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Gosiker B, Moutchia J, Nguyen N, Getahun D, Goodman M. Changes in Blood Lipids Following Initiation of Gender Affirming Hormone Therapy: A Systematic Review and Meta-Analysis. J Clin Transl Endocrinol 2024; 36:100349. [PMID: 38737626 PMCID: PMC11087959 DOI: 10.1016/j.jcte.2024.100349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/08/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
Aim The aim of this study was to conduct a systematic review and meta-analysis of changes in low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), total cholesterol, and triglycerides following initiation of feminizing or masculinizing gender affirming hormone therapy (GAHT). Methods A search of Ovid MEDLINE, Embase, Web of Science, SCOPUS, and CINAHL databases identified potentially relevant articles published from 1990 through 2024. Both observational and randomized trials of adults receiving feminizing or masculinizing GAHT with baseline and follow-up measures were included. Articles were reviewed for eligibility using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. The risk of bias in each study was quantified using the NHLBI Study Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group. Random effects models were used to compute the before-and-after meta-differences in mean values for each parameter along with the I2 statistic to assess heterogeneity of results. Results Thirty-five studies met the criteria for inclusion in the meta-analysis. Masculinizing GAHT was associated with significant changes in serum lipids from baseline up through the 60-month timepoint with meta-difference of means (95% CI) estimates of 26.2mg/dL (23.3,29.0) for LDL-C, 26.1mg/dL (22.8,29.4) for total cholesterol, 30.7mg/dL (6.9,54.6) for triglycerides and -9.4mg/dL (-12.1, -6.7) for HDL-C. Studies evaluating the effects of feminizing GAHT on balance demonstrated no notable changes in HDL-C or triglycerides while the results for LDL-C and total cholesterol were inconsistent. Heterogeneity of results ranged from minimal (I2 = 0%) to substantial (I2 = 90%). Conclusions While the results for transfeminine individuals on GAHT appear somewhat reassuring, transmasculine patients receiving testosterone may benefit from closer monitoring of lipid profiles.
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Affiliation(s)
- Bennett Gosiker
- Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Jude Moutchia
- Penn Medicine, University of Pennsylvania, United States
| | - Nghiem Nguyen
- Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Darios Getahun
- Kaiser Permanente Southern California, Department of Research and Evaluation, Southern California Permanente Medical Group, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, United States
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Moutchia J, McClelland RL, Al-Naamani N, Appleby DH, Holmes JH, Minhas J, Mazurek JA, Palevsky HI, Ventetuolo CE, Kawut SM. Pulmonary arterial hypertension treatment: an individual participant data network meta-analysis. Eur Heart J 2024:ehae049. [PMID: 38416633 DOI: 10.1093/eurheartj/ehae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 11/20/2023] [Accepted: 01/18/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND AND AIMS Effective therapies that target three main signalling pathways are approved to treat pulmonary arterial hypertension (PAH). However, there are few large patient-level studies that compare the effectiveness of these pathways. The aim of this analysis was to compare the effectiveness of the treatment pathways in PAH and to assess treatment heterogeneity. METHODS A network meta-analysis was performed using individual participant data of 6811 PAH patients from 20 Phase III randomized clinical trials of therapy for PAH that were submitted to the US Food and Drug Administration. Individual drugs were grouped by the following treatment pathways: endothelin, nitric oxide, and prostacyclin pathways. RESULTS The mean (±standard deviation) age of the sample was 49.2 (±15.4) years; 78.4% were female, 59.7% had idiopathic PAH, and 36.5% were on background PAH therapy. After covariate adjustment, targeting the endothelin + nitric oxide pathway {β: 43.7 m [95% confidence interval (CI): 32.9, 54.4]}, nitric oxide pathway [β: 29.4 m (95% CI: 22.6, 36.3)], endothelin pathway [β: 25.3 m (95% CI: 19.8, 30.8)], and prostacyclin pathway [oral/inhaled β: 19.1 m (95% CI: 14.2, 24.0), intravenous/subcutaneous β: 24.4 m (95% CI: 15.1, 33.7)] significantly increased 6 min walk distance at 12 or 16 weeks compared with placebo. Treatments also significantly reduced the likelihood of having clinical worsening events. There was significant heterogeneity of treatment effects by age, body mass index, hypertension, diabetes, and coronary artery disease. CONCLUSIONS Drugs targeting the three traditional treatment pathways significantly improve outcomes in PAH, with significant treatment heterogeneity in patients with some comorbidities. Randomized clinical trials are warranted to identify the most effective treatment strategies in a personalized approach.
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Affiliation(s)
- Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn L McClelland
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dina H Appleby
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John H Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jasleen Minhas
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Harold I Palevsky
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey E Ventetuolo
- Department of Medicine and Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Minhas J, Moutchia J, Al-Naamani N, Mazurek JA, Holmes JH, Appleby D, Smith KA, Fritz JS, Pugliese SC, Palevsky HI, Kawut SM. Electrocardiographic Abnormalities and Their Association with Outcomes in Randomized Clinical Trials of Pulmonary Arterial Hypertension. Ann Am Thorac Soc 2024. [PMID: 38241602 DOI: 10.1513/annalsats.202307-609oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/18/2024] [Indexed: 01/21/2024] Open
Abstract
Rationale PAH is a progressive disease with manifestations including right atrial enlargement, right ventricular dysfunction, dilation and hypertrophy. ECG is a non-invasive, inexpensive test that is routinely performed in clinical settings. Prior studies have described separate abnormal findings in ECGs of patients with PAH. However, the role of composite ECG findings reflective of right heart disease for risk stratification, clinical trial enrichment and management of patients with PAH has not been explored. Objectives i. Describe a pattern of right heart disease on ECG in patients with PAH. ii. Investigate the association of this pattern with clinical measures of disease severity and outcomes. Methods We harmonized individual participant data from 18 Phase-III randomized clinical trials of therapies for PAH (1998 - 2013) submitted to the FDA. Right heart disease (RHD) was defined as the presence of RV hypertrophy, right axis deviation, right atrial enlargement, or right bundle branch block on ECG. Random effects linear regression, multilevel ordinal regression (cumulative link model), and Cox proportional hazards models were used to assess the association of RHD by ECG with six-minute walk distance (6MWD), WHO functional class, and clinical worsening after a priori adjustment for age, sex, body mass index and PAH etiology. Effect modification of treatment and ECG abnormalities was assessed by including an interaction term. Results 4439 patients had baseline ECGs and 68% patients had evidence of RHD. RHD on ECG was associated with higher PVR (p<0.001) and higher mean PA pressures (p<0.001). Patients with RHD on ECG had 10 meters shorter 6MWD (p=0.005) and worse WHO functional class (p<0.001) at baseline. RHD on baseline ECG was associated with increased risk of clinical worsening (HR=1.42, 95%CI=1.21,1.67, p<0.001). Patients with RHD had greater treatment effect in terms of 6MWD, WHO-FC and time to clinical worsening compared to those without (p for interaction= 0.03, 0.001 and 0.03, respectively). Conclusion Right heart disease by ECG may be associated with a worse outcomes and potentially greater treatment effect. ECGs could be an inexpensive, widely available noninvasive method to enrich clinical trial populations in PAH.
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Affiliation(s)
- Jasleen Minhas
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States;
| | - Jude Moutchia
- University of Pennsylvania, 6572, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Nadine Al-Naamani
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
| | - Jeremy A Mazurek
- University of Pennsylvania, 6572, Cardiology, Philadelphia, Pennsylvania, United States
| | - John H Holmes
- University of Pennsylvania, 6572, Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Dina Appleby
- University of Pennsylvania, 6572, Department of Biostatistics, Epidemiology, & Informatics, Philadelphia, Pennsylvania, United States
| | - Kerri A Smith
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
| | - Jason S Fritz
- University of Pennsylvania, 6572, Pulmonary, Allergy, Critical Care, Philadelphia, Pennsylvania, United States
| | - Steven C Pugliese
- University of Pennsylvania, 6572, Pulmonary, Allergy, Critical Care, Philadelphia, Pennsylvania, United States
| | - Harold I Palevsky
- University of Pennsylvania, 6572, Pulmonary, Allergy, Critical Care, Philadelphia, Pennsylvania, United States
| | - Steven M Kawut
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
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Weatherald J, Moutchia J, Al-Naamani N, McClelland RL, Ventetuolo CE, Palevsky HI, Harhay MO, Kawut SM. Win Statistics in Pulmonary Arterial Hypertension Clinical Trials. Am J Respir Crit Care Med 2023; 208:1231-1234. [PMID: 37734029 PMCID: PMC10868347 DOI: 10.1164/rccm.202305-0800le] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023] Open
Affiliation(s)
- Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics and
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Corey E. Ventetuolo
- Department of Medicine and
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - Harold I. Palevsky
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael O. Harhay
- Department of Biostatistics, Epidemiology, and Informatics and
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven M. Kawut
- Department of Biostatistics, Epidemiology, and Informatics and
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Blette BS, Moutchia J, Al-Naamani N, Ventetuolo CE, Cheng C, Appleby D, Urbanowicz RJ, Fritz J, Mazurek JA, Li F, Kawut SM, Harhay MO. Is low-risk status a surrogate outcome in pulmonary arterial hypertension? An analysis of three randomised trials. Lancet Respir Med 2023; 11:873-882. [PMID: 37230098 PMCID: PMC10592525 DOI: 10.1016/s2213-2600(23)00155-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Targeting short-term improvements in multicomponent risk scores for mortality in patients with pulmonary arterial hypertension (PAH) could result in improved long-term outcomes. We aimed to determine whether PAH risk scores were adequate surrogates for clinical worsening or mortality outcomes in PAH randomised clinical trials (RCTs). METHODS We performed an individual participant data meta-analysis of RCTs selected from PAH trials provided by the US Food and Drug Administration (FDA). We calculated predicted risk using the COMPERA, COMPERA 2.0, non-invasive FPHR, REVEAL 2.0, and REVEAL Lite 2 risk scores. The primary outcome of interest was time to clinical worsening, a composite endpoint composed of any of the following events: all-cause death, hospitalisation for worsening PAH, lung transplantation, atrial septostomy, discontinuation of study treatment (or study withdrawal) for worsening PAH, initiation of parenteral prostacyclin analogue therapy, or decrease of at least 15% in 6-min walk distance from baseline, combined with either worsening of WHO functional class from baseline or the addition of an approved PAH treatment. The secondary outcome of interest was time to all-cause mortality. We assessed the surrogacy of these risk scores, parameterised as attainment of low-risk status by 16 weeks, for improvement in long-term clinical worsening and survival using mediation and meta-analysis frameworks. FINDINGS Of 28 trials received from the FDA, three RCTs (AMBITION, GRIPHON, and SERAPHIN; n=2508) had the data necessary to assess long-term surrogacy. The mean age was 49 years (SD 16), 1956 (78%) participants were women, 1704 (68%) were classified as White, and 280 (11%) were Hispanic or Latino. 1388 (55%) of 2503 participants with available data had idiopathic PAH and 776 (31%) of 2503 had PAH associated with connective tissue disease. In a mediation analysis, the proportions of treatment effects explained by attainment of low-risk status ranged only from 7% to 13%. In a meta-analysis of trial-regions, the treatment effects on low-risk status were not predictive of the treatment effects on time to clinical worsening (R2 values 0·01-0·19) nor the treatment effects on time to all-cause mortality (R2 values 0-0·2). A leave-one-out analysis suggested that the use of these risk scores as surrogates might lead to biased inferences regarding the effect of therapies on clinical outcomes in PAH RCTs. Results were similar when using absolute risk scores at 16 weeks as the potential surrogates. INTERPRETATION Multicomponent risk scores have utility for the prediction of outcomes in patients with PAH. Clinical surrogacy for long-term outcomes cannot be inferred from observational studies of outcomes. Our analyses of three PAH trials with long-term follow-up suggest that further study is necessary before using these or other scores as surrogate outcomes in PAH RCTs or clinical care. FUNDING Cardiovascular Medical Research and Education Fund, US National Institutes of Health.
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Affiliation(s)
- Bryan S Blette
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey E Ventetuolo
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Chao Cheng
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Dina Appleby
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan J Urbanowicz
- Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jason Fritz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Steven M Kawut
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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6
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Scott JV, Moutchia J, McClelland RL, Al-Naamani N, Weinberg E, Palevsky HI, Minhas J, Appleby DK, Smith A, Pugliese SC, Ventetuolo CE, Kawut SM. Novel Liver Injury Phenotypes and Outcomes in Pulmonary Arterial Hypertension. medRxiv 2023:2023.09.28.23296316. [PMID: 37808731 PMCID: PMC10557839 DOI: 10.1101/2023.09.28.23296316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are disorders of the pulmonary vasculature that cause right ventricular dysfunction. Systemic consequences of right ventricular dysfunction include damage to other solid organs, such as the liver. However, the profiles and consequences of hepatic injury due to PAH and CTEPH have not been well-studied. Methods We aimed to identify underlying patterns of liver injury in a cohort of PAH and CTEPH patients enrolled in 15 randomized clinical trials conducted between 1998 and 2012. We used unsupervised machine learning to identify liver injury clusters in 13 trials and validated the findings in two additional trials. We then determined whether these liver injury clusters were associated with clinical outcomes or treatment effect heterogeneity. Results Our training dataset included 4,219 patients and our validation dataset included 1,756 patients with complete liver laboratory panels (serum total bilirubin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and albumin). Using k-means clustering paired with factor analysis, we identified four unique liver phenotypes (no liver injury, hepatocellular injury, cholestatic injury, and combined injury patterns). Patients in the cholestatic injury liver cluster had the shortest time to clinical worsening and highest chance of worsening World Health Organization functional class. Randomization to the experimental arm was associated with a transition to healthier liver clusters compared to randomization to the control arm. The cholestatic injury group experienced the greatest placebo-corrected treatment benefit in terms of six-minute walk distance. Conclusions Liver injury patterns were associated with adverse outcomes in patients with PAH and CTEPH. Randomization to active treatment of pulmonary hypertension in these clinical trials had beneficial effects on liver health compared to placebo. The independent role of liver disease (often subclinical) in determining outcomes warrants prospective studies of the clinical utility of liver phenotyping for PAH prognosis and contribution to clinical disease.
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Pan HM, McClelland RL, Moutchia J, Appleby DH, Fritz JS, Holmes JH, Minhas J, Palevsky HI, Urbanowicz RJ, Kawut SM, Al-Naamani N. Heterogeneity of treatment effects by risk in pulmonary arterial hypertension. Eur Respir J 2023; 62:2300190. [PMID: 37169384 PMCID: PMC10919241 DOI: 10.1183/13993003.00190-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND It is currently unknown if disease severity modifies response to therapy in pulmonary arterial hypertension (PAH). We aimed to explore if disease severity, as defined by established risk-prediction algorithms, modified response to therapy in randomised clinical trials in PAH. METHODS We performed a meta-analysis using individual participant data from 18 randomised clinical trials of therapy for PAH submitted to the United States Food and Drug Administration to determine if predicted risk of 1-year mortality at randomisation modified the treatment effect on three outcomes: change in 6-min walk distance (6MWD), clinical worsening at 12 weeks and time to clinical worsening. RESULTS Of 6561 patients with a baseline US Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL 2.0) score, we found that individuals with higher baseline risk had higher probabilities of clinical worsening but no difference in change in 6MWD. We detected a significant interaction of REVEAL 2.0 risk and treatment assignment on change in 6MWD. For every 3-point increase in REVEAL 2.0 score, there was a 12.49 m (95% CI 5.86-19.12 m; p=0.001) greater treatment effect in change in 6MWD. We did not detect a significant risk by treatment interaction on clinical worsening with most of the risk-prediction algorithms. CONCLUSIONS We found that predicted risk of 1-year mortality in PAH modified treatment effect as measured by 6MWD, but not clinical worsening. Our findings highlight the importance of identifying sources of treatment heterogeneity by predicted risk to tailor studies to patients most likely to have the greatest treatment response.
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Affiliation(s)
- Hao-Min Pan
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn L McClelland
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA
| | - Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dina H Appleby
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jason S Fritz
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - John H Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jasleen Minhas
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Harold I Palevsky
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan J Urbanowicz
- Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Cox-Flaherty K, Moutchia J, Krowka MJ, Al-Naamani N, Fallon MB, DuBrock H, Forde KA, Krok K, Doyle MF, Kawut SM, Ventetuolo CE. Six-Minute walk distance predicts outcomes in liver transplant candidates. Liver Transpl 2023; 29:521-530. [PMID: 36691988 PMCID: PMC10101910 DOI: 10.1097/lvt.0000000000000071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/06/2022] [Indexed: 01/25/2023]
Abstract
A 6-minute walk test is a simple tool for assessing submaximal exercise capacity. We sought to determine whether a 6-minute walk distance (6MWD) predicts outcomes in patients with cirrhosis. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study that enrolled adults with portal hypertension during liver transplantation evaluation. We excluded subjects with an incident or prevalent portopulmonary hypertension. The 6-minute walk test was performed using standardized methods. Cox proportional hazards modeling and multivariable linear regression analysis were performed to determine the relationship between baseline 6MWD and outcomes. The study sample included 352 subjects. The mean 6MWD was 391±101 m. For each 50-meter decrease in 6MWD, there was a 25% increase in the risk of death (HR 1.25, 95% CI [1.11, 1.41], p < 0.001) after adjustment for age, gender, body mass index, MELD-Na, and liver transplant as a time-varying covariate. In a multistate model, each 50-meter decrease in 6MWD was associated with an increased risk of death before the liver transplant ( p < 0.001) but not after the transplant. 6MWD was similar to MELD-Na in discriminating mortality. Each 50-meter decrease in 6MWD was associated with an increase in all-cause ( p < 0.001) and transplant-free hospitalizations ( p < 0.001) in multivariable models for time-to-recurrent events. Shorter 6MWD was associated with worse Short Form-36 physical ( p < 0.001) and mental component scores ( p = 0.05). In conclusion, shorter 6MWD is associated with an increased risk of death, hospitalizations, and worse quality of life in patients evaluated for liver transplantation. The 6-minute walk distance may be a useful adjunct for risk assessment in patients undergoing liver transplant evaluation.
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Affiliation(s)
| | - Jude Moutchia
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Nadine Al-Naamani
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Kimberly A. Forde
- Department of Medicine, Lewis Katz School of Medicine at Temple University, PA, USA
| | - Karen Krok
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center
| | | | - Steven M. Kawut
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey E. Ventetuolo
- Departments of Medicine, Brown University, Providence, RI, USA
- Health Services, Policy and Practice, Brown University, Providence, RI, USA
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Moutchia J, McClelland RL, Al-Naamani N, Appleby DH, Blank K, Grinnan D, Holmes JH, Mathai SC, Minhas J, Ventetuolo CE, Zamanian RT, Kawut SM. Minimal Clinically Important Difference in the 6-minute-walk Distance for Patients with Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2023; 207:1070-1079. [PMID: 36629737 PMCID: PMC10112451 DOI: 10.1164/rccm.202208-1547oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/10/2023] [Indexed: 01/12/2023] Open
Abstract
Rationale: The 6-minute-walk distance (6MWD) is an important clinical and research metric in pulmonary arterial hypertension (PAH); however, there is no consensus about what minimal change in 6MWD is clinically significant. Objectives: We aimed to determine the minimal clinically important difference in the 6MWD. Methods: We performed a meta-analysis using individual participant data from eight randomized clinical trials of therapy for PAH submitted to the U.S. Food and Drug Administration to derive minimal clinically important differences in the 6MWD. The estimates were externally validated using the Pulmonary Hypertension Association Registry. We anchored the change in 6MWD to the change in the Medical Outcomes Survey Short Form physical component score. Measurements and Main Results: The derivation (clinical trial) and validation (Pulmonary Hypertension Association Registry) samples were comprised of 2,404 and 537 adult patients with PAH, respectively. The mean ± standard deviation age of the derivation sample was 50.5 ± 15.2 years, and 1,849 (77%) were female, similar to the validation sample. The minimal clinically important difference in the derivation sample was 33 meters (95% confidence interval, 27-38), which was almost identical to that in the validation sample (36 m [95% confidence interval, 29-43]). The minimal clinically important difference did not differ by age, sex, race, pulmonary hypertension etiology, body mass index, use of background therapy, or World Health Organization functional class. Conclusions: We estimated a 6MWD minimal clinically important difference of approximately 33 meters for adults with PAH. Our findings can be applied to the design of clinical trials of therapies for PAH.
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Affiliation(s)
- Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics and
| | - Robyn L. McClelland
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dina H. Appleby
- Department of Biostatistics, Epidemiology, and Informatics and
| | - Kristina Blank
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Dan Grinnan
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - John H. Holmes
- Department of Biostatistics, Epidemiology, and Informatics and
| | - Stephen C. Mathai
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jasleen Minhas
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corey E. Ventetuolo
- Departments of Medicine and Health Services, Policy and Practice, Brown University, Providence, Rhode Island; and
| | - Roham T. Zamanian
- Department of Medicine, School of Medicine, Stanford University, Palo Alto, California
| | - Steven M. Kawut
- Department of Biostatistics, Epidemiology, and Informatics and
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Ventetuolo CE, Moutchia J, Baird GL, Appleby DH, McClelland RL, Minhas J, Min J, Holmes JH, Urbanowicz RJ, Al-Naamani N, Kawut SM. Baseline Sex Differences in Pulmonary Arterial Hypertension Randomized Clinical Trials. Ann Am Thorac Soc 2023; 20:58-66. [PMID: 36053665 PMCID: PMC9819259 DOI: 10.1513/annalsats.202203-207oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 03/14/2022] [Accepted: 09/02/2022] [Indexed: 02/05/2023] Open
Abstract
Rationale: Sex-based differences in pulmonary arterial hypertension (PAH) are known, but the contribution to disease measures is understudied. Objectives: We examined whether sex was associated with baseline 6-minute-walk distance (6MWD), hemodynamics, and functional class. Methods: We conducted a secondary analysis of participant-level data from randomized clinical trials of investigational PAH therapies conducted between 1998 and 2014 and provided by the U.S. Food and Drug Administration. Outcomes were modeled as a function of an interaction between sex and age or sex and body mass index (BMI), respectively, with generalized mixed modeling. Results: We included a total of 6,633 participants from 18 randomized clinical trials. A total of 5,197 (78%) were female, with a mean age of 49.1 years and a mean BMI of 27.0 kg/m2. Among 1,436 males, the mean age was 49.7 years, and the mean BMI was 26.4 kg/m2. The most common etiology of PAH was idiopathic. Females had shorter 6MWD. For every 1 kg/m2 increase in BMI for females, 6MWD decreased 2.3 (1.6-3.0) meters (P < 0.001), whereas 6MWD did not significantly change with BMI in males (0.31 m [-0.30 to 0.92]; P = 0.32). Females had lower right atrial pressure (RAP) and mean pulmonary artery pressure, and higher cardiac index than males (all P < 0.03). Age significantly modified the sex by RAP and mean pulmonary artery pressure relationships. For every 10-year increase in age, RAP was lower in males (0.5 mm Hg [0.3-0.7]; P < 0.001), but not in females (0.13 [-0.03 to 0.28]; P = 0.10). There was a significant decrease in pulmonary vascular resistance (PVR) with increasing age regardless of sex (P < 0.001). For every 1 kg/m2 increase in BMI, there was a 3% decrease in PVR for males (P < 0.001), compared with a 2% decrease in PVR in females (P < 0.001). Conclusions: Sexual dimorphism in subjects enrolled in clinical trials extends to 6MWD and hemodynamics; these relationships are modified by age and BMI. Sex, age, and body size should be considered in the evaluation and interpretation of surrogate outcomes in PAH.
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Affiliation(s)
- Corey E. Ventetuolo
- Department of Medicine
- Department of Health Services, Policy, and Practice, School of Public Health, and
| | - Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics and
| | - Grayson L. Baird
- Department of Diagnostic Imaging, Alpert Medical School, Brown University, Providence, Rhode Island
- Lifespan Hospital System, Providence, Rhode Island
| | - Dina H. Appleby
- Department of Biostatistics, Epidemiology, and Informatics and
| | - Robyn L. McClelland
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington; and
| | - Jasleen Minhas
- Department of Biostatistics, Epidemiology, and Informatics and
| | - Jeff Min
- Department of Biostatistics, Epidemiology, and Informatics and
| | - John H. Holmes
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan J. Urbanowicz
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadine Al-Naamani
- Department of Biostatistics, Epidemiology, and Informatics and
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington; and
| | - Steven M. Kawut
- Department of Biostatistics, Epidemiology, and Informatics and
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Sow A, Lemoine M, Toure PS, Diop M, Lo G, De Veiga J, Pape OT, Seck K, Ndow G, Bojang L, Kane A, Oudiane M, Howell J, Nayagam S, Moutchia J, Chemin I, Mendy M, Toure-Kane C, Thursz M, Ka M, Shimakawa Y, Mboup S. HBV continuum of care using community- and hospital-based screening interventions in Senegal: Results from the PROLIFICA programme. JHEP Rep 2022; 4:100533. [PMID: 36052221 PMCID: PMC9424572 DOI: 10.1016/j.jhepr.2022.100533] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 11/22/2022] Open
Abstract
Background & Aims Strategies to implement HBV screening and treatment are critical to achieve HBV elimination but have been inadequately evaluated in sub-Saharan Africa (sSA). Methods We assessed the feasibility of screen-and-treat interventions in 3 real-world settings (community, workplace, and hospital) in Senegal. Adult participants were screened using a rapid HBsAg point-of-care test. The proportion linked to care, the proportion who had complete clinical staging (alanine transaminase [ALT], viral load, and FibroScan®), and the proportion eligible for treatment were compared among the 3 intervention groups. Results In 2013-2016, a total of 3,665 individuals were screened for HBsAg in the community (n = 2,153) and in workplaces (n = 1,512); 199/2,153 (9.2%) and 167/1,512 (11%) were HBsAg-positive in the community and workplaces, respectively. In the hospital setting (outpatient clinics), 638 HBsAg-positive participants were enrolled in the study. All infected participants were treatment naïve. Linkage to care was similar among community-based (69.9%), workplace-based (69.5%), and hospital-based interventions (72.6%, p = 0.617). Of HBV-infected participants successfully linked to care, full clinical staging was obtained in 47.5% (66/139), 59.5% (69/116), and 71.1% (329/463) from the community, workplaces, and hospitals, respectively (p <0.001). The proportion eligible for treatment (EASL criteria) differed among community- (9.1%), workplace- (30.4%), and hospital-based settings (17.6%, p = 0.007). Acceptability of antiviral therapy, adherence, and safety at 1 year were very good. Conclusions HBV screen-and-treat interventions are feasible in non-hospital and hospital settings in Senegal. However, the continuum of care is suboptimal owing to limited access to full clinical staging. Improvement in access to diagnostic services is urgently needed in sSA. Lay summary Hepatitis B infection is highly endemic in Senegal. Screening for infection can be done outside hospitals, in communities or workplaces. However, the hepatitis B continuum of care is suboptimal in Senegal and needs to be simplified to scale-up diagnosis and treatment coverage.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine transaminase
- APRI, AST-to-platelet ratio index
- AST, aspartate aminotransferase
- Africa
- Diagnosis
- GGT, gamma-glutamyl transferase
- HBsAg, hepatitis B surface antigen
- HCC, hepatocellular carcinoma
- Hepatitis B
- LSM, liver stiffness measurement
- POC, point of care
- PROLIFICA, Prevention of Liver Fibrosis and Cancer in Africa
- Screening
- TDF, tenofovir disoproxil fumarate
- Treatment
- WHO, World Health Organization
- aOR, adjusted odds ratio
- cOR, crude odds ratio
- eGFR, estimated glomerular filtration rate
- qPCR, quantitative polymerase chain reaction
- sSA, sub-Saharan Africa
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Affiliation(s)
- Amina Sow
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation (IRESSEF) Laboratoire CHNU Dalal Jamm Guediawaye, IRESSEF Diamnoadio Dakar, Senegal
- Laboratoire de Virology, Hopital Le Dantec, Dakar, Senegal
| | - Maud Lemoine
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, Section of Hepatology, St Mary’s Hospital, Imperial College London, London, UK
- Medical Research Council the Gambia Unit at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Papa Souleymane Toure
- UFR des Sciences de la Sante, Thies, Senegal
- Centre hospitalier de Tivaoaune, Service de Medecine interne, Thies, Senegal
| | - Madoky Diop
- UFR des Sciences de la Sante, Thies, Senegal
| | - Gora Lo
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation (IRESSEF) Laboratoire CHNU Dalal Jamm Guediawaye, IRESSEF Diamnoadio Dakar, Senegal
- Laboratoire de Virology, Hopital Le Dantec, Dakar, Senegal
| | - Jean De Veiga
- Hopital Saint Jean de Dieu, Service d’Hepatologie et Gastroenterologie, Thies, Senegal
| | - Omar Thiaw Pape
- Hopital Saint Jean de Dieu, Laboratoire d’analyse biochimique et hématologique, Thies, Senegal
| | - Khady Seck
- Centre hospitalier régional de Thies, Service de Medecine interne, Thies, Senegal
| | - Gibril Ndow
- Medical Research Council the Gambia Unit at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Lamin Bojang
- Medical Research Council the Gambia Unit at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Arame Kane
- UFR des Sciences de la Sante, Thies, Senegal
- Centre hospitalier de Tivaoaune, Service de Medecine interne, Thies, Senegal
| | - Marina Oudiane
- UFR des Sciences de la Sante, Thies, Senegal
- Centre hospitalier de Tivaoaune, Service de Medecine interne, Thies, Senegal
| | - Jess Howell
- Disease Elimination, Burnet Institute, Department of Gastroenterology, St. Vincent's Hospital Department of Epidemiology and Preventive Medicine, Monash University Melbourne, Melbourne, Victoria, Australia
| | - Shevanthi Nayagam
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, Section of Hepatology, St Mary’s Hospital, Imperial College London, London, UK
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Jude Moutchia
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur Paris, France
| | - Isabelle Chemin
- INSERM U1052, CNRS 5286, Université Lyon, Université Claude Bernard Lyon 1, Centre Léon Bérard, Centre de Recherche en Cancérologie de Lyon, F-69000, Lyon, France
| | - Maimuna Mendy
- International Agency for Research on Cancer (IARC), Lyon, France
| | - Coumba Toure-Kane
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation (IRESSEF) Laboratoire CHNU Dalal Jamm Guediawaye, IRESSEF Diamnoadio Dakar, Senegal
- Laboratoire de Virology, Hopital Le Dantec, Dakar, Senegal
| | - Mark Thursz
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, Section of Hepatology, St Mary’s Hospital, Imperial College London, London, UK
| | - Mourtalla Ka
- UFR des Sciences de la Sante, Thies, Senegal
- Centre hospitalier de Tivaoaune, Service de Medecine interne, Thies, Senegal
| | - Yusuke Shimakawa
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur Paris, France
| | - Souleymane Mboup
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation (IRESSEF) Laboratoire CHNU Dalal Jamm Guediawaye, IRESSEF Diamnoadio Dakar, Senegal
- Laboratoire de Virology, Hopital Le Dantec, Dakar, Senegal
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12
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Kawut SM, Krowka MJ, Forde KA, Al-Naamani N, Krok KL, Patel M, Bartoli CR, Doyle M, Moutchia J, Lin G, Oh JK, Mottram CD, Scanlon PD, Fallon MB. Impact of hepatopulmonary syndrome in liver transplantation candidates and the role of angiogenesis. Eur Respir J 2022; 60:2102304. [PMID: 34949701 PMCID: PMC10967655 DOI: 10.1183/13993003.02304-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/30/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome affects 10-30% of patients with cirrhosis and portal hypertension. We evaluated the serum angiogenic profile of hepatopulmonary syndrome and assessed the clinical impact of hepatopulmonary syndrome in patients evaluated for liver transplantation. METHODS The Pulmonary Vascular Complications of Liver Disease 2 study was a multicentre, prospective cohort study of adults undergoing their first liver transplantation evaluation. Hepatopulmonary syndrome was defined as an alveolar-arterial oxygen gradient ≥15 mmHg (≥20 mmHg if age >64 years), positive contrast-enhanced transthoracic echocardiography and absence of lung disease. RESULTS We included 85 patients with hepatopulmonary syndrome and 146 patients without hepatopulmonary syndrome. Patients with hepatopulmonary syndrome had more complications of portal hypertension and slightly higher Model for End-Stage Liver Disease-Na score compared to those without hepatopulmonary syndrome (median (interquartile range) 15 (12-19) versus 14 (10-17), p=0.006). Hepatopulmonary syndrome patients had significantly lower 6-min walk distance and worse functional class. Hepatopulmonary syndrome patients had higher circulating angiopoietin 2, Tie2, tenascin C, tyrosine protein kinase Kit (c-Kit), vascular cell adhesion molecule 1 and von Willebrand factor levels, and lower E-selectin levels. Patients with hepatopulmonary syndrome had an increased risk of death (hazard ratio 1.80, 95% CI 1.03-3.16, p=0.04), which persisted despite adjustment for covariates (hazard ratio 1.79, 95% CI 1.02-3.15, p=0.04). This association did not vary based on levels of oxygenation, reflecting the severity of hepatopulmonary syndrome. CONCLUSION Hepatopulmonary syndrome was associated with a profile of abnormal systemic angiogenesis, worse exercise and functional capacity, and an overall increased risk of death.
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Affiliation(s)
- Steven M Kawut
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kimberly A Forde
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen L Krok
- Dept of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Mamta Patel
- Dept of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carlo R Bartoli
- Division of Cardiovascular Surgery, Dept of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiothoracic Surgery, Dept of Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Margaret Doyle
- Dept of Pathology, University of Vermont, Burlington, VT, USA
| | - Jude Moutchia
- Center for Clinical Epidemiology and Biostatistics, Dept of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Lin
- Dept of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jae K Oh
- Dept of Medicine, Mayo Clinic, Rochester, MN, USA
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13
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Moutchia J, Njouom R, Rumpler E, Besombes C, Texier G, Tejiokem M, Crépey P, Fontanet A, Shimakawa Y. Maternal age at first childbirth and geographical variation in HBV prevalence in Cameroon: Important role of mother-to-child transmission. Clin Infect Dis 2021; 74:836-845. [PMID: 34125878 DOI: 10.1093/cid/ciab548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The prevalence of hepatitis B virus (HBV) infection varies geographically around the world. However, the underlying reasons for this variation are unknown. Using a nationally representative population-based sample from all 58 administrative divisions in Cameroon, we examined the association between median maternal age at first childbirth in a preceding generation, a proxy for the frequency of mother-to-child transmission (MTCT) of HBV in a region, and the risk of chronic HBV infection, defined as positive surface antigen (HBsAg), in the index generation. METHODS We estimated a division-specific median maternal age at first childbirth using historical data from Demographic Health Surveys (DHS) in 1991/1998/2004/2011. We tested HBsAg in 2011 DHS participants. We used maps to display spatial variation and spatial models for the analysis. RESULTS In 14,150 participants (median 27 years old, 51% females), the overall weighted prevalence of HBsAg was 11.9% (95%CI: 11.0-12.8), with a wide geographical variation across the divisions (range: 6.3-23.7%). After adjusting for confounding factors and spatial dependency, lower maternal age at first childbirth was significantly associated with positive HBsAg at the division level (β: 1.89 [95%CI: 1.26-2.52], p<0.001), and at the individual level (OR: 1.20 [95%CI: 1.04-1.39], p=0.016). A similar ecological correlation was observed across other African countries. CONCLUSIONS The significant association between the maternal age at first childbirth and HBsAg-positivity suggests a crucial role of MTCT in maintaining high HBV endemicity in some areas in Cameroon. This underlines an urgent need to effectively prevent MTCT in order to achieve WHO's global hepatitis elimination goals.
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Affiliation(s)
- Jude Moutchia
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur, Paris, France.,REPERES « Recherche en Pharmaco-Epidémiologie et Recours aux Soins » - EA 7449, Université Rennes, Ecole des Hautes Etudes en Santé Publique, Rennes, France
| | - Richard Njouom
- Department of Virology, Centre Pasteur du Cameroun, Yaoundé, Cameroon
| | - Eva Rumpler
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur, Paris, France
| | - Camille Besombes
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur, Paris, France
| | - Gaëtan Texier
- Department of Epidemiology and Public Health, Centre Pasteur du Cameroun, Yaoundé, Cameroon.,Aix Marseille University, IRD, AP-HM, SSA, VITROME, IHU Méditerranée Infection, Marseille, France
| | - Mathurin Tejiokem
- Department of Epidemiology and Public Health, Centre Pasteur du Cameroun, Yaoundé, Cameroon
| | - Pascal Crépey
- REPERES « Recherche en Pharmaco-Epidémiologie et Recours aux Soins » - EA 7449, Université Rennes, Ecole des Hautes Etudes en Santé Publique, Rennes, France
| | - Arnaud Fontanet
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur, Paris, France.,PACRI unit, Conservatoire National des Arts et Métiers, Paris, France
| | - Yusuke Shimakawa
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur, Paris, France
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14
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Moutchia J, Pokharel P, Kerri A, McGaw K, Uchai S, Nji M, Goodman M. Clinical laboratory parameters associated with severe or critical novel coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis. PLoS One 2020; 15:e0239802. [PMID: 33002041 PMCID: PMC7529271 DOI: 10.1371/journal.pone.0239802] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/09/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND To date, several clinical laboratory parameters associated with Coronavirus disease 2019 (COVID-19) severity have been reported. However, these parameters have not been observed consistently across studies. The aim of this review was to assess clinical laboratory parameters which may serve as markers or predictors of severe or critical COVID-19. METHODS AND FINDINGS We conducted a systematic search of MEDLINE, Embase, Web of Science, CINAHL and Google Scholar databases from 2019 through April 18, 2020, and reviewed bibliographies of eligible studies, relevant systematic reviews, and the medRxiv pre-print server. We included hospital-based observational studies reporting clinical laboratory parameters of confirmed cases of COVID-19 and excluded studies having large proportions (>10%) of children and pregnant women. Two authors independently carried out screening of articles, data extraction and quality assessment. Meta-analyses were done using random effects model. Meta-median difference (MMD) and 95% confidence interval (CI) was calculated for each laboratory parameter. Forty-five studies in 6 countries were included. Compared to non-severe COVID-19 cases, severe or critical COVID-19 was characterised by higher neutrophil count (MMD: 1.23 [95% CI: 0.58 to 1.88] ×109 cells/L), and lower lymphocyte, CD4 and CD8 T cell counts with MMD (95% CI) of -0.39 (-0.47, -0.31) ×109 cells/L, -204.9 (-302.6, -107.1) cells/μl and -123.6 (-170.6, -76.6) cells/μl, respectively. Other notable results were observed for C-reactive protein (MMD: 36.97 [95% CI: 27.58, 46.35] mg/L), interleukin-6 (MMD: 17.37 [95% CI: 4.74, 30.00] pg/ml), Troponin I (MMD: 0.01 [0.00, 0.02] ng/ml), and D-dimer (MMD: 0.65 [0.45, 0.85] mg/ml). CONCLUSIONS Relative to non-severe COVID-19, severe or critical COVID-19 is characterised by increased markers of innate immune response, decreased markers of adaptive immune response, and increased markers of tissue damage and major organ failure. These markers could be used to recognise severe or critical disease and to monitor clinical course of COVID-19.
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Affiliation(s)
- Jude Moutchia
- Bamenda Regional Hospital, Bamenda, Cameroon
- EHESP–French School of Public Health, Paris, France
| | - Pratik Pokharel
- EHESP–French School of Public Health, Paris, France
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Aldiona Kerri
- EHESP–French School of Public Health, Paris, France
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Kaodi McGaw
- EHESP–French School of Public Health, Paris, France
- University of Cambridge, Cambridge, United Kingdom
| | - Shreeshti Uchai
- EHESP–French School of Public Health, Paris, France
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Miriam Nji
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, United States of America
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, United States of America
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15
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Pokharel P, Rana J, Moutchia J, Uchai S, Kerri A, Luna Gutiérrez PL, Islam RM. Effect of exercise on symptoms of premenstrual syndrome in low and middle-income countries: a protocol for systematic review and meta-analysis. BMJ Open 2020; 10:e039274. [PMID: 32998927 PMCID: PMC7528354 DOI: 10.1136/bmjopen-2020-039274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Premenstrual syndrome (PMS) has the potential to affect the quality of life adversely. Published guidelines recommend the use of exercise as part of the first-line management interventions for PMS. However, the published evidence related to the effectiveness of physical activity and PMS is inconclusive. This review will assess the effectiveness of exercise-based interventions in reducing PMS in women screened or diagnosed with PMS in low and middle-income countries, where the prevalence of PMS is high. METHODS AND ANALYSIS Electronic databases will be researched, including Embase, Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, Web of Science, ClinicalTrials.gov and Google Scholar. All the studies published until March 2020 will be included. A standardised data extraction form will be used adapted from the Cochrane Handbook of Systematic Reviews of Interventions. Included articles will be assessed using the risk of bias tools based on study design. Data will be analysed using Review Manager V.5.3. The inverse-variance random-effects method will be used to report the standardised mean difference. A meta-analysis will be used only if studies are sufficiently homogenous. A narrative synthesis will be undertaken when studies are heterogeneous. Methodological heterogeneity between studies will be evaluated by considering the study types. Statistical heterogeneity will be tested using the I2 test. Subgroup analyses may be performed only for the primary outcome in case of sufficient studies. Sensitivity analysis will be conducted to assess the impact of intervention excluding studies without randomisation and studies with a high risk of bias. Funnel plots will be used to assess the potential reporting bias and small-study effects only when there are more than 10 studies included in the meta-analysis. ETHICS AND DISSEMINATION This study does not require ethical approval, as the review is entirely based on published studies. The results will be published and/or will be presented at a pertinent conference. PROSPERO REGISTRATION NUMBER CRD42020163377.
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Affiliation(s)
- Pratik Pokharel
- Forum for Health Research and Development, Dharan, Nepal
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- École des hautes études en santé publique (EHESP), Paris, France
| | - Juwel Rana
- Department of Public Health, North South University, Dhaka, Bangladesh
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Jude Moutchia
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- École des hautes études en santé publique (EHESP), Paris, France
| | - Shreeshti Uchai
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- École des hautes études en santé publique (EHESP), Paris, France
| | - Aldiona Kerri
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- École des hautes études en santé publique (EHESP), Paris, France
| | | | - Rakibul M Islam
- Women's Health Research Program, Monash University, Melbourne, Victoria, Australia
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Doualla M, Halle MP, Moutchia J, Tegang S, Ashuntantang G. Determinants of hyperuricemia in non-dialysed chronic kidney disease patients in three hospitals in Cameroon. BMC Nephrol 2018; 19:169. [PMID: 29986666 PMCID: PMC6038336 DOI: 10.1186/s12882-018-0959-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/25/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) poses a substantial health burden in sub-Saharan Africa, with risk factors ranging from communicable to non-communicable diseases. Hyperuricemia has been recently identified as a factor of progression of CKD. Identifying factors associated with hyperuricemia in CKD patients would help determine interventions to reduce CKD mortality, particularly in resources limited countries. We sought to determine the prevalence and factors associated with hyperuricemia in non-dialysed CKD adult patients in Cameroon. METHODS This was a cross-sectional study of non-dialysed CKD patients, conducted in 3 referral nephrology units in Cameroon. Relevant clinical and laboratory data were collected using interviewer-administered questionnaires. Serum uric acid, spot urine protein and spot urine creatinine were assessed. Associations between variables were assessed using multivariate analysis. Level of statistical significance was set at α < 0.05. RESULTS A sample of 103 participants was included. Mean age of study participants was 55.78 ± 12.58 years, and 59.3% were men. Sixty-nine (67%) had hyperuricemia. Patient's age (OR: 1.08, 95% CI: 1.03-1.13), estimated glomerular filtration rate (OR: 0.94, 95% CI: 0.90-0.98), spot urine protein-creatinine ratio (OR: 1.83, 95% CI: 1.07-3.12), no hypertension (OR: 0.09, 95% CI: 0.02-0.46), urate lowering therapy (OR: 4.99, 95% CI: 1.54-16.16), loop diuretics (OR: 3.39, 95% CI: 1.01-11.42), obesity (OR: 6.12, 95% CI: 1.15-32.55) and no anaemia (OR: 0.04, 95% CI: 0.00-0.29) were independently significantly associated with hyperuricemia. CONCLUSIONS In this sample of non-dialysed CKD patients in Cameroon, about 7 out of 10 had hyperuricemia. Hyperuricemia was independently associated with patient's age, estimated glomerular filtration rate, spot urine protein-creatinine ratio, hypertension, urate lowering therapy, loop diuretics, obesity and anaemia. More studies are required to establish causal relationships between these associations.
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Affiliation(s)
- Marie Doualla
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Douala General Hospital, P.O. Box 4856, Douala, Cameroon
| | - Marie Patrice Halle
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Jude Moutchia
- Douala General Hospital, P.O. Box 4856, Douala, Cameroon
| | - Steve Tegang
- Douala General Hospital, P.O. Box 4856, Douala, Cameroon
| | - Gloria Ashuntantang
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
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Doualla-Bija M, Takang MA, Mankaa E, Moutchia J, Ongolo-Zogo P, Luma-Namme H. Characteristics and determinants of clinical symptoms in radiographic lumbar spinal stenosis in a tertiary health care centre in sub-Saharan Africa. BMC Musculoskelet Disord 2017; 18:494. [PMID: 29179752 PMCID: PMC5704579 DOI: 10.1186/s12891-017-1844-2] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 11/14/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) refers to narrowing of the lumbar central spinal canal, lateral recess, and/or neuro-foramina. Radiographic LSS plays an important role in clinical LSS but is not solely accountable for the presence of symptoms. We sought to characterise clinical LSS and to determine factors associated with presence of symptoms of LSS in patients with radiographic LSS in a sub Saharan Africa setting. METHODS After prior ethical clearance, a case control study was done in a tertiary hospital in Douala-Cameroon, including 105 patients with radiographic LSS: 57 with symptoms of LSS (cases) and 58 with no symptoms (controls). Spinal stenosis was assessed using computed tomography (CT) scans. Data were analysed using SPSS version 23. RESULTS The mean age of our study participants was 53.4 ± 13.1 years. The mean age of onset of symptoms of LSS was 50.3 ± 11.6 years and the most common symptoms were Low back pain (100.0%), radicular symptoms (98.2%) and neurogenic claudication (98.2%). Obesity (p < 0.001) and a high waist circumference (p = 0.002) were significantly associated with presence of LSS symptoms in persons with radiographic LSS. After adjusting for body mass index, a positive family history of low back pain (p = 0.004), vertebra lesion at L2 (p = 0.034), L3 (p = 0.002), L4 (p = 0.025) and multiple (p = 0.008) levels, degenerative disc protrusion (p = 0.044), disc lesion at L3-L4 (p = 0.001), L4-L5 (p = 0.011) and multiple (p = 0.046) levels were significantly associated with presence of symptoms of LSS in persons with radiographic LSS. CONCLUSION Characteristics of clinical LSS have been described in this sub-Saharan Africa population. Obesity, a high waist circumference and a positive family history of low back pain are significantly associated with presence of symptoms of LSS in persons with radiographic LSS.
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Affiliation(s)
- Marie Doualla-Bija
- Faculty of medicine and Biomedical Sciences, University of Yaounde I, Yaoundé, Cameroon. .,General Hospital Douala-Cameroon, P.O. Box 4856, Douala, Africa, Cameroon.
| | - Mbeng Ashu Takang
- General Hospital Douala-Cameroon, P.O. Box 4856, Douala, Africa, Cameroon
| | - Emmanuella Mankaa
- General Hospital Douala-Cameroon, P.O. Box 4856, Douala, Africa, Cameroon
| | - Jude Moutchia
- General Hospital Douala-Cameroon, P.O. Box 4856, Douala, Africa, Cameroon
| | - Pierre Ongolo-Zogo
- Faculty of medicine and Biomedical Sciences, University of Yaounde I, Yaoundé, Cameroon
| | - Henry Luma-Namme
- Faculty of medicine and Biomedical Sciences, University of Yaounde I, Yaoundé, Cameroon.,General Hospital Douala-Cameroon, P.O. Box 4856, Douala, Africa, Cameroon
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