAC discharge. A breakthrough (BT) infection was associated with lower likelihood of DH and PAC. CONCLUSION Older age, higher EI, CRP and D-Dimer are associated with PAC and DH discharges following hospitalization with COVID-19 infection. BT infection reduces the likelihood of being discharged to PAC and DH.
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Affiliation(s)
- Farha Ikramuddin
- Department of Rehabilitation Medicine, Division of PM&R, University of Minnesota, Minneapolis, MN, United States of America
| | - Tanya Melnik
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN, United States of America
| | - Nicholas E Ingraham
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN, United States of America
| | - Nguyen Nguyen
- Department of Rehabilitation Medicine, Division of PM&R, University of Minnesota, Minneapolis, MN, United States of America
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
| | - Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Division of Acute Care Surgery, Minneapolis, MN, United States of America
| | - Leslie Morse
- Department of Rehabilitation Medicine, Division of PM&R, University of Minnesota, Minneapolis, MN, United States of America
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22
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Peng L, Luo G, Walker A, Zaiman Z, Jones EK, Gupta H, Kersten K, Burns JL, Harle CA, Magoc T, Shickel B, Steenburg SD, Loftus T, Melton GB, Gichoya JW, Sun J, Tignanelli CJ. Evaluation of federated learning variations for COVID-19 diagnosis using chest radiographs from 42 US and European hospitals. J Am Med Inform Assoc 2022; 30:54-63. [PMID: 36214629 PMCID: PMC9619688 DOI: 10.1093/jamia/ocac188] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/31/2022] [Accepted: 10/07/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Federated learning (FL) allows multiple distributed data holders to collaboratively learn a shared model without data sharing. However, individual health system data are heterogeneous. "Personalized" FL variations have been developed to counter data heterogeneity, but few have been evaluated using real-world healthcare data. The purpose of this study is to investigate the performance of a single-site versus a 3-client federated model using a previously described Coronavirus Disease 19 (COVID-19) diagnostic model. Additionally, to investigate the effect of system heterogeneity, we evaluate the performance of 4 FL variations. MATERIALS AND METHODS We leverage a FL healthcare collaborative including data from 5 international healthcare systems (US and Europe) encompassing 42 hospitals. We implemented a COVID-19 computer vision diagnosis system using the Federated Averaging (FedAvg) algorithm implemented on Clara Train SDK 4.0. To study the effect of data heterogeneity, training data was pooled from 3 systems locally and federation was simulated. We compared a centralized/pooled model, versus FedAvg, and 3 personalized FL variations (FedProx, FedBN, and FedAMP). RESULTS We observed comparable model performance with respect to internal validation (local model: AUROC 0.94 vs FedAvg: 0.95, P = .5) and improved model generalizability with the FedAvg model (P < .05). When investigating the effects of model heterogeneity, we observed poor performance with FedAvg on internal validation as compared to personalized FL algorithms. FedAvg did have improved generalizability compared to personalized FL algorithms. On average, FedBN had the best rank performance on internal and external validation. CONCLUSION FedAvg can significantly improve the generalization of the model compared to other personalization FL algorithms; however, at the cost of poor internal validity. Personalized FL may offer an opportunity to develop both internal and externally validated algorithms.
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Affiliation(s)
- Le Peng
- Department of Computer Science and Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gaoxiang Luo
- Department of Computer Science and Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew Walker
- Department of Computer Science and Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Zachary Zaiman
- Department of Computer Science, Emory University, Atlanta, Georgia, USA
| | - Emma K Jones
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Hemant Gupta
- Fairview Health Services, Minneapolis, Minnesota, USA
| | | | - John L Burns
- The School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Christopher A Harle
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Tanja Magoc
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Benjamin Shickel
- Department of Medicine, University of Florida, Gainesville, Florida, USA
- Intelligent Critical Care Center, University of Florida, Gainesville, Florida, USA
| | - Scott D Steenburg
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tyler Loftus
- Intelligent Critical Care Center, University of Florida, Gainesville, Florida, USA
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Fairview Health Services, Minneapolis, Minnesota, USA
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis, Minnesota, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Ju Sun
- Department of Computer Science and Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis, Minnesota, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
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23
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Hohle RD, Wothe JK, Hillmann BM, Tignanelli CJ, Harmon JV, Vakayil VR. Massive blood transfusion following older adult trauma: The effect of blood ratios on mortality. Acad Emerg Med 2022; 29:1422-1430. [PMID: 35943831 PMCID: PMC10087121 DOI: 10.1111/acem.14580] [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] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/27/2022] [Accepted: 08/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Massive blood transfusion (MBT) following older adult trauma poses unique challenges. Despite extensive evidence on optimal resuscitative strategies in the younger adult patients, there is limited research in the older adult population. METHODS We used the Trauma Quality Improvement Program (TQIP) database from 2013 to 2017 to identify all patients over 65 years old who received a MBT. We stratified our population into six fresh-frozen plasma:packed red blood cell (FFP:pRBC) ratio cohorts (1:1, 1:2, 1:3, 1:4, 1:5, 1:6+). Our primary outcomes were 24-h and 30-day mortality. We constructed multivariable regression models with 1:1 group as the baseline and adjusted for confounders to estimate the independent effect of blood ratios on mortality. RESULTS A total of 3134 patients met our inclusion criteria (median age 73 ± 7.6 years, 65% male). On risk-adjusted multivariable analysis, 1:1 FFP:pRBC ratio was independently associated with lowest 24-h mortality (1:2 odds ratio [OR] 1.60, 95% confidence interval [CI] 1.25-2.06, p < 0.001) and 30-day mortality (1:2 OR 1.44, 95% CI 1.15-1.80, p = 0.002). CONCLUSIONS Compared to all other ratios, the 1:1 FFP:pRBC ratio had the lowest 24-h and 30-day mortality following older adult trauma consistent with findings in the younger adult population.
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Affiliation(s)
- Rae D Hohle
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jillian K Wothe
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Benjamin M Hillmann
- Department of Computer Science and Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - James V Harmon
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Victor R Vakayil
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Bergman ZR, Tignanelli CJ, Gould R, Pendleton KM, Chipman JG, Lusczek E, Beilman G. Factors Associated with Mortality in Patients with COVID-19 Receiving Prolonged Ventilatory Support. Surg Infect (Larchmt) 2022; 23:893-901. [PMID: 36383156 PMCID: PMC9784594 DOI: 10.1089/sur.2022.195] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Since its emergence in early 2020, coronavirus disease 2019 (COVID-19)-associated pneumonia has caused a global strain on intensive care unit (ICU) resources with many intubated patients requiring prolonged ventilatory support. Outcomes for patients with COVID-19 who receive prolonged intubation (>21 days) and possible predictors of mortality in this group are not well established. Patients and Methods: Data were prospectively collected from adult patients with COVID-19 requiring mechanical ventilation from March 2020 through December 2021 across a system of 11 hospitals. The primary end point was in-hospital mortality. Factors associated with mortality were evaluated using univariable and multivariable logistic regression analyses. Results: Six hundred six patients were placed on mechanical ventilation for COVID-19 pneumonia during the study period, with in-hospital mortality of 40.3% (n = 244). Increased age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03-1.09), increased creatinine (OR, 1.40; 95% CI, 1.08-1.82), and receiving corticosteroids (OR, 2.68; 95% CI, 1.20-5.98) were associated with mortality. Intubations lasting longer than 21 days (n = 140) had a lower in-hospital mortality of 25.7% (n = 36; p < 0.001). Increasing Elixhauser comorbidity index (OR, 1.12; 95% CI, 1.04-1.19) and receiving corticosteroids (OR, 1.92; 95% CI, 1.06-3.47) were associated with need for prolonged ventilation. In this group, increased age (OR, 1.06; 95% CI, 1.01-1.08) and non-English speaking (OR, 3.74; 95% CI, 1.13-12.3) were associated with mortality. Conclusions: In-hospital mortality in mechanically ventilated patients with COVID-19 pneumonia occurs primarily in the first 21 days after intubation, possibly related to the early active inflammatory process. In patients on prolonged mechanical ventilation, increased age and being non-English speaking were associated with mortality.
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Affiliation(s)
- Zachary R. Bergman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,Address correspondence to: Dr. Zachary Bergman, Department of Surgery, University of Minnesota, 420 East Delaware Street, Mayo Mail Code 195, Minneapolis, MN 55455, USA
| | | | - Robert Gould
- Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Jeffrey G. Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth Lusczek
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Greg Beilman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,M Health Fairview Health System Management, Minneapolis, Minnesota, USA
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25
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Boulware DR, Murray TA, Proper JL, Tignanelli CJ, Buse JB, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Siegel LK, Klatt NR, Odde DJ, Karger AB, Ingraham NE, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Lindberg S, Fricton R, Lee S, Zaman A, Saveraid HG, Tordsen WJ, Pullen MF, Sherwood NE, Huling JD, Bramante CT. Impact of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Vaccination and Booster on Coronavirus Disease 2019 (COVID-19) Symptom Severity Over Time in the COVID-OUT Trial. Clin Infect Dis 2022; 76:e1-e9. [PMID: 36124697 PMCID: PMC9494422 DOI: 10.1093/cid/ciac772] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/15/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination has decreasing protection from acquiring any infection with emergence of new variants; however, vaccination continues to protect against progression to severe coronavirus disease 2019 (COVID-19). The impact of vaccination status on symptoms over time is less clear. METHODS Within a randomized trial on early outpatient COVID-19 therapy testing metformin, ivermectin, and/or fluvoxamine, participants recorded symptoms daily for 14 days. Participants were given a paper symptom diary allowing them to circle the severity of 14 symptoms as none (0), mild (1), moderate (2), or severe (3). This is a secondary analysis of clinical trial data on symptom severity over time using generalized estimating equations comparing those unvaccinated, SARS-CoV-2 vaccinated with primary vaccine series only, or vaccine-boosted. RESULTS The parent clinical trial prospectively enrolled 1323 participants, of whom 1062 (80%) prospectively recorded some daily symptom data. Of these, 480 (45%) were unvaccinated, 530 (50%) were vaccinated with primary series only, and 52 (5%) vaccine-boosted. Overall symptom severity was least for the vaccine-boosted group and most severe for unvaccinated at baseline and over the 14 days (P < .001). Individual symptoms were least severe in the vaccine-boosted group including cough, chills, fever, nausea, fatigue, myalgia, headache, and diarrhea, as well as smell and taste abnormalities. Results were consistent over Delta and Omicron variant time periods. CONCLUSIONS SARS-CoV-2 vaccine-boosted participants had the least severe symptoms during COVID-19, which abated the quickest over time. Clinical Trial Registration. NCT04510194.
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Affiliation(s)
- David R Boulware
- Alternative Corresponding Author: David R Boulware MD, MPH, CTropMed, FIDSA Professor of Medicine Infectious Disease & International Medicine Department of Medicine
- University of Minnesota Microbiology Research Facility (MRF) 4-103, 689 SE 23rd Ave, Minneapolis, MN 55455 USA
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer L Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - John B Buse
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - David M Liebovitz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jacinda M Nicklas
- Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | - Michael A Puskarich
- Department of Emergency Medicine, School of Medicine, University of Minnesota, Minneapolis, MN, USA,Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA, USA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - David J Odde
- Department of Medicine, Olive View - University of California, Los Angeles, CA, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas E Ingraham
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M Hartman
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Via Rao
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Aubrey A Hagen
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L Fenno
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nandini Avula
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Neha V Reddy
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Spencer M Erickson
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Sarah Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Regina Fricton
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Samuel Lee
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adnin Zaman
- Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Hanna G Saveraid
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Walker J Tordsen
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Matthew F Pullen
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Carolyn T Bramante
- Corresponding Author: Carolyn Bramante, MD MPH Division of General Internal Medicine and Pediatrics University of Minnesota 717 Delaware St SE, MMC 1932 Minneapolis, MN 55414, USA
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26
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Navarro SM, Vakayil VR, Solaiman RH, Keil EJ, Cohen MW, Spartz EJ, Tignanelli CJ, Harmon JV. Risk of hospital admission related to scooter trauma injuries: a national emergency room database study. BMC Emerg Med 2022; 22:150. [PMID: 36050639 PMCID: PMC9438147 DOI: 10.1186/s12873-022-00711-8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 08/24/2022] [Indexed: 11/21/2022] Open
Abstract
Background We investigated key risk factors for hospital admission related to powered scooters, which are modes of transportation with increasing accessibility across the United States (US). Methods We queried the National Electronic Injury Surveillance System (NEISS) for injuries related to powered scooters, obtaining US population projections of injuries and hospital admissions. We determined mechanism of injury, characterized injury types, and performed multivariate regression analyses to determine factors associated with hospital admission. Results One thousand one hundred ninety-one patients sustained electric-motorized scooter (e-scooter) injuries and 10.9% (131) required hospitalization from 2013 to 2018. This extrapolated to a US annual total of 862 (95% CI:745–979) scooter injuries requiring hospitalization, with estimated annual mortality of 6.7 patients per year (95% CI:4.8–8.5). The incidence of hospital admissions increased by an average of 13.1% each year of the study period. Fall (79 [60%]) and motor vehicle collision (33 [25%]) were the most common mechanism. Injury locations included head (44 [34%]), lower extremity (22 [17%]), and lower trunk (16 [12%]). On multivariable analysis, significant factors associated with admission included increased age (OR 1.02, 95% CI:1.01–1.02), torso injuries (OR 6.19, 2.93–13.10), concussion (25.45, 5.88–110.18), fractures (21.98, 7.13–67.66), musculoskeletal injury (6.65, 1.20–36.99), and collision with vehicle (3.343, 2.009–5.562). Scooter speed, seasonality, and gender were not associated with risk of hospitalization. Conclusion Our findings show increased hospital admissions and mortality from powered scooter trauma, with fall and motor vehicle collisions as the most common mechanisms resulting in hospitalization. This calls for improved rider safety measures and regulation surrounding vehicular collision scenarios.
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Affiliation(s)
- Sergio M Navarro
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA. .,Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK.
| | - Victor R Vakayil
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Rafat H Solaiman
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Evan J Keil
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Matthew W Cohen
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Ellen J Spartz
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | | | - James V Harmon
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
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27
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Jones EK, Hultman G, Schmoke K, Ninkovic I, Dodge S, Bahr M, Melton GB, Marquard J, Tignanelli CJ. Combined Expert and User-Driven Usability Assessment of Trauma Decision Support Systems Improves User-Centered Design. Surgery 2022; 172:1537-1548. [PMID: 36031451 DOI: 10.1016/j.surg.2022.05.037] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/11/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Trauma clinical decision support systems improve adherence with evidence-based practice but suffer from poor usability and the lack of a user-centered design. The objective of this study was to compare the effectiveness of user and expert-driven usability testing methods to detect usability issues in a rib fracture clinical decision support system and identify guiding principles for trauma clinical decision support systems. METHODS A user-driven and expert-driven usability investigation was conducted using a clinical decision support system developed for patients with rib fractures. The user-driven usability evaluation was as follows: 10 clinicians were selected for simulation-based usability testing using snowball sampling, and each clinician completed 3 simulations using a video-conferencing platform. End-users participated in a novel team-based approach that simulated realistic clinical workflows. The expert-driven heuristic evaluation was as follows: 2 usability experts conducted a heuristic evaluation of the clinical decision support system using 10 common usability heuristics. Usability issues were identified, cataloged, and ranked for severity using a 4-level ordinal scale. Thematic analysis was utilized to categorize the identified usability issues. RESULTS Seventy-nine usability issues were identified; 63% were identified by experts and 48% by end-users. Notably, 58% of severe usability issues were identified by experts alone. Only 11% of issues were identified by both methods. Five themes were identified that could guide the design of clinical decision support systems-transparency, functionality and integration into workflow, automated and noninterruptive, flexibility, and layout and appearance. Themes were preferentially identified by different methods. CONCLUSION We found that a dual-method usability evaluation involving usability experts and end-users drastically improved detection of usability issues over single-method alone. We identified 5 themes to guide trauma clinical decision support system design. Performing usability testing via a remote video-conferencing platform facilitated multi-site involvement despite a global pandemic.
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Affiliation(s)
- Emma K Jones
- Department of Surgery, University of Minnesota, Minneapolis, MN.
| | - Gretchen Hultman
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN
| | - Kristine Schmoke
- Veterans Health Administration, Department of Veterans Affairs, Washington, DC
| | | | - Sarah Dodge
- Fairview Health Services IT, Minneapolis, MN
| | - Matthew Bahr
- Trauma Services, Fairview Health Services, Minneapolis, MN
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, Minneapolis, MN; Institute for Health Informatics, University of Minnesota, Minneapolis, MN; Fairview Health Services IT, Minneapolis, MN; Center for Learning Health System Sciences, University of Minnesota, Minneapolis, MN
| | - Jenna Marquard
- School of Nursing, University of Minnesota, Minneapolis, MN
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN; Institute for Health Informatics, University of Minnesota, Minneapolis, MN; Center for Learning Health System Sciences, University of Minnesota, Minneapolis, MN
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28
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Gnanenthiran SR, Borghi C, Burger D, Caramelli B, Charchar F, Chirinos JA, Cohen JB, Cremer A, Di Tanna GL, Duvignaud A, Freilich D, Gommans DHF, Gracia-Ramos AE, Murray TA, Pelorosso F, Poulter NR, Puskarich MA, Rizas KD, Rothlin R, Schlaich MP, Schreinlecher M, Steckelings UM, Sharma A, Stergiou GS, Tignanelli CJ, Tomaszewski M, Unger T, van Kimmenade RRJ, Wainford RD, Williams B, Rodgers A, Schutte AE. Renin-Angiotensin System Inhibitors in Patients With COVID-19: A Meta-Analysis of Randomized Controlled Trials Led by the International Society of Hypertension. J Am Heart Assoc 2022; 11:e026143. [PMID: 36000426 PMCID: PMC9496439 DOI: 10.1161/jaha.122.026143] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Published randomized controlled trials are underpowered for binary clinical end points to assess the safety and efficacy of renin‐angiotensin system inhibitors (RASi) in adults with COVID‐19. We therefore performed a meta‐analysis to assess the safety and efficacy of RASi in adults with COVID‐19. Methods and Results MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Controlled Trial Register were searched for randomized controlled trials that randomly assigned patients with COVID‐19 to RASi continuation/commencement versus no RASi therapy. The primary outcome was all‐cause mortality at ≤30 days. A total of 14 randomized controlled trials met the inclusion criteria and enrolled 1838 participants (aged 59 years, 58% men, mean follow‐up 26 days). Of the trials, 11 contributed data. We found no effect of RASi versus control on all‐cause mortality (7.2% versus 7.5%; relative risk [RR], 0.95; [95% CI, 0.69–1.30]) either overall or in subgroups defined by COVID‐19 severity or trial type. Network meta‐analysis identified no difference between angiotensin‐converting enzyme inhibitors versus angiotensin II receptor blockers. RASi users had a nonsignificant reduction in acute myocardial infarction (2.1% versus 3.6%; RR, 0.59; [95% CI, 0.33–1.06]), but increased risk of acute kidney injury (7.0% versus 3.6%; RR, 1.82; [95% CI, 1.05–3.16]), in trials that initiated and continued RASi. There was no increase in need for dialysis or differences in congestive cardiac failure, cerebrovascular events, venous thromboembolism, hospitalization, intensive care admission, inotropes, or mechanical ventilation. Conclusions This meta‐analysis of randomized controlled trials evaluating angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers versus control in patients with COVID‐19 found no difference in all‐cause mortality, a borderline decrease in myocardial infarction, and an increased risk of acute kidney injury with RASi. Our findings provide strong evidence that RASi can be used safely in patients with COVID‐19.
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Affiliation(s)
- Sonali R Gnanenthiran
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Claudio Borghi
- Department of Medical and Surgical Sciences University of Bologna Italy
| | - Dylan Burger
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Ottawa Hospital Research Institute University of Ottawa Canada
| | - Bruno Caramelli
- Interdisciplinary Medicine in Cardiology Unit, InCor University of Sao Paulo Brazil
| | - Fadi Charchar
- School of Health and Life Sciences Federation University Australia Ballarat VIC Australia
| | - Julio A Chirinos
- Division of Cardiovascular Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division and Department of Biostatistics, Epidemiology, and Informatics University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Antoine Cremer
- Department of Cardiology and Hypertension, Hypertension Excellence Center Hôpital Saint André, Centre Hospitalier Universitaire de Bordeaux & University Bordeaux Bordeaux France
| | - Gian Luca Di Tanna
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Alexandre Duvignaud
- Department of Infectious Diseases and Tropical Medicine, Division of Tropical Medicine and Clinical International Health Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux & University Bordeaux Bordeaux France
| | | | - D H Frank Gommans
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Abraham E Gracia-Ramos
- Departamento de Medicina Interna, Hospital General, Centro Médico Nacional "La Raza" Instituto Mexicano del Seguro Social Mexico City Mexico.,Departamento de Medicina Interna Hospital Regional de Alta Especialidad de Zumpango Estado de Mexico Mexico
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health University of Minnesota Minneapolis MN
| | - Facundo Pelorosso
- Asociacion Argentina de Medicamentos Ciudad Autonoma de Buenos Aires Argentina.,Servicio de Anatomía Patologica, Hospital de Alta Complejidad El Calafate SAMIC Santa Cruz Argentina
| | - Neil R Poulter
- Imperial Clinical Trials Unit Imperial College London London UK
| | - Michael A Puskarich
- Department of Emergency Medicine Hennepin County Medical Center University of Minnesota Minneapolis MN
| | - Konstantinos D Rizas
- Medizinische Klinik und Poliklinik I Ludwig Maximilian University Hospital Munich Munich Germany
| | - Rodolfo Rothlin
- Asociacion Argentina de Medicamentos Ciudad Autonoma de Buenos Aires Argentina.,Sociedad Argentina de Farmacología Clínica, Asociacion Medica Argentina Buenos Aires Argentina
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, Royal Perth Hospital Unit-Royal Perth Hospital Medical Research Foundation University of Western Australia Perth Australia
| | - Michael Schreinlecher
- Department of Internal Medicine III, Cardiology and Angiology Medical University of Innsbruck Innsbruck Austria
| | | | - Abhinav Sharma
- Division of Cardiology McGill University Health Centre Montreal Quebec Canada
| | - George S Stergiou
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital National and Kapodistrian University of Athens Athens Greece
| | | | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health University of Manchester Manchester UK.,Manchester Academic Health Science Centre Manchester University National Health Service Foundation Trust Manchester Manchester UK
| | - Thomas Unger
- Cardiovascular Research Institute Maastricht-School for Cardiovascular Diseases Maastricht University Maastricht The Netherlands
| | - Roland R J van Kimmenade
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Richard D Wainford
- Department of Pharmacology and Experimental Therapeutics and the Whitaker Cardiovascular Institute Boston University School of Medicine Boston MA
| | - Bryan Williams
- Institute of Cardiovascular Science University College London and National Institute for Health Research University College London Hospitals Biomedical Research Centre London UK
| | - Anthony Rodgers
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Aletta E Schutte
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
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29
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Bramante CT, Huling JD, Tignanelli CJ, Buse JB, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Proper JL, Siegel LK, Klatt NR, Odde DJ, Luke DG, Anderson B, Karger AB, Ingraham NE, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Lindberg S, Fricton R, Lee S, Zaman A, Saveraid HG, Tordsen WJ, Pullen MF, Biros M, Sherwood NE, Thompson JL, Boulware DR, Murray TA. Randomized Trial of Metformin, Ivermectin, and Fluvoxamine for Covid-19. N Engl J Med 2022; 387:599-610. [PMID: 36070710 PMCID: PMC9945922 DOI: 10.1056/nejmoa2201662] [Citation(s) in RCA: 107] [Impact Index Per Article: 53.5] [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: 12/15/2022]
Abstract
BACKGROUND Early treatment to prevent severe coronavirus disease 2019 (Covid-19) is an important component of the comprehensive response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHODS In this phase 3, double-blind, randomized, placebo-controlled trial, we used a 2-by-3 factorial design to test the effectiveness of three repurposed drugs - metformin, ivermectin, and fluvoxamine - in preventing serious SARS-CoV-2 infection in nonhospitalized adults who had been enrolled within 3 days after a confirmed diagnosis of infection and less than 7 days after the onset of symptoms. The patients were between the ages of 30 and 85 years, and all had either overweight or obesity. The primary composite end point was hypoxemia (≤93% oxygen saturation on home oximetry), emergency department visit, hospitalization, or death. All analyses used controls who had undergone concurrent randomization and were adjusted for SARS-CoV-2 vaccination and receipt of other trial medications. RESULTS A total of 1431 patients underwent randomization; of these patients, 1323 were included in the primary analysis. The median age of the patients was 46 years; 56% were female (6% of whom were pregnant), and 52% had been vaccinated. The adjusted odds ratio for a primary event was 0.84 (95% confidence interval [CI], 0.66 to 1.09; P = 0.19) with metformin, 1.05 (95% CI, 0.76 to 1.45; P = 0.78) with ivermectin, and 0.94 (95% CI, 0.66 to 1.36; P = 0.75) with fluvoxamine. In prespecified secondary analyses, the adjusted odds ratio for emergency department visit, hospitalization, or death was 0.58 (95% CI, 0.35 to 0.94) with metformin, 1.39 (95% CI, 0.72 to 2.69) with ivermectin, and 1.17 (95% CI, 0.57 to 2.40) with fluvoxamine. The adjusted odds ratio for hospitalization or death was 0.47 (95% CI, 0.20 to 1.11) with metformin, 0.73 (95% CI, 0.19 to 2.77) with ivermectin, and 1.11 (95% CI, 0.33 to 3.76) with fluvoxamine. CONCLUSIONS None of the three medications that were evaluated prevented the occurrence of hypoxemia, an emergency department visit, hospitalization, or death associated with Covid-19. (Funded by the Parsemus Foundation and others; COVID-OUT ClinicalTrials.gov number, NCT04510194.).
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Affiliation(s)
- Carolyn T Bramante
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Jared D Huling
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Christopher J Tignanelli
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - John B Buse
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - David M Liebovitz
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Jacinda M Nicklas
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Kenneth Cohen
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Michael A Puskarich
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Hrishikesh K Belani
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Jennifer L Proper
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Lianne K Siegel
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Nichole R Klatt
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - David J Odde
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Darlette G Luke
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Blake Anderson
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Amy B Karger
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Nicholas E Ingraham
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Katrina M Hartman
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Via Rao
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Aubrey A Hagen
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Barkha Patel
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Sarah L Fenno
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Nandini Avula
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Neha V Reddy
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Spencer M Erickson
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Sarah Lindberg
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Regina Fricton
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Samuel Lee
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Adnin Zaman
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Hanna G Saveraid
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Walker J Tordsen
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Matthew F Pullen
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Michelle Biros
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Nancy E Sherwood
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Jennifer L Thompson
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - David R Boulware
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Thomas A Murray
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
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Lim S, Tignanelli CJ, Hoertel N, Boulware DR, Usher MG. Prevalence of medical contraindications to nirmatrelvir/ritonavir in a cohort of hospitalized and non-hospitalized patients with COVID-19. Open Forum Infect Dis 2022; 9:ofac389. [PMID: 36000003 PMCID: PMC9384640 DOI: 10.1093/ofid/ofac389] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/01/2022] [Indexed: 11/21/2022] Open
Abstract
This analysis describes the prevalence of contraindications to nirmatrelvir/ritonavir among 66 007 patients with coronavirus disease 2019 in a large health care system. A possible contradiction was present in 9830 patients (14.8%), with the prevalence of contraindications increasing with higher acuity of illness.
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Affiliation(s)
- Sarah Lim
- Minnesota Department of Health , St. Paul, MN , USA
| | | | - Nicolas Hoertel
- Université de Paris, AP-HP, Hôpital Corentin-Celton, DMU Psychiatrie et Addictologie, INSERM U1266, Institut de Psychiatrie et Neuroscience de Paris , F-75014 Paris , France
| | - David R Boulware
- Department of Medicine, University of Minnesota , Minneapolis, MN , USA
| | - Michael G Usher
- Department of Medicine, University of Minnesota , Minneapolis, MN , USA
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Sun J, Peng L, Li T, Adila D, Zaiman Z, Melton-Meaux GB, Ingraham NE, Murray E, Boley D, Switzer S, Burns JL, Huang K, Allen T, Steenburg SD, Gichoya JW, Kummerfeld E, Tignanelli CJ. Performance of a Chest Radiograph AI Diagnostic Tool for COVID-19: A Prospective Observational Study. Radiol Artif Intell 2022; 4:e210217. [PMID: 35923381 PMCID: PMC9344211 DOI: 10.1148/ryai.210217] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/31/2022] [Accepted: 05/11/2022] [Indexed: 05/27/2023]
Abstract
PURPOSE To conduct a prospective observational study across 12 U.S. hospitals to evaluate real-time performance of an interpretable artificial intelligence (AI) model to detect COVID-19 on chest radiographs. MATERIALS AND METHODS A total of 95 363 chest radiographs were included in model training, external validation, and real-time validation. The model was deployed as a clinical decision support system, and performance was prospectively evaluated. There were 5335 total real-time predictions and a COVID-19 prevalence of 4.8% (258 of 5335). Model performance was assessed with use of receiver operating characteristic analysis, precision-recall curves, and F1 score. Logistic regression was used to evaluate the association of race and sex with AI model diagnostic accuracy. To compare model accuracy with the performance of board-certified radiologists, a third dataset of 1638 images was read independently by two radiologists. RESULTS Participants positive for COVID-19 had higher COVID-19 diagnostic scores than participants negative for COVID-19 (median, 0.1 [IQR, 0.0-0.8] vs 0.0 [IQR, 0.0-0.1], respectively; P < .001). Real-time model performance was unchanged over 19 weeks of implementation (area under the receiver operating characteristic curve, 0.70; 95% CI: 0.66, 0.73). Model sensitivity was higher in men than women (P = .01), whereas model specificity was higher in women (P = .001). Sensitivity was higher for Asian (P = .002) and Black (P = .046) participants compared with White participants. The COVID-19 AI diagnostic system had worse accuracy (63.5% correct) compared with radiologist predictions (radiologist 1 = 67.8% correct, radiologist 2 = 68.6% correct; McNemar P < .001 for both). CONCLUSION AI-based tools have not yet reached full diagnostic potential for COVID-19 and underperform compared with radiologist prediction.Keywords: Diagnosis, Classification, Application Domain, Infection, Lung Supplemental material is available for this article.. © RSNA, 2022.
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Usher MG, Tignanelli CJ, Hilliard B, Kaltenborn ZP, Lupei MI, Simon G, Shah S, Kirsch JD, Melton GB, Ingraham NE, Olson AP, Baum KD. Responding to COVID-19 Through Interhospital Resource Coordination: A Mixed-Methods Evaluation. J Patient Saf 2022; 18:287-294. [PMID: 34569998 PMCID: PMC8940726 DOI: 10.1097/pts.0000000000000916] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The COVID-19 pandemic stressed hospital operations, requiring rapid innovations to address rise in demand and specialized COVID-19 services while maintaining access to hospital-based care and facilitating expertise. We aimed to describe a novel hospital system approach to managing the COVID-19 pandemic, including multihospital coordination capability and transfer of COVID-19 patients to a single, dedicated hospital. METHODS We included patients who tested positive for SARS-CoV-2 by polymerase chain reaction admitted to a 12-hospital network including a dedicated COVID-19 hospital. Our primary outcome was adherence to local guidelines, including admission risk stratification, anticoagulation, and dexamethasone treatment assessed by differences-in-differences analysis after guideline dissemination. We evaluated outcomes and health care worker satisfaction. Finally, we assessed barriers to safe transfer including transfer across different electronic health record systems. RESULTS During the study, the system admitted a total of 1209 patients. Of these, 56.3% underwent transfer, supported by a physician-led System Operations Center. Patients who were transferred were older (P = 0.001) and had similar risk-adjusted mortality rates. Guideline adherence after dissemination was higher among patients who underwent transfer: admission risk stratification (P < 0.001), anticoagulation (P < 0.001), and dexamethasone administration (P = 0.003). Transfer across electronic health record systems was a perceived barrier to safety and reduced quality. Providers positively viewed our transfer approach. CONCLUSIONS With standardized communication, interhospital transfers can be a safe and effective method of cohorting COVID-19 patients, are well received by health care providers, and have the potential to improve care quality.
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Affiliation(s)
- Michael G. Usher
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota Medical School
- Institute for Health Informatics, University of Minnesota
| | - Brian Hilliard
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Zachary P. Kaltenborn
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | | | - Gyorgy Simon
- Institute for Health Informatics, University of Minnesota
| | - Surbhi Shah
- Division of Hematology and Oncology, Department of Medicine
| | - Jonathan D. Kirsch
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Genevieve B. Melton
- Department of Surgery, University of Minnesota Medical School
- Institute for Health Informatics, University of Minnesota
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Andrew P.J. Olson
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Karyn D. Baum
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
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Morris RS, Figueroa JF, Pokrzywa CJ, Barber JK, Temkin NR, Bergner C, Karam BS, Murphy P, Nelson LD, Laud P, Cooper Z, de Moya M, Trevino C, Tignanelli CJ, deRoon-Cassini TA. Predicting outcomes after traumatic brain injury: A novel hospital prediction model for a patient reported outcome. Am J Surg 2022; 224:1150-1155. [DOI: 10.1016/j.amjsurg.2022.05.016] [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] [Received: 02/11/2022] [Revised: 04/14/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
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Abdelwahab N, Ingraham NE, Nguyen N, Siegel L, Silverman G, Sahoo HS, Pakhomov S, Morse LR, Billings J, Usher MG, Melnik TE, Tignanelli CJ, Ikramuddin F. Predictors of Post-Acute Sequelae of COVID-19 Development and Rehabilitation: A Retrospective Study. Arch Phys Med Rehabil 2022; 103:2001-2008. [PMID: 35569640 PMCID: PMC9098397 DOI: 10.1016/j.apmr.2022.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 04/08/2022] [Accepted: 04/13/2022] [Indexed: 12/02/2022]
Abstract
Objective To examine the frequency of postacute sequelae of SARS-CoV-2 (PASC) and the factors associated with rehabilitation utilization in a large adult population with PASC. Design Retrospective study. Setting Midwest hospital health system. Participants 19,792 patients with COVID-19 from March 10, 2020, to January 17, 2021. Intervention Not applicable. Main Outcome Measures Descriptive analyses were conducted across the entire cohort along with an adult subgroup analysis. A logistic regression was performed to assess factors associated with PASC development and rehabilitation utilization. Results In an analysis of 19,792 patients, the frequency of PASC was 42.8% in the adult population. Patients with PASC compared with those without had a higher utilization of rehabilitation services (8.6% vs 3.8%, P<.001). Risk factors for rehabilitation utilization in patients with PASC included younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-1.00; P=.01). In addition to several comorbidities and demographics factors, risk factors for rehabilitation utilization solely in the inpatient population included male sex (OR, 1.24; 95% CI, 1.02-1.50; P=.03) with patients on angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers 3 months prior to COVID-19 infections having a decreased risk of needing rehabilitation (OR, 0.80; 95% CI, 0.64-0.99; P=.04). Conclusions Patients with PASC had higher rehabilitation utilization. We identified several clinical and demographic factors associated with the development of PASC and rehabilitation utilization.
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Affiliation(s)
- Nermine Abdelwahab
- Department of Medicine, University of Minnesota, Division of General Internal Medicine, Minneapolis, MN.
| | - Nicholas E Ingraham
- Department of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN
| | - Nguyen Nguyen
- Department of Rehabilitation Medicine, University of Minnesota, Division of PM&R, Minneapolis, MN
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Greg Silverman
- Department of Surgery, University of Minnesota Division of Acute Care Surgery, Minneapolis, MN
| | - Himanshu Shekhar Sahoo
- Department of Surgery, University of Minnesota Division of Acute Care Surgery, Minneapolis, MN; Department of Electrical and Computer Engineering, University of Minnesota, Minneapolis, MN
| | - Serguei Pakhomov
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN
| | - Leslie R Morse
- Department of Rehabilitation Medicine, University of Minnesota, Division of PM&R, Minneapolis, MN
| | - Joanne Billings
- Department of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN
| | - Michael G Usher
- Department of Medicine, University of Minnesota, Division of General Internal Medicine, Minneapolis, MN
| | - Tanya E Melnik
- Department of Medicine, University of Minnesota, Division of General Internal Medicine, Minneapolis, MN
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Division of Acute Care Surgery, Minneapolis, MN; Institute for Health Informatics, University of Minnesota, Minneapolis, MN
| | - Farha Ikramuddin
- Department of Rehabilitation Medicine, University of Minnesota, Division of PM&R, Minneapolis, MN
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Kushniruk A, Banks A, Melton GB, Porta CM, Tignanelli CJ. Barriers to and Facilitators for Acceptance of Comprehensive Clinical Decision Support System-Driven Care Maps for Patients With Thoracic Trauma: Interview Study Among Health Care Providers and Nurses. JMIR Hum Factors 2022; 9:e29019. [PMID: 35293873 PMCID: PMC8968578 DOI: 10.2196/29019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 11/04/2021] [Accepted: 12/19/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Comprehensive clinical decision support (CDS) care maps can improve the delivery of care and clinical outcomes. However, they are frequently plagued by usability problems and poor user acceptance. OBJECTIVE This study aims to characterize factors influencing successful design and use of comprehensive CDS care maps and identify themes associated with end-user acceptance of a thoracic trauma CDS care map earlier in the process than has traditionally been done. This was a planned adaptive redesign stage of a User Acceptance and System Adaptation Design development and implementation strategy for a CDS care map. This stage was based on a previously developed prototype CDS care map guided by the Unified Theory of Acceptance and Use of Technology. METHODS A total of 22 multidisciplinary end users (physicians, advanced practice providers, and nurses) were identified and recruited using snowball sampling. Qualitative interviews were conducted, audio-recorded, and transcribed verbatim. Generation of prespecified codes and the interview guide was informed by the Unified Theory of Acceptance and Use of Technology constructs and investigative team experience. Interviews were blinded and double-coded. Thematic analysis of interview scripts was conducted and yielded descriptive themes about factors influencing the construction and potential use of an acceptable CDS care map. RESULTS A total of eight dominant themes were identified: alert fatigue (theme 1), automation (theme 2), redundancy (theme 3), minimalistic design (theme 4), evidence based (theme 5), prevent errors (theme 6), comprehensive across the spectrum of disease (theme 7), and malleability (theme 8). Themes 1 to 4 addressed factors directly affecting end users, and themes 5 to 8 addressed factors affecting patient outcomes. More experienced providers prioritized a system that is easy to use. Nurses prioritized a system that incorporated evidence into decision support. Clinicians across specialties, roles, and ages agreed that the amount of extra work generated should be minimal and that the system should help them administer optimal care efficiently. CONCLUSIONS End user feedback reinforces attention toward factors that improve the acceptance and use of a CDS care map for patients with thoracic trauma. Common themes focused on system complexity, the ability of the system to fit different populations and settings, and optimal care provision. Identifying these factors early in the development and implementation process may facilitate user-centered design and improve adoption.
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Affiliation(s)
| | - Alyssa Banks
- University of Minnesota, Minneapolis, MN, United States
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Carolyn M Porta
- School of Nursing, University of Minnesota, Minneapolis, MN, United States
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States.,Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, United States
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Puskarich MA, Ingraham NE, Merck LH, Driver BE, Wacker DA, Black LP, Jones AE, Fletcher CV, South AM, Murray TA, Lewandowski C, Farhat J, Benoit JL, Biros MH, Cherabuddi K, Chipman JG, Schacker TW, Guirgis FW, Voelker HT, Koopmeiners JS, Tignanelli CJ. Efficacy of Losartan in Hospitalized Patients With COVID-19-Induced Lung Injury: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e222735. [PMID: 35294537 PMCID: PMC8928006 DOI: 10.1001/jamanetworkopen.2022.2735] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/23/2022] [Indexed: 12/14/2022] Open
Abstract
Importance SARS-CoV-2 viral entry may disrupt angiotensin II (AII) homeostasis, contributing to COVID-19 induced lung injury. AII type 1 receptor blockade mitigates lung injury in preclinical models, although data in humans with COVID-19 remain mixed. Objective To test the efficacy of losartan to reduce lung injury in hospitalized patients with COVID-19. Design, Setting, and Participants This blinded, placebo-controlled randomized clinical trial was conducted in 13 hospitals in the United States from April 2020 to February 2021. Hospitalized patients with COVID-19 and a respiratory sequential organ failure assessment score of at least 1 and not already using a renin-angiotensin-aldosterone system (RAAS) inhibitor were eligible for participation. Data were analyzed from April 19 to August 24, 2021. Interventions Losartan 50 mg orally twice daily vs equivalent placebo for 10 days or until hospital discharge. Main Outcomes and Measures The primary outcome was the imputed arterial partial pressure of oxygen to fraction of inspired oxygen (Pao2:Fio2) ratio at 7 days. Secondary outcomes included ordinal COVID-19 severity; days without supplemental o2, ventilation, or vasopressors; and mortality. Losartan pharmacokinetics and RAAS components (AII, angiotensin-[1-7] and angiotensin-converting enzymes 1 and 2)] were measured in a subgroup of participants. Results A total of 205 participants (mean [SD] age, 55.2 [15.7] years; 123 [60.0%] men) were randomized, with 101 participants assigned to losartan and 104 participants assigned to placebo. Compared with placebo, losartan did not significantly affect Pao2:Fio2 ratio at 7 days (difference, -24.8 [95%, -55.6 to 6.1]; P = .12). Compared with placebo, losartan did not improve any secondary clinical outcomes and led to fewer vasopressor-free days than placebo (median [IQR], 9.4 [9.1-9.8] vasopressor-free days vs 8.7 [8.2-9.3] vasopressor-free days). Conclusions and Relevance This randomized clinical trial found that initiation of orally administered losartan to hospitalized patients with COVID-19 and acute lung injury did not improve Pao2:Fio2 ratio at 7 days. These data may have implications for ongoing clinical trials. Trial Registration ClinicalTrials.gov Identifier: NCT04312009.
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Affiliation(s)
- Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Lisa H. Merck
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | - Brian E. Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - David A. Wacker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Lauren Page Black
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson
| | | | - Andrew M. South
- Section of Nephrology, Department of Pediatrics, Wake Forest School of Medicine and Brenner Children's Hospital, Winston Salem, North Carolina
- Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, North Carolina
- Department of Surgery-Hypertension and Vascular Research, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Thomas A. Murray
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Christopher Lewandowski
- Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, Michigan
| | - Joseph Farhat
- Department of Surgery, North Memorial Medical Center, Minneapolis, Minnesota
| | - Justin L. Benoit
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michelle H. Biros
- Department of Emergency Medicine, University of Minnesota, Minneapolis
| | - Kartik Cherabuddi
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | | | - Timothy W. Schacker
- Division of Infectious Disease, Department of Medicine, University of Minnesota, Minneapolis
| | - Faheem W. Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville
| | - Helen T. Voelker
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Joseph S. Koopmeiners
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
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Bramante CT, Proper JL, Boulware DR, Karger A, Murray T, Rao V, Hagen A, Tignanelli CJ, Puskarich M, Cohen K, Liebovitz DM, Klatt NR, Broedlow C, Hartman KM, Nicklas J, Ibrahim S, Zaman A, Saveraid H, Belani H, Ingraham N, Christensen G, Siegel L, Sherwood NE, Fricton R, Lee S, Odde DJ, Buse JB, Huling JD. Vaccination against SARS-CoV-2 is associated with a lower viral load and likelihood of systemic symptoms. Open Forum Infect Dis 2022; 9:ofac066. [PMID: 35392460 PMCID: PMC8982774 DOI: 10.1093/ofid/ofac066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/15/2022] [Indexed: 11/24/2022] Open
Abstract
Background Data conflict on whether vaccination decreases severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load. The objective of this analysis was to compare baseline viral load and symptoms between vaccinated and unvaccinated adults enrolled in a randomized trial of outpatient coronavirus disease 2019 (COVID-19) treatment. Methods Baseline data from the first 433 sequential participants enrolling into the COVID-OUT trial were analyzed. Adults aged 30–85 with a body mass index (BMI) ≥25 kg/m2 were eligible within 3 days of a positive SARS-CoV-2 test and <7 days of symptoms. Log10 polymerase chain reaction viral loads were normalized to human RNase P by vaccination status, by time from vaccination, and by symptoms. Results Two hundred seventy-four participants with known vaccination status contributed optional nasal swabs for viral load measurement: median age, 46 years; median (interquartile range) BMI 31.2 (27.4–36.4) kg/m2. Overall, 159 (58%) were women, and 217 (80%) were White. The mean relative log10 viral load for those vaccinated <6 months from the date of enrollment was 0.11 (95% CI, –0.48 to 0.71), which was significantly lower than the unvaccinated group (P = .01). Those vaccinated ≥6 months before enrollment did not differ from the unvaccinated with respect to viral load (mean, 0.99; 95% CI, –0.41 to 2.40; P = .85). The vaccinated group had fewer moderate/severe symptoms of subjective fever, chills, myalgias, nausea, and diarrhea (all P < .05). Conclusions These data suggest that vaccination within 6 months of infection is associated with a lower viral load, and vaccination was associated with a lower likelihood of having systemic symptoms.
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Affiliation(s)
- Carolyn T Bramante
- General Internal Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Jennifer L Proper
- Biostatistics, University of Minnesota School of Public Health, Minneapolis, USA
| | - David R Boulware
- Infectious Diseases & International Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Amy Karger
- Laboratory Medicine & Pathology, University of Minnesota Medical School, Minneapolis, USA
| | - Thomas Murray
- Biostatistics, University of Minnesota School of Public Health, Minneapolis, USA
| | - Via Rao
- General Internal Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Aubrey Hagen
- General Internal Medicine, University of Minnesota Medical School, Minneapolis, USA
| | | | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Ken Cohen
- Optum Center for Research and Innovation, Optum, Minnetonka, USA
| | - David M Liebovitz
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Nichole R Klatt
- Surgery, University of Minnesota Medical School, Minneapolis, USA
| | | | - Katrina M Hartman
- General Internal Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Jacinda Nicklas
- General Internal Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Sherehan Ibrahim
- General Internal Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Adnin Zaman
- General Internal Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Hanna Saveraid
- General Internal Medicine, University of Minnesota Medical School, Minneapolis, USA
| | | | - Nicholas Ingraham
- Pulmonary, Allergy, Critical Care & Sleep Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Grace Christensen
- General Internal Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Lianne Siegel
- Biostatistics, University of Minnesota School of Public Health, Minneapolis, USA
| | - Nancy E Sherwood
- Epidemiology, University of Minnesota School of Public Health, Minneapolis, USA
| | - Regina Fricton
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Sam Lee
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - David J Odde
- Biomedical Engineering, University of Minnesota, Minneapolis, USA
| | - John B Buse
- Endocrinology, University of North Carolina School of Medicine, Chapel Hill, USA
| | - Jared D Huling
- Biostatistics, University of Minnesota School of Public Health, Minneapolis, USA
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Ingraham NE, Vakayil V, Pendleton KM, Robbins AJ, Freese RL, Palzer EF, Charles A, Dudley RA, Tignanelli CJ. Recent Trends in Admission Diagnosis and Related Mortality in the Medically Critically Ill. J Intensive Care Med 2022; 37:185-194. [PMID: 33353475 DOI: 10.1177/0885066620982905] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE With decades of declining ICU mortality, we hypothesized that the outcomes and distribution of diseases cared for in the ICU have changed and we aimed to further characterize them. STUDY DESIGN AND METHODS A retrospective cohort analysis of 287,154 nonsurgical-critically ill adults, from 237 U.S. ICUs, using the manually abstracted Cerner APACHE Outcomes database from 2008 to 2016 was performed. Surgical patients, rare admission diagnoses (<100 occurrences), and low volume hospitals (<100 total admissions) were excluded. Diagnoses were distributed into mutually exclusive organ system/disease-based categories based on admission diagnosis. Multi-level mixed-effects negative binomial regression was used to assess temporal trends in admission, in-hospital mortality, and length of stay (LOS). RESULTS The number of ICU admissions remained unchanged (IRR 0.99, 0.98-1.003) while certain organ system/disease groups increased (toxicology [25%], hematologic/oncologic [55%] while others decreased (gastrointestinal [31%], pulmonary [24%]). Overall risk-adjusted in-hospital mortality was unchanged (IRR 0.98, 0.96-1.0004). Risk-adjusted ICU LOS (Estimate -0.06 days/year, -0.07 to -0.04) decreased. Risk-adjusted mortality varied significantly by disease. CONCLUSION Risk-adjusted ICU mortality rate did not change over the study period, but there was evidence of shifting disease burden across the critical care population. Our data provides useful information regarding future ICU personnel and resource needs.
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Affiliation(s)
- Nicholas E Ingraham
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
| | - Victor Vakayil
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kathryn M Pendleton
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alexandria J Robbins
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
| | - Rebecca L Freese
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, 311816University of Minnesota, Minneapolis, MN, USA
| | - Elise F Palzer
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, 311816University of Minnesota, Minneapolis, MN, USA
| | - Anthony Charles
- Department of Surgery, 2331University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Gillings School of Global Public Health, 2331University of North Carolina, Chapel Hill, NC, USA
| | - R Adams Dudley
- Department of Medicine, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- School of Public Health, 311816University of Minnesota, Minneapolis, MN, USA
- Institute for Health Informatics, 311816University of Minnesota Academic Health Center, Minneapolis, MN, USA
| | - Christopher J Tignanelli
- Department of Surgery, 311816University of Minnesota Medical School, Minneapolis, MN, USA
- Institute for Health Informatics, 311816University of Minnesota Academic Health Center, Minneapolis, MN, USA
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, USA
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Lupei MI, Li D, Ingraham NE, Baum KD, Benson B, Puskarich M, Milbrandt D, Melton GB, Scheppmann D, Usher MG, Tignanelli CJ. A 12-hospital prospective evaluation of a clinical decision support prognostic algorithm based on logistic regression as a form of machine learning to facilitate decision making for patients with suspected COVID-19. PLoS One 2022; 17:e0262193. [PMID: 34986168 PMCID: PMC8730444 DOI: 10.1371/journal.pone.0262193] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/20/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To prospectively evaluate a logistic regression-based machine learning (ML) prognostic algorithm implemented in real-time as a clinical decision support (CDS) system for symptomatic persons under investigation (PUI) for Coronavirus disease 2019 (COVID-19) in the emergency department (ED). METHODS We developed in a 12-hospital system a model using training and validation followed by a real-time assessment. The LASSO guided feature selection included demographics, comorbidities, home medications, vital signs. We constructed a logistic regression-based ML algorithm to predict "severe" COVID-19, defined as patients requiring intensive care unit (ICU) admission, invasive mechanical ventilation, or died in or out-of-hospital. Training data included 1,469 adult patients who tested positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) within 14 days of acute care. We performed: 1) temporal validation in 414 SARS-CoV-2 positive patients, 2) validation in a PUI set of 13,271 patients with symptomatic SARS-CoV-2 test during an acute care visit, and 3) real-time validation in 2,174 ED patients with PUI test or positive SARS-CoV-2 result. Subgroup analysis was conducted across race and gender to ensure equity in performance. RESULTS The algorithm performed well on pre-implementation validations for predicting COVID-19 severity: 1) the temporal validation had an area under the receiver operating characteristic (AUROC) of 0.87 (95%-CI: 0.83, 0.91); 2) validation in the PUI population had an AUROC of 0.82 (95%-CI: 0.81, 0.83). The ED CDS system performed well in real-time with an AUROC of 0.85 (95%-CI, 0.83, 0.87). Zero patients in the lowest quintile developed "severe" COVID-19. Patients in the highest quintile developed "severe" COVID-19 in 33.2% of cases. The models performed without significant differences between genders and among race/ethnicities (all p-values > 0.05). CONCLUSION A logistic regression model-based ML-enabled CDS can be developed, validated, and implemented with high performance across multiple hospitals while being equitable and maintaining performance in real-time validation.
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Affiliation(s)
- Monica I. Lupei
- Division of Critical Care, Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Danni Li
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Nicholas E. Ingraham
- Division of Pulmonary and Critical Care, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Karyn D. Baum
- Division of General Internal Medicine, Department of Medicine, Section of Hospital Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Bradley Benson
- Division of General Internal Medicine, Department of Medicine, Section of Hospital Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - David Milbrandt
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Genevieve B. Melton
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Daren Scheppmann
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Michael G. Usher
- Division of General Internal Medicine, Department of Medicine, Section of Hospital Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, United States of America
- Division of Critical Care and Acute Care Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
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Ingraham NE, Purcell LN, Karam BS, Dudley RA, Usher MG, Warlick CA, Allen ML, Melton GB, Charles A, Tignanelli CJ. Racial and Ethnic Disparities in Hospital Admissions from COVID-19: Determining the Impact of Neighborhood Deprivation and Primary Language. J Gen Intern Med 2021; 36:3462-3470. [PMID: 34003427 PMCID: PMC8130213 DOI: 10.1007/s11606-021-06790-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/01/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite past and ongoing efforts to achieve health equity in the USA, racial and ethnic disparities persist and appear to be exacerbated by COVID-19. OBJECTIVE Evaluate neighborhood-level deprivation and English language proficiency effect on disproportionate outcomes seen in racial and ethnic minorities diagnosed with COVID-19. DESIGN Retrospective cohort study SETTING: Health records of 12 Midwest hospitals and 60 clinics in Minnesota between March 4, 2020, and August 19, 2020 PATIENTS: Polymerase chain reaction-positive COVID-19 patients EXPOSURES: Area Deprivation Index (ADI) and primary language MAIN MEASURES: The primary outcome was COVID-19 severity, using hospitalization within 45 days of diagnosis as a marker of severity. Logistic and competing-risk regression models assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race, effects of ADI and primary language were measured using logistic regression. RESULTS A total of 5577 individuals infected with SARS-CoV-2 were included; 866 (n = 15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p < 0.001) and more likely to be male (n = 425 [49.1%] vs. 2049 [43.5%], p = 0.002). Of those requiring hospitalization, 43.9% (n = 381), 19.9% (n = 172), 18.6% (n = 161), and 11.8% (n = 102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity: Hispanic patients (OR 3.8, 95% CI 2.72-5.30), Asians (OR 2.39, 95% CI 1.74-3.29), and Blacks (OR 1.50, 95% CI 1.15-1.94). ADI was not associated with hospitalization. Non-English-speaking (OR 1.91, 95% CI 1.51-2.43) significantly increased odds of hospital admission across and within minority groups. CONCLUSIONS Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the ongoing need to determine the mechanisms that contribute to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity among minority groups.
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Affiliation(s)
- Nicholas E. Ingraham
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN USA
| | - Laura N. Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, NC USA
| | - Basil S. Karam
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI USA
| | - R. Adams Dudley
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN USA
| | - Michael G. Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN USA
| | | | - Michele L. Allen
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN USA
| | - Genevieve B. Melton
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, University of Minnesota, Minneapolis, MN USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, NC USA
- School of Public Health, University of North Carolina, Chapel Hill, NC USA
| | - Christopher J. Tignanelli
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN USA
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Hozayen SM, Zychowski D, Benson S, Lutsey PL, Haslbauer J, Tzankov A, Kaltenborn Z, Usher M, Shah S, Tignanelli CJ, Demmer RT. Outpatient and inpatient anticoagulation therapy and the risk for hospital admission and death among COVID-19 patients. EClinicalMedicine 2021; 41:101139. [PMID: 34585129 PMCID: PMC8461367 DOI: 10.1016/j.eclinm.2021.101139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/27/2021] [Accepted: 09/07/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state. Limited data exist informing the relationship between anticoagulation therapy and risk for COVID-19 related hospitalization and mortality. METHODS We evaluated all patients over the age of 18 diagnosed with COVID-19 in a prospective cohort study from March 4th to August 27th, 2020 among 12 hospitals and 60 clinics of M Health Fairview system (USA). We investigated the relationship between (1) 90-day anticoagulation therapy among outpatients before COVID-19 diagnosis and the risk for hospitalization and mortality and (2) Inpatient anticoagulation therapy and mortality risk. FINDINGS Of 6195 patients, 598 were immediately hospitalized and 5597 were treated as outpatients. The overall case-fatality rate was 2•8% (n = 175 deaths). Among the patients who were hospitalized, the inpatient mortality was 13%. Among the 5597 COVID-19 patients initially treated as outpatients, 160 (2.9%) were on anticoagulation and 331 were eventually hospitalized (5.9%). In a multivariable analysis, outpatient anticoagulation use was associated with a 43% reduction in risk for hospital admission, HR (95% CI = 0.57, 0.38-0.86), p = 0.007, but was not associated with mortality, HR (95% CI=0.88, 0.50 - 1.52), p = 0.64. Inpatients who were not on anticoagulation (before or after hospitalization) had an increased risk for mortality, HR (95% CI = 2.26, 1.17-4.37), p = 0.015. INTERPRETATION Outpatients with COVID-19 who were on outpatient anticoagulation at the time of diagnosis experienced a 43% reduced risk of hospitalization. Failure to initiate anticoagulation upon hospitalization or maintaining outpatient anticoagulation in hospitalized COVID-19 patients was associated with increased mortality risk. FUNDING No funding was obtained for this study.
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Key Words
- %, percentage
- (n), number
- ACEi, angiotensin-converting enzyme inhibitors
- ARBs, angiotensin receptor blockers
- Anticoagulation
- CI, confidence intervals
- CKD, chronic kidney disease
- CO2, carbon dioxide
- COPD, chronic obstructive pulmonary disease
- COVID-19
- COVID-19, coronavirus disease 2019
- D-dimer
- DIC, disseminated intravascular coagulation
- DOAC, direct oral anticoagulant
- EHR, electronic health records
- EMR, electronic medical records
- HCT, hematocrit
- HIT, heparin-induced thrombocytopenia
- HR, hazard ratio
- Hospitalization
- IPAC, inpatient anticoagulation therapy
- IRB, institutional review board
- Inpatient
- MI, prior myocardial infarction
- Mortality
- OPAC, outpatient persistent anticoagulation therapy
- Outpatient
- RDW, red blood cell distribution width
- SARS-CoV-2, severe Acute Respiratory Syndrome Coronavirus-2
- SBP, systolic blood pressure
- SBP-min, minimum systolic blood pressure
- SD, standard deviations
- SE, standard errors
- SpO2-min, minimum oxygen saturation
- T1DM, type 1 diabetes mellitus
- T2DM, type 2 diabetes mellitus
- VTE, venous thromboembolism
- WBC, white blood cell
- mg/dl, milligram per deciliter
- rt-PCR, reverse transcriptase-polymerase chain reaction
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Affiliation(s)
- Sameh M. Hozayen
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
- Corresponding author.
| | - Diana Zychowski
- Department of Medical Education, University of Minnesota, United States
| | - Sydney Benson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Jasmin Haslbauer
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Switzerland
| | - Alexandar Tzankov
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Switzerland
| | - Zachary Kaltenborn
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
| | - Michael Usher
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
| | - Surbhi Shah
- Department of Hematology and oncology, Mayo Clinic, Arizona, United States
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, United States
| | - Ryan T. Demmer
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
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Sangji NF, Cain-Nielsen AH, Neiman P, Tignanelli CJ, Scott JW, Hemmila MR. Calculation and Feedback of Risk-adjusted Antibiotic Days as a Process Measure in a Statewide Trauma Collaborative. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.577] [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: 11/26/2022]
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Silverman GM, Sahoo HS, Ingraham NE, Lupei M, Puskarich MA, Usher M, Dries J, Finzel RL, Murray E, Sartori J, Simon G, Zhang R, Melton GB, Tignanelli CJ, Pakhomov SVS. NLP Methods for Extraction of Symptoms from Unstructured Data for Use in Prognostic COVID-19 Analytic Models. J ARTIF INTELL RES 2021. [DOI: 10.1613/jair.1.12631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Statistical modeling of outcomes based on a patient's presenting symptoms (symptomatology) can help deliver high quality care and allocate essential resources, which is especially important during the COVID-19 pandemic. Patient symptoms are typically found in unstructured notes, and thus not readily available for clinical decision making. In an attempt to fill this gap, this study compared two methods for symptom extraction from Emergency Department (ED) admission notes. Both methods utilized a lexicon derived by expanding The Center for Disease Control and Prevention's (CDC) Symptoms of Coronavirus list. The first method utilized a word2vec model to expand the lexicon using a dictionary mapping to the Uni ed Medical Language System (UMLS). The second method utilized the expanded lexicon as a rule-based gazetteer and the UMLS. These methods were evaluated against a manually annotated reference (f1-score of 0.87 for UMLS-based ensemble; and 0.85 for rule-based gazetteer with UMLS). Through analyses of associations of extracted symptoms used as features against various outcomes, salient risks among the population of COVID-19 patients, including increased risk of in-hospital mortality (OR 1.85, p-value < 0.001), were identified for patients presenting with dyspnea. Disparities between English and non-English speaking patients were also identified, the most salient being a concerning finding of opposing risk signals between fatigue and in-hospital mortality (non-English: OR 1.95, p-value = 0.02; English: OR 0.63, p-value = 0.01). While use of symptomatology for modeling of outcomes is not unique, unlike previous studies this study showed that models built using symptoms with the outcome of in-hospital mortality were not significantly different from models using data collected during an in-patient encounter (AUC of 0.9 with 95% CI of [0.88, 0.91] using only vital signs; AUC of 0.87 with 95% CI of [0.85, 0.88] using only symptoms). These findings indicate that prognostic models based on symptomatology could aid in extending COVID-19 patient care through telemedicine, replacing the need for in-person options. The methods presented in this study have potential for use in development of symptomatology-based models for other diseases, including for the study of Post-Acute Sequelae of COVID-19 (PASC).
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Morris RS, Tignanelli CJ, deRoon-Cassini T, Laud P, Sparapani R. Improved Prediction of Older Adult Discharge After Trauma Using a Novel Machine Learning Paradigm. J Surg Res 2021; 270:39-48. [PMID: 34628162 DOI: 10.1016/j.jss.2021.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/16/2021] [Accepted: 08/27/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The ability to reliably predict outcomes after trauma in older adults (age ≥ 65 y) is critical for clinical decision making. Using novel machine-learning techniques, we sought to design a nonlinear, competing risks paradigm for prediction of older adult discharge disposition following injury. MATERIALS AND METHODS The National Trauma Databank (NTDB) was used to identify patients 65+ y between 2007 and 2014. Training was performed on an enriched cohort of diverse patients. Factors included age, comorbidities, length of stay, and physiologic parameters to predict in-hospital mortality and discharge disposition (home versus skilled nursing/long-term care facility). Length of stay and discharge status were analyzed via competing risks survival analysis with Bayesian additive regression trees and a multinomial mixed model. RESULTS The resulting sample size was 47,037 patients. Admission GCS and age were important in predicting mortality and discharge disposition. As GCS decreased, patients were more likely to die (risk ratio increased by average of 1.4 per 2-point drop in GCS, P < 0.001). As GCS decreased, patients were also more likely to be discharged to a skilled nursing or long-term care facility (risk ratio decreased by 0.08 per 2-point decrease in GCS, P< 0.001). The area under curve for prediction of discharge home was improved in the competing risks model 0.73 versus 0.43 in the traditional multinomial mixed model. CONCLUSIONS Predicting older adult discharge disposition after trauma is improved using machine learning over traditional regression analysis. We confirmed that a nonlinear, competing risks paradigm enhances prediction on any given hospital day post injury.
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Affiliation(s)
- Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota; Department of Surgery, North Memorial Medical Center, Robbinsdale, Minnesota; Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota
| | | | - Purushottam Laud
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
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Jenkins PC, Dixon BE, Savage SA, Carroll AE, Newgard CD, Tignanelli CJ, Hemmila MR, Timsina L. Comparison of a trauma comorbidity index with other measures of comorbidities to estimate risk of trauma mortality. Acad Emerg Med 2021; 28:1150-1159. [PMID: 33914402 DOI: 10.1111/acem.14270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Comorbidities influence the outcomes of injured patients, yet a lack of consensus exists regarding how to quantify that association. This study details the development and internal validation of a trauma comorbidity index (TCI) designed for use with trauma registry data and compares its performance to other existing measures to estimate the association between comorbidities and mortality. METHODS Indiana state trauma registry data (2013-2015) were used to compare the TCI with the Charlson and Elixhauser comorbidity indices, a count of comorbidities, and comorbidities as separate variables. The TCI approach utilized a randomly selected training cohort and was internally validated in a distinct testing cohort. The C-statistic of the adjusted models was tested using each comorbidity measure in the testing cohort to assess model discrimination. C-statistics were compared using a Wald test, and stratified analyses were performed based on predicted risk of mortality. Multiple imputation was used to address missing data. RESULTS The study included 84,903 patients (50% each in training and testing cohorts). The Indiana TCI model demonstrated no significant difference between testing and training cohorts (p = 0.33). It produced a C-statistic of 0.924 in the testing cohort, which was significantly greater than that of models using the other indices (p < 0.05). The C-statistics of models using the Indiana TCI and the inclusion of comorbidities as separate variables-the method used by the American College of Surgeons Trauma Quality Improvement Program-were comparable (p = 0.11) but use of the TCI approach reduced the number of comorbidity-related variables in the mortality model from 19 to one. CONCLUSIONS When examining trauma mortality, the TCI approach using Indiana state trauma registry data demonstrated superior model discrimination and/or parsimony compared to other measures of comorbidities.
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Affiliation(s)
- Peter C. Jenkins
- Department of Surgery Indiana University School of Medicine Indianapolis Indiana USA
| | - Brian E. Dixon
- Regenstrief Institute Indianapolis Indiana USA
- Indiana UniversityRichard M. Fairbanks School of Public Health Indianapolis Indiana USA
| | | | - Aaron E. Carroll
- Regenstrief Institute Indianapolis Indiana USA
- Pediatric and Adolescent Comparative Effectiveness Research Department of Pediatrics Indiana University School of Medicine Indianapolis Indiana USA
| | - Craig D. Newgard
- Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland Oregon USA
| | - Christopher J. Tignanelli
- Department of Surgery University of Minnesota School of Medicine Minneapolis Minnesota USA
- Department of Surgery North Memorial Health Hospital Robbinsdale Minnesota USA
- Institute for Health Informatics University of Minnesota Minneapolis Minnesota USA
| | - Mark R. Hemmila
- Department of Surgery University of Michigan School of Medicine Ann Arbor Michigan USA
| | - Lava Timsina
- Department of Surgery Indiana University School of Medicine Indianapolis Indiana USA
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Bramante CT, Buse J, Tamaritz L, Palacio A, Cohen K, Vojta D, Liebovitz D, Mitchell N, Nicklas J, Lingvay I, Clark JM, Aronne LJ, Anderson E, Usher M, Demmer R, Melton GB, Ingraham N, Tignanelli CJ. Back Cover Image, Volume 93, Number 7, July 2021. J Med Virol 2021. [DOI: 10.1002/jmv.26961] [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: 11/08/2022]
Affiliation(s)
- Carolyn T. Bramante
- Department of Medicine, Division of General Internal Medicine University of Minnesota Minneapolis Minnesota USA
| | - John Buse
- Department of Medicine, Division of Endocrinology University of North Carolina Chapel Hill North Carolina USA
| | - Leonardo Tamaritz
- Humana Health Services Research Center, Miami University Miami Florida USA
| | - Ana Palacio
- Humana Health Services Research Center, Miami University Miami Florida USA
| | - Ken Cohen
- UnitedHealth Group Research and Development Minnetonka Minnesota USA
| | - Deneen Vojta
- UnitedHealth Group Research and Development Minnetonka Minnesota USA
| | - David Liebovitz
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Nia Mitchell
- Department of Medicine Duke University School of Medicine Durham North Carolina USA
| | - Jacinda Nicklas
- Department of Medicine, Division of General Internal Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Ildiko Lingvay
- Department of Medicine/Endocrinology UT Southwestern Medical Center Dallas Texas USA
- Department of Population and Data Sciences UT Southwestern Medical Center Dallas Texas USA
| | - Jeanne M. Clark
- Department of Medicine, Division of General Internal Medicine John Hopkins Baltimore Maryland USA
| | - Louis J. Aronne
- Department of Medicine Weill Cornell Medicine New York New York USA
| | - Erik Anderson
- Department of Emergency Medicine Alameda County Oakland California USA
| | - Michael Usher
- Department of Medicine, Division of General Internal Medicine University of Minnesota Minneapolis Minnesota USA
| | - Ryan Demmer
- Department of Epidemiology, Division of Epidemiology and Community Health University of Minnesota School of Public Health Minneapolis Minnesota USA
| | - Genevieve B. Melton
- Department of Medicine, Division of Pulmonary Medicine University of Minnesota Minneapolis Minnesota USA
| | - Nicholas Ingraham
- Department of Surgery, Division of Surgical Oncology University of Minnesota Minneapolis Minnesota USA
| | - Christopher J. Tignanelli
- Department of Medicine, Division of Pulmonary Medicine University of Minnesota Minneapolis Minnesota USA
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47
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Puskarich MA, Cummins NW, Ingraham NE, Wacker DA, Reilkoff RA, Driver BE, Biros MH, Bellolio F, Chipman JG, Nelson AC, Beckman K, Langlois R, Bold T, Aliota MT, Schacker TW, Voelker HT, Murray TA, Koopmeiners JS, Tignanelli CJ. A multi-center phase II randomized clinical trial of losartan on symptomatic outpatients with COVID-19. EClinicalMedicine 2021; 37:100957. [PMID: 34195577 PMCID: PMC8225661 DOI: 10.1016/j.eclinm.2021.100957] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The SARS-CoV-2 virus enters cells via Angiotensin-converting enzyme 2 (ACE2), disrupting the renin-angiotensin-aldosterone axis, potentially contributing to lung injury. Treatment with angiotensin receptor blockers (ARBs), such as losartan, may mitigate these effects, though induction of ACE2 could increase viral entry, replication, and worsen disease. METHODS This study represents a placebo-controlled blinded randomized clinical trial (RCT) to test the efficacy of losartan on outpatients with COVID-19 across three hospital systems with numerous community sites in Minnesota, U.S. Participants included symptomatic outpatients with COVID-19 not already taking ACE-inhibitors or ARBs, enrolled within 7 days of symptom onset. Patients were randomized to 1:1 losartan (25 mg orally twice daily unless estimated glomerular filtration rate, eGFR, was reduced, when dosing was reduced to once daily) versus placebo for 10 days, and all patients and outcome assesors were blinded. The primary outcome was all-cause hospitalization within 15 days. Secondary outcomes included functional status, dyspnea, temperature, and viral load. (clinicatrials.gov, NCT04311177, closed to new participants). FINDINGS From April to November 2020, 117 participants were randomized 58 to losartan and 59 to placebo, and all were analyzed under intent to treat principles. The primary outcome did not differ significantly between the two arms based on Barnard's test [losartan arm: 3 events (5.2% 95% CI 1.1, 14.4%) versus placebo arm: 1 event (1.7%; 95% CI 0.0, 9.1%)]; proportion difference -3.5% (95% CI -13.2, 4.8%); p = 0.32]. Viral loads were not statistically different between treatment groups at any time point. Adverse events per 10 patient days did not differ signifcantly [0.33 (95% CI 0.22-0.49) for losartan vs. 0.37 (95% CI 0.25-0.55) for placebo]. Due to a lower than expected hospitalization rate and low likelihood of a clinically important treatment effect, the trial was terminated early. INTERPRETATION In this multicenter blinded RCT for outpatients with mild symptomatic COVID-19 disease, losartan did not reduce hospitalizations, though assessment was limited by low event rate. Importantly, viral load was not statistically affected by treatment. This study does not support initiation of losartan for low-risk outpatients.
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Affiliation(s)
- Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Nathan W. Cummins
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David A. Wacker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ronald A. Reilkoff
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Michelle H. Biros
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fernanda Bellolio
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Andrew C. Nelson
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Kenneth Beckman
- University of Minnesota Genomics Center, University of Minnesota, Minneapolis, MN, USA
| | - Ryan Langlois
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN, USA
| | - Tyler Bold
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Matthew T. Aliota
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Twin Cities, St. Paul, MN, USA
| | - Timothy W. Schacker
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Helen T. Voelker
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A Murray
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Joseph S. Koopmeiners
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Christopher J. Tignanelli
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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48
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Sahoo HS, Silverman GM, Ingraham NE, Lupei MI, Puskarich MA, Finzel RL, Sartori J, Zhang R, Knoll BC, Liu S, Liu H, Melton GB, Tignanelli CJ, Pakhomov SVS. A fast, resource efficient, and reliable rule-based system for COVID-19 symptom identification. JAMIA Open 2021; 4:ooab070. [PMID: 34423261 PMCID: PMC8374371 DOI: 10.1093/jamiaopen/ooab070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/16/2021] [Accepted: 08/05/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE With COVID-19, there was a need for a rapidly scalable annotation system that facilitated real-time integration with clinical decision support systems (CDS). Current annotation systems suffer from a high-resource utilization and poor scalability limiting real-world integration with CDS. A potential solution to mitigate these issues is to use the rule-based gazetteer developed at our institution. MATERIALS AND METHODS Performance, resource utilization, and runtime of the rule-based gazetteer were compared with five annotation systems: BioMedICUS, cTAKES, MetaMap, CLAMP, and MedTagger. RESULTS This rule-based gazetteer was the fastest, had a low resource footprint, and similar performance for weighted microaverage and macroaverage measures of precision, recall, and f1-score compared to other annotation systems. DISCUSSION Opportunities to increase its performance include fine-tuning lexical rules for symptom identification. Additionally, it could run on multiple compute nodes for faster runtime. CONCLUSION This rule-based gazetteer overcame key technical limitations facilitating real-time symptomatology identification for COVID-19 and integration of unstructured data elements into our CDS. It is ideal for large-scale deployment across a wide variety of healthcare settings for surveillance of acute COVID-19 symptoms for integration into prognostic modeling. Such a system is currently being leveraged for monitoring of postacute sequelae of COVID-19 (PASC) progression in COVID-19 survivors. This study conducted the first in-depth analysis and developed a rule-based gazetteer for COVID-19 symptom extraction with the following key features: low processor and memory utilization, faster runtime, and similar weighted microaverage and macroaverage measures for precision, recall, and f1-score compared to industry-standard annotation systems.
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Affiliation(s)
- Himanshu S Sahoo
- Department of Electrical and Computer Engineering, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Greg M Silverman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas E Ingraham
- Pulmonary Disease and Critical Care Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Monica I Lupei
- Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Raymond L Finzel
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
| | - John Sartori
- Department of Electrical and Computer Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rui Zhang
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Benjamin C Knoll
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sijia Liu
- Department of Health Science Research, Mayo Clinic, Rochester, New York, USA
| | - Hongfang Liu
- Department of Health Science Research, Mayo Clinic, Rochester, New York, USA
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Serguei V S Pakhomov
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
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49
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Bramante CT, Buse J, Tamaritz L, Palacio A, Cohen K, Vojta D, Liebovitz D, Mitchell N, Nicklas J, Lingvay I, Clark JM, Aronne LJ, Anderson E, Usher M, Demmer R, Melton GB, Ingraham N, Tignanelli CJ. Outpatient metformin use is associated with reduced severity of COVID-19 disease in adults with overweight or obesity. J Med Virol 2021; 93:4273-4279. [PMID: 33580540 PMCID: PMC8013587 DOI: 10.1002/jmv.26873] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 01/22/2023]
Abstract
Observational studies suggest outpatient metformin use is associated with reduced mortality from coronavirus disease-2019 (COVID-19). Metformin is known to decrease interleukin-6 and tumor-necrosis factor-α, which appear to contribute to morbidity in COVID-19. We sought to understand whether outpatient metformin use was associated with reduced odds of severe COVID-19 disease in a large US healthcare data set. Retrospective cohort analysis of electronic health record (EHR) data that was pooled across multiple EHR systems from 12 hospitals and 60 primary care clinics in the Midwest between March 4, 2020 and December 4, 2020. Inclusion criteria: data for body mass index (BMI) > 25 kg/m2 and a positive SARS-CoV-2 polymerase chain reaction test; age ≥ 30 and ≤85 years. Exclusion criteria: patient opt-out of research. Metformin is the exposure of interest, and death, admission, and intensive care unit admission are the outcomes of interest. Metformin was associated with a decrease in mortality from COVID-19, OR 0.32 (0.15, 0.66; p = .002), and in the propensity-matched cohorts, OR 0.38 (0.16, 0.91; p = .030). Metformin was associated with a nonsignificant decrease in hospital admission for COVID-19 in the overall cohort, OR 0.78 (0.58-1.04, p = .087). Among the subgroup with a hemoglobin HbA1c available (n = 1193), the adjusted odds of hospitalization (including adjustment for HbA1c) for metformin users was OR 0.75 (0.53-1.06, p = .105). Outpatient metformin use was associated with lower mortality and a trend towards decreased admission for COVID-19. Given metformin's low cost, established safety, and the mounting evidence of reduced severity of COVID-19 disease, metformin should be prospectively assessed for outpatient treatment of COVID-19.
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Affiliation(s)
- Carolyn T. Bramante
- Department of Medicine, Division of General Internal MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - John Buse
- Department of Medicine, Division of EndocrinologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Leonardo Tamaritz
- Humana Health Services Research Center, Miami UniversityMiamiFloridaUSA
| | - Ana Palacio
- Humana Health Services Research Center, Miami UniversityMiamiFloridaUSA
| | - Ken Cohen
- UnitedHealth Group Research and DevelopmentMinnetonkaMinnesotaUSA
| | - Deneen Vojta
- UnitedHealth Group Research and DevelopmentMinnetonkaMinnesotaUSA
| | - David Liebovitz
- Department of Medicine Northwestern UniversityFeinberg School of MedicineChicagoIllinoisUSA
| | - Nia Mitchell
- Department of MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Jacinda Nicklas
- Department of Medicine, Division of General Internal MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Ildiko Lingvay
- Department of Medicine/EndocrinologyUT Southwestern Medical CenterDallasTexasUSA
- Department of Population and Data SciencesUT Southwestern Medical CenterDallasTexasUSA
| | - Jeanne M. Clark
- Department of Medicine, Division of General Internal MedicineJohn HopkinsBaltimoreMarylandUSA
| | - Louis J. Aronne
- Department of MedicineWeill Cornell MedicineNew YorkNew YorkUSA
| | - Erik Anderson
- Department of Emergency MedicineAlameda CountyOaklandCaliforniaUSA
| | - Michael Usher
- Department of Medicine, Division of General Internal MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Ryan Demmer
- Department of Epidemiology, Division of Epidemiology and Community HealthUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Genevieve B. Melton
- Department of Medicine, Division of Pulmonary MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Nicholas Ingraham
- Department of Surgery, Division of Surgical OncologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Christopher J. Tignanelli
- Department of Medicine, Division of Pulmonary MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
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50
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Ingraham NE, King S, Proper J, Siegel L, Zolfaghari EJ, Murray TA, Vakayil V, Sheka A, Feng R, Guzman G, Roy SS, Muddappa D, Usher MG, Chipman JG, Tignanelli CJ, Pendleton KM. Morbidity and Mortality Trends of Pancreatitis: An Observational Study. Surg Infect (Larchmt) 2021; 22:1021-1030. [PMID: 34129395 DOI: 10.1089/sur.2020.473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Pancreatitis accounts for more than $2.5 billion of healthcare costs and remains the most common gastrointestinal (GI) admission. Few contemporary studies have assessed temporal trends of incidence, complications, management, and outcomes for acute pancreatitis in hospitalized patients at the national level. Methods: We used data from one of the largest hospital-based databases available in the United States, the Healthcare Cost and Utilization Project's (HCUP) State Inpatient Database, from 10 states between 2008 and 2015. We included patients with a diagnosis of acute pancreatitis (ICD-9 CM 577.0). Patient- and hospital-level data were used to estimate incidence and inpatient mortality rates. Results: From 80,736,256 hospitalizations, 929,914 (1.15%) cases of acute pancreatitis were identified, 186,226 (20.2%) of which were caused by gallbladder disease). The median age was 53 years (interquartile range [IQR], 41-67) and 50.8% were men. In-hospital mortality was 2.5% and crude mortality rates declined from 2.9% to 2.0% over the study period. Admission year remained significant after adjusting for patient demographics and comorbidities (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.89-0.90; p < 0.001). Gallbladder disease was associated with decreased odds of mortality (OR, 0.60; 95% CI, 0.57-0.62). Median length of stay was four days (IQR, 2-7) and decreased over time. The rates of surgical and endoscopic interventions were highest in 2011 (peak incidence of 16.1% and 9.5%, respectively) and have been decreasing since. Surgical providers were, on average, more likely than medical providers to perform surgery in both those with and without gallbladder disease etiology (gallbladder disease OR, 7.11; 95% CI, 5.46-9.25; non-gallbladder disease OR, 20.50; 95% CI, 16.81-25.01), endoscopy (gallbladder disease OR, 1.22; 95% CI, 0.87-1.72; non-gallbladder disease OR, 1.60; 95% CI, 1.18-2.16), or both (gallbladder disease OR, 7.00; 95% CI, 5.22-9.37; non-gallbladder disease OR, 8.85; 95% CI, 5.61-13.96). Conclusions: The incidence of pancreatitis, from 2008 to 2015, has increased whereas inpatient mortality (i.e., case fatality) has decreased. Understanding temporal trends in outcomes and management along with provider, hospital, and regional variation can better identify areas for future research and collaboration in managing these patients.
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Affiliation(s)
- Nicholas E Ingraham
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Samantha King
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adam Sheka
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ruoying Feng
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gabriel Guzman
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Samit Sunny Roy
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Dhannanjay Muddappa
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA.,Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathryn M Pendleton
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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