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Duncan I, Stocking A, Fitzner K, Ahmed T, Huynh N. The Prevalence of Incontinence and Its Association With Urinary Tract Infections, Dermatitis, Slips and Falls, and Behavioral Disturbances Among Older Adults in Medicare Fee-for-Service. J Wound Ostomy Continence Nurs 2024; 51:138-145. [PMID: 38527324 PMCID: PMC11008436 DOI: 10.1097/won.0000000000001054] [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: 03/27/2024]
Abstract
PURPOSE The purpose of this study was to examine the prevalence of urinary (UI), fecal (FI), and dual incontinence (DI) in older adults and their association with urinary tract infections, dermatitis, slips and falls, and behavioral disturbances based on Medicare fee-for-service (FFS) claims data. DESIGN Retrospective analysis. SUBJECTS AND SETTINGS Data from administrative claims from the CMS Medicare Limited Data Set (5% sample) for all months in 2018 were reviewed. The analysis was limited to FFS Medicare beneficiaries, with minimum of 3-month enrollment in Parts A and B who were at least 65 years old. This cohort included 1.2 million beneficiaries in the United States. METHODS We used diagnosis codes to identify members with incontinence and grouped these members into 3 categories (UI only, FI only, and DI). We also divided claims based on 4 sites of care (nursing home, skilled nursing facility, home health, and self- or family care). We then determined the prevalence of (1) urinary tract infections (UTIs), (2) dermatitis, (3) slips and falls, and (4) behavioral disturbances for each type of incontinence. RESULTS We found that 11.2% of Medicare members had a claims-based diagnosis of incontinence in 2018. On average, those diagnosed with incontinence experienced 5 times more UTIs, 2 times as many dermatitis events, more than twice as many slips and falls, and 2.8 times more behavior disturbances compared to those without an incontinence diagnosis. For those with DI, the prevalence of the 4 outcomes was significantly higher (between 22% and 185%) compared to those with UI only. CONCLUSIONS Findings show that Medicare beneficiaries diagnosed as incontinent experience a much higher prevalence of UTIs, dermatitis, slips and falls, and behavioral disturbances compared to those without a diagnosis of incontinence. Our results suggest that incontinence may be an important indicator diagnosis for multiple other conditions and, if not well-managed, may challenge the desire for those who are incontinent to age at home.
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Affiliation(s)
- Ian Duncan
- Correspondence: Ian Duncan, PhD, FSA, MAAA, Department of Statistics and Applied Probability, University of California, Santa Barbara, South Hall 5518, Santa Barbara, CA 93106 ()
| | - Andrew Stocking
- Ian Duncan, PhD, FSA, MAAA, Department of Statistics and Applied Probability, University of California, Santa Barbara
- Andrew Stocking, PhD, Principle Business Enterprises Inc, Dunbridge, Ohio
- Karen Fitzner, PhD, Santa Barbara Actuaries Inc, Santa Barbara, California
- Tamim Ahmed, PhD, MBA, Santa Barbara Actuaries Inc, Santa Barbara, California
- Nhan Huynh, PhD, Santa Barbara Actuaries Inc, Santa Barbara, California
| | - Karen Fitzner
- Ian Duncan, PhD, FSA, MAAA, Department of Statistics and Applied Probability, University of California, Santa Barbara
- Andrew Stocking, PhD, Principle Business Enterprises Inc, Dunbridge, Ohio
- Karen Fitzner, PhD, Santa Barbara Actuaries Inc, Santa Barbara, California
- Tamim Ahmed, PhD, MBA, Santa Barbara Actuaries Inc, Santa Barbara, California
- Nhan Huynh, PhD, Santa Barbara Actuaries Inc, Santa Barbara, California
| | - Tamim Ahmed
- Ian Duncan, PhD, FSA, MAAA, Department of Statistics and Applied Probability, University of California, Santa Barbara
- Andrew Stocking, PhD, Principle Business Enterprises Inc, Dunbridge, Ohio
- Karen Fitzner, PhD, Santa Barbara Actuaries Inc, Santa Barbara, California
- Tamim Ahmed, PhD, MBA, Santa Barbara Actuaries Inc, Santa Barbara, California
- Nhan Huynh, PhD, Santa Barbara Actuaries Inc, Santa Barbara, California
| | - Nhan Huynh
- Ian Duncan, PhD, FSA, MAAA, Department of Statistics and Applied Probability, University of California, Santa Barbara
- Andrew Stocking, PhD, Principle Business Enterprises Inc, Dunbridge, Ohio
- Karen Fitzner, PhD, Santa Barbara Actuaries Inc, Santa Barbara, California
- Tamim Ahmed, PhD, MBA, Santa Barbara Actuaries Inc, Santa Barbara, California
- Nhan Huynh, PhD, Santa Barbara Actuaries Inc, Santa Barbara, California
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Amzajerdian F, Hamedani H, Baron R, Loza L, Duncan I, Ruppert K, Kadlecek S, Rizi R. Simultaneous quantification of hyperpolarized xenon-129 ventilation and gas exchange with multi-breath xenon-polarization transfer contrast (XTC) MRI. Magn Reson Med 2023; 90:2334-2347. [PMID: 37533368 PMCID: PMC10543483 DOI: 10.1002/mrm.29804] [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: 04/07/2023] [Revised: 06/21/2023] [Accepted: 07/05/2023] [Indexed: 08/04/2023]
Abstract
PURPOSE To demonstrate the feasibility of a multi-breath xenon-polarization transfer contrast (XTC) MR imaging approach for simultaneously evaluating regional ventilation and gas exchange parameters. METHODS Imaging was performed in five healthy volunteers and six chronic obstructive pulmonary disease (COPD) patients. The multi-breath XTC protocol consisted of three repeated schemes of six wash-in breaths of a xenon mixture and four normoxic wash-out breaths, with and without selective saturation of either the tissue membrane or red blood cell (RBC) resonances. Acquisitions were performed at end-exhalation while subjects maintained tidal breathing throughout the session. The no-saturation, membrane-saturation, and RBC-saturation images were fit to a per-breath gas replacement model for extracting voxelwise tidal volume (TV), functional residual capacity (FRC), and fractional ventilation (FV), as well as tissue- and RBC-gas exchange (fMem and fRBC , respectively). The sensitivity of the derived model was also evaluated via simulations. RESULTS With the exception of FRC, whole-lung averages for all metrics were decreased in the COPD subjects compared to the healthy cohort, significantly so for FV, fRBC , and fMem . Heterogeneity was higher overall in the COPD subjects, particularly for fRBC , fMem , and fRBC:Mem . The anterior-to-posterior gradient associated with the gravity-dependence of lung function in supine imaging was also evident for FV, fRBC , and fMem values in the healthy subjects, but noticeably absent in the COPD cohort. CONCLUSION Multi-breath XTC imaging generated high-resolution, co-registered maps of ventilation and gas exchange parameters acquired during tidal breathing and with low per-breath xenon doses. Clear differences between healthy and COPD subjects were apparent and consistent with spirometry.
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Affiliation(s)
- Faraz Amzajerdian
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Baron
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luis Loza
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rahim Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kerr D, Duncan I, Repetto E, Maroun R, Wu A, Perkins C, Bergman G, Giorgino F. Cost analysis of self-monitoring blood glucose in nonintensively managed type 2 diabetes. Am J Manag Care 2023; 29:670-675. [PMID: 38170484 DOI: 10.37765/ajmc.2023.89422] [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] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVES To compare health care resource utilization (HCRU) and costs between self-monitoring of blood glucose (SMBG) and continuous glucose monitoring (CGM) users in adults with nonintensively managed type 2 diabetes (T2D). STUDY DESIGN Retrospective analysis of the MarketScan Databases. METHODS Adults with T2D using SMBG or initiating CGM between January 2018 and March 2019 were eligible for inclusion. Inclusion criteria were (1) 2 consecutive claims for T2D or 1 claim for T2D and a claim for glucose-lowering therapy, (2) at least 1 pharmacy claim for SMBG strips or CGM sensors, and (3) continuous enrollment for 1 year before and after the index date. Individuals with evidence of CGM in the preindex period, pregnancy, use of rapid-acting insulin or glucagon, type 1 diabetes, gestational diabetes, or secondary diabetes at any time during the study period were excluded. SMBG and CGM patients were matched using propensity score, and all-cause HCRU and costs during a 1-year period were compared. RESULTS A total of 3498 patients were included in each matched cohort. The per-patient per-year (PPPY) all-cause cost was $20,542 in CGM users vs $19,349 in SMBG users (P < .001). The PPPY cost of glucose-lowering medication was $6312 in CGM users vs $5606 in SMBG users (P < .001). No significant differences in the number of emergency department visits or hospitalizations were observed, but CGM users had more all-cause outpatient visits and office visits with an endocrinologist. CONCLUSIONS In adults with nonintensively managed T2D, SMBG appears to be less costly than CGM and is associated with lower pharmacy costs.
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Affiliation(s)
- David Kerr
- Diabetes Technology Society, 845 Malcolm Rd, Ste 5, Burlingame, CA 94010.
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Duncan I, Kerr D, Aggarwal R, Huynh N. New Drugs for Obesity, Is the Excitement Affordable? Popul Health Manag 2023; 26:356-357. [PMID: 37276026 PMCID: PMC10611954 DOI: 10.1089/pop.2023.0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Affiliation(s)
- Ian Duncan
- Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California, USA
- Diabetes Technology Society, Santa Barbara, California, USA
| | - David Kerr
- Diabetes Technology Society, Santa Barbara, California, USA
| | | | - Nhan Huynh
- Santa Barbara Actuaries, Inc., Santa Barbara, California, USA
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Gnoni V, Wasserman D, Duncan I, Tsai CC, Cash D, Higgins S, Drakatos P, Nesbitt A, Leschziner G, O'Regan D, Rosenzweig I. Cognitive dysfunction in ‘pure’ OSA patients without any other comorbidities. Sleep Med 2022. [DOI: 10.1016/j.sleep.2022.05.649] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Xin Y, Cereda M, Yehya N, Humayun S, Delvecchio P, Thompson JM, Martin K, Hamedani H, Martorano P, Duncan I, Kadlecek S, Makvandi M, Brenner JS, Rizi RR. Imatinib alleviates lung injury and prolongs survival in ventilated rats. Am J Physiol Lung Cell Mol Physiol 2022; 322:L866-L872. [PMID: 35438574 PMCID: PMC9142156 DOI: 10.1152/ajplung.00006.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/06/2022] [Revised: 03/28/2022] [Accepted: 04/13/2022] [Indexed: 11/22/2022] Open
Abstract
Imatinib, a tyrosine kinase inhibitor, attenuates pulmonary edema and inflammation in lung injury. However, the physiological effects of this drug and their impact on outcomes are poorly characterized. Using serial computed tomography (CT), we tested the hypothesis that imatinib reduces injury severity and improves survival in ventilated rats. Hydrochloric acid (HCl) was instilled in the trachea (pH 1.5, 2.5 mL/kg) of anesthetized, intubated supine rats. Animals were randomized (n = 17 each group) to receive intraperitoneal imatinib or vehicle immediately prior to HCl. All rats then received mechanical ventilation. CT was performed hourly for 4 h. Images were quantitatively analyzed to assess the progression of radiological abnormalities. Injury severity was confirmed via hourly blood gases, serum biomarkers, bronchoalveolar lavage (BAL), and histopathology. Serial blood drug levels were measured in a subset of rats. Imatinib reduced mortality while delaying functional and radiological injury progression: out of 17 rats per condition, 2 control vs. 8 imatinib-treated rats survived until the end of the experiment (P = 0.02). Imatinib attenuated edema after lung injury (P < 0.05), and survival time in both groups was negatively correlated with increased lung mass (R2 = 0.70) as well as other physiological and CT parameters. Capillary leak (BAL protein concentration) was significantly lower in the treated group (P = 0.04). Peak drug concentration was reached after 70 min, and the drug half-life was 150 min. Imatinib decreased both mortality and lung injury severity in mechanically ventilated rats. Pharmacological inhibition of edema could be used during mechanical ventilation to improve the severity and outcome of lung injury.
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Affiliation(s)
- Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadir Yehya
- Pediatric Sepsis Program and Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shiraz Humayun
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paolo Delvecchio
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jill M Thompson
- Pediatric Sepsis Program and Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin Martin
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul Martorano
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mehran Makvandi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacob S Brenner
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
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Fernandez C, Rusk S, Glattard N, Turkington F, Nygate Y, Kaiser M, McClurg J, Richard M, Duncan I, Watson N. 0068 Impact of OSA Therapy on Healthcare Economics: Actuarial Analysis of OSA Prevalence, Therapy Adherence, Co-morbidity, and Costs in a Large CMS Population Cohort. Sleep 2022. [DOI: 10.1093/sleep/zsac079.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Research studying the economics of OSA therapy faces confounds including the prevalence of undiagnosed OSA, rate of diagnosed patients declining therapy, spectrum of treatment adherence, and effects of concurrent co-morbidity. We provide an actuarial analysis to study the economic impact of OSA therapy, accounting for these confounds, using the 2016-2018 Medicare 5% LDS Analytical File, a random sample of Medicare Claims containing approximately 2.9 million patients/year, resulting in N=2,001,538 eligible Fee-For-Service patients excluding managed care patients and incomplete data.
Methods
We segmented the study population into three cohorts and three 12-month time-periods. The cohorts analyzed were A) patients with OSA diagnosis and >12 months treatment, B) patients with OSA and <12 months treatment, and C) patients with OSA diagnosis who never received treatment, resulting in 1,351,838 patient-months. We analyzed the healthcare costs in each cohort in the year before treatment, the first year of treatment, and following treatment year. We applied actuarial risk adjustment within each cohort and time-period to provide a risk-adjusted cost comparison. Results were analyzed cross-sectionally given zero-to-seven co-morbidities among obesity, hypertension, type-II diabetes, depression, COPD, CHF, and/or prior stroke, facility-vs-home testing, and with-or-without surgical procedures.
Results
The average per-patient-per-month (PPPM) total medical spending was highest in the diagnosed-but-never-treated cohort-C ($1,375), second highest in <12-months treatment cohort-B ($1,005), and lowest in >12-months treatment cohort-A ($983). In both cohorts that started therapy, average/quantile costs decreased from pre-treatment year to post-treatment year, and from the first-to-second year on therapy. Compared to no-therapy cohort-C, costs were 29% lower in cohort-A and 27% lower in cohort-B. Among co-morbid, 75th quartile of cost members, we observed similar differences (18% and 16%) but larger absolute dollars. Patients undergoing surgical procedures had higher costs but lower spend reduction in initial and following year of therapy (22% and 5%).
Conclusion
We observed significant differences in cost between OSA patients that started treatment versus those that did not, and those differences further increased the year following therapy onset. These findings imply that receiving treatment for OSA reduces a patients overall medical spend. In terms of mean cost, the >12-month and <12-month cohorts costs fell in both follow-up treatment years.
Support (If Any)
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Baron R, Kadlecek S, Loza L, Xin Y, Amzajerdian F, Duncan I, Hamedani H, Rizi R. Deriving Regionally Specific Biomarkers of Emphysema and Small Airways Disease Using Variable Threshold Parametric Response Mapping on Volumetric Lung CT Images. Acad Radiol 2022; 29 Suppl 2:S127-S136. [PMID: 34272162 PMCID: PMC8755853 DOI: 10.1016/j.acra.2021.05.021] [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: 04/12/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE This study aims to develop and validate a parametric response mapping (PRM) methodology to accurately identify diseased regions of the lung by using variable thresholds to account for alterations in regional lung function between the gravitationally-independent (anterior) and gravitationally-dependent (posterior) lung in CT images acquired in the supine position. METHODS 34 male Sprague-Dawley rats (260-540 g) were imaged, 4 of which received elastase injection (100 units/kg) as a model for emphysema (EMPH). Gated volumetric CT was performed at end-inspiration (EI) and end-expiration (EE) on separate groups of free-breathing (n = 20) and ventilated (n = 10) rats in the supine position. To derive variable thresholds for the new PRM methodology, voxels were first grouped into 100 bins based on the fractional distance along the anterior-to-posterior direction. Lower limits of normal (LLN) for x-ray attenuation in each bin were set by determining the smallest region that enclosed 98% of voxels from healthy, ventilated animals. RESULTS When utilizing fixed thresholds in the conventional PRM methodology, a distinct posterior-anterior gradient was seen, in which nearly the entire posterior region of the lung was identified as HEALTHY, while the anterior lung was labeled as significantly less so (t(29) = -3.27, p = 0.003). In both cohorts, %SAD progressively increased from posterior to anterior, while %HEALTHY lung decreased in the same direction. After applying our PRM methodology with variable thresholds to the same rat images, the posterior-anterior trend in %SAD quantification was removed from all rats and the significant increase of diseased lung in the anterior was removed. CONCLUSIONS The PRM methodology using variable thresholds provides regionally specific markers of %SAD and %EMPH by correcting for alterations in regional lung function associated with the naturally occurring vertical gradient of dependent vs. non-dependent lung density and compliance.
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Affiliation(s)
- Ryan Baron
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Steve Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Luis Loza
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Faraz Amzajerdian
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rahim Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
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Hamedani H, Ma K, DiBardino D, Baron R, Kadlecek S, Amzajerdian F, Ruppert K, Duncan I, Rizi RR. Simultaneous Imaging of Ventilation and Gas Exchange with Hyperpolarized 129Xe MRI for Monitoring Patients with Endobronchial Valve Interventions. Am J Respir Crit Care Med 2022; 205:e48-e50. [PMID: 35044897 DOI: 10.1164/rccm.202106-1395im] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hooman Hamedani
- University of Pennsylvania, 6572, Radiology, Philadelphia, Pennsylvania, United States
| | - Kevin Ma
- University of Pennsylvania Perelman School of Medicine, 14640, Pulmonary, Allergy, and Critical Care, Philadelphia, Pennsylvania, United States
| | - David DiBardino
- University of Pennsylvania Perelman School of Medicine, 14640, Pulmonary, Allergy, and Critical Care, Philadelphia, Pennsylvania, United States
| | - Ryan Baron
- University of Pennsylvania, Radiology, Philadelphia, Pennsylvania, United States
| | - Stephen Kadlecek
- University of Pennsylvania, 6572, Radiology, Philadelphia, Pennsylvania, United States
| | - Faraz Amzajerdian
- University of Pennsylvania, 6572, Radiology, Philadelphia, Pennsylvania, United States
| | - Kai Ruppert
- University of Pennsylvania, 6572, Radiology, Philadelphia, Pennsylvania, United States
| | - Ian Duncan
- University of Pennsylvania, Radiology, Philadelphia, Pennsylvania, United States
| | - Rahim R Rizi
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States;
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Xin Y, Martin K, Morais CC, Delvecchio P, Gerard SE, Hamedani H, Herrmann J, Abate N, Lenart A, Humayun S, Sidhu U, Petrov M, Reutlinger K, Mandelbaum T, Duncan I, Tustison N, Kadlecek S, Chatterjee S, Gee JC, Rizi RR, Berra L, Cereda M. Diminishing Efficacy of Prone Positioning With Late Application in Evolving Lung Injury. Crit Care Med 2021; 49:e1015-e1024. [PMID: 33938714 PMCID: PMC8448902 DOI: 10.1097/ccm.0000000000005071] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES It is not known how lung injury progression during mechanical ventilation modifies pulmonary responses to prone positioning. We compared the effects of prone positioning on regional lung aeration in late versus early stages of lung injury. DESIGN Prospective, longitudinal imaging study. SETTING Research imaging facility at The University of Pennsylvania (Philadelphia, PA) and Medical and Surgical ICUs at Massachusetts General Hospital (Boston, MA). SUBJECTS Anesthetized swine and patients with acute respiratory distress syndrome (acute respiratory distress syndrome). INTERVENTIONS Lung injury was induced by bronchial hydrochloric acid (3.5 mL/kg) in 10 ventilated Yorkshire pigs and worsened by supine nonprotective ventilation for 24 hours. Whole-lung CT was performed 2 hours after hydrochloric acid (Day 1) in both prone and supine positions and repeated at 24 hours (Day 2). Prone and supine images were registered (superimposed) in pairs to measure the effects of positioning on the aeration of each tissue unit. Two patients with early acute respiratory distress syndrome were compared with two patients with late acute respiratory distress syndrome, using electrical impedance tomography to measure the effects of body position on regional lung mechanics. MEASUREMENTS AND MAIN RESULTS Gas exchange and respiratory mechanics worsened over 24 hours, indicating lung injury progression. On Day 1, prone positioning reinflated 18.9% ± 5.2% of lung mass in the posterior lung regions. On Day 2, position-associated dorsal reinflation was reduced to 7.3% ± 1.5% (p < 0.05 vs Day 1). Prone positioning decreased aeration in the anterior lungs on both days. Although prone positioning improved posterior lung compliance in the early acute respiratory distress syndrome patients, it had no effect in late acute respiratory distress syndrome subjects. CONCLUSIONS The effects of prone positioning on lung aeration may depend on the stage of lung injury and duration of prior ventilation; this may limit the clinical efficacy of this treatment if applied late.
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Affiliation(s)
- Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin Martin
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Caio C.A. Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Paolo Delvecchio
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah E. Gerard
- Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob Herrmann
- Department of Biomedical Engineering, Boston University, Boston, MA, USA
| | - Nicholas Abate
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Austin Lenart
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Shiraz Humayun
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Uday Sidhu
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Mihail Petrov
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristan Reutlinger
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Tal Mandelbaum
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Shampa Chatterjee
- Department of Physiology, University of Pennsylvania, Philadelphia, PA, USA
| | - James C. Gee
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rahim R. Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Maurizio Cereda
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
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Noureddin M, Mackenzie A, Zhao E, Howell SC, Tunkelrott M, Duncan I. Population-based return on investment of deploying transient elastography. Am J Manag Care 2021; 27:376-381. [PMID: 34533907 DOI: 10.37765/ajmc.2021.88645] [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] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the cost savings outcomes, from the payer's perspective, of deploying vibration-controlled transient elastography/controlled attenuation parameter (VCTE/CAP) machines for detecting and monitoring fatty liver disease (FLD). STUDY DESIGN We modeled disease transitions and costs under the current observed pathway and under an alternative pathway in which VCTE/CAP devices are adopted. Marginal savings (or costs) due to implementing the device are derived by comparing the aggregate costs between the 2 pathways. Sources of potential savings are 2-fold. First, VCTE/CAP tests result in early identification of patients with FLD (the majority are currently undiagnosed), allowing for proactive intervention and behavior change to slow the progression of disease in these patients. Second, VCTE/CAP tests can reduce the aggregate volume of some current diagnosis methods, such as liver biopsy, imaging, and laboratory work. METHODS Our model relied on administrative claims data consisting of 5 million commercial members and 3 million Medicare members to inform baseline statistics on disease prevalence, health care cost and utilization, and disease progression associated with different severities of liver disease. We consulted expert clinical opinion and medical literature to inform our assumptions related to device adoption and use. RESULTS Scenario testing demonstrated positive net savings within 2 to 3 years after device deployment. Across a 5-year time span, we estimate net savings up to $2.64 per member per month (PMPM) for Medicare payers and up to $1.91 PMPM for commercial payers. CONCLUSIONS We conclude that deploying VCTE/CAP devices is a financially advantageous solution to address the epidemic of FLD.
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Affiliation(s)
| | - Andrew Mackenzie
- Santa Barbara Actuaries, 3221 Calle Mariposa, Santa Barbara, CA 93105.
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Hamedani H, Kadlecek S, Ruppert K, Xin Y, Duncan I, Rizi RR. Ventilation heterogeneity imaged by multibreath wash-ins of hyperpolarized 3 He and 129 Xe in healthy rabbits. J Physiol 2021; 599:4197-4223. [PMID: 34256417 DOI: 10.1113/jp281584] [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: 03/15/2021] [Accepted: 06/30/2021] [Indexed: 12/20/2022] Open
Abstract
KEY POINTS Multibreath imaging to estimate regional gas mixing efficiency is superior to intensity-based single-breath ventilation markers, as it is capable of revealing minute but essential measures of ventilation heterogeneity which may be sensitive to subclinical alterations in the early stages of both obstructive and restrictive respiratory disorders. Large-scale convective stratification of ventilation in central-to-peripheral directions is the dominant feature of observed ventilation heterogeneity when imaging a heavy/less diffusive xenon gas mixture; smaller-scale patchiness, probably originating from asymmetric lung function at bronchial airway branching due to the interaction of convective and diffusive flows, is the dominant feature when imaging a lighter/more diffusive helium gas mixture. Since detecting low regional ventilation is crucial for characterizing diseased lungs, our results suggest that dilution with natural abundance helium and imaging at higher lung volumes seem advisable when imaging with hyperpolarized 129 Xe; this will allow the imaging gas to reach slow-filling and/or non-dependent lung regions, which might otherwise be impossible to distinguish from total ventilation shunt regions. The ability to differentiate these regions from those of total shunt is worse with typical single-breath imaging techniques. ABSTRACT The mixing of freshly inhaled gas with gas already present in the lung can be directly assessed with heretofore unachievable precision via magnetic resonance imaging of signal build-up resulting from multiple wash-ins of a hyperpolarized (HP) gas. Here, we used normoxic HP 3 He and 129 Xe mixtures to study regional ventilation at different spatial scales in five healthy mechanically ventilated supine rabbits at two different inspired volumes. To decouple the respective effects of density and diffusion rates on ventilation heterogeneity, two additional studies were performed: one in which 3 He was diluted with an equal fraction of natural abundance xenon, and one in which 129 Xe was diluted with an equal fraction of 4 He. We observed systematic differences in the spatial scale of specific ventilation heterogeneity between HP 3 He and 129 Xe. We found that large-scale, central-to-peripheral convective ventilation inhomogeneity is the dominant cause of observed heterogeneity when breathing a normoxic xenon gas mixture. In contrast, small-scale ventilation heterogeneity in the form of patchiness, probably originating from asymmetric lung function at bronchial airway branching due to interactions between convective and diffusive flows, is the dominant feature when breathing a normoxic helium gas mixture, for which the critical zone occurs more proximally and at an imageable spatial scale. We also showed that the existence of particular underventilated non-dependent lung regions when breathing a heavy gas mixture is the result of the density of that mixture - rather than, for example, its diffusion rate or viscosity. Finally, we showed that gravity-dependent ventilation heterogeneity becomes substantially more uniform at higher inspired volumes for xenon gas mixtures compared to helium mixtures.
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Affiliation(s)
- Hooman Hamedani
- Department of Radiology, Functional and Metabolic Imaging Group, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Penn Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Kadlecek
- Department of Radiology, Functional and Metabolic Imaging Group, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kai Ruppert
- Department of Radiology, Functional and Metabolic Imaging Group, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi Xin
- Department of Radiology, Functional and Metabolic Imaging Group, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Penn Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ian Duncan
- Department of Radiology, Functional and Metabolic Imaging Group, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rahim R Rizi
- Department of Radiology, Functional and Metabolic Imaging Group, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Duncan I, Fitzner K, Zhao E, Shtein Y. Patient Post-discharge Transitions and Inpatient Readmissions Impose Costly Burdens for Employers and Carriers. Popul Health Manag 2021; 24:722-726. [PMID: 33848438 DOI: 10.1089/pop.2021.0037] [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: 11/12/2022] Open
Abstract
Although the Centers for Medicare & Medicaid Services has focused on Medicare hospital readmissions for select diagnoses through the Hospital Readmissions Reduction program, there is no similar initiative for employers, who account for the majority of the 48% of private health care spending in the United States. Readmissions are costly and it is estimated that as many as half of these may be preventable. This study analyzes a national claims database to understand post-discharge transitions and their cost in the working population. Within an employer-sponsored, commercially-insured population, this study found that 4% of members are hospitalized annually and drive 37% of population health care cost. Of these members, 17% undergo additional admissions in the year following discharge and drive approximately 67% of the cost of the admitted population. This study found that the post-discharge site of care transitions has significant implications for the cumulative cost of care. More than a third of patients discharged home will transition to higher cost settings over the course of a year. Mental health and substance abuse diagnoses add significantly to admission/readmission rates and costs. Prior research indicates that post-discharge interventions that activate and engage patients in self-management are beneficial in mitigating overall cost and readmissions.
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Affiliation(s)
- Ian Duncan
- Statistics Department, University of California Santa Barbara, Santa Barbara, California, USA
| | - Karen Fitzner
- Santa Barbara Actuaries, Santa Barbara, California, USA
| | - Elaine Zhao
- Santa Barbara Actuaries, Santa Barbara, California, USA
| | - Yoni Shtein
- Laguna Health, San Francisco, California, USA
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Duncan I, Maxwell TL, Huynh N, Todd M. Polypharmacy, Medication Possession, and Deprescribing of Potentially Non-Beneficial Drugs in Hospice Patients. Am J Hosp Palliat Care 2020; 37:1076-1085. [PMID: 32662276 DOI: 10.1177/1049909120939091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patients frequently have comorbidities that when combined with their primary diagnosis qualifies the patient for hospice. Consequently, patients are at risk for polypharmacy due to the number of medications prescribed to treat both the underlying conditions and the related symptoms. Polypharmacy is associated with negative consequences, including increased risk for adverse drug events, drug-drug and drug-disease interactions, reduced functional status and falls, multiple geriatric syndromes, medication nonadherence, and increased mortality. Polypharmacy also increases the complexity of medication management for caregivers and contributes to the cost of prescription drugs for hospices and patients. Deprescribing or removing nonbeneficial or ineffective medications can reduce polypharmacy in hospice. We study medication possession ratios and rates of deprescribing of commonly prescribed but potentially nonbeneficial classes of medication using a large hospice pharmacy database. Prevalence of some classes of potentially inappropriate medications is high. We report possession ratios for 10 frequently prescribed classes, and, because death and prescription termination are competing events, we calculate prescription termination rates using Cumulative Incidence Functions. Median duration of antifungal and antiviral medications is brief (5 and 7 days, respectively), while statins and diabetes medications have slow discontinuance rates (median termination durations of 93 and 197 days). Almost all patients with a proton pump inhibitor prescription have the drug for their entire hospice stay. Data from this study identify those drug classes that are commonly deprescribed slowly, suggesting drug classes and diagnoses that hospices may wish to focus on more closely, as they act to limit polypharmacy and reduce prescription costs.
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Affiliation(s)
- Ian Duncan
- Department of Statistics & Applied Probability, 8786University of California-Santa Barbara, CA, USA
| | | | - Nhan Huynh
- Department of Statistics & Applied Probability, 8786University of California-Santa Barbara, CA, USA
| | - Marisa Todd
- 142913Enclara Pharmacia Inc, Philadelphia, PA, USA
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Pourfathi M, Xin Y, Rosalino M, Cereda M, Kadlecek S, Duncan I, Profka H, Hamedani H, Siddiqui S, Ruppert K, Chatterjee S, Rizi RR. Pulmonary pyruvate metabolism as an index of inflammation and injury in a rat model of acute respiratory distress syndrome. NMR Biomed 2020; 33:e4380. [PMID: 32681670 DOI: 10.1002/nbm.4380] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/15/2020] [Accepted: 06/29/2020] [Indexed: 06/11/2023]
Abstract
Increased pulmonary lactate production is correlated with severity of lung injury and outcome in acute respiratory distress syndrome (ARDS) patients. This study was conducted to investigate the relative contributions of inflammation and hypoxia to the lung's metabolic shift to glycolysis in an experimental animal model of ARDS using hyperpolarized (HP) 13 C MRI. Fifty-three intubated and mechanically ventilated male rats were imaged using HP 13 C MRI before, and 1, 2.5 and 4 hours after saline (sham) or hydrochloric acid (HCl; 0.5 ml/kg) instillation in the trachea, followed by protective and nonprotective mechanical ventilation (HCl-PEEP and HCl-ZEEP) or the start of moderate or severe hypoxia (Hyp90 and Hyp75 groups). Pulmonary and cardiac HP lactate-to-pyruvate ratios were compared among groups for different time points. Postmortem histology and immunofluorescence were used to assess lung injury severity and quantify the expression of innate inflammatory markers and local tissue hypoxia. HP pulmonary lactate-to-pyruvate ratio progressively increased in rats with lung injury and moderate hypoxia (HCl-ZEEP), with no significant change in pulmonary lactate-to-pyruvate ratio in noninjured but moderately hypoxic rats (Hyp90). Pulmonary lactate-to-pyruvate ratio was elevated in otherwise healthy lung tissue only in severe systemic hypoxia (Hyp75 group). ex vivo histological and immunopathological assessment further confirmed the link between elevated glycolysis and the recruitment into and presence of activated neutrophils in injured lungs. HP lactate-to-pyruvate ratio is elevated in injured lungs predominantly as a result of increased glycolysis in activated inflammatory cells, but can also increase due to severe inflammation-induced hypoxia.
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Affiliation(s)
- Mehrdad Pourfathi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Rosalino
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maurizio Cereda
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harrilla Profka
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shampa Chatterjee
- Department of Physiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Glantz NM, Morales JM, Bevier WC, Larez A, Hoppe CB, Duncan I, Mackenzie A, Kerr D. Insurance Status and Biological and Psychosocial Determinants of Cardiometabolic Risk Among Mexican-Origin U.S. Hispanic/Latino Adults with Type 2 Diabetes. Health Equity 2020; 4:142-149. [PMID: 32440613 PMCID: PMC7241055 DOI: 10.1089/heq.2019.0119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Purpose: Hispanics/Latinos in the United States bear higher burden of type 2 diabetes (T2D) and associated complications compared with the general population. Health insurance coverage is also lower in this population. We examined the association of health insurance with biological and psychosocial determinants of cardiometabolic risk among U.S. Mexican-origin Hispanic/Latino adults with T2D. Methods: Participants were self-reported Hispanic/Latino adults with T2D diagnosis. Trained bilingual community health workers collected cross-sectional information on biological and psychosocial factors using clinical examinations, laboratory tests, validated questionnaires, and wearable activity monitors. Results: One hundred and seven Hispanic/Latino adults (54±12 years, 65% female, 36% prescribed insulin, 60% uninsured) with T2D were enrolled. While 93% had low language-based acculturation, 88% had high health literacy in Spanish. Forty percent were food insecure and 47% expressed at least one social need. Overall, 35% had an HbA1c <7.0% (indicating good control) and 31% had an HbA1c >9.0%. Sixty-three percent had blood pressure within target (<130/80 mmHg), and overall participants were moderately physically active. However, 53% were obese (body mass index ≥30 kg/m2) and 76% had a waist measurement defined as high risk (>88 cm for women and >102 cm for men). Participants without health insurance were younger (51.9±10.4 vs. 58.8±10.5 years mean±standard deviation, p=0.0008) but had higher HbA1c (8.4±2.2% vs. 7.6±1.6, p=0.031) and fasting glucose (184.9±86.5 vs. 148.6±61.2 mg/dl, p=0.008) levels. Conclusions: Health insurance status appears to influence achieved glycemic control for U.S. Hispanic/Latino adults with T2D. However, various psychosocial factors potentially influencing cardiometabolic risk independently of health insurance status may also be implicated in the inequitable burden of T2D. ClinicalTrials.gov Identifier: NCT03736486.
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Affiliation(s)
- Namino M Glantz
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | | | - Wendy C Bevier
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Arianna Larez
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Charis B Hoppe
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
| | - Ian Duncan
- Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California, USA
| | | | - David Kerr
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
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Morales J, Glantz N, Larez A, Bevier W, Conneely M, Fan L, Reed B, Alatorre C, Paczkowski R, Ahmed T, Mackenzie A, Duncan I, Kerr D. Understanding the impact of five major determinants of health (genetics, biology, behavior, psychology, society/environment) on type 2 diabetes in U.S. Hispanic/Latino families: Mil Familias - a cohort study. BMC Endocr Disord 2020; 20:4. [PMID: 31906923 PMCID: PMC6945604 DOI: 10.1186/s12902-019-0483-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In the United States (U.S.), the prevalence of both diagnosed and undiagnosed type 2 diabetes (T2D) is nearly twice as high among Mexican-origin Hispanic/Latino adults compared to non-Hispanic Whites. Rates of diabetes-related complications, e.g., acute stroke and end-stage renal disease, are also higher among Hispanic/Latino adults compared to their non-Hispanic/Latino White counterparts. Beyond genetic and biological factors, it is now recognized that sociocultural influences are also important factors in determining risk for T2D and the associated complications. These influences include ethnicity, acculturation, residence, education, and economic status. The primary objective of this study is to determine the influence of the 5 major determinants of human health (genetics, biology, behavior, psychology, society/environment) on the burden of T2D for Latino families. To achieve this objective, Mil Familias (www.milfamilias.sansum.org/) is establishing an observational cohort of 1000 Latino families, with at least one family member living with T2D. METHODS Specially trained, bilingual Latino/a community health workers (Especialistas) recruit participant families and conduct research activities. Each individual family member will contribute data annually on over 100 different variables relating to their genetics, biology, psychology, behavior, and society/environment, creating a Latino-focused biobank ("Living Information Bank"). This observational cohort study is cross-sectional and longitudinal. Participants are divided into 4 groups: adults age ≥ 18 years with and without T2D, and children age ≥ 7 and < 18 years with and without T2D. Study activities take place through encounters between families and their Especialista. Encounters include screening/enrollment, informed consent, health promotion assessment, laboratory tests, questionnaires, physical activity monitoring, and reflection. DISCUSSION By creating and providing the framework for the Cohort Establishment study, we intend to inform new approaches regarding equity and excellence in diabetes research and care. We will examine the complex set of factors that contribute to the burden of diabetes in Latino families and assess if cardio-metabolic disease risks go beyond the traditional biological and genetic factors. Breaking the code on the interplay of cardio-metabolic risk factors may help not only this fast growing segment of the U.S. population, but also other high-risk populations. TRIAL REGISTRATION Study retrospectively registered at ClinicalTrials.gov (NCT03830840), 2/5/2019 (enrollment began 2/1/2019).
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Affiliation(s)
- Jessikah Morales
- Sansum Diabetes Research Institute, 2219 Bath Street, Santa Barbara, CA 93105 USA
| | - Namino Glantz
- Sansum Diabetes Research Institute, 2219 Bath Street, Santa Barbara, CA 93105 USA
| | - Arianna Larez
- Sansum Diabetes Research Institute, 2219 Bath Street, Santa Barbara, CA 93105 USA
| | - Wendy Bevier
- Sansum Diabetes Research Institute, 2219 Bath Street, Santa Barbara, CA 93105 USA
| | - Mary Conneely
- Sansum Diabetes Research Institute, 2219 Bath Street, Santa Barbara, CA 93105 USA
| | - Ludi Fan
- Eli Lilly and Company, Indianapolis, IN USA
| | | | | | | | - Tamim Ahmed
- Santa Barbara Actuaries, Santa Barbara, CA USA
| | | | - Ian Duncan
- Santa Barbara Actuaries, Santa Barbara, CA USA
| | - David Kerr
- Sansum Diabetes Research Institute, 2219 Bath Street, Santa Barbara, CA 93105 USA
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Spierto FW, MacNeil ML, Culbreth P, Duncan I, Burtis CA. Development and validation of a liquid-chromatographic procedure for serum creatinine. Clin Chem 2019. [DOI: 10.1093/clinchem/26.2.0286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Anderson NA, Campos S, Butler S, Copley RCB, Duncan I, Harrison S, Le J, Maghames R, Pastor-Garcia A, Pritchard JM, Rowedder JE, Smith CE, Thomas J, Vitulli G, Macdonald SJF. Discovery of an Orally Bioavailable Pan αv Integrin Inhibitor for Idiopathic Pulmonary Fibrosis. J Med Chem 2019; 62:8796-8808. [PMID: 31497959 DOI: 10.1021/acs.jmedchem.9b00962] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The heterodimeric transmembrane αv integrin receptors have recently emerged as potential targets for the treatment of idiopathic pulmonary fibrosis. Herein, we describe how subtle modifications of the central aromatic ring of a series of phenylbutyrate-based antagonists of the vitronectin receptors αvβ3 and αvβ5 significantly change the biological activities against αvβ6 and αvβ8. This resulted in the discovery of a pan αv antagonist (compound 39, 4-40 nM for the integrin receptors named above) possessing excellent oral pharmacokinetic properties in rats (with a clearance of 7.6 mL/(min kg) and a bioavailability of 97%).
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Affiliation(s)
- Niall A Anderson
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Sebastien Campos
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Sharon Butler
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Royston C B Copley
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Ian Duncan
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Stephen Harrison
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Joelle Le
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Rosemary Maghames
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Aleix Pastor-Garcia
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - John M Pritchard
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - James E Rowedder
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Claire E Smith
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Jack Thomas
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Giovanni Vitulli
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
| | - Simon J F Macdonald
- GlaxoSmithKline Medicines Research Centre , Gunnels Wood Road , Stevenage SG1 2NY , U.K
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Siddiqui S, Habertheuer A, Xin Y, Pourfathi M, Tao JQ, Hamedani H, Kadlecek S, Duncan I, Vallabhajosyula P, Naji A, Chatterjee S, Rizi R. Detection of lung transplant rejection in a rat model using hyperpolarized [1- 13 C] pyruvate-based metabolic imaging. NMR Biomed 2019; 32:e4107. [PMID: 31112351 PMCID: PMC6620127 DOI: 10.1002/nbm.4107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/19/2019] [Accepted: 03/29/2019] [Indexed: 05/03/2023]
Abstract
The current standard for noninvasive imaging of acute rejection consists of X-ray/CT, which derive their contrast from changes in ventilation, inflammation and edema, as well as remodeling during rejection. We propose the use of hyperpolarized [1-13 C] pyruvate MRI-which provides real-time metabolic assessment of tissue-as an early biomarker for tissue rejection. In this preliminary study, we used μCT-derived parameters and HP 13 C MR-derived biomarkers to predict rejection in an orthotopic left lung transplant model in both allogeneic and syngeneic rats. On day 3, the normalized lung density-a parameter that accounts for both lung volume (mL) and density (HU)-was -0.335 (CI: -0.598, -0.073) and - 0.473 (CI: -0.726, -0.220) for the allograft and isograft, respectively (not significant, 0.40). The lactate-to-pyruvate ratios-derived from the HP 13 C MRI-for the allograft and isograft were 0.200 (CI: 0.161, 0.240) and 0.114 (CI: 0.074, 0.153), respectively (significant, 0.020). Both techniques showed tissue rejection on day 7. A separate sub-study revealed CD8+ cells as the primary source of the lactate-to-pyruvate signal. Our study suggests that hyperpolarized (HP) [1-13 C] pyruvate MRI is a promising early biomarker for tissue rejection that provides metabolic assessment in real time based on changes in cellularity and metabolism of lung tissue and the infiltrating inflammatory cells, and may be able to predict tissue rejection earlier than X-ray/CT.
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Affiliation(s)
- Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania, PA, USA
| | | | - Yi Xin
- Department of Radiology, University of Pennsylvania, PA, USA
| | | | - Jian-quin Tao
- Institute for Environmental Medicine, University of Pennsylvania, PA, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, PA, USA
| | | | - Ian Duncan
- Department of Radiology, University of Pennsylvania, PA, USA
| | | | - Ali Naji
- Department of Surgery, University of Pennsylvania, PA, USA
| | - Shampa Chatterjee
- Institute for Environmental Medicine, University of Pennsylvania, PA, USA
| | - Rahim Rizi
- Department of Radiology, University of Pennsylvania, PA, USA
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Glantz NM, Duncan I, Ahmed T, Fan L, Reed BL, Kalirai S, Kerr D. Racial and Ethnic Disparities in the Burden and Cost of Diabetes for US Medicare Beneficiaries. Health Equity 2019; 3:211-218. [PMID: 31289781 PMCID: PMC6608694 DOI: 10.1089/heq.2019.0004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose: To examine the burden and cost of diabetes among fee-for-service Medicare beneficiaries. Methods: Medicare 5% File data for type 1 diabetes (T1D) and type 2 diabetes (T2D) consisting of 1,397,933 enrollees in fee-for-service without Medicare Advantage during the period 2012-2013 were analyzed by race and ethnicity. Results: Although non-Hispanic whites (nHWs) comprised most of this population (86%), prevalence of T1D and T2D was higher for Hispanics than nHWs (3.4% vs. 1.8%, p=0.0006, for T1D and 33.4% vs. 21.9%, p<0.0001, for T2D). Hispanics also had more acute hospital admissions (p=0.0235 for T1D and p=0.0009 for T2D) and longer lengths of stay (7.5 vs. 6.9 days for T1D, p=0.0105, and 6.7 vs. 6.2 days for T2D, p<0.0001) compared with nHWs. Allowed and paid costs per member per month adjusted for confounding were higher for Hispanics than nHWs for T2D (both p<0.0001) and lower for those with T1D (both p<0.0001). Mean number of chronic diseases in patients with diabetes was higher in Hispanics than nHWs (both T1D and T2D, p<0.0000). For T2D, Hispanics were more likely to have glycated hemoglobin (HbA1c) and lipid testing as well as nephropathy screening (all p<0.0001). Hispanics with T1D were also more likely to have HbA1c and lipid tests (p=0.0014 and p=0.0011, respectively); retinopathy and nephropathy screening rates did not differ significantly from rates among nHWs. Conclusion: Diabetes disproportionately impacts US seniors, with Hispanics almost twice as likely as nHWs to be diagnosed. Racial and ethnic disparities exist in the burden and cost of diabetes care for Medicare recipients.
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Affiliation(s)
- Namino M Glantz
- Sansum Diabetes Research Institute, Santa Barbara, California
| | - Ian Duncan
- Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California
| | - Tamim Ahmed
- Santa Barbara Actuaries, Inc., Santa Barbara, California
| | - Ludi Fan
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | - David Kerr
- Sansum Diabetes Research Institute, Santa Barbara, California
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22
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Abstract
Aims: The aim of this study is to compare some machine learning methods with traditional statistical parametric analyses using logistic regression to investigate the relationship of risk factors for diabetes and cardiovascular (cardiometabolic risk) for U.S. adults using a cross-sectional data from participants in a wellness improvement program. Methods: Logistic regression was used to find the relationship between individual risk factors, predictor and cardiometabolic risk. Supervised machine learning methods were used to predict risk and produce a ranking of variables' importance. A clustering method was used to identify subpopulations of interest. Predictors were divided into those that are nonmodifiable and those that are modifiable. Results: The population comprised 217,254 adults of whom 8.1% had diabetes. Using logistic regression, six variables were identified to be negatively related and eleven were positively related to cardiometabolic risk. Three supervised machine learning classifiers (random forest, gradient boosting, and bagging) were applied with average AUC to be 0.806. Each classifier also produced a ranking of variables' importance. Four subgroups were identified with a k-medoid clustering algorithm, which were mainly distinguished by gender and diabetes status. Conclusions: The study illustrates that machine learning is an important addition to traditional logistic regression in terms of identifying important cardiometabolic risk factors and ranking their importance and the potential for interventions based on lifestyle and medications at an individual level.
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Affiliation(s)
- Xiyue Liao
- 1 Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California
| | - David Kerr
- 2 Sansum Diabetes Research Institute, Santa Barbara, California
| | | | - Ian Duncan
- 1 Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California
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23
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Yosick L, Crook RE, Gatto M, Maxwell TL, Duncan I, Ahmed T, Mackenzie A. Effects of a Population Health Community-Based Palliative Care Program on Cost and Utilization. J Palliat Med 2019; 22:1075-1081. [PMID: 30950679 PMCID: PMC6735317 DOI: 10.1089/jpm.2018.0489] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: New population health community-based models of palliative care can result in more compassionate, affordable, and sustainable high-quality care. Objectives: We evaluated utilization and cost outcomes of a standardized, population health community-based palliative care program provided by nurses and social workers. Design: We conducted a retrospective propensity-adjusted study to quantify cost savings and resource utilization associated with a community-based palliative care program. We analyzed claims data from a Medicare Advantage (MA) plan and used a proprietary predictive model to identify 804 members at high risk for overmedicalized end-of-life care. We enrolled 204 members in the palliative care program and compared them with 600 who received standard, telephonic, health plan case management. We excluded members with fewer than two months of enrolled experience or those with insufficient data for analysis, leaving 176 members in the study group and 570 in the control group for evaluation. We compared differences in utilization and costs (medical and pharmacy), hospital admissions, bed days (acute and intensive care unit [ICU]), and emergency department visits. Setting/Subjects: A 30,000-member MA plan and a health system in Central Ohio between October 2015 and June 2016. Results: Members who received community-based palliative care showed a statistically significant 20% reduction in total medical costs ($619 per enrolled member per month), 38% reduction in ICU admissions, 33% reduction in hospital admissions, and 12% reduction in hospital days. Conclusion: A structured nurse and social work model of community-based palliative care using a predictive model to identify MA candidates for intervention can reduce utilization and medical costs.
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Affiliation(s)
| | - Robert E Crook
- Mount Carmel Hospice and Palliative Care, Columbus, Ohio
| | | | | | - Ian Duncan
- Department of Statistics and Applied Probability, University of California at Santa Barbara, Santa Barbara, California
| | - Tamim Ahmed
- Santa Barbara Actuaries, Inc., Santa Barbara, California
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24
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Abstract
As the Medicare program struggles to control expenditures, there is increased focus on
opportunities to manage patient populations more efficiently and at a lower cost. A major
source of expense for the Medicare program is beneficiaries at end of life. Estimates of
the percentage of Medicare costs that arise from patients in the last year of life differ,
ranging from 13% to 25%, depending on methods and assumptions. We analyze the most
recently available Medicare Limited Data Set to update prior studies of end-of-life costs
and examine different methods of performing this calculation. Based upon these findings,
we conclude that higher estimates that take into account the spending over the 12 months
leading up to death more accurately reflect the full cost of a patient’s last year of
life. Comparing current year costs of decedents with Medicare’s current year costs
understates the full budgetary impact of end-of-life patients. Because risk-taking
entities such as Medicare Advantage plans and Accountable Care Organizations (ACOs) need
to reduce costs while improving the quality of care, they should initiate programs to
better manage the care of patients with serious or advanced illness. We also calculate
costs for beneficiaries dying in different settings and conclude that more effective use
of palliative care and hospice benefits offers a lower cost, higher quality alternative
for patients at end of life.
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Affiliation(s)
- Ian Duncan
- 1 Department of Statistics and Applied Probability, University of California, Santa Barbara, Santa Barbara, CA, USA
| | - Tamim Ahmed
- 2 Santa Barbara Actuaries Inc, Santa Barbara, CA, USA
| | - Henry Dove
- 3 Turn-Key Health, Philadelphia, PA, USA
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25
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Abstract
Purpose: It is well known that minority patients, and particularly African Americans undergo lower rates of cardiac procedures than the white population, even when covered by equivalent insurance. Methods: We analyzed the rates of percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) and for intermediate coronary syndrome (ICS), and rates of transcatheter aortic valve replacement for aortic stenosis in the 2012–2013 Medicare Limited Data Set (5% sample) file. Results: Although blacks have similar prevalence rates for AMI and ICS, they experience lower PTCA rates when compared with that of white patients (10.57 vs. 19.40, −46%). “Normalizing” procedure rates in the African American community to match their disease prevalence will require education and participation of all stakeholders: patients, providers, manufacturers, insurers, and advocacy organizations. Beyond improved clinical outcomes, financial incentives to “normalize care” exist. We estimate “lost” revenue within the Medicare population as a result of the lower procedure rates, at ∼$90 million annually ($22.0 million AMI, $9.4 million ICS and $68.7 million aortic valve disease). Conclusions: Providing evidence-based care to all patients improves health equity and can lower downstream high-cost conditions such as heart failure and multiple repeat inpatient admissions. As we move toward value-based care, the opportunity to normalize treatment for everyone seeking care is within our data analytics, innovative and collective reach.
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Affiliation(s)
| | - Ian Duncan
- Department of Statistics and Applied Probability, University of California, Santa Barbara, Santa Barbara, California
| | | | - Juan F Granada
- Cardiovascular Research Foundation, Columbia University Medical Center, New York, New York
| | - Tamim Ahmed
- Santa Barbara Actuaries, Inc., Santa Barbara, California
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26
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Khan B, Duncan I, Saad M, Schaefer D, Jordan A, Smith D, Neaigus A, Des Jarlais D, Hagan H, Dombrowski K. Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment. PLoS One 2018; 13:e0206356. [PMID: 30496209 PMCID: PMC6264850 DOI: 10.1371/journal.pone.0206356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 01/24/2018] [Accepted: 10/11/2018] [Indexed: 01/17/2023] Open
Abstract
Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents—a scenario quite different from the open, mobile populations known to most health agencies. This paper uses data from the Centers for Disease Control’s National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated. Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.
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Affiliation(s)
- Bilal Khan
- Department of Sociology, University of Nebraska, Lincoln NE, United States of America
| | - Ian Duncan
- Department of Sociology, University of Nebraska, Lincoln NE, United States of America
| | - Mohamad Saad
- Department of Sociology, University of Nebraska, Lincoln NE, United States of America
| | - Daniel Schaefer
- Department of Sociology, University of Nebraska, Lincoln NE, United States of America
| | - Ashly Jordan
- Rory Meyers College of Nursing, New York University, New York, NY, United States of America
- Center for Drug Use and HIV Research, New York University, New York, NY, United States of America
| | - Daniel Smith
- Rory Meyers College of Nursing, New York University, New York, NY, United States of America
| | - Alan Neaigus
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Don Des Jarlais
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Holly Hagan
- Rory Meyers College of Nursing, New York University, New York, NY, United States of America
- Center for Drug Use and HIV Research, New York University, New York, NY, United States of America
| | - Kirk Dombrowski
- Department of Sociology, University of Nebraska, Lincoln NE, United States of America
- * E-mail:
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27
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Goldman H, Singh N, Harding C, McGirr J, Seal A, Duncan I, Sowter S. Accuracy of multiparametric magnetic resonance imaging to detect significant prostate cancer and index lesion location. ANZ J Surg 2018; 89:106-110. [DOI: 10.1111/ans.14754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 05/02/2018] [Accepted: 06/01/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Hariette Goldman
- School of Medicine; The University of Notre Dame Australia; Sydney New South Wales Australia
- Rural Clinical School; The University of New South Wales; Wagga Wagga New South Wales Australia
| | - Neha Singh
- Rural Clinical School; The University of New South Wales; Wagga Wagga New South Wales Australia
- Wagga Wagga Base Hospital; Wagga Wagga New South Wales Australia
- Calvary Healthcare Regional Imaging; Wagga Wagga New South Wales Australia
| | - Catherine Harding
- School of Medicine; The University of Notre Dame Australia; Sydney New South Wales Australia
| | - Joe McGirr
- School of Medicine; The University of Notre Dame Australia; Sydney New South Wales Australia
| | - Alexa Seal
- School of Medicine; The University of Notre Dame Australia; Sydney New South Wales Australia
| | - Ian Duncan
- Calvary Healthcare Regional Imaging; Wagga Wagga New South Wales Australia
| | - Steven Sowter
- Rural Clinical School; The University of New South Wales; Wagga Wagga New South Wales Australia
- Wagga Wagga Base Hospital; Wagga Wagga New South Wales Australia
- Riverina Urology; Wagga Wagga New South Wales Australia
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28
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Affiliation(s)
- Ian Duncan
- Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California
| | - Nhan Huynh
- Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California
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29
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Xin Y, Cereda M, Hamedani H, Pourfathi M, Siddiqui S, Meeder N, Kadlecek S, Duncan I, Profka H, Rajaei J, Tustison NJ, Gee JC, Kavanagh BP, Rizi RR. Unstable Inflation Causing Injury. Insight from Prone Position and Paired Computed Tomography Scans. Am J Respir Crit Care Med 2018; 198:197-207. [PMID: 29420904 PMCID: PMC6058981 DOI: 10.1164/rccm.201708-1728oc] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 01/16/2023] Open
Abstract
RATIONALE It remains unclear how prone positioning improves survival in acute respiratory distress syndrome. Using serial computed tomography (CT), we previously reported that "unstable" inflation (i.e., partial aeration with large tidal density swings, indicating increased local strain) is associated with injury progression. OBJECTIVES We prospectively tested whether prone position contains the early propagation of experimental lung injury by stabilizing inflation. METHODS Injury was induced by tracheal hydrochloric acid in rats; after randomization to supine or prone position, injurious ventilation was commenced using high tidal volume and low positive end-expiratory pressure. Paired end-inspiratory (EI) and end-expiratory (EE) CT scans were acquired at baseline and hourly up to 3 hours. Each sequential pair (EI, EE) of CT images was superimposed in parametric response maps to analyze inflation. Unstable inflation was then measured in each voxel in both dependent and nondependent lung. In addition, five pigs were imaged (EI and EE) prone versus supine, before and (1 hour) after hydrochloric acid aspiration. MEASUREMENTS AND MAIN RESULTS In rats, prone position limited lung injury propagation and increased survival (11/12 vs. 7/12 supine; P = 0.01). EI-EE densities, respiratory mechanics, and blood gases deteriorated more in supine versus prone rats. At baseline, more voxels with unstable inflation occurred in dependent versus nondependent regions when supine (41 ± 6% vs. 18 ± 7%; P < 0.01) but not when prone. In supine pigs, unstable inflation predominated in dorsal regions and was attenuated by prone positioning. CONCLUSIONS Prone position limits the radiologic progression of early lung injury. Minimizing unstable inflation in this setting may alleviate the burden of acute respiratory distress syndrome.
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Affiliation(s)
- Yi Xin
- Department of Radiology and
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Natalie Meeder
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Nicholas J. Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia; and
| | | | - Brian P. Kavanagh
- Department of Critical Care Medicine and
- Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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30
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Turski CA, Turski GN, Chen B, Wang H, Heidari M, Li L, Noguchi KK, Westmark C, Duncan I, Ikonomidou C. Clemastine effects in rat models of a myelination disorder. Pediatr Res 2018; 83:1200-1206. [PMID: 29584714 PMCID: PMC6621548 DOI: 10.1038/pr.2018.45] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Received: 08/07/2017] [Accepted: 02/23/2018] [Indexed: 01/15/2023]
Abstract
BackgroundPelizaeus Merzbacher disease (PMD) is a dysmyelinating disorder of the central nervous system caused by impaired differentiation of oligodendrocytes. This study was prompted by findings that antimuscarinic compounds enhance oligodendrocyte differentiation and remyelination in vitro. One of these compounds, clemastine fumarate, is licensed for treatment of allergic conditions. We tested whether clemastine fumarate can promote myelination in two rodent PMD models, the myelin-deficient and the PLP transgenic rat.MethodsPups were treated with daily injections of clemastine (10-30 mg/kg/day) on postnatal days 1-21. Neurologic phenotypes and myelination patterns in the brain, optic nerves, and spinal cords were assessed using histological techniques.ResultsNo changes in neurological phenotype or survival were observed even at the highest dose of clemastine. Postmortem staining with Luxol fast blue and myelin basic protein immunohistochemistry revealed no evidence for improved myelination in the CNS of treated rats compared to vehicle-treated littermates. Populations of mature oligodendrocytes were unaffected by the treatment.ConclusionThese results demonstrate lack of therapeutic effect of clemastine in two rat PMD models. Both models have rapid disease progression consistent with the connatal form of the disease. Further studies are necessary to determine whether clemastine bears a therapeutic potential in milder forms of PMD.
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Affiliation(s)
| | - Gabrielle N Turski
- Department of Ophthalmology, Rheinische Friedrich Wilhelms University, Bonn, Germany
| | - Bingming Chen
- School of Pharmacy and Department of Chemistry, University of Wisconsin, Madison, Wisconsin
| | - Hauhui Wang
- Department of Psychiatry, Washington University, St Louis, Missouri
| | - Moones Heidari
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, Wisconsin
| | - Lingjun Li
- School of Pharmacy and Department of Chemistry, University of Wisconsin, Madison, Wisconsin
| | - Kevin K Noguchi
- Department of Psychiatry, Washington University, St Louis, Missouri
| | - Cara Westmark
- Department of Neurology, University of Wisconsin, Madison, Wisconsin
| | - Ian Duncan
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, Wisconsin
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31
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Pourfathi M, Cereda M, Chatterjee S, Xin Y, Kadlecek S, Duncan I, Hamedani H, Siddiqui S, Profka H, Ehrich J, Ruppert K, Rizi RR. Lung Metabolism and Inflammation during Mechanical Ventilation; An Imaging Approach. Sci Rep 2018; 8:3525. [PMID: 29476083 PMCID: PMC5824838 DOI: 10.1038/s41598-018-21901-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 02/13/2018] [Indexed: 12/20/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major cause of mortality in critically ill patients. Patients are currently managed by protective ventilation and alveolar recruitment using positive-end expiratory pressure (PEEP). However, the PEEP's effect on both pulmonary metabolism and regional inflammation is poorly understood. Here, we demonstrate the effect of PEEP on pulmonary anaerobic metabolism in mechanically ventilated injured rats, using hyperpolarized carbon-13 imaging. Pulmonary lactate-to-pyruvate ratio was measured in 21 rats; 14 rats received intratracheal instillation of hydrochloric-acid, while 7 rats received sham saline. 1 hour after acid/saline instillation, PEEP was lowered to 0 cmH2O in 7 injured rats (ZEEP group) and in all sham rats; PEEP was continued in the remaining 7 injured rats (PEEP group). Pulmonary compliance, oxygen saturation, histological injury scores, ICAM-1 expression and myeloperoxidase expression were measured. Lactate-to-pyruvate ratio progressively increased in the dependent lung during mechanical ventilation at ZEEP (p < 0.001), but remained unchanged in PEEP and sham rats. Lactate-to-pyruvate ratio was correlated with hyaline membrane deposition (r = 0.612), edema severity (r = 0.663), ICAM-1 (r = 0.782) and myeloperoxidase expressions (r = 0.817). Anaerobic pulmonary metabolism increases during lung injury progression and is contained by PEEP. Pulmonary lactate-to-pyruvate ratio may indicate in-vivo neutrophil activity due to atelectasis.
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Affiliation(s)
- Mehrdad Pourfathi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department Electrical and Systems Engineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Shampa Chatterjee
- Department of Physiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Harrilla Profka
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Ehrich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA.
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32
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Duncan I, Habecker P, Hautala D, Khan B, Dombrowski K. Injection-related hepatitis C serosorting behaviors among people who inject drugs: An urban/rural comparison. J Ethn Subst Abuse 2018; 18:578-593. [PMID: 29436977 DOI: 10.1080/15332640.2018.1425950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 10/18/2022]
Abstract
Although previous research has focused on injection drug use behaviors in both urban and rural settings, few have drawn direct comparisons between adjacent rural and urban areas. Using data from the National HIV Behavioral Surveillance study as well as original data collected in a similar fashion, we compare the risk behaviors of people who inject drugs (PWID) in San Juan, Puerto Rico, with those of PWID in nearby rural areas. Specifically, we examine whether one's own hepatitis C (HCV) infection status can be used to predict whether one asked their most recent co-injection partner about their HCV status. Acquiring such information allows injectors to seek out co-injection partners of concordant status as a way to minimize the risk of viral transmission. Results indicate that urban PWID with a known HCV+ status were more likely to know their last co-injector partner's HCV status than were their peers with a negative or unknown HCV status. However, this relationship was not present in the rural data. These findings suggest that there are different risk norms in rural and urban PWID communities and that interventions successful in one type of community may not be so in others.
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Affiliation(s)
- Ian Duncan
- University of Nebraska , Lincoln , Nebraska
| | | | | | - Bilal Khan
- University of Nebraska , Lincoln , Nebraska
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33
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Cunningham D, Denvir D, Duncan I, Morrow T. Up-conversion Using Stimulated Anti-stokes Raman Scattering and Stimulated Collisional Induced Fluorescence in Tl. ACTA ACUST UNITED AC 2017. [DOI: 10.1080/09670269600651451a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- D.G. Cunningham
- a Department of Pure and Applied Physics, Queen's University of Belfast, Belfast BT7 1NN, Northern Ireland
| | - D. Denvir
- a Department of Pure and Applied Physics, Queen's University of Belfast, Belfast BT7 1NN, Northern Ireland
| | - I. Duncan
- a Department of Pure and Applied Physics, Queen's University of Belfast, Belfast BT7 1NN, Northern Ireland
| | - T. Morrow
- a Department of Pure and Applied Physics, Queen's University of Belfast, Belfast BT7 1NN, Northern Ireland
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34
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Duncan I, Fitzner K, Handmaker KE. Augmented Intelligence: Enhancing the Roles of Health Actuaries and Health Economists for Population Health Management. Popul Health Manag 2017; 21:341-343. [PMID: 29064330 DOI: 10.1089/pop.2017.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ian Duncan
- 1 Department of Statistics and Applied Probability, University of California Santa Barbara , Santa Barbara, California
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35
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Duncan I, Habecker P, Abadie R, Curtis R, Khan B, Dombrowski K. Needle acquisition patterns, network risk and social capital among rural PWID in Puerto Rico. Harm Reduct J 2017; 14:69. [PMID: 29047371 PMCID: PMC5648484 DOI: 10.1186/s12954-017-0195-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/02/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND People who inject drugs (PWID) take on significant risks of contracting blood-borne infection, including injecting with a large number of partners and acquiring needles from unsafe sources. When combined, risk of infection can be magnified. METHODS Using a sample of PWID in rural Puerto Rico, we model the relationship between a subject's number of injection partners and the likelihood of having used an unsafe source of injection syringes. Data collection with 315 current injectors identified six sources of needles. RESULTS Of the six possible sources, only acquisition from a seller (paid or free), or using syringes found on the street, was significantly related to number of partners. CONCLUSIONS These results suggest that sources of syringes do serve to multiply risk of infection caused by multi-partner injection concurrency. They also suggest that prior research on distinct forms of social capital among PWID may need to be rethought.
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Affiliation(s)
- Ian Duncan
- University of Nebraska, Lincoln, Nebraska USA
| | | | | | - Ric Curtis
- John Jay College of Criminal Justice, New York, USA
| | - Bilal Khan
- University of Nebraska, Lincoln, Nebraska USA
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36
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Xin Y, Cereda M, Kadlecek S, Emami K, Hamedani H, Duncan I, Rajaei J, Hughes L, Meeder N, Naji J, Profka H, Bolognese BJ, Foley JP, Podolin PL, Rizi RR. Hyperpolarized gas diffusion MRI of biphasic lung inflation in short- and long-term emphysema models. Am J Physiol Lung Cell Mol Physiol 2017; 313:L305-L312. [PMID: 28473321 DOI: 10.1152/ajplung.00048.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 02/03/2017] [Revised: 04/28/2017] [Accepted: 04/29/2017] [Indexed: 11/22/2022] Open
Abstract
During lung inflation, airspace dimensions are affected nonlinearly by both alveolar expansion and recruitment, potentially confounding the identification of emphysematous lung by hyperpolarized helium-3 diffusion magnetic resonance imaging (HP MRI). This study aimed to characterize lung inflation over a broad range of inflation volume and pressure values in two different models of emphysema, as well as in normal lungs. Elastase-treated rats (n = 7) and healthy controls (n = 7) were imaged with HP MRI. Gradual inflation was achieved by incremental changes to both inflation volume and airway pressure. The apparent diffusion coefficient (ADC) was measured at each level of inflation and fitted to the corresponding airway pressures as the second-order response equation, with minimizing residue (χ2 < 0.001). A biphasic ADC response was detected, with an initial ADC increase followed by a decrease at airway pressures >18 cmH2O. Discrimination between treated and control rats was optimal when airway pressure was intermediate (between 10 and 11 cmH2O). Similar findings were confirmed in mice following long-term exposure to cigarette smoke, where optimal discrimination between treated and healthy mice occurred at a similar airway pressure as in the rats. We subsequently explored the evolution of ADC measured at the intermediate inflation level in mice after prolonged smoke exposure and found a significant increase (P < 0.01) in ADC over time. Our results demonstrate that measuring ADC at intermediate inflation enhances the distinction between healthy and diseased lungs, thereby establishing a model that may improve the diagnostic accuracy of future HP gas diffusion studies.
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Affiliation(s)
- Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Liam Hughes
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Natalie Meeder
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph Naji
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harrilla Profka
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Joseph P Foley
- Glaxosmithkline, Incorpoarted, King of Prussia, Pennsylvania
| | | | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania;
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Duncan I, Curtis R, Reyes JC, Abadie R, Khan B, Dombrowski K. Hepatitis C serosorting among people who inject drugs in rural Puerto Rico. Prev Med Rep 2017; 6:38-43. [PMID: 28271018 PMCID: PMC5328718 DOI: 10.1016/j.pmedr.2017.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/10/2016] [Accepted: 02/05/2017] [Indexed: 12/15/2022] Open
Abstract
Due to the high cost of treatment, preventative measures to limit Hepatitis C (HCV) transmission among people who inject drugs (PWID) are encouraged by many public health officials. A key one of these is serosorting, where PWID select risk partners based on concordant HCV status. Research on the general U.S. population by Smith et al. (2013) found that knowledge of one's own HCV status facilitated serosorting behaviors among PWID, such that respondents with knowledge of their own status were more likely to ask potential partners about their status prior to sharing risk. Our objective was to see if this held true in rural Puerto Rico. We replicate this study using a sample of PWID in rural Puerto Rico to draw comparisons. We used respondent driven sampling to survey 315 participants, and have a final analytic sample of 154. The survey was heavily modeled after the National HIV Behavioral Survey, which was the dataset used by the previous researchers. We found that among PWID in rural Puerto Rico, unlike in the general population, knowledge of one's own HCV status had no significant effect on the selection of one's most recent injection partner, based on his/her HCV status. We conclude that PWID in rural Puerto Rico differ from the general U.S. population when it comes to serosorting behaviors, and that these differences should be taken into account in future outreaches and intervention strategies. Recent study finds PWID ask potential partners about infections once own status known. We replicate this using similar measures with a sample in rural Puerto Rico. Find no evidence this happens in rural Puerto Rico, though women more likely to ask. Null finding may be due to small sample size, but pattern still appears unique.
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Affiliation(s)
- Ian Duncan
- University of Nebraska – Lincoln, United States
- Corresponding author.
| | - Ric Curtis
- John Jay College of Criminal Justice, United States
| | | | | | - Bilal Khan
- University of Nebraska – Lincoln, United States
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Drachman N, Kadlecek S, Duncan I, Rizi R. Quantifying reaction kinetics of the non-enzymatic decarboxylation of pyruvate and production of peroxymonocarbonate with hyperpolarized13C-NMR. Phys Chem Chem Phys 2017; 19:19316-19325. [DOI: 10.1039/c7cp02041d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Hyperpolarized13C-NMR is used to study the reaction mechanism and kinetics for non-enzymatic decarboxylation of pyruvate and formation of peroxymonocarbonate.
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Affiliation(s)
| | | | - Ian Duncan
- University of Pennsylvania
- Radiology
- Philadelphia
- USA
| | - Rahim Rizi
- University of Pennsylvania
- Radiology
- Philadelphia
- USA
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Duncan I, Clark K, Wang S. Cost and Utilization of Retail Clinics vs. Other Providers for Treatment of Pediatric Acute Otitis Media. Popul Health Manag 2016; 19:341-8. [DOI: 10.1089/pop.2015.0051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ian Duncan
- Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California
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Affiliation(s)
- Ian Duncan
- 1 University of California Santa Barbara , Department of Statistics and Applied Probability, Santa Barbara, California
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Kerr D, Yadollahi M, Bautista HM, Chen X, Dong S, Guerrier SNA, Laan RJ, Duncan I. Use of a Publicly Available Database to Determine the Impact of Diabetes on Length of Hospital Stay for Elective Orthopedic Procedures in California. Popul Health Manag 2016; 19:439-444. [PMID: 27007572 DOI: 10.1089/pop.2015.0125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In California, 1 in 3 hospital beds are occupied by adults with diabetes. The aim of this study was to examine whether diabetes impacts length of stay (LOS) following common elective orthopedic procedures compared to nondiabetic individuals, and also the performance of hospitals across California for these procedures. Using the Public Use California Patient Discharge Data Files for 2010-2012, the authors examined LOS for elective discharges for hip, spine, or knee surgery (n = 318,861) from the total population of all discharges (n = 11,476,073) for 309 hospitals across California. In all, 16% of discharges had a codiagnosis of diabetes. Unadjusted average LOS was 3.11 days without and 3.40 days with diabetes (mean difference 0.29 [95% confidence interval (0.27, 0.31) days, P < 0.01]). After adjusting for covariates, diabetes no longer resulted in a significant difference in LOS. However, the presence of common comorbidities did significantly impact LOS. Average LOS for patients with diabetes also varied widely by hospital, ranging between -50% and +100% of the mean LOS for all hospitals. Diabetes does not prolong LOS after orthopedic procedures unless comorbidities are present. Nevertheless, across California there is significant variation in LOS between individual hospitals, which may inform the decision-making process for prospective patients and payers.
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Affiliation(s)
- David Kerr
- 1 William Sansum Diabetes Center , Santa Barbara, California
| | - Meroe Yadollahi
- 2 Department of Statistics and Applied Probability, University of California , Santa Barbara, California
| | - Hemerson M Bautista
- 2 Department of Statistics and Applied Probability, University of California , Santa Barbara, California
| | - Xin Chen
- 2 Department of Statistics and Applied Probability, University of California , Santa Barbara, California
| | - Shuyan Dong
- 2 Department of Statistics and Applied Probability, University of California , Santa Barbara, California
| | - Stephane N A Guerrier
- 3 Deptartment of Statistics, University of Illinois at Urbana-Champaign , Champaign, Illinois
| | - Remmert J Laan
- 1 William Sansum Diabetes Center , Santa Barbara, California
| | - Ian Duncan
- 2 Department of Statistics and Applied Probability, University of California , Santa Barbara, California
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Sharp L, Cotton SC, Cruickshank ME, Gray NM, Neal K, Rothnie K, Thornton AJ, Walker LG, Little J, Cruickshank M, Murray G, Parkin D, Smart L, Walker E, Waugh N, Avis M, Chilvers C, Fielding K, Hammond R, Jenkins D, Johnson J, Neal K, Seth R, Whynes D, Duncan I, Robertson A, Little J, Sharp L, Russell I, Walker L, Anthony B, Bell S, Bowie A, Brown K, Brown J, Chew K, Cochran C, Cotton S, Dean J, Dunn K, Edwards J, Evans D, Fenty J, Finlayson A, Gallagher M, Gray N, Heddle M, Innes A, Jobson D, Keillor M, MacGregor J, Mackenzie S, Mackie A, McPherson G, Okorocha I, Reilly M, Rodgers J, Thornton A, Yeats R, Alexander L, Buchanan L, Henderson S, Iterbeke T, Lucas S, Manderson G, Nicol S, Reid G, Robinson C, Sandilands T, Adrian M, Al-Sahab A, Bentley E, Brook H, Bushby C, Cannon R, Cooper B, Dowell R, Dunderdale M, Gabrawi, Guo L, Heideman L, Jones S, Lawson S, Philips Z, Platt C, Prabhakaran S, Rippin J, Thompson R, Williams E, Woolley C, Cotton S, Harrild K, Norrie J, Sharp L, Day N, Marteau T, Parmar M, Patnick J, Woodman C, Altman D, Moss S, Wells M. Long-Term Worries after Colposcopy: Which Women Are at Increased Risk? Womens Health Issues 2015; 25:517-27. [DOI: 10.1016/j.whi.2015.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 03/19/2015] [Accepted: 04/06/2015] [Indexed: 10/23/2022]
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DuChane J, Clark B, Staskon F, Miller R, Love K, Duncan I. Walgreens connected care: impact of managed therapy on adherence to medications used to treat multiple sclerosis and related comorbid conditions. Int J MS Care 2015; 17:57-64. [PMID: 25892975 DOI: 10.7224/1537-2073.2013-051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Walgreens Connected Care Multiple Sclerosis (CCMS) treatment management program provides enhanced levels of monitoring, oversight, and care for patients taking MS disease-modifying agents. This study compared rates of adherence to MS medications for patients participating in the CCMS program for at least 6 months with those for patients participating for less than 6 months. For a subsample of patients, we also examined the relationship between adherence and the presence of fatigue or depression. METHODS This was a retrospective study of patients new to the CCMS program and followed up for 1 year of participation. Adherence to MS medications was measured as the proportion of days covered, with propensity scores used to match the CCMS intervention group to the less-managed comparison group. The impact of program participation on the relationship between depression or fatigue and adherence over time was a separate analysis. RESULTS Mean proportion of days covered rates improved significantly in the group managed for at least 6 months compared with those who were less managed. Positive screenings for fatigue and depression reduced adherence in the less-managed group but not in patients with longer participation in the program. CONCLUSIONS Overall, the CCMS program significantly increased adherence to MS medications. This improved adherence was not negatively impacted by positive screenings for fatigue and depression.
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Affiliation(s)
- Janeen DuChane
- Health Services and Outcomes Research, Walgreen Co, Deerfield, IL, USA (JD, BC, FS, ID); and Specialty Solutions Group, Walgreen Co, Pittsburgh, PA, USA (RM, KL)
| | - Bobby Clark
- Health Services and Outcomes Research, Walgreen Co, Deerfield, IL, USA (JD, BC, FS, ID); and Specialty Solutions Group, Walgreen Co, Pittsburgh, PA, USA (RM, KL)
| | - Francis Staskon
- Health Services and Outcomes Research, Walgreen Co, Deerfield, IL, USA (JD, BC, FS, ID); and Specialty Solutions Group, Walgreen Co, Pittsburgh, PA, USA (RM, KL)
| | - Rick Miller
- Health Services and Outcomes Research, Walgreen Co, Deerfield, IL, USA (JD, BC, FS, ID); and Specialty Solutions Group, Walgreen Co, Pittsburgh, PA, USA (RM, KL)
| | - Kathleen Love
- Health Services and Outcomes Research, Walgreen Co, Deerfield, IL, USA (JD, BC, FS, ID); and Specialty Solutions Group, Walgreen Co, Pittsburgh, PA, USA (RM, KL)
| | - Ian Duncan
- Health Services and Outcomes Research, Walgreen Co, Deerfield, IL, USA (JD, BC, FS, ID); and Specialty Solutions Group, Walgreen Co, Pittsburgh, PA, USA (RM, KL)
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DuChane J, Clark B, Hou J, Fitzner K, Pietrandoni G, Duncan I. Impact of HIV-specialized pharmacies on adherence to medications for comorbid conditions. J Am Pharm Assoc (2003) 2015; 54:493-501. [PMID: 25216879 DOI: 10.1331/japha.2014.13165] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine if patients using human immunodeficiency virus (HIV)-specialized pharmacies have greater adherence to drugs used to treat comorbid conditions and HIV compared with patients who use traditional pharmacies. DESIGN Retrospective cohort study, with patients' propensity matched based on pharmacy use: HIV-specialized versus traditional. SETTING Nationwide pharmacy chain. PARTICIPANTS Adult patients who filled at least two prescriptions for an antiretroviral therapy (ART). Patients also needed to have at least two prescriptions for an angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) or a statin for analyses examining comorbid conditions. MAIN OUTCOME MEASURE Proportion of days covered (PDC). RESULTS The adherence analyses for ART, ACE inhibitors/ARBs, and statins included 14,278, 1,484, and 1,372 pairs, respectively. The mean PDC for ART patients using HIV-specialized pharmacies was higher than that for patients using traditional pharmacies (86.20% vs. 81.87%; P <0.0001). Patients taking ACE inhibitors/ARBs in the specialized group also had a higher mean PDC compared with patients in the traditional group (82.61 vs. 79.66; P = 0.0002), as did specialized pharmacy users in the statin group (83.77 vs. 81.29; P = 0.0009). CONCLUSION HIV patients managed by an HIV-specialized pharmacy have significantly higher adherence to medication for comorbid conditions compared with patients using traditional pharmacies. Patients of HIV-specialized pharmacies also have significantly higher adherence to ART compared with peers using traditional pharmacies.
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Kirkham HS, Clark BL, Bolas CA, Lewis GH, Jackson AS, Fisher D, Duncan I. Which Modifiable Health Risks Are Associated with Changes in Productivity Costs? Popul Health Manag 2015; 18:30-8. [DOI: 10.1089/pop.2014.0033] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | - Geraint Hywel Lewis
- Walgreen Co., Deerfield, Illinois
- Current affiliation is National Health Service England, Leeds, United Kingdom
| | | | | | - Ian Duncan
- Walgreen Co., Deerfield, Illinois
- Current affiliation is Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California
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Abstract
Despite levels of health spending that are higher per capita and as share of gross domestic product than any country worldwide, the US health care system is fragmented, technology and administration heavy, and primary care deficient. Studies of regional variations in US health care show similar "disconnects" between higher spending and better health outcomes. Faced with rising health benefit costs and suboptimal workforce health amid economic downturn, concerned US employers have implemented innovative payment and health care delivery strategies such as consumer-driven health plans and targeted prevention programs. The former may impose undue cost shifting, prohibitive out-of-pocket expenses, and health literacy challenges, while the latter have shown inconsistent near-term economic returns and long-term clinical efficacy. Employers have begun exploring more comprehensive health delivery platforms such as integrated worksite primary care clinics that have potential to cost-effectively address several pressing problems with current US health care: the growing primary care physician shortage, poor access to routine care, lack of coordinated and patient-centered treatment models, low rates of childhood immunizations, and "quality-blind" fee-for-service payment mechanisms. Such on-site medical clinics exploit one of the rare comparative strengths of the US health care system-its plentiful supply of highly skilled registered nurses-to offer workers and their dependents convenient, high-quality, affordable care. A relatively recent health care paradigm, worksite clinics must yet develop consistent reporting strategies and credible demonstration of outcomes. This review explores available evidence regarding worksite primary care clinics, including current rationale, historical trends, prevalence and projected growth, expected health and financial benefits, challenges, and future research directions.
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Affiliation(s)
- Victoria Shahly
- 1 Department of Health Care Policy, Harvard Medical School , Boston, Massachusetts
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Kirkham HS, Clark BL, Paynter J, Lewis GH, Duncan I. The effect of a collaborative pharmacist–hospital care transition program on the likelihood of 30-day readmission. Am J Health Syst Pharm 2014; 71:739-45. [DOI: 10.2146/ajhp130457] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | - Jacquelyn Paynter
- Rockdale Medical Center, Conyers, GA; at the time of writing she was Executive Director, Care Management, DeKalb Medical, Decatur, GA
| | - Geraint H. Lewis
- Patients and Information, National Health Service England, Leeds, United Kingdom
| | - Ian Duncan
- Clinical Outcomes and Analytics, Walgreen Company
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Yabuki T, Duncan I, Okuda T. Comparative study reveals unique features of the mycobiota in peat soils samples from Japan and Scotland. MYCOSCIENCE 2014. [DOI: 10.1016/j.myc.2013.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The objective of this study was to examine the efficacy of a worksite weight management program on the reduction of weight and lipid levels in employees and their dependents. This retrospective study examined the impact of a one-on-one worksite weight management program. Patients with a body mass index (BMI)>30, or a BMI>25 and 2 or more risk factors were eligible for inclusion. Laboratory and biometric readings at study end were compared to those at baseline. In addition, the percentage change of patients reaching recommended guideline levels was reported. Of the 310 employees enrolled, 157 completed the program (50.6%) with an average weight loss of 5.6%. Improvement was realized for pre-post weight (-6.0 lbs.; P≤.0001), BMI (-0.9; P≤.0001), blood pressure (systolic: -2.6; P≤.0001; diastolic: -1.9; P≤.0001), total cholesterol (-5.9; P=.0485), low-density lipoprotein cholesterol (LDL; -4.7; P=.0004), and triglycerides (-7.6; P=.0060). The proportion moving to within guideline levels increased for the following metrics: normal BMI category (2.6%; P=.0060),<30 BMI (10%; P≤.0001), systolic and diastolic blood pressure readings (7.7%; P=.0011 and 6.1; P=.0056, respectively), total cholesterol (6.5%; P=.0020), LDL (3.9%; P=.0396), and triglycerides (4.8; P=.0137). Retention in the worksite program was almost twice that seen in some commercial weight loss programs and significant improvements in laboratory and biometric readings were achieved. This study suggests that employer worksite-based programs may have an important role in improving the health of an employee population, which is of particular interest given the high prevalence of obesity and its attendant costs.
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