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McLaughlin A, Lin N, Jiang W, Lodi S, Lioznov D, Patts G, Gnatienko N, Blokhina E, Bendiks S, Freiberg MS, Tindle HA, Krupitsky E, Hahn JA, Samet JH, So-Armah K. Association of Alcohol Consumption With CD4 Recovery After Antiretroviral Therapy Initiation in St. Petersburg, Russia. J Acquir Immune Defic Syndr 2023; 94:244-252. [PMID: 37850982 PMCID: PMC10593489 DOI: 10.1097/qai.0000000000003250] [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: 10/31/2022] [Accepted: 06/21/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Delayed CD4 recovery after initiating antiretroviral therapy (ART) is a novel potential mechanism by which alcohol consumption leads to increased morbidity and mortality in people with HIV. We hypothesized that alcohol consumption at ART initiation is associated with slower CD4 recovery. METHODS We retrospectively analyzed 2 pooled longitudinal alcohol/HIV cohorts (2014-2019) in St. Petersburg, Russia. Eligible participants initiated the first ART during parent studies; had alcohol consumption assessed by the blood biomarker, phosphatidylethanol (PEth), at the last research visit before ART initiation; and had ≥1 CD4 count measurement before and after initiating ART. Participants were stratified by low, moderate, and high PEth (<8, 8-80, and >80 ng/mL, respectively). We used random-effects piecewise linear regression models to estimate CD4 recovery, defined as CD4 count change per 30 days after ART initiation, by the alcohol group. RESULTS Of 60 eligible participants, median age was 34 years and 28% were female. The median pre-ART PEth in the low, moderate, and high PEth groups were <8, 23, and 232 ng/mL, respectively. After starting ART, the CD4 count increased by 13.60 cells/mm3/mo (95% CI: 0.33 to 26.87) with low PEth, 0.93 cells/mm3/mo (95% CI: -6.18 to 8.04) with moderate PEth, and 2.33 cells/mm3/mo (95% CI: -3.44 to 8.09) with high PEth. CONCLUSIONS Among Russians with HIV, we observed faster CD4 recovery after ART initiation in those with low alcohol consumption compared with those with moderate and high alcohol consumption, as assessed by PEth. This analysis provides further evidence for the possible value of alcohol reduction interventions for people with HIV who are initiating ART.
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Affiliation(s)
- Angela McLaughlin
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Nina Lin
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Wenqing Jiang
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Dmitry Lioznov
- Department of Infectious Diseases and Epidemiology, First Pavlov State Medical University, St. Petersburg, Russia
| | - Gregory Patts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Natalia Gnatienko
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Elena Blokhina
- First Pavlov State Medical University, St. Petersburg, Russia
| | - Sally Bendiks
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Matthew S. Freiberg
- Department of Medicine, Vanderbilt University School of Medicine, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Hilary A. Tindle
- Department of Medicine, Vanderbilt University School of Medicine, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Evgeny Krupitsky
- First Pavlov State Medical University, St. Petersburg, Russia
- V.M. Bekhterev National Research Medical Center for Psychiatry and Neurology, St. Petersburg, Russia
| | - Judith A. Hahn
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jeffrey H. Samet
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Kaku So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Delamerced J, Ramirez L, Kimberly JA, Vargas SI, Flanigan TP, Sanchez MC, Bruciati K, So-Armah K. Going to the Source: Discussions With Early and Mid-Career Faculty From Groups Underrepresented in Biomedical Research to Develop and Enhance CFAR Services. J Acquir Immune Defic Syndr 2023; 94:S108-S115. [PMID: 37707857 DOI: 10.1097/qai.0000000000003256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND To include, sustain, and retain HIV-focused early career faculty from groups historically excluded from biomedical research, the Providence/Boston Center for AIDS Research (CFAR) conducted focus groups and individual interviews with early and mid-career faculty to discern their needs. METHODS We conducted focus groups and interviews with 15 faculty at institutions affiliated with Providence/Boston CFAR from groups underrepresented in biomedical research. The discussion was guided using the domains of an Asset Bundle Model encompassing scientific human capital, social capital, and financial capital. RESULT Participants' identities, including their race, ethnicity, gender, sexual orientation, and being a parent affected their vision of themselves as scientists. Participants reported confusion or limited training on or access to resources for professional development, hiring staff, meeting NIH reporting requirements, international research, support for working parents, sabbaticals, and addressing workplace conflict or unsupportive work environments. Some described feeling like they were a burden on their mentors who seemed overextended. They identified attributes of effective mentors, such as believing in and investing in the mentee; having the requisite content area expertise and self-confidence; being able to identify mentees needs and meet them where they are; and being consistent, communicative, respectful, and kind. They described a need for additional education and support preresearch and postresearch grant award management. CONCLUSIONS To learn how to equitably serve all interested in HIV research, CFARs should engage and include perspectives from scientists who have historically been excluded from biomedical research. Our future work will test, implement, and disseminate the ideas generated by these focus group discussions.
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Affiliation(s)
| | | | - Judy A Kimberly
- Division of Biology and Medicine, Brown University, Providence, RI
| | - Sara I Vargas
- The Miriam Hospital/Brown Medical School, Providence, RI
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Greenberg AE, Wutoh A, Bowleg L, Robinson B, Magnus M, Segarra L, Simon P, Wutoh A, Blankenship K, Burke M, Okeke NL, Corneli A, Hussen S, Holliday RC, Ciaranello A, Ghebremichael M, Haberer J, Irvin R, Irvin N, Antoine DG, Chen Z, Momplaisir F, Jordan-Sciutto K, So-Armah K, Kuo C, Flanigan T, Sanchez M, Levine AD, Sluis-Cremer N, Koethe JR, Dash C, Pereira FA, Rice AP, Newell A, Dācus J, Wood C, Elopre L, Rana A, Pitpitan E, Stockman JK, Sauceda J, Marquez C, Robinson S, Chi BH, Balkus J, Walters K, Lewin A, Schoonmaker A, Wong E, Refsland E. Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI): Developing Career Pathways for Early-Stage Scholars From Racial and Ethnic Groups Underrepresented in HIV Science and Medicine. J Acquir Immune Defic Syndr 2023; 94:S5-S12. [PMID: 37707842 PMCID: PMC10567097 DOI: 10.1097/qai.0000000000003270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND There is an urgent need to increase diversity among scientific investigators in the HIV research field to be more reflective of communities highly affected by the HIV epidemic. Thus, it is critical to promote the inclusion and advancement of early-stage scholars from racial and ethnic groups underrepresented in HIV science and medicine. METHODS To widen the HIV research career pathway for early-stage scholars from underrepresented minority groups, the National Institutes of Health supported the development of the Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI). This program was created through partnerships between CFARs and Historically Black Colleges and Universities and other Minority Serving Institutions throughout the United States. RESULTS Seventeen CFARs and more than 20 Historically Black Colleges and Universities and Minority Serving Institutions have participated in this initiative to date. Programs were designed for the high school (8), undergraduate (13), post baccalaureate (2), graduate (12), and postdoctoral (4) levels. Various pedagogical approaches were used including didactic seminar series, intensive multiday workshops, summer residential programs, and mentored research internship opportunities. During the first 18 months of the initiative, 257 student scholars participated in CDEIPI programs including 150 high school, 73 undergraduate, 3 post baccalaureate, 27 graduate, and 4 postdoctoral students. CONCLUSION Numerous student scholars from a wide range of educational levels, geographic backgrounds, and racial and ethnic minority groups have engaged in CDEIPI programs. Timely and comprehensive program evaluation data will be critical to support a long-term commitment to this unique training initiative.
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Ly SM, Fitzpatrick AM, Canfield J, Powis A, So-Armah K, Hurstak EE. Improving DEIB in Addiction Medicine Training Through Interdisciplinary Collaboration and Program Evaluation. Subst Abus 2023; 44:277-281. [PMID: 37830542 DOI: 10.1177/08897077231199552] [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: 10/14/2023]
Abstract
Developing a diverse Addiction Medicine (AM) workforce will improve medical and public health responses to the increasing health risks created by substance use disorders (SUDs). A workforce that embraces diversity, equity, inclusion, and belonging (DEIB) principles may foster novel responses to address the disparities in treatment and outcomes experienced by Black, Indigenous, and People of Color (BIPOC) who are impacted by SUDs. However, experiences of bias and discrimination in the workplace and a lack of exposure to addiction-related content in educational settings limit opportunities to develop and retain a diverse workforce. In this commentary, we describe the creation of the Inclusion, Diversity, and Equity in Addiction medicine, Addiction research, and Addiction health professions (IDEAAA) initiative, a strategy to foster diversity in the field of addiction through efforts targeting learners at different stages of the biomedical education pipeline. Now in its second year, the IDEAAA Program is focused on programmatic evaluation through a qualitative interview study of AM training programs to improve the understanding of experiences of participants who are self-identified members of underrepresented groups (URGs). Interdisciplinary programs with multi-faceted approaches are a strategy to improve DEIB in the AM workforce; IDEAAA's design and methods can inform other AM programs who have the desire to improve DEIB through novel approaches.
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Affiliation(s)
- Sophia M Ly
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amanda M Fitzpatrick
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Jules Canfield
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Amaya Powis
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kaku So-Armah
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Emily E Hurstak
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
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Torgersen J, Akers S, Huo Y, Terry JG, Carr JJ, Ruutiainen AT, Skanderson M, Levin W, Lim JK, Taddei TH, So-Armah K, Bhattacharya D, Rentsch CT, Shen L, Carr R, Shinohara RT, McClain M, Freiberg M, Justice AC, Re VL. Performance of an automated deep learning algorithm to identify hepatic steatosis within noncontrast computed tomography scans among people with and without HIV. Pharmacoepidemiol Drug Saf 2023; 32:1121-1130. [PMID: 37276449 PMCID: PMC10527049 DOI: 10.1002/pds.5648] [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: 11/10/2022] [Revised: 05/06/2023] [Accepted: 05/31/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE Hepatic steatosis (fatty liver disease) affects 25% of the world's population, particularly people with HIV (PWH). Pharmacoepidemiologic studies to identify medications associated with steatosis have not been conducted because methods to evaluate liver fat within digitized images have not been developed. We determined the accuracy of a deep learning algorithm (automatic liver attenuation region-of-interest-based measurement [ALARM]) to identify steatosis within clinically obtained noncontrast abdominal CT images compared to manual radiologist review and evaluated its performance by HIV status. METHODS We performed a cross-sectional study to evaluate the performance of ALARM within noncontrast abdominal CT images from a sample of patients with and without HIV in the US Veterans Health Administration. We evaluated the ability of ALARM to identify moderate-to-severe hepatic steatosis, defined by mean absolute liver attenuation <40 Hounsfield units (HU), compared to manual radiologist assessment. RESULTS Among 120 patients (51 PWH) who underwent noncontrast abdominal CT, moderate-to-severe hepatic steatosis was identified in 15 (12.5%) persons via ALARM and 12 (10%) by radiologist assessment. Percent agreement between ALARM and radiologist assessment of absolute liver attenuation <40 HU was 95.8%. Sensitivity, specificity, positive predictive value, and negative predictive value of ALARM were 91.7% (95%CI, 51.5%-99.8%), 96.3% (95%CI, 90.8%-99.0%), 73.3% (95%CI, 44.9%-92.2%), and 99.0% (95%CI, 94.8%-100%), respectively. No differences in performance were observed by HIV status. CONCLUSIONS ALARM demonstrated excellent accuracy for moderate-to-severe hepatic steatosis regardless of HIV status. Application of ALARM to radiographic repositories could facilitate real-world studies to evaluate medications associated with steatosis and assess differences by HIV status.
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Affiliation(s)
- Jessie Torgersen
- Department of Medicine, Penn Center for AIDS Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Real World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Scott Akers
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Yuankai Huo
- Department of Computer Science, Vanderbilt University, Nashville, TN, USA
| | - James G. Terry
- Department of Radiology and Radiological Sciences, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - J. Jeffrey Carr
- Department of Radiology and Radiological Sciences, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Melissa Skanderson
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Woody Levin
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Joseph K. Lim
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Tamar H. Taddei
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Kaku So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Debika Bhattacharya
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Christopher T. Rentsch
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Li Shen
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Real World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rotonya Carr
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Russell T. Shinohara
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Real World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Biomedical Image Computing and Analysis (CBICA), Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104
- Penn Statistics in Imaging and Visualization Endeavor (PennSIVE), Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, 19104
| | | | - Matthew Freiberg
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Amy C. Justice
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
- Division of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Vincent Lo Re
- Department of Medicine, Penn Center for AIDS Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Real World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Kane JC, Allen I, Fatch R, Scheffler A, Emenyonu N, Puryear SB, Chirayil P, So-Armah K, Kahler CW, Magidson JF, Conroy AA, Edelman EJ, Woolf-King S, Parry C, Kiene SM, Chamie G, Adong J, Go VF, Cook RL, Muyindike W, Morojele N, Blokhina E, Krupitsky E, Fiellin DA, Hahn JA. Efficacy of alcohol reduction interventions among people with HIV as evaluated by self-report and a phosphatidylethanol (PEth) outcome: protocol for a systematic review and individual participant data meta-analysis. BMJ Open 2023; 13:e070713. [PMID: 37280036 PMCID: PMC10254608 DOI: 10.1136/bmjopen-2022-070713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/07/2023] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION Unhealthy alcohol use is associated with a range of adverse outcomes among people with HIV (PWH). Testing the efficacy and promoting the availability of effective interventions to address unhealthy alcohol use among PWH is thus a priority. Alcohol use outcomes in intervention studies are often measured by self-report alone, which can lead to spurious results due to information biases (eg, social desirability). Measuring alcohol outcomes objectively through biomarkers, such as phosphatidylethanol (PEth), in addition to self-report has potential to improve the validity of intervention studies. This protocol outlines the methods for a systematic review and individual participant data meta-analysis that will estimate the efficacy of interventions to reduce alcohol use as measured by a combined categorical self-report/PEth variable among PWH and compare these estimates to those generated when alcohol is measured by self-report or PEth alone. METHODS AND ANALYSIS We will include randomised controlled trials that: (A) tested an alcohol intervention (behavioural and/or pharmacological), (B) enrolled participants 15 years or older with HIV; (C) included both PEth and self-report measurements, (D) completed data collection by 31 August 2023. We will contact principal investigators of eligible studies to inquire about their willingness to contribute data. The primary outcome variable will be a combined self-report/PEth alcohol categorical variable. Secondary outcomes will include PEth alone, self-report alone and HIV viral suppression. We will use a two-step meta-analysis and random effects modelling to estimate pooled treatment effects; I2 will be calculated to evaluate heterogeneity. Secondary and sensitivity analyses will explore treatment effects in adjusted models and within subgroups. Funnel plots will be used to explore publication bias. ETHICS AND DISSEMINATION The study will be conducted with deidentified data from completed randomised controlled trials and will be considered exempt from additional ethical approval. Results will be disseminated through peer-reviewed publications and international scientific meetings. PROSPERO REGISTRATION NUMBER CRD42022373640.
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Affiliation(s)
- Jeremy C Kane
- Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Isabel Allen
- Epidemiology & Biostatistics, University of California, San Francisco, California, USA
| | - Robin Fatch
- Medicine, University of California, San Francisco, California, USA
| | - Aaron Scheffler
- Epidemiology & Biostatistics, University of California, San Francisco, California, USA
| | - Nneka Emenyonu
- Medicine, University of California, San Francisco, California, USA
| | - Sarah B Puryear
- Medicine, University of California, San Francisco, California, USA
| | - Priya Chirayil
- Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Kaku So-Armah
- School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Christopher W Kahler
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jessica F Magidson
- Psychology, University of Maryland, College Park, Maryland, USA
- Center for Substance Use, Addiction & Health Research, University of Maryland, College Park, MD, USA
| | - Amy A Conroy
- Medicine, University of California, San Francisco, California, USA
| | | | | | - Charles Parry
- Mental Health, Alcohol, Substance Use & Tobacco Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Susan M Kiene
- Epidemiology and Biostatistics, San Diego State University College of Health and Human Services School of Public Health, San Diego, California, USA
| | - Gabriel Chamie
- Medicine, University of California, San Francisco, California, USA
| | - Julian Adong
- Makerere University School of Public Health, Kampala, Uganda
| | - Vivian F Go
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Robert L Cook
- Epidemiology, University of Florida, Gainesville, Florida, USA
| | | | - Neo Morojele
- University of Johannesburg, Auckland Park, South Africa
| | - Elena Blokhina
- Global Health Institute, St. Petersburg, Russian Federation
| | - Evgeny Krupitsky
- V.M. Bekhterev National Medical Research Center for Psychiatry and Neuroology, St. Petersburg, Russian Federation
| | | | - Judith A Hahn
- Epidemiology & Biostatistics, University of California, San Francisco, California, USA
- Medicine, University of California, San Francisco, California, USA
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Chen J, Hui Q, Wang Z, Wilson FP, So-Armah K, Freiberg MS, Justice AC, Xu K, Zhao W, Ammous F, Smith JA, Kardia SL, Gwinn M, Marconi VC, Sun YV. Epigenome-Wide Meta-Analysis Reveals Differential DNA Methylation Associated With Estimated Glomerular Filtration Rate Among African American Men With HIV. Kidney Int Rep 2023; 8:1076-1086. [PMID: 37180517 PMCID: PMC10166785 DOI: 10.1016/j.ekir.2023.02.1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 03/05/2023] Open
Abstract
Introduction People with HIV (PWH) of African ancestry have faster decline of kidney function and faster progression to end-stage renal disease than PWH of European ancestry. DNA methylation have been associated with kidney function in the general population, however, their relationships are unclear for PWH of African ancestry. Methods We performed epigenome-wide association studies (EWAS) of estimated glomerular filtration rate (eGFR) among PWH of African ancestry in 2 subsets of the Veterans Aging Cohort Study cohort (N = 885), followed by a meta-analysis to combine the results. Replication was conducted among independent African American samples without HIV. Results DNA methylation sites cg17944885 near Zinc Finger Family Member 788 (ZNF788) and Zinc Finger Protein 20 (ZNF20), and cg06930757 in SHANK1 were significantly associated with eGFR among PWH of African ancestry (false discovery rate < 0.05). DNA methylation site cg17944885 was also associated with eGFR among different populations including African Americans without HIV. Conclusions Our study attempted to address an important gap in the literature and to understand the role of DNA methylation in renal diseases in PWH of African ancestry. Replication of cg17944885 among different populations suggests there may be a common pathway for renal diseases progression among PWH and people without HIV, and across different ancestral groups. Our results suggest that genes ZNF788/ZNF20 and SHANK1 could be involved in a pathway linking DNA methylation to renal diseases among PWH and are worth further investigation.
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Affiliation(s)
- Junyu Chen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Qin Hui
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Zeyuan Wang
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Francis P. Wilson
- Department of Medicine, Yale University School of Medicine, Connecticut, USA
| | - Kaku So-Armah
- Boston University School of Medicine, Massachusetts, USA
| | - Matthew S. Freiberg
- Cardiovascular Medicine Division, Vanderbilt University School of Medicine and Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Amy C. Justice
- Connecticut Veteran Health System, West Haven, Connecticut, USA
- Schools of Medicine and Public Health, Yale University, New Haven, Connecticut, USA
| | - Ke Xu
- Connecticut Veteran Health System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Wei Zhao
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Farah Ammous
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer A. Smith
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Sharon L.R. Kardia
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Marta Gwinn
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Vincent C. Marconi
- Hubert Department of Global Health, Rollins School of Public Health, Atlanta, Georgia, USA
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta Veterans Affairs Health Care System, Decatur, Georgia, USA
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Atlanta Veterans Affairs Health Care System, Decatur, Georgia, USA
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Mensah S, Kundu S, Chang CCH, Doyle M, Werekuu A, Kiyanda A, Patil P, Koethe J, Tindle HA, Freiberg MS, So-Armah K. Abstract P186: HIV Status, Immune Cell Subsets and Type of Incident Heart Failure. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p186] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Introduction:
Immune dysfunction is a mechanism involved in atherosclerosis; atherosclerotic cardiac events contribute to heart failure (HF) risk. We investigated whether immune cell subtypes were associated with HF and HF types in people with and without HIV.
Hypothesis:
Six CD4+ and CD8+ T-cell subsets previously associated with atherosclerosis will be associated with increased HF with reduced ejection fraction (HFrEF) risk. Other lymphocyte subsets will be associated with increased HF with preserved ejection fraction (HFpEF) risk.
Methods:
We measured lymphocyte subsets (T-, B-, and natural killer cells) in the Veterans Aging Cohort Study (VACS) Biomarker Cohort. Primary analyses used Cox proportional hazards models to estimate hazard ratios of HFpEF or HFrEF per standard deviation increment in each of the 6 pro-atherosclerotic T-cell subsets. Secondary analyses used survival random forest analysis to rank the importance of a broader under-studied set of lymphocyte subsets in HF risk prediction and Cox models to estimate HF risk.
Results:
Among 2174 (66% PWH) participants without prevalent cardiovascular disease, 269 had incident HF (22% HFrEF, 47% HFpEF) over 8.8 years median follow-up time. Participants were predominantly male (>90%) and black (>66%). After adjusting for age, race/ethnicity, cytomegalovirus status, and HIV status, we did not detect associations the 6 T-cell subsets with HFrEF. We detected positive associations of CD4+CD28-, CD4+CD45RA+CD28-CD57+, TH1, TH17 cells with HFpEF. Survival random forest analysis revealed the relative importance of lymphocyte subsets for prediction of HF beyond those previously associated with atherosclerosis (Fig 1).
Conclusion:
Contrary to hypotheses, pro-atherosclerotic subsets of CD4+ and CD8+ T-cells were associated with HFpEF but not HFrEF. Other lymphocyte subsets previously-understudied for incident human cardiac outcomes were associated with HF incidence. Future work will examine whether these associations differ by HIV status.
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9
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Oursler KK, Marconi VC, Wang Z, Xu K, Montano M, So-Armah K, Justice AC, Sun YV. Epigenetic Age Acceleration Markers Are Associated With Physiologic Frailty and All-Cause Mortality in People With Human Immunodeficiency Virus. Clin Infect Dis 2023; 76:e638-e644. [PMID: 35970820 PMCID: PMC10169393 DOI: 10.1093/cid/ciac656] [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: 05/27/2022] [Revised: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Biomarkers that provide insight into drivers of aging are needed for people with human immunodeficiency virus (PWH). The study objective was to determine if epigenetic age acceleration (EAA) markers are associated with physiologic frailty measured by the Veterans Aging Cohort Study (VACS) Index and predict all-cause mortality for PWH. METHODS Epigenome-wide DNA methylation was profiled in VACS total white blood cell samples collected during 2005-2007 from 531 PWH to generate 6 established markers of EAA. The association of each EAA marker was tested with VACS Index 2.0. All-cause mortality was assessed over 10 years. For each EAA marker, the hazard ratio per increased year was determined using Cox regression. To evaluate mortality discrimination, C-statistics were derived. RESULTS Participants were mostly men (98.5%) and non-Hispanic Black (84.4%), with a mean age of 52.4 years (standard deviation [SD], 7.8 years). Mean VACS Index score was 59.3 (SD, 16.4) and 136 deaths occurred over a median follow-up of 8.7 years. Grim age acceleration (AA), PhenoAA, HannumAA, and extrinsic epigenetic AA were associated with the VACS Index and mortality. HorvathAA and intrinsic epigenetic AA were not associated with either outcome. GrimAA had the greatest mortality discrimination among EAA markers and predicted mortality independently of the VACS Index. One-year increase in GrimAA was associated with a 1-point increase in VACS Index and a 10% increased hazard for mortality. CONCLUSIONS The observed associations between EAA markers with physiologic frailty and mortality support future research to provide mechanistic insight into the accelerated aging process and inform interventions tailored to PWH for promoting increased healthspan.
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Affiliation(s)
- Krisann K Oursler
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine and Veterans Affairs Salem Healthcare System, Roanoke, Virginia, USA
| | - Vincent C Marconi
- Department of Medicine, Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia, USA.,Veterans Affairs Atlanta Healthcare System, Decatur, Georgia, USA
| | - Zeyuan Wang
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ke Xu
- Department of Psychiatry, Yale School of Medicine, West Haven, Connecticut, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Monty Montano
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kaku So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Medicine, Yale School of Medicine, West Haven, Connecticut, USA.,Division of Health Policy, Yale School of Public Health, West Haven, Connecticut, USA
| | - Yan V Sun
- Veterans Affairs Atlanta Healthcare System, Decatur, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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10
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Basukala B, Rossi S, Bendiks S, Gnatienko N, Patts G, Krupitsky E, Lioznov D, So-Armah K, Sagar M, Cheng C, Henderson AJ. Virally Suppressed People Living with HIV Who Use Opioids Have Diminished Latency Reversal. Viruses 2023; 15:415. [PMID: 36851631 PMCID: PMC9961149 DOI: 10.3390/v15020415] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
Of the 12 million people who inject drugs worldwide, 13% live with HIV. Whether opioid use impacts HIV pathogenesis and latency is an outstanding question. To gain insight into whether opioid use influences the proviral landscape and latent HIV reservoir, we performed intact proviral DNA assays (IPDA) on peripheral blood mononuclear cells (PBMCs) from antiretroviral therapy (ART)-suppressed people living with HIV (PWH) with or without current opioid use. No differences were observed between PWH with and without opioid use in the frequency of HIV intact and defective proviral genomes. To evaluate the latent reservoir, we activated PBMCs from ART-suppressed PWH with or without opioid use and assessed the induction of HIV RNA. PWH using opioids had diminished responses to ex vivo HIV reactivation, suggesting a smaller reversible reservoir of HIV-1 latently infected cells. However, in vitro studies using primary CD4+ T cells treated with morphine showed no effect of opioids on HIV-1 infection, replication or latency establishment. The discrepancy in our results from in vitro and clinical samples suggests that while opioids may not directly impact HIV replication, latency and reactivation in CD4+ T cells, opioid use may indirectly shape the HIV reservoir in vivo by modulating general immune functions.
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Affiliation(s)
- Binita Basukala
- Department of Biology, Boston University, Boston, MA 02215, USA
| | - Sarah Rossi
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
| | - Sally Bendiks
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
| | - Natalia Gnatienko
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
| | - Gregory Patts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA 02118, USA
| | - Evgeny Krupitsky
- Laboratory of Clinical Pharmacology of Addictions, Pavlov First St. Petersburg State Medical University, Saint-Petersburg 197022, Russia
- Department of Addictions, Bekhterev National Medical Research Center for Psychiatry and Neurology, Saint-Petersburg 192019, Russia
| | - Dmitry Lioznov
- Laboratory of Clinical Pharmacology of Addictions, Pavlov First St. Petersburg State Medical University, Saint-Petersburg 197022, Russia
| | - Kaku So-Armah
- Clinical Addiction Research and Education (CARE) Unit, Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
| | - Manish Sagar
- Department of Medicine, Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
- Department of Microbiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
| | - Christine Cheng
- Department of Biology, Boston University, Boston, MA 02215, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093, USA
| | - Andrew J. Henderson
- Department of Medicine, Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
- Department of Microbiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
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11
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Titanji BK, Lee M, Wang Z, Chen J, Hui Q, Lo Re III V, So-Armah K, Justice AC, Xu K, Freiberg M, Gwinn M, Marconi VC, Sun YV. Epigenome-wide association study of biomarkers of liver function identifies albumin-associated DNA methylation sites among male veterans with HIV. Front Genet 2022; 13:1020871. [PMID: 36303554 PMCID: PMC9592923 DOI: 10.3389/fgene.2022.1020871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Liver disease (LD) is an important cause of morbidity and mortality for people with HIV (PWH). The molecular factors linked with LD in PWH are varied and incompletely characterized. We performed an epigenome-wide association study (EWAS) to identify associations between DNA methylation (DNAm) and biomarkers of liver function-aspartate transaminase, alanine transaminase, albumin, total bilirubin, platelet count, FIB-4 score, and APRI score-in male United States veterans with HIV. Methods: Blood samples and clinical data were obtained from 960 HIV-infected male PWH from the Veterans Aging Cohort Study. DNAm was assessed using the Illumina 450K or the EPIC 850K array in two mutually exclusive subsets. We performed a meta-analysis for each DNAm site measured by either platform. We also examined the associations between four measures of DNAm age acceleration (AA) and liver biomarkers. Results: Nine DNAm sites were positively associated with serum albumin in the meta-analysis of the EPIC and 450K EWAS after correcting for multiple testing. Four DNAm sites (cg16936953, cg18942579, cg01409343, and cg12054453), annotated within the TMEM49 and four of the remaining five sites (cg18181703, cg03546163, cg20995564, and cg23966214) annotated to SOCS3, FKBP5, ZEB2, and SAMD14 genes, respectively. The DNAm site, cg12992827, was not annotated to any known coding sequence. No significant associations were detected for the other six liver biomarkers. Higher PhenoAA was significantly associated with lower level of serum albumin (β = -0.007, p-value = 8.6 × 10-4, CI: -0.011116, -0.002884). Conclusion: We identified epigenetic associations of both individual DNAm sites and DNAm AA with liver function through serum albumin in men with HIV. Further replication analyses in independent cohorts are warranted to confirm the epigenetic mechanisms underlying liver function and LD in PWH.
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Affiliation(s)
- Boghuma K. Titanji
- Division of Infectious Disease, Emory School of Medicine, Atlanta, GA, United States
| | - Mitch Lee
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Zeyuan Wang
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Junyu Chen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Qin Hui
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Vincent Lo Re III
- Division of Infectious Diseases Department of Medicine and Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine University of Pennsylvania, Philadelphia, PA, United States
| | - Kaku So-Armah
- Boston University Medical School, Boston, MA, United States
| | - Amy C. Justice
- Connecticut Veteran Health System, West Haven, CT, United States,Yale University School of Medicine, New Haven, CT, United States
| | - Ke Xu
- Connecticut Veteran Health System, West Haven, CT, United States,Yale University School of Medicine, New Haven, CT, United States
| | - Matthew Freiberg
- Cardiovascular Medicine Division and Tennessee Valley Healthcare System, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Marta Gwinn
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Vincent C. Marconi
- Division of Infectious Disease, Emory School of Medicine, Atlanta, GA, United States,Atlanta Veterans Affairs Health Care System, Decatur, GA, United States,Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA, United States,Emory Vaccine Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, United States
| | - Yan V. Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States,Atlanta Veterans Affairs Health Care System, Decatur, GA, United States,*Correspondence: Yan V. Sun,
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12
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Titanji BK, Wang Z, Chen J, Hui Q, So-Armah K, Freiberg M, Justice AC, Ke X, Marconi VC, Sun YV. Soluble CD14-associated DNA methylation sites predict mortality among men with HIV infection. AIDS 2022; 36:1563-1571. [PMID: 35979830 PMCID: PMC9394925 DOI: 10.1097/qad.0000000000003279] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Elevated plasma levels of sCD14 predict all-cause mortality in people with HIV (PWH). Epigenetic regulation plays a key role in infection and inflammation. To reveal the epigenetic relationships between sCD14, immune function and disease progression among PWH, we conducted an epigenome-wide association study (EWAS) of sCD14 and investigated the relationship with mortality. DESIGN AND METHODS DNA methylation (DNAm) levels of peripheral blood samples from PWH in the Veterans Aging Cohort Study (VACS) were measured using the Illumina Infinium Methylation 450K (n = 549) and EPIC (850K) BeadChip (n = 526). Adjusted for covariates and multiple testing, we conducted an epigenome-wide discovery, replication, and meta-analysis to identify significant associations with sCD14. We then examined and replicated the relationship between the principal epigenetic sites and survival using Cox regression models. FINDINGS We identified 118 DNAm sites significantly associated with sCD14 in the meta-analysis of 1075 PWH. The principal associated DNAm sites mapped to genes (e.g. STAT1, PARP9, IFITM1, MX1, and IFIT1) related to inflammation and antiviral response. Adjusting for multiple testing, 10 of 118 sCD14-associated DNAm sites significantly predicted survival time conditional on sCD14 levels. CONCLUSION The identification of DNAm sites independently predicting survival may improve our understanding of prognosis and potential therapeutic targets among PWH.
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Affiliation(s)
- Boghuma K Titanji
- Division of Infectious Diseases, Emory University School of Medicine
| | - Zeyuan Wang
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Junyu Chen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Qin Hui
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Matthew Freiberg
- Cardiovascular Medicine Division and Tennessee Valley Healthcare System, Vanderbilt University Medical Center, Nashville, TN
| | - Amy C Justice
- Yale University School of Medicine, New Haven
- Connecticut Veteran Health System, West Haven, CT
| | - Xu Ke
- Yale University School of Medicine, New Haven
- Connecticut Veteran Health System, West Haven, CT
| | - Vincent C Marconi
- Division of Infectious Diseases, Emory University School of Medicine
- Atlanta Veterans Affairs Healthcare System, Decatur
- Hubert Department of Global Health, Rollins School of Public Health
- Emory Vaccine Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
| | - Yan V Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Atlanta Veterans Affairs Healthcare System, Decatur
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13
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Tindle HA, Freiberg MS, Cheng DM, Gnatienko N, Blokhina E, Yaroslavtseva T, Bendiks S, Patts G, Hahn J, So-Armah K, Stein MD, Bryant K, Lioznov D, Krupitsky E, Samet JH. Effectiveness of Varenicline and Cytisine for Alcohol Use Reduction Among People With HIV and Substance Use: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2225129. [PMID: 35930287 PMCID: PMC9356316 DOI: 10.1001/jamanetworkopen.2022.25129] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
IMPORTANCE Cigarette smoking and risky alcohol consumption co-occur and are undertreated. Nicotine receptor partial agonists and nicotine replacement therapy (NRT) treat smoking but are unproven for alcohol, and clinical trials rarely include individuals with HIV, substance use, and mental health conditions. OBJECTIVE To compare the effects on drinking and smoking of nicotinic acetylcholine receptor partial agonists varenicline and cytisine with those of NRT. DESIGN, SETTING, AND PARTICIPANTS This 4-group randomized, double-blinded, placebo-controlled clinical trial was conducted from July 2017 to December 2020 in St Petersburg, Russia. Included participants were 400 individuals with HIV who engaged in risky drinking (≥5 prior-month heavy-drinking days [HDDs]) and daily smoking; they were followed up for 12 months after enrollment. Data were analyzed from May 2021 through June 2022. INTERVENTIONS Participants received alcohol and tobacco counseling, 1 active medication, and 1 placebo in 1 of 4 groups: active varenicline and placebo NRT (group 1), placebo varenicline and active NRT (group 2), active cytisine and placebo NRT (group 3), or placebo cytisine and active NRT (group 4). MAIN OUTCOMES AND MEASURES The primary outcome was number of prior-month HDDs at 3 months. Secondary outcomes included biochemically validated abstinence from alcohol at 3 months and smoking at 6 months. RESULTS Among 400 participants (263 [65.8%] men; mean [SD] age, 39 [6] years), 97 individuals (24.3%) used opioids and 156 individuals (39.1%) had depressive symptoms. These individuals had a mean (SD) CD4 count of 391 (257) cells/mm3, smoked a mean (SD) of 21 [8] cigarettes/d, and reported a mean (SD) of 9.3 (5.8) HDDs in the prior 30 days. At 3 months, the mean (SD) number of HDDs was decreased vs baseline across all groups (group 1: 2.0 [3.8] HDDs vs. 9.5 [6.1] HDDs; group 2: 2.1 [4.3] HDDs vs 9.3 [5.7] HDDs; group 3: 1.5 [3.3] HDDs vs 8.9 [5.0] HDDs; group 4: 2.4 [5.2] HDDs vs 9.6 [6.3] HDDs). There were no significant differences at 3 months between groups in mean (SD) HDDs, including group 1 vs 2 (incident rate ratio [IRR], 0.94; 95% CI, 0.49-1.79), 3 vs 4 (IRR, 0.60; 95% CI, 0.30-1.18), and 1 vs 3 (IRR, 1.29; 95% CI, 0.65-2.55). There were no significant differences at 6 months between groups in smoking abstinence, including group 1 vs 2 (15 of 100 individuals [15.0%] vs 17 of 99 individuals [17.2%]; odds ratio [OR],0.89; 95% CI, 0.38-2.08), 3 vs 4 (19 of 100 individuals [19.0%] vs 19 of 101 individuals [18.8%]; OR, 1.00; 95% CI, 0.46-2.17), and 1 vs 3 (OR, 0.79; 95% CI, 0.35-1.78). Post hoc analyses suggested lower mean (SD) HDDs (eg, at 3 months: 0.7 [1.8] HDDs vs 2.3 [4.6] HDDs) and higher alcohol abstinence (eg, at 3 months: 30 of 85 individuals [35.3%] vs 54 of 315 individuals [17.1%]) among those who quit vs continued smoking. CONCLUSIONS AND RELEVANCE This study found that among individuals with HIV who engaged in risky drinking and smoking, varenicline and cytisine were not more efficacious than NRT to treat risky drinking and smoking but that behavior change rates were high in all groups. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02797587.
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Affiliation(s)
- Hilary A. Tindle
- Vanderbilt Center for Tobacco, Addiction and Lifestyle, Vanderbilt University Medical Center, Division of Internal Medicine and Public Health, Nashville, Tennessee
| | - Matthew S. Freiberg
- Vanderbilt Center for Clinical Cardiovascular Trials Evaluation, Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Natalia Gnatienko
- Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Elena Blokhina
- First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
| | - Tatiana Yaroslavtseva
- First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
| | - Sally Bendiks
- Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Gregory Patts
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Judith Hahn
- Department of Medicine, University of California, San Francisco
| | - Kaku So-Armah
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts
| | - Michael D. Stein
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Kendall Bryant
- HIV/AIDS Research, National Institute on Alcohol Abuse and Alcoholism, National Institute of Health, Bethesda, Maryland
| | - Dmitry Lioznov
- First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
| | - Evgeny Krupitsky
- First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
- Department of Addictions, V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology, St Petersburg, Russian Federation
| | - Jeffrey H. Samet
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, Massachusetts
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
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14
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Bahji A, Li Y, Vickers-Smith R, Crystal S, Kerns RD, Gordon KS, Macmadu A, Skanderson M, So-Armah K, Sung ML, Bhondoekhan F, Marshall BDL, Edelman EJ. Self-Reported Cannabis Use and HIV Viral Control among Patients with HIV Engaged in Care: Results from a National Cohort Study. Int J Environ Res Public Health 2022; 19:5649. [PMID: 35565045 PMCID: PMC9101884 DOI: 10.3390/ijerph19095649] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/26/2022] [Accepted: 04/29/2022] [Indexed: 02/04/2023]
Abstract
Background: The association between cannabis use and HIV-1 RNA (viral load) among people with HIV (PWH) engaged in care is unclear. Methods: We used data collected from 2002 to 2018 on PWH receiving antiretroviral therapy (ART) enrolled in the Veterans Aging Cohort Study. Generalized estimating equations were used to estimate associations between self-reported past-year cannabis use and detectable viral load (≥500 copies/mL), with and without adjustment for demographics, other substance use, and adherence. Results: Among 2515 participants, 97% were male, 66% were Black, the mean age was 50 years, and 33% had detectable HIV viral load at the first study visit. In unadjusted analyses, PWH with any past-year cannabis use had 21% higher odds of a detectable viral load than those with no past-year use (OR = 1.21; 95% CI, 1.07-1.37). However, there was no significant association between cannabis use and viral load after adjustment. Conclusions: Among PWH engaged in care and receiving ART, cannabis use is associated with decreased adherence in unadjusted analyses but does not appear to directly impact viral control. Future studies are needed to understand other potential risks and benefits of cannabis use among PWH.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, AB T2N 4N1, Canada;
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 4N1, Canada
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada
- Research in Addiction Medicine Scholars Program, Boston University Medical Center, Boston, MA 02118, USA
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Yu Li
- Department of Epidemiology, Brown University School of Public Health, Providence, RI 02912, USA; (Y.L.); (A.M.); (F.B.); (B.D.L.M.)
| | - Rachel Vickers-Smith
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, KY 40536, USA;
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, Rutgers, NJ 08901, USA;
| | - Robert D. Kerns
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, USA;
- VA Connecticut Healthcare System, West Haven, CT 06516, USA; (K.S.G.); (M.S.); (M.L.S.)
| | - Kirsha S. Gordon
- VA Connecticut Healthcare System, West Haven, CT 06516, USA; (K.S.G.); (M.S.); (M.L.S.)
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - Alexandria Macmadu
- Department of Epidemiology, Brown University School of Public Health, Providence, RI 02912, USA; (Y.L.); (A.M.); (F.B.); (B.D.L.M.)
| | - Melissa Skanderson
- VA Connecticut Healthcare System, West Haven, CT 06516, USA; (K.S.G.); (M.S.); (M.L.S.)
| | - Kaku So-Armah
- Clinical Addiction Research & Education (CARE) Unit, Boston University School of Medicine, Boston, MA 02118, USA;
| | - Minhee L. Sung
- VA Connecticut Healthcare System, West Haven, CT 06516, USA; (K.S.G.); (M.S.); (M.L.S.)
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - Fiona Bhondoekhan
- Department of Epidemiology, Brown University School of Public Health, Providence, RI 02912, USA; (Y.L.); (A.M.); (F.B.); (B.D.L.M.)
| | - Brandon D. L. Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI 02912, USA; (Y.L.); (A.M.); (F.B.); (B.D.L.M.)
| | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT 06511, USA
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15
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Kholodnaia A, So-Armah K, Cheng D, Gnatienko N, Patts G, Samet JH, Freiberg M, Lioznov D. Impact of illicit opioid use on markers of monocyte activation and systemic inflammation in people living with HIV. PLoS One 2022; 17:e0265504. [PMID: 35511802 PMCID: PMC9070930 DOI: 10.1371/journal.pone.0265504] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/02/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION We hypothesize that illicit opioid use increases bacterial translocation from the gut, which intensifies systemic inflammation. OBJECTIVE To investigate the association between opioid use and plasma soluble CD14 [sCD14], interleukin-6 [IL-6] and D-dimer in people living with HIV (PLWH). METHODS We analyzed data from the Russia ARCH study-an observational cohort of 351 ART-naive PLWH in St. Petersburg, Russia. Plasma levels of sCD14 (primary outcome), IL-6 and D-dimer (secondary outcomes) were evaluated at baseline, 12, and 24 months. Participants were categorized into three groups based on illicit opioid use: current, prior, and never opioid use. Linear mixed effects models were used to evaluate associations. RESULTS Compared to never opioid use, sCD14 levels were significantly higher for participants with current opioid use (AMD = 197.8 ng/ml [11.4, 384.2], p = 0.04). IL-6 levels were also higher for participants with current vs. never opioid use (ARM = 2.10 [1.56, 2.83], p <0.001). D-dimer levels were higher for current (ARM = 1.95 [1.43, 2.64], p <0.001) and prior (ARM = 1.57 [1.17, 2.09], p = 0.004) compared to never opioid use. CONCLUSIONS Among PLWH, current opioid use compared to never use is associated with increased monocyte activation and systemic inflammation.
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Affiliation(s)
- Anastasia Kholodnaia
- Department of Infectious Diseases and Epidemiology, Academician I.P. Pavlov First St. Petersburg State Medical University, Saint-Petersburg, Russian Federation
| | - Kaku So-Armah
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine/Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, United States of America
| | - Debbie Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America
| | - Natalia Gnatienko
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, United States of America
| | - Gregory Patts
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, United States of America
| | - Jeffrey H. Samet
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine/Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, United States of America
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, United States of America
| | - Matthew Freiberg
- Vanderbilt Center for Clinical Cardiovascular Trials Evaluation (V-C3REATE), Vanderbilt University Medical Center, Cardiovascular Division, Nashville, TN, United States of America
| | - Dmitry Lioznov
- Department of Infectious Diseases and Epidemiology, Academician I.P. Pavlov First St. Petersburg State Medical University, Saint-Petersburg, Russian Federation
- Smorodintsev Research Institute of Influenza, St. Petersburg, Russian Federation
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16
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Bourgi K, Kundu S, Stewart JC, So-Armah K, Freiberg M, Gupta SK. Associations of HIV and Depression with Incident Diabetes Mellitus: Veterans Aging Cohort Study. Clin Infect Dis 2022; 78:ciac085. [PMID: 35134838 PMCID: PMC10874269 DOI: 10.1093/cid/ciac085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Persons with HIV (PWH) are at increasingly higher risk for metabolic complications, including diabetes mellitus (DM). Additionally, depression is highly prevalent among PWH and has been associated with increased risk for DM in the general population. However, the association of HIV and depression with incident DM has not been well established. METHODS Using the Veterans Aging Cohort Study (VACS), we selected adults with and without HIV who did not have DM at baseline. Prevalent depression was defined as having a Patient Health Questionnaire-9 (PHQ-9) score of ≥10. Incident DM was identified using validated Kelly's criteria. Basic clinical and demographic characteristics were collected, and cox proportional hazards regression models were run to test the association between depression and incident DM stratified by HIV serostatus. RESULTS A total of 5,722 participants were analyzed, 2,886 (53%) had HIV and 1,124 (20%) had depression at baseline. 1,235 (22%) participants developed incident DM during follow-up, with 26% of HIV-negative participants developing DM compared to 17% of participants with HIV. Depression was significantly associated with increased risk of incident DM among HIV-negative participants (adjusted HR [aHR] = 1.31; p-value 0.003), but not among participants with HIV (aHR 1.09; p-value 0.44). However, among participants with HIV with baseline viral load < 500 copies/mL, we noted a stronger association between depression and incident DM. CONCLUSIONS Incident DM in the VACS cohort is significantly higher for HIV-negative participants compared to veterans with HIV. A significant association between depression and incident DM was noted among HIV-negative participants but not among those with HIV.
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Affiliation(s)
- Kassem Bourgi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Suman Kundu
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jesse C Stewart
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kaku So-Armah
- Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Samir K Gupta
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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17
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Kiyanda A, Mensah S, Patts G, Cheng D, Jiang W, Samet J, So-Armah K. Change in alcohol consumption and altered coagulation in people with HIV (PWH). Alcohol 2021. [DOI: 10.1016/j.alcohol.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Corcorran MA, Ludwig-Baron N, Cheng DM, Lioznov D, Gnatienko N, Patts G, So-Armah K, Blokhina E, Bendiks S, Krupitsky E, Samet JH, Tsui JI. The Hepatitis C Continuum of Care Among HIV-Positive Persons with Heavy Alcohol Use in St. Petersburg, Russia. AIDS Behav 2021; 25:2533-2541. [PMID: 33730255 DOI: 10.1007/s10461-021-03214-y] [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] [Accepted: 02/26/2021] [Indexed: 11/28/2022]
Abstract
This study describes the self-reported prevalence of hepatitis C virus (HCV) coinfection and the HCV care continuum among persons enrolled in the St PETER HIV Study, a randomized controlled trial of medications for smoking and alcohol cessation in HIV-positive heavy drinkers and smokers in St. Petersburg, Russia. Baseline health questionnaire data were used to calculate proportions and 95% confidence intervals for self-reported steps along the HCV continuum of care. The cohort included 399 HIV-positive persons, of whom 387 [97.0% (95% CI 95.3-98.7%)] reported a prior HCV test and 315 [78.9% (95% CI 74.9-82.9%)] reported a prior diagnosis of HCV. Among those reporting a diagnosis of HCV, 43 [13.7% (95% CI 9.9-17.4%)] had received treatment for HCV, and 31 [9.8% (95% CI 6.6-13.1%)] had been cured. Despite frequent HCV testing in this HIV-positive Russian cohort, the proportion reporting prior effective HCV treatment was strikingly low. Increased efforts are needed to scale-up HCV treatment among HIV-positive Russians in St. Petersburg.
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Affiliation(s)
- Maria A Corcorran
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA.
- Division of Allergy and Infectious Diseases, Department of Medicine, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave, Box 359782, Seattle, WA, 98104, USA.
| | | | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Dmitry Lioznov
- First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russian Federation
- Smorodintsev Research Institute of Influenza, St. Petersburg, Russian Federation
| | - Natalia Gnatienko
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, USA
| | - Gregory Patts
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Kaku So-Armah
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine/Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, USA
| | - Elena Blokhina
- First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russian Federation
| | - Sally Bendiks
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, USA
| | - Evgeny Krupitsky
- First Pavlov State Medical University of St. Petersburg, St. Petersburg, Russian Federation
- Department of Addictions, V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology, St. Petersburg, Russian Federation
| | - Jeffrey H Samet
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine/Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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19
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Sico JJ, Kundu S, So-Armah K, Gupta SK, Chang CCH, Butt AA, Gibert CL, Marconi VC, Crystal S, Tindle HA, Freiberg MS, Stewart JC. Depression as a Risk Factor for Incident Ischemic Stroke Among HIV-Positive Veterans in the Veterans Aging Cohort Study. J Am Heart Assoc 2021; 10:e017637. [PMID: 34169726 PMCID: PMC8403311 DOI: 10.1161/jaha.119.017637] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background HIV infection and depression are each associated with increased ischemic stroke risk. Whether depression is a risk factor for stroke within the HIV population is unknown. Methods and Results We analyzed data on 106 333 (33 528 HIV‐positive; 72 805 HIV‐negative) people who were free of baseline cardiovascular disease from an observational cohort of HIV‐positive people and matched uninfected veterans in care from April 1, 2003 through December 31, 2014. International Classification of Diseases, Ninth Revision (ICD‐9) codes from medical records were used to determine baseline depression and incident stroke. Depression occurred in 19.5% of HIV‐positive people. After a median of 9.2 years of follow‐up, stroke rates were highest among people with both HIV and depression and lowest among those with neither condition. In Cox proportional hazard models, depression was associated with an increased risk of stroke for HIV‐positive people after adjusting for sociodemographic characteristics and cerebrovascular risk factors (hazard ratio [HR], 1.18; 95% CI: 1.03–1.34; 0.014). The depression‐stroke relationship was attenuated by alcohol use disorders, cocaine use, and baseline antidepressant use, and unaffected by combined antiretroviral therapy use or individual antiretroviral agents. A numerically higher HR of depression on stroke was found among those younger than 60 years. Conclusions Depression is associated with an increased risk of stroke among HIV‐positive people after adjusting for sociodemographic characteristics, traditional cerebrovascular risk factors, and HIV‐specific factors. Alcohol use disorders, cocaine use, and baseline antidepressant use accounted for some of the observed stroke risk. Depression may be a novel, independent risk factor for ischemic stroke in HIV, particularly among younger people.
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Affiliation(s)
- Jason J Sico
- Neurology Service VA Connecticut Healthcare System West Haven CT.,Department of Neurology Yale School of Medicine New Haven CT.,Center for NeuroEpidemiological and Clinical Neurological Research Yale School of Medicine New Haven CT.,Department of Internal Medicine Yale School of Medicine New Haven CT.,Clinical Epidemiology Research Center (CERC) VA Connecticut Healthcare System West Haven CT.,Pain Research, Informatics, and Multi-morbidities, and Education (PRIME) Center VA Connecticut Healthcare System West Haven CT.,Vanderbilt Center for Clinical Cardiovascular Outcomes Research and Trials Evaluation (V-CREATE) Vanderbilt University School of Medicine Nashville TN
| | - Suman Kundu
- Vanderbilt Center for Clinical Cardiovascular Outcomes Research and Trials Evaluation (V-CREATE) Vanderbilt University School of Medicine Nashville TN.,Tennessee Valley Geriatrics Research Education and Clinical Centers (GRECC) VA Tennessee Valley Healthcare System Nashville TN
| | | | - Samir K Gupta
- Department of Medicine Indiana University School of Medicine Indianapolis IN
| | | | - Adeel A Butt
- VA Pittsburgh Healthcare System Pittsburgh PA.,Weill Cornell Medical College New York NY.,Weill Cornell Medical College Doha Qatar.,Hamad Medical Corporation Doha Qatar
| | - Cynthia L Gibert
- Washington DC Veterans Affairs Medical Center and George Washington University School of Medicine and Health Sciences Washington DC
| | - Vincent C Marconi
- Emory University School of Medicine and Rollins School of Public Health Emory Center for AIDS Research, and the Atlanta VA Medical Center Atlanta GA
| | - Stephen Crystal
- Center for Health Services Research Institute for Health Rutgers University New Brunswick NJ
| | - Hilary A Tindle
- Tennessee Valley Geriatrics Research Education and Clinical Centers (GRECC) VA Tennessee Valley Healthcare System Nashville TN.,Vanderbilt University Medical Center Nashville TN
| | - Matthew S Freiberg
- Vanderbilt Center for Clinical Cardiovascular Outcomes Research and Trials Evaluation (V-CREATE) Vanderbilt University School of Medicine Nashville TN.,Tennessee Valley Geriatrics Research Education and Clinical Centers (GRECC) VA Tennessee Valley Healthcare System Nashville TN
| | - Jesse C Stewart
- Department of Psychology Indianapolis University-Purdue University Indianapolis (IUPUI) Indianapolis IN
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20
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Liang X, Justice AC, So-Armah K, Krystal JH, Sinha R, Xu K. DNA methylation signature on phosphatidylethanol, not on self-reported alcohol consumption, predicts hazardous alcohol consumption in two distinct populations. Mol Psychiatry 2021; 26:2238-2253. [PMID: 32034291 PMCID: PMC8440221 DOI: 10.1038/s41380-020-0668-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 08/25/2019] [Revised: 12/20/2019] [Accepted: 01/28/2020] [Indexed: 12/28/2022]
Abstract
The process of diagnosing hazardous alcohol drinking (HAD) is based on self-reported data and is thereby vulnerable to bias. There has been an interest in developing epigenetic biomarkers for HAD that might complement clinical assessment. Because alcohol consumption has been previously linked to DNA methylation (DNAm), we aimed to select DNAm signatures in blood to predict HAD from two demographically and clinically distinct populations (Ntotal = 1,549). We first separately conducted an epigenome-wide association study (EWAS) for phosphatidylethanol (PEth), an objective measure of alcohol consumption, and for self-reported alcohol consumption in Cohort 1. We identified 83 PEth-associated CpGs, including 23 CpGs previously associated with alcohol consumption or alcohol use disorder. In contrast, no CpG reached epigenome-wide significance on self-reported alcohol consumption. Using a machine learning approach, two CpG subsets from EWAS on PEth and on self-reported alcohol consumption from Cohort 1 were separately tested for the prediction of HAD in Cohort 2. We found that a subset of 143 CpGs selected from the EWAS on PEth showed an excellent prediction of HAD with the area under the receiver operating characteristic curve (AUC) of 89.4% in training set and 73.9% in validation set of Cohort 2. However, CpGs preselected from the EWAS on self-reported alcohol consumption showed a poor prediction of HAD with AUC 75.2% in training set and 57.6% in validation set. Our results demonstrate that an objective measure for alcohol consumption is a more informative phenotype than self-reported data for revealing epigenetic mechanisms. The PEth-associated DNAm signature in blood could serve as a robust biomarker for alcohol consumption.
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Affiliation(s)
- Xiaoyu Liang
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Kaku So-Armah
- Boston University School of Medicine, Boston, MA, USA
| | - John H Krystal
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Rajita Sinha
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Child Study Center, Yale School of Medicine, New Haven, CT, USA
- Stress Center, Yale School of Medicine, New Haven, CT, USA
| | - Ke Xu
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
- VA Connecticut Healthcare System, West Haven, CT, USA.
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21
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Hahn JA, Murnane PM, Vittinghoff E, Muyindike WR, Emenyonu NI, Fatch R, Chamie G, Haberer JE, Francis JM, Kapiga S, Jacobson K, Myers B, Couture MC, DiClemente RJ, Brown JL, So-Armah K, Sulkowski M, Marcus GM, Woolf-King S, Cook RL, Richards VL, Molina P, Ferguson T, Welsh D, Piano MR, Phillips SA, Stewart S, Afshar M, Page K, McGinnis K, Fiellin DA, Justice AC, Bryant K, Saitz R. Factors associated with phosphatidylethanol (PEth) sensitivity for detecting unhealthy alcohol use: An individual patient data meta-analysis. Alcohol Clin Exp Res 2021; 45:1166-1187. [PMID: 33837975 PMCID: PMC8254773 DOI: 10.1111/acer.14611] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Objective measurement of alcohol consumption is important for clinical care and research. Adjusting for self-reported alcohol use, we conducted an individual participant data (IPD) meta-analysis to examine factors associated with the sensitivity of phosphatidylethanol (PEth), an alcohol metabolite, among persons self-reporting unhealthy alcohol consumption. METHODS We identified 21 eligible studies and obtained 4073 observations from 3085 participants with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) positive scores (≥3 for women and ≥4 for men) and PEth measurements. We conducted 1-step IPD meta-analysis using mixed effects models with random intercepts for study site. We examined the associations between demographic (sex, race/ethnicity, and age) and biologic (body mass index-BMI, hemoglobin, HIV status, liver fibrosis, and venous versus finger-prick blood collection) variables with PEth sensitivity (PEth≥8 ng/ml), adjusting for the level of self-reported alcohol use using the AUDIT-C score. RESULTS One third (31%) of participants were women, 32% were African, 28% African American, 28% White, and 12% other race/ethnicity. PEth sensitivity (i.e., ≥8 ng/ml) was 81.8%. After adjusting for AUDIT-C, we found no associations of sex, age, race/ethnicity, or method of blood collection with PEth sensitivity. In models that additionally included biologic variables, those with higher hemoglobin and indeterminate and advanced liver fibrosis had significantly higher odds of PEth sensitivity; those with higher BMI and those living with HIV had significantly lower odds of PEth sensitivity. African Americans and Africans had higher odds of PEth sensitivity than whites in models that included biologic variables. CONCLUSIONS Among people reporting unhealthy alcohol use, several biological factors (hemoglobin, BMI, liver fibrosis, and HIV status) were associated with PEth sensitivity. Race/ethnicity was associated with PEth sensitivity in some models but age, sex, and method of blood collection were not. Clinicians should be aware of these factors, and researchers should consider adjusting analyses for these characteristics where possible.
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Affiliation(s)
- Judith A Hahn
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Pamela M Murnane
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Winnie R Muyindike
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nneka I Emenyonu
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Robin Fatch
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Gabriel Chamie
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Joel M Francis
- National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Department of Family Medicine and Primary Care, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Saidi Kapiga
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Karen Jacobson
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Tygerberg, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Ralph J DiClemente
- Department of Social and Behavioral Sciences, NYU School of Global Public Health, New York, NY, USA
| | - Jennifer L Brown
- Department of Psychology and Psychiatry and Behavioral Neuroscience, Center for Addiction Research, University of Cincinnati, Cincinnati, OH, USA
| | - Kaku So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mark Sulkowski
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gregory M Marcus
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sarah Woolf-King
- Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Robert L Cook
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
| | | | - Patricia Molina
- Comprehensive Alcohol-HIV/AIDS Research Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
- Department of Physiology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Tekeda Ferguson
- Comprehensive Alcohol-HIV/AIDS Research Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
- Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - David Welsh
- Comprehensive Alcohol-HIV/AIDS Research Center, Louisiana State University Health Sciences Center, New Orleans, LA, USA
- Department of Internal Medicine, Department of Microbiology, Immunology, & Parasitology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Mariann R Piano
- Center for Research Development and Scholarship, Vanderbilt University, Nashville, TN, USA
| | | | - Scott Stewart
- Department of Family Medicine, Division of Addiction Medicine, University at Buffalo, Buffalo, NY, USA
| | - Majid Afshar
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin - Madison, Madison, WI, USA
| | - Kimberly Page
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Kathleen McGinnis
- West Haven VA Healthcare System, United States Department of Veterans Affairs, West Haven, CT, USA
| | - David A Fiellin
- Yale School of Medicine, New Haven, CT, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Amy C Justice
- West Haven VA Healthcare System, United States Department of Veterans Affairs, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Kendall Bryant
- National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Richard Saitz
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Grayken Center on Addiction, Boston Medical Center, Boston, MA, USA
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22
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Pierre F, Forman LS, Winter M, Cheng D, Ngabirano C, Emenyonu N, Hunt PW, Huang Y, Muyindike W, Samet J, Hahn JA, So-Armah K. Alcohol Consumption and Tryptophan Metabolism Among People with HIV Prior to Antiretroviral Therapy Initiation: The Uganda ARCH Cohort Study. Alcohol Alcohol 2021; 57:219-225. [PMID: 34027552 PMCID: PMC8919408 DOI: 10.1093/alcalc/agab033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Alcohol is hypothesized to have effects on the kynurenine pathway of tryptophan catabolism, a potential mechanism for alcohol-induced depression and aggression. A biomarker of this pathway, the plasma kynurenine to tryptophan ratio (K/T ratio), has been associated with HIV progression, mortality and depression. Our aim was to assess whether hazardous alcohol consumption is associated higher K/T ratio among people with HIV. METHODS Participants were a subset of the Uganda Alcohol Research Collaboration on HIV/AIDS Cohort. Alcohol consumption was categorized (abstinent, moderate and hazardous alcohol use) using the Alcohol Use Disorders Identification Test-Consumption and phosphatidylethanol (PEth). K/T ratio was the primary outcome. We used linear regression adjusted for age, sex, FIB-4, hepatitis B surface antigen, log (HIV viral load) to estimate the association between alcohol consumption and K/T ratio. RESULTS Compared to abstinent participants, hazardous drinkers and moderate drinkers had higher K/T ratio but these differences did not reach statistical significance. CONCLUSIONS Our results suggest that hazardous alcohol consumption, in the context of untreated HIV infection, may not significantly alter kynurenine to tryptophan ratio as a measure of activity of the kynurenine pathway of tryptophan metabolism.
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Affiliation(s)
- Frantz Pierre
- Department of Epidemiology and Biostatistics, Boston University School of Public Health, 72 E Concord St, Boston, MA 02118, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, 85 East Newton Street, M921, Boston, MA 02118, USA
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, 85 East Newton Street, M921, Boston, MA 02118, USA
| | - Debbie Cheng
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave Boston, MA 02119, USA
| | - Christine Ngabirano
- Mbarara University of Science and Technology Department of Internal Medicine P.O Box 1410 Mbarara Uganda, Uganda
| | - Nneka Emenyonu
- Department of Medicine, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, USA
| | - Peter W Hunt
- Division of HIV/AIDS, San Francisco General Hospital, San Francisco, CA, USA
| | - Yong Huang
- Department of Bioengineering and Therapeutics, University of California San Francisco, 1700 4th Street, San Francisco, CA 94158, USA
| | - Winnie Muyindike
- Mbarara University of Science and Technology Department of Internal Medicine P.O Box 1410 Mbarara, Uganda
| | - Jeffrey Samet
- Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave Crosstown, 2nd Floor Boston, MA 02118, USA
| | - Judith A Hahn
- Departments of Medicine and Epidemiology & Biostatistics, University of California San Francisco, 550 16th St., 3rd floor San Francisco, CA 94158-2549, USA
| | - Kaku So-Armah
- Corresponding author: Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor Boston, MA 02118, USA. Tel.: 617 414 6624; E-mail:
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23
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Fuster D, So-Armah K, Cheng DM, Coleman SM, Gnatienko N, Lioznov D, Krupitsky EM, Freiberg MS, Samet JH. Lack of association between recent cannabis use and advanced liver fibrosis among HIV-positive heavy drinkers. Curr HIV Res 2021; 19:324-331. [PMID: 34061004 DOI: 10.2174/1570162x19666210519151320] [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: 10/01/2020] [Revised: 03/16/2021] [Accepted: 03/24/2021] [Indexed: 11/22/2022]
Abstract
AIMS To analyze the association between any past month cannabis use and advanced liver fibrosis. BACKGROUND Cannabinoid receptors play a role in acute and chronic liver injury, but human studies addressing the impact of cannabis use on liver fibrosis have shown mixed results. OBJECTIVES To explore and estimate the association between past month cannabis use and advanced liver fibrosis (ALF) in a cohort of Russian HIV-positive individuals with heavy alcohol use and high prevalence of hepatitis C virus (HCV) coinfection. METHODS Baseline data were analyzed from participants of the ZINC study, a trial that enrolled HIV-positive Russian patients without prior antiretroviral therapy. Cannabis use during the prior month was assessed at study entry. ALF was defined as FIB-4>3.25 and/or APRI>1.5, transient elastography was used to detect advanced liver fibrosis among participants with FIB-4 values in the intermediate range (between 1.45 and 3.25). RESULTS Participants (n=248) were mostly male (72.6%), young (median age of 33.9 years), infected with HCV (87.9%) and not with advanced immunosuppression (median CD4 count 462). Cannabis use was uncommon (12.4%) and the prevalence of advanced liver disease was 21.7%. The prevalence of ALF was similar among those who used cannabis compared to those who did not (25.8% vs. 21.7%). We were unable to detect an association between cannabis use and ALF (adjusted odds ratio: 1.28, 95% confidence interval: 0.53-3.12, p=0.59) in logistic regression models adjusting for age, sex, heavy drinking, BMI and CD4 cell count. CONCLUSION In this exploratory study among HIV-positive heavy drinking Russians we did not detect an association between recent cannabis use and ALF. Larger scale studies including more participants with cannabis use are needed to further examine this relationship.
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Affiliation(s)
- Daniel Fuster
- Internal Medicine Department. Addiction Unit. Hospital Universitari Germans Trias I Pujol, Universitat Autònoma de Barcelona. Badalona . Spain
| | - Kaku So-Armah
- Clinical Addiction Research and Education Unit. Section of General Internal Medicine, Department of Medicine. Boston University School of Medicine/Boston Medical Center. Boston (MA), United States
| | - Debbie M Cheng
- Biostatistics Department. Boston University School of Public Health. Boston (MA), United States
| | - Sharon M Coleman
- Biostatistics and Epidemiology Data Analytics Center. Boston University School of Public Health. Boston (MA), United States
| | - Natalia Gnatienko
- Clinical Addiction Research and Education Unit. Department of Medicine, Section of General Internal Medicine. Boston Medical Center. Boston (MA), United States
| | - Dmitry Lioznov
- Department of Infectious Diseases and Epidemiology. First Pavlov State Medical University. St. Petersburg. Russian Federation
| | - Evgeny M Krupitsky
- V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology. St. Petersburg. Russian Federation
| | - Matthew S Freiberg
- Cardiovascular Medicine Division. Vanderbilt University Medical Center. Nashville (TN), United States
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit. Section of General Internal Medicine, Department of Medicine. Boston University School of Medicine/Boston Medical Center. Boston (MA), United States
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24
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Berg C, Patel B, Reynolds M, Tuzovic M, Chew K, Sico J, Bhattacharya D, Butt AA, Lim JK, Bedimo RJ, Brown ST, Gottdiener J, Warner A, Freiberg M, So-Armah K, Nguyen KL. LEFT ATRIAL STRAIN AND DIASTOLIC DYSFUNCTION AMONGST HIV-POSITIVE INDIVIDUALS: INSIGHTS FROM THE VETERANS AGING COHORT STUDY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02780-7] [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: 10/21/2022]
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25
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Chen J, Huang Y, Hui Q, Mathur R, Gwinn M, So-Armah K, Freiberg MS, Justice AC, Xu K, Marconi VC, Sun YV. Epigenetic Associations With Estimated Glomerular Filtration Rate Among Men With Human Immunodeficiency Virus Infection. Clin Infect Dis 2021; 70:667-673. [PMID: 30893429 DOI: 10.1093/cid/ciz240] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 03/19/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND People living with human immunodeficiency virus (HIV) infection have higher risk for chronic kidney disease (CKD), defined by a reduced estimated glomerular filtration rate (eGFR). Previous studies have implicated epigenetic changes related to CKD; however, the mechanism of HIV-related CKD has not been thoroughly investigated. METHODS We conducted an epigenome-wide association study of eGFR among 567 HIV-positive and 117 HIV-negative male participants in the Veterans Aging Cohort Study to identify epigenetic signatures of kidney function. RESULTS By surveying more than 400 000 cytosine guanine dinucleotide (CpG) sites measured from peripheral blood mononuclear cells, we identified 15 sites that were significantly associated with eGFR (false discovery rate Q value < 0.05) among HIV-positive participants. The most significant CpG sites, located at MAD1L1, TSNARE1/BAI1, and LTV1, were all negatively associated with eGFR (cg06329547, P = 5.25 × 10-9; cg23281907, P = 1.37 × 10-8; cg18368637, P = 5.17 × 10-8). We also replicated previously reported eGFR-associated CpG sites including cg17944885 (P = 2.5 × 10-5) located between ZNF788 and ZNF20 on chromosome 19 in the pooled population. CONCLUSIONS In this study we uncovered novel epigenetic associations with kidney function among people living with HIV and suggest potential epigenetic mechanisms linked with HIV-related CKD risk.
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Affiliation(s)
- Junyu Chen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yunfeng Huang
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Qin Hui
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Raina Mathur
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Marta Gwinn
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Matthew S Freiberg
- Cardiovascular Medicine Division, Vanderbilt University School of Medicine and Tennessee Valley Healthcare System, Nashville
| | - Amy C Justice
- Connecticut Veteran Health System, West Haven.,Yale University School of Medicine, New Haven
| | - Ke Xu
- Connecticut Veteran Health System, West Haven.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Vincent C Marconi
- Hubert Department of Global Health, Rollins School of Public Health.,Division of Infectious Diseases, Emory University School of Medicine, Atlanta.,Atlanta Veterans Affairs Healthcare System, Decatur
| | - Yan V Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Healthcare System, Decatur.,Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, Georgia
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26
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Zola CE, Duncan MS, So-Armah K, Crothers KA, Butt AA, Gibert CL, Kim JWW, Lim JK, Re VL, Tindle HA, Freiberg MS, Brittain EL. HIV- and HCV-specific markers and echocardiographic pulmonary artery systolic pressure among United States veterans. Sci Rep 2020; 10:18729. [PMID: 33127959 PMCID: PMC7599329 DOI: 10.1038/s41598-020-75290-4] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 10/08/2020] [Indexed: 01/05/2023] Open
Abstract
Hepatitis C virus (HCV) may increase pulmonary hypertension (PH) risk among people living with HIV (PLWH). Prior studies on this topic have been relatively small and examined selected populations. We determine whether HIV/HCV coinfection is associated with higher pulmonary artery systolic pressure (PASP) and prevalent echocardiographic PH. We performed a cross-sectional analysis of 6032 (16% HIV/HCV coinfected) Veterans Aging Cohort Study participants enrolled 4/1/2003-9/30/2012 with echocardiographic PASP measures. We performed multiple linear and logistic regression analyses to determine whether HIV/HCV mono- or co-infection were associated with PASP and PH compared to uninfected individuals. Individuals with HIV/HCV coinfection displayed a higher PASP than uninfected individuals ([Formula: see text]=1.10, 95% CI 0.01, 2.20) but there was no association between HIV/HCV coinfection and prevalent PH. Subset analyses examined HIV and HCV disease severity markers separately and jointly. Among PLWH, HCV coinfection ([Formula: see text]=1.47, 95% CI 0.26, 2.67) and CD4 + cell count ([Formula: see text]= - 0.68, 95% CI - 1.10, - 0.27), but not HIV viral load nor ART regimen, were associated with PASP. Among people with HCV, neither HIV coinfection nor HCV biomarkers were associated with PASP. Among US veterans referred for echocardiography, HIV/HCV coinfection was not associated with a clinically significant elevation in pulmonary pressure. Lower absolute CD4 + T-cell count was inversely associated with PASP which warrants further investigation in prospective studies.
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Affiliation(s)
- Courtney E Zola
- Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meredith S Duncan
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 300A, Nashville, TN, 37203, USA
| | - Kaku So-Armah
- School of Medicine, Section of General Internal Medicine, Boston University, Boston, MA, USA
| | - Kristina A Crothers
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Adeel A Butt
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Weill Cornell Medical College, New York, NY, USA
- Weill Cornell Medical College, Doha, Qatar
| | - Cynthia L Gibert
- Department of Medicine, George Washington University, Washington, DC, USA
| | - Joon Woo W Kim
- Department of Medicine, Icahn School of Medicine At Mt. Sinai, James J. Peters VA Medical Center, New York City, NY, USA
| | - Joseph K Lim
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Vincent Lo Re
- Division of Infectious Disease, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hilary A Tindle
- Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S Freiberg
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 300A, Nashville, TN, 37203, USA
- Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 300A, Nashville, TN, 37203, USA.
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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27
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So-Armah K, Benjamin LA, Bloomfield GS, Feinstein MJ, Hsue P, Njuguna B, Freiberg MS. HIV and cardiovascular disease. Lancet HIV 2020; 7:e279-e293. [PMID: 32243826 DOI: 10.1016/s2352-3018(20)30036-9] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/24/2022]
Abstract
HIV-related cardiovascular disease research is predominantly from Europe and North America. Of the estimated 37·9 million people living with HIV worldwide, 25·6 million live in sub-Saharan Africa. Although mechanisms for HIV-related cardiovascular disease might be the same in all people with HIV, the distribution of cardiovascular disease risk factors varies by geographical location. Sub-Saharan Africa has a younger population, higher prevalence of elevated blood pressure, lower smoking rates, and lower prevalence of elevated cholesterol than western Europe and North America. These variations mean that the profile of cardiovascular disease differs between low-income and high-income countries. Research in, implementation of, and advocacy for risk reduction of cardiovascular disease in the global context of HIV should account for differences in the distribution of traditional cardiovascular disease risk factors (eg, hypertension, smoking), consider non-traditional cardiovascular disease risk factors (eg, access to antiretroviral therapy with more benign cardiovascular disease side effect profiles, indoor air pollution), and encourage the inclusion of relevant risk reduction approaches for cardiovascular disease in HIV-care guidelines. Future research priorities include implementation science to scale up and expand integrated HIV and cardiovascular disease care models, which have shown promise in sub-Saharan Africa; HIV and cardiovascular disease epidemiology and mechanisms in women; and tobacco cessation for people living with HIV.
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Affiliation(s)
- Kaku So-Armah
- Boston University School of Medicine, Boston, MA, USA.
| | - Laura A Benjamin
- UCL Queen Square Institute of Neurology, University College London, London, UK; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, NC, USA
| | | | | | | | - Matthew S Freiberg
- Vanderbilt University Medical Center, Nashville VA Medical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
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28
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Bailin SS, McGinnis KA, McDonnell WJ, So-Armah K, Wellons M, Tracy RP, Doyle MF, Mallal S, Justice AC, Freiberg MS, Landay AL, Wanjalla C, Koethe JR. T Lymphocyte Subsets Associated With Prevalent Diabetes in Veterans With and Without Human Immunodeficiency Virus. J Infect Dis 2020; 222:252-262. [PMID: 32052044 PMCID: PMC7323499 DOI: 10.1093/infdis/jiaa069] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A higher proportion of circulating memory CD4+ T cells is associated with prevalent diabetes mellitus in the general population. Given the broad changes in adaptive immunity, including memory T-cell expansion, and rising prevalence of diabetes in the human immunodeficiency virus (HIV) population, we assessed whether similar relationships were present in persons with HIV (PWH). METHODS Multiple CD4+ and CD8+ T-cell subsets were measured by flow cytometry, and prevalent diabetes cases were adjudicated by 2 physicians for PWH and HIV-negative participants in the Veterans Aging Cohort Study. Multivariable logistic regression models evaluated the association of T-cell subsets and diabetes stratified by HIV status, adjusted for cytomegalovirus serostatus and traditional risk factors. RESULTS Among 2385 participants (65% PWH, 95% male, 68% African American), higher CD45RO+ memory CD4+ T cells and lower CD38+ CD4+ T cells were associated with prevalent diabetes, and had a similar effect size, in both the PWH and HIV-negative (P ≤ .05 for all). Lower CD38+CD8+ T cells were also associated with diabetes in both groups. CONCLUSIONS The CD4+ and CD8+ T-cell subsets associated with diabetes are similar in PWH and HIV-negative individuals, suggesting that diabetes in PWH may be related to chronic immune activation.
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Affiliation(s)
- Samuel S Bailin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathleen A McGinnis
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Wyatt J McDonnell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kaku So-Armah
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Melissa Wellons
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Russell P Tracy
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont, USA
| | - Margaret F Doyle
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont, USA
| | - Simon Mallal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, West Haven, Connecticut, USA
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Alan L Landay
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Celestine Wanjalla
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John R Koethe
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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29
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Freiberg MS, Cheng DM, Gnatienko N, Blokhina E, Coleman SM, Doyle MF, Yaroslavtseva T, Bridden C, So-Armah K, Tracy R, Bryant K, Lioznov D, Krupitsky E, Samet JH. Effect of Zinc Supplementation vs Placebo on Mortality Risk and HIV Disease Progression Among HIV-Positive Adults With Heavy Alcohol Use: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e204330. [PMID: 32383748 PMCID: PMC7210486 DOI: 10.1001/jamanetworkopen.2020.4330] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Zinc supplementation can reduce alcohol-related microbial translocation and inflammation. OBJECTIVE To assess whether zinc supplementation reduces markers of mortality and risk of cardiovascular disease, reduces levels of inflammation and microbial translocation, and slows HIV disease progression in people with heavy alcohol use who are living with HIV/AIDS. DESIGN, SETTING, AND PARTICIPANTS This study is a double-blinded placebo-controlled randomized clinical trial of zinc supplementation among participants recruited from 2013 to 2015. Participants were recruited from HIV and addiction clinical and nonclinical care sites in St Petersburg, Russia. Participants were adults (aged 18-70 years) with documented HIV infection who were antiretroviral therapy-naive at baseline and had past 30-day heavy alcohol consumption. Data analysis was performed from February 2017 to February 2020. INTERVENTION Pharmacy-grade zinc gluconate supplementation (15 mg for men and 12 mg for women, taken daily by mouth for 18 months) was compared with a placebo. MAIN OUTCOMES AND MEASURES The primary outcome was mortality risk measured as a change in Veterans Aging Cohort Study (VACS) Index score between baseline and 18 months. The VACS Index scores range from 0 to 164, with higher scores indicating higher mortality risk. Secondary outcomes were change in CD4 cell count between baseline and 18 months, the assessment of cardiovascular disease risk (Reynolds Risk Score, which ranges from 0% to 100%, with higher scores indicating higher risk), and changes in inflammatory or microbial translocation biomarkers at 18 months. Adjusted linear regression analyses were performed. RESULTS A total of 254 participants (184 men [72%]; mean [SD] age, 34 [6] years) were enrolled in the trial; 126 were randomized to receive zinc, and 128 were randomized to receive placebo. Participants had high CD4 cell counts (mean [SD], 521 [292] cells/mm3), and 188 (74%) reported heavy drinking in the past week. In the main analyses, zinc supplementation did not affect changes in the VACS Index score at 18 months (change for zinc, mean [SD], 0.49 [14.6]; median [interquartile range], 0.0 [-7.0 to 6.0]; change for placebo, mean [SD], 5.5 [17.2]; median [interquartile range], 6.0 [-6.0 to 14.0]; adjusted mean difference [AMD], -4.68; 95% CI, -9.62 to 0.25; P = .06) or any secondary outcomes, including change in CD4 cell count (AMD, 41.8 cells/mm3; 95% CI, -20.3 to 103.8 cells/mm3; P = .19), Reynolds Risk Score (AMD, -0.014; 95% CI, -0.167 to 0.139; P = .85), interleukin-6 level (AMD, -0.13 pg/mL; 95% CI, -0.38 to 0.11 pg/mL; P = .30), dimerized plasmin fragment D level (AMD, -0.21 μg/mL fibrinogen equivalent units; 95% CI, -0.48 to 0.07 μg/mL fibrinogen equivalent units; P = .14), soluble CD14 level (AMD, -38.01 ng/mL; 95% CI, -166.90 to 90.88 ng/mL; P = .56), intestinal fatty acid binding protein level (AMD, 0.08 pg/mL; 95% CI, -0.07 to 0.22 pg/mL; P = .32), and lipopolysaccharide binding protein level (AMD, -0.09 ng/mL; 95% CI, -0.23 to 0.06 ng/mL; P = .24). In the per-protocol analyses, zinc supplementation statistically significantly affected changes in the VACS Index score at 18 months (AMD, -7.49; 95% CI, -13.74 to -1.23; P = .02); however, the adherence rate to zinc supplementation was 51%. CONCLUSIONS AND RELEVANCE Zinc supplementation did not reduce mortality risk, CD4 cell counts, cardiovascular disease risk, and levels of inflammation or microbial translocation in people with heavy alcohol use who are living with HIV/AIDS. Zinc supplementation did not change the VACS Index score but may have been limited by low adherence. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01934803.
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Affiliation(s)
- Matthew S. Freiberg
- Vanderbilt Center for Clinical Cardiovascular Trials Evaluation (V-C3REATE), Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Authority Health Care System, Nashville, Tennessee
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Natalia Gnatienko
- Clinical Addiction Research and Education (CARE) Unit, Boston Medical Center, Boston, Massachusetts
| | - Elena Blokhina
- First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
| | - Sharon M. Coleman
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, Massachusetts
| | - Margaret F. Doyle
- Larner College of Medicine, Department of Pathology and Laboratory Medicine, The University of Vermont, Colchester
| | - Tatiana Yaroslavtseva
- First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
| | - Carly Bridden
- Clinical Addiction Research and Education (CARE) Unit, Boston Medical Center, Boston, Massachusetts
| | - Kaku So-Armah
- Clinical Addiction Research and Education (CARE) Unit, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Russell Tracy
- Larner College of Medicine, Department of Pathology and Laboratory Medicine, The University of Vermont, Colchester
| | - Kendall Bryant
- HIV/AIDS Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | - Dmitry Lioznov
- First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
- Research Institute of Influenza, St Petersburg, Russian Federation
| | - Evgeny Krupitsky
- First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
- Department of Addictions, V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology, St Petersburg, Russian Federation
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education (CARE) Unit, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
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30
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White LF, Jiang W, Ma Y, So-Armah K, Samet JH, Cheng DM. Tutorial in Biostatistics: The use of generalized additive models to evaluate alcohol consumption as an exposure variable. Drug Alcohol Depend 2020; 209:107944. [PMID: 32145664 PMCID: PMC7171980 DOI: 10.1016/j.drugalcdep.2020.107944] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 11/30/2022]
Abstract
Alcohol consumption is a commonly studied risk factor for many poor health outcomes. Various instruments exist to measure alcohol consumption, including the AUDIT-C, Single Alcohol Screening Questionnaire (SASQ) and Timeline Followback. The information gathered by these instruments is often simplified and analyzed as a dichotomous measure, risking the loss of information of potentially prognostic value. We discuss generalized additive models (GAM) as a useful tool to understand the association between alcohol consumption and a health outcome. We demonstrate how this analytic strategy can guide the development of a regression model that retains maximal information about alcohol consumption. We illustrate these approaches using data from the Russia ARCH (Alcohol Research Collaboration on HIV/AIDS) study to analyze the association between alcohol consumption and biomarker of systemic inflammation, interleukin-6 (IL-6). We provide SAS and R code to implement these methods. GAMs have the potential to increase statistical power and allow for better elucidation of more nuanced and non-linear associations between alcohol consumption and important health outcomes.
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Affiliation(s)
- Laura F White
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118 United States.
| | - Wenqing Jiang
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118 United States
| | - Yicheng Ma
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118 United States; Department of Biostatistics, University of Michigan, 1415 Washington Hts, Ann Arbor, MI 48109 United States
| | - Kaku So-Armah
- General Internal Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118 United States
| | - Jeffrey H Samet
- General Internal Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02118 United States
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118 United States
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31
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Mathur R, Hui Q, Huang Y, Gwinn M, So-Armah K, Freiberg MS, Justice AC, Xu K, Marconi VC, Sun YV. DNA Methylation Markers of Type 2 Diabetes Mellitus Among Male Veterans With or Without Human Immunodeficiency Virus Infection. J Infect Dis 2020; 219:1959-1962. [PMID: 30649532 DOI: 10.1093/infdis/jiz023] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 08/22/2018] [Accepted: 01/10/2019] [Indexed: 12/20/2022] Open
Abstract
Epigenetic modifications such as DNA methylation are associated with both human immunodeficiency virus (HIV) infection and type 2 diabetes mellitus (T2DM). We investigated epigenetic associations with T2DM according to HIV infection status and assessed interaction effects among 681 male participants of the Veterans Aging Cohort Study. Methylation at previously reported sites, cg1963031 (TXNIP), cg18181703 (SOCS3), and cg09152259 (PROC), was significantly associated with T2DM in HIV-infected individuals. We identified 3 novel associations with suggestive statistical significance: cg1231141 (ADAMTS2), cg19534769 (HGFAC), and cg13163919 (TLE3). Suggestive interaction with HIV infection status was found at cg17862404 (TSC22D1). The implicated genes are involved in inflammation, pancreatic β-cell function, and T2DM pathogenesis.
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Affiliation(s)
- Raina Mathur
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta
| | - Qin Hui
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta
| | - Yunfeng Huang
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta
| | - Marta Gwinn
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta
| | - Kaku So-Armah
- Department Global Health, Emory University Rollins School of Public Health, Atlanta
| | - Matthew S Freiberg
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta
| | - Amy C Justice
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta.,Atlanta Veterans Affairs Medical Center, Georgia
| | - Ke Xu
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta.,Boston University School of Medicine, Massachusetts
| | - Vincent C Marconi
- Cardiovascular Medicine Division, Vanderbilt University School of Medicine and Tennessee Valley Healthcare System, Nashville.,Connecticut Veteran Health System, West Haven.,Department of Psychiatry, New Haven, Connecticut
| | - Yan V Sun
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta.,Cardiovascular Medicine Division, Vanderbilt University School of Medicine and Tennessee Valley Healthcare System, Nashville.,Yale School of Medicine, New Haven, Connecticut
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32
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So-Armah K, Freiberg M, Cheng D, Lim JK, Gnatienko N, Patts G, Doyle M, Fuster D, Lioznov D, Krupitsky E, Samet J. Liver fibrosis and accelerated immune dysfunction (immunosenescence) among HIV-infected Russians with heavy alcohol consumption - an observational cross-sectional study. BMC Gastroenterol 2019; 20:1. [PMID: 31892306 PMCID: PMC6938606 DOI: 10.1186/s12876-019-1136-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 12/05/2019] [Indexed: 12/23/2022] Open
Abstract
Background The multifactorial mechanisms driving negative health outcomes among risky drinkers with HIV may include immunosenescence. Immunosenescence, aging of the immune system, may be accentuated in HIV and leads to poor outcomes. The liver regulates innate immunity and adaptive immune tolerance. HIV-infected people have high prevalence of liver-related comorbidities. We hypothesize that advanced liver fibrosis/cirrhosis is associated with alterations in T-cell subsets consistent with immunosenescence. Methods ART-naïve people with HIV with a recent history of heavy drinking were recruited into a clinical trial of zinc supplementation. Flow cytometry was used to characterize T-cell subsets. The two primary dependent variables were CD8+ and CD4+ T-cells expressing CD28-CD57+ (senescent cell phenotype). Secondary dependent variables were CD8+ and CD4+ T-cells expressing CD45RO + CD45RA- (memory phenotype), CD45RO-CD45RA+ (naïve phenotype), and the naïve phenotype to memory phenotype T-cell ratio (lower ratios associated with immunosenescence). Advanced liver fibrosis/cirrhosis was defined as FIB-4 > 3.25, APRI≥1.5, or Fibroscan measurement ≥10.5 kPa. Analyses were conducted using multiple linear regression adjusted for potential confounders. Results Mean age was 34 years; 25% female; 88% hepatitis C. Those with advanced liver fibrosis/cirrhosis (N = 25) had higher HIV-1 RNA and more hepatitis C. Advanced liver fibrosis/cirrhosis was not significantly associated with primary or secondary outcomes in adjusted analyses. Conclusions Advanced liver fibrosis/cirrhosis was not significantly associated with these senescent T-cell phenotypes in this exploratory study of recent drinkers with HIV. Future studies should assess whether liver fibrosis among those with HIV viral suppression and more advanced, longstanding liver disease is associated with changes in these and other potentially senescent T-cell subsets.
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Affiliation(s)
- Kaku So-Armah
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown Building, 2nd Floor, Boston, MA, 02118, USA.
| | - Matthew Freiberg
- Department of Medicine, Vanderbilt University School of Medicine; Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Debbie Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Joseph K Lim
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Gregory Patts
- Department of Biostatistics and Data Coordinating Center, Boston University School of Public Health, Boston, MA, USA
| | - Margaret Doyle
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT, USA
| | - Daniel Fuster
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Dmitry Lioznov
- Department of Infectious Diseases and Epidemiology, Smorodintsev Research Institute of Influenza, First Pavlov State Medical University, St. Petersburg, Russia
| | - Evgeny Krupitsky
- First Pavlov State Medical University, V. M. Bekhterev National Research Medical Center for Psychiatry and Neurology, St. Petersburg, Russia
| | - Jeffrey Samet
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
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Bailin S, McGinnis K, McDonnell WJ, So-Armah K, Wellons M, Doyle M, Mallal S, Justice A, Freiberg M, Koethe J. 343. T-cell Subsets Associated with Diabetes in Veterans with and without HIV. Open Forum Infect Dis 2019. [PMCID: PMC6810455 DOI: 10.1093/ofid/ofz360.416] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Depletion of naïve CD4+ T cells and elevated adaptive immune activation are hallmarks of HIV infection. Higher proportions of memory CD4+ T cells are associated with prevalent diabetes in the general population, but few studies of persons with HIV (PWH) exist.
Methods
We analyzed data from 1532 PWH and 836 uninfected veterans in the longitudinal Veterans Aging Cohort Study (VACS), which archived peripheral mononuclear cells from these veterans between 2005 and 2007. We used flow cytometry to phenotype CD4+ and CD8+ T cells, including naïve, activated CD38+, senescent CD57+, total memory, and memory subsets. Prevalent diabetes (at blood collection) was identified in the VA electronic medical record using random glucose, hemoglobin A1c, ICD-9 codes, and medication. Cases were validated by two-physician chart review. We used multivariate logistic regression models adjusted for age, gender, body mass index, race/ethnicity, unhealthy alcohol use, hepatitis C, CMV status, and viral suppression stratified by HIV status to identify T-cell subsets associated with diabetes in PWH and uninfected.
Results
The cohort was 95% male, 68% African-American, and 22% diabetic. Higher CD4+CD45RO+ memory T cells were associated with prevalent diabetes in the uninfected and in PWH (P = 0.03 and P = 0.07, respectively; Figure A). Among subsets, diabetes was associated with higher transitional memory CD4+ T cells in the uninfected (P = 0.01), but higher central memory cells (P = 0.02) and lower effector memory cells (P = 0.04) in PWH. T effector memory RA+ cells were not associated with diabetes. Lower senescent CD4+CD57+ T cells were associated with diabetes in both PWH and uninfected (P = 0.03 and P = 0.04, respectively; Figure B), but results for naïve CD8+ T cells diverged: diabetes was associated with higher naïve CD8+cells in PWH but lower in uninfected (P = 0.01 and P < 0.01, respectively; Figure C). We assessed interaction by HIV status in a pooled model, which was only significant for the naïve CD8+ T cells (P = 0.01).
Conclusion
The adaptive immune profile associated with prevalent diabetes was similar by HIV status and characterized by a shift in CD4+ T cells from senescent to memory phenotypes, suggesting that chronic immune activation contributes to the higher risk of diabetes in PWH.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
- Samuel Bailin
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Kaku So-Armah
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Simon Mallal
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy Justice
- Yale School of Medicine, West Haven, Connecticut
| | | | - John Koethe
- Vanderbilt University Medical Center, Nashville, Tennessee
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Abstract
PURPOSE OF REVIEW The objective of this review is to provide an update on the link between HIV infection and cardiovascular disease (CVD). We will focus our review mainly on literature describing clinical CVD events and understudied topics of importance. RECENT FINDINGS Heart failure, peripheral artery disease, and stroke are CVD modalities deserving more attention in the context of HIV infection in the highly active antiretroviral therapy era. Incidence data on clinical CVD from HIV populations in low- and middle-income countries are limited. Multisubstance use is common in HIV, but understudied as a moderator or mediator of the association between HIV and CVD. CVD risk assessment in HIV remains challenging, but new research into novel biomarkers may provide further insights. There is also a need for inclusion of non-biologic factors in our attempts to understand, quantify, and predict CVD risk among PLWHA. Significant attention has been paid to generating and testing hypotheses to understand the mechanisms of myocardial infarction in HIV. Similar attention is deserving for heart failure, PAD, stroke, and cardiovascular disease risk in resource-limited settings and among substance users with HIV.
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Affiliation(s)
- Kaku So-Armah
- School of Medicine, Boston University, Boston, MA, USA.
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Torgersen J, So-Armah K, Freiberg MS, Goetz MB, Budoff MJ, Lim JK, Taddei T, Butt AA, Rodriguez-Barradas MC, Justice AC, Kostman JR, Lo Re V. Comparison of the prevalence, severity, and risk factors for hepatic steatosis in HIV-infected and uninfected people. BMC Gastroenterol 2019; 19:52. [PMID: 30987601 PMCID: PMC6466708 DOI: 10.1186/s12876-019-0969-1] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 03/28/2019] [Indexed: 12/26/2022] Open
Abstract
Background Hepatic steatosis is prevalent in Western countries, but few studies have evaluated whether the frequency and severity of steatosis are greater in the setting of HIV infection. We compared the prevalence and severity of hepatic steatosis between HIV-infected (HIV+) and uninfected persons and identified factors associated with greater steatosis severity within both groups. Methods We performed a cross-sectional study among participants without cardiovascular disease who participated in a substudy of the Veterans Aging Cohort Study. Hepatic steatosis was defined by noncontrast computed tomography (CT) liver-to-spleen (L/S) attenuation ratio < 1.0. Multivariable linear regression was used to: 1) evaluate the association between HIV infection and severity of hepatic steatosis, as measured by absolute liver attenuation, and 2) identify factors associated with greater severity of steatosis, by HIV status. Results Among 268 participants (median age, 55 years; 99% male; 79% black; 23% obese; 64% HIV+ [91% on antiretroviral therapy]), the overall prevalence of steatosis was 7.8% and was similar between HIV+ and uninfected individuals (13 [7.6%] versus 8 [8.2%], respectively; p = 0.85). Participants with HIV, the majority of whom received antiretroviral therapy, had a higher mean absolute liver attenuation (mean difference, 5.68 Hounsfield units; p < 0.001), correlating with lesser hepatic steatosis severity, compared to uninfected participants. After adjusting for covariates, only advanced hepatic fibrosis was associated with greater severity of steatosis in HIV+ persons (p = 0.03) and uninfected individuals (p < 0.001). Conclusions In this sample of participants without cardiovascular disease, the prevalence of hepatic steatosis by noncontrast abdominal CT was not different by HIV status. Increasing severity of steatosis was independently associated with advanced hepatic fibrosis in both groups. Electronic supplementary material The online version of this article (10.1186/s12876-019-0969-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jessie Torgersen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3910 Powelton Ave 4nd Floor, Ste. 411F, Philadelphia, PA, 19104, USA.
| | - Kaku So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Matthew B Goetz
- Department of Medicine, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Matthew J Budoff
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph K Lim
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tamar Taddei
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA, and VA Connecticut Healthcare, West Haven, CT, USA
| | - Adeel A Butt
- Department of Medicine, Weill Cornell Medical College, Ar-Rayyan, Qatar
| | | | - Amy C Justice
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA, and VA Connecticut Healthcare, West Haven, CT, USA
| | - Jay R Kostman
- John Bell Health Center, Philadelphia FIGHT, Philadelphia, PA, USA
| | - Vincent Lo Re
- Department of Medicine and Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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So-Armah K, Gupta SK, Kundu S, Stewart JC, Goulet JL, Butt AA, Sico JJ, Marconi VC, Crystal S, Rodriguez-Barradas MC, Budoff M, Gibert CL, Chang CC, Bedimo R, Freiberg MS. Depression and all-cause mortality risk in HIV-infected and HIV-uninfected US veterans: a cohort study. HIV Med 2019; 20:317-329. [PMID: 30924577 DOI: 10.1111/hiv.12726] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The contribution of depression to mortality in adults with and without HIV infection is unclear. We hypothesized that depression increases mortality risk and that this association is stronger among those with HIV infection. METHODS Veterans Aging Cohort Study (VACS) data were analysed from the first clinic visit on or after 1 April 2003 (baseline) to 30 September 2015. Depression definitions were: (1) major depressive disorder defined using International Classification of Diseases, Ninth Revision (ICD-9) codes; (2) depressive symptoms defined as Patient Health Questionnaire (PHQ)-9 scores ≥ 10. The outcome was all-cause mortality. Covariates were demographics, comorbid conditions and health behaviours. RESULTS Among 129 140 eligible participants, 30% had HIV infection, 16% had a major depressive disorder diagnosis, and 24% died over a median follow-up time of 11 years. The death rate was 25.3 [95% confidence interval (CI) 25.0-25.6] deaths per 1000 person-years. Major depressive disorder was associated with mortality [hazard ratio (HR) 1.04; 95% CI 1.01, 1.07]. This association was modified by HIV status (interaction P-value = 0.02). In HIV-stratified analyses, depression was significantly associated with mortality among HIV-uninfected veterans but not among those with HIV infection. Among those with PHQ-9 data (n = 7372), 50% had HIV infection, 22% had PHQ-9 scores ≥ 10, and 28% died over a median follow-up time of 12 years. The death rate was 27.3 (95% CI 26.1-28.5) per 1000 person-years. Depressive symptoms were associated with mortality (HR 1.16; 95% CI 1.04, 1.28). This association was modified by HIV status (interaction P-value = 0.05). In HIV-stratified analyses, depressive symptoms were significantly associated with mortality among veterans with HIV infection but not among those without HIV infection. CONCLUSIONS Depression was associated with all-cause mortality. This association was modified by HIV status and method of depression ascertainment.
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Affiliation(s)
- K So-Armah
- Boston University School of Medicine, Boston, MA, USA
| | - S K Gupta
- Indiana University School of Medicine, Indianapolis (IUPUI), Indianapolis, IN, USA
| | - S Kundu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - J C Stewart
- Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - J L Goulet
- VA Connecticut Healthcare System, West Haven, CT, USA.,Yale University School of Medicine, New Haven, CT, USA
| | - A A Butt
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Weill Cornell Medical College, New York, NY, USA.,Weill Cornell Medical College, Doha, Qatar.,Hamad Medical Corporation, Doha, Qatar
| | - J J Sico
- VA Connecticut Healthcare System, West Haven, CT, USA.,Yale University School of Medicine, New Haven, CT, USA
| | - V C Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta VA Medical Center, Atlanta, GA, USA
| | - S Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, New Brunswick, NJ, USA
| | - M C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VAMC, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - M Budoff
- Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles (UCLA), Torrance, CA, USA
| | - C L Gibert
- Washington DC Veterans Affairs Medical Center and George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - C-Ch Chang
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - R Bedimo
- VA North Texas Health Care System, Dallas, TX, USA
| | - M S Freiberg
- VA Tennessee Valley Healthcare System, Vanderbilt University School of Medicine, Nashville, TN, USA
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37
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Colbert RW, Kundu S, Duncan MS, So-Armah K, Freiberg MS. MORTALITY RISK AFTER HEART FAILURE DIAGNOSIS IN HIV PATIENTS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31399-3] [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: 11/16/2022]
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38
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Barocas J, So-Armah K, Cheng D, Lioznov D, Baum M, Gallagher K, Fuster D, Gnatienko N, Krupitsky E, Freiberg M, Samet J. 2232. Zinc deficiency and advanced liver fibrosis among HIV/HCV co-infected persons in Russia. Open Forum Infect Dis 2018. [PMCID: PMC6252516 DOI: 10.1093/ofid/ofy210.1885] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Affiliation(s)
- Joshua Barocas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Kaku So-Armah
- School of Public Health, Boston University, Boston, Massachusetts
| | - Debbie Cheng
- Boston University School of Public Health, Boston, Massachusetts
| | - Dmitry Lioznov
- First Pavlov State Medical University, St. Petersburg, Russian Federation
| | - Marianna Baum
- Florida International University, Robert Stempel College of Public Health and Social Work, Miami, Florida
| | - Kerrin Gallagher
- Boston University School of Public Health, Boston, Massachusetts
| | - Daniel Fuster
- Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | | | - Evgeny Krupitsky
- First St. Petersburg Pavlov State Medical University, St. Petersburg, Russian Federation
| | - Matthew Freiberg
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
| | - Jeffrey Samet
- Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts
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39
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Marconi VC, Duncan MS, So-Armah K, Re VL, Lim JK, Butt AA, Goetz MB, Rodriguez-Barradas MC, Alcorn CW, Lennox J, Beckman JA, Justice A, Freiberg M. Bilirubin Is Inversely Associated With Cardiovascular Disease Among HIV-Positive and HIV-Negative Individuals in VACS (Veterans Aging Cohort Study). J Am Heart Assoc 2018; 7:JAHA.117.007792. [PMID: 29720501 PMCID: PMC6015337 DOI: 10.1161/jaha.117.007792] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [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] [Indexed: 11/26/2022]
Abstract
Background Bilirubin may protect against cardiovascular disease (CVD) by reducing oxidative stress. Whether elevated bilirubin reduces the risk of CVD events among HIV+ individuals and if this differs from uninfected individuals remain unclear. We assessed whether bilirubin independently predicted the risk of CVD events among HIV+ and uninfected participants in VACS (Veterans Aging Cohort Study). Methods and Results We conducted a prospective cohort study using VACS participants free of baseline CVD. Total bilirubin was categorized by quartiles. CVD as well as acute myocardial infarction, heart failure, and ischemic stroke events were assessed. Cox regression was used to evaluate hazard ratios of outcomes associated with quartiles of total bilirubin in HIV+ and uninfected people after adjusting for multiple risk factors. There were 96 381 participants (30 427 HIV+); mean age was 48 years, 48% were black, and 97% were men. There were 6603 total incident CVD events over a mean of 5.7 years. In adjusted models, increasing quartiles of baseline total bilirubin were associated with decreased hazards of all outcomes (hazard ratio, 0.86; 95% confidence interval, 0.80–0.91). Among HIV+ participants, results persisted for heart failure, ischemic stroke, and total CVD, but nonsignificant associations were observed for acute myocardial infarction. Conclusions VACS participants (regardless of HIV status) with elevated bilirubin levels had a lower risk of incident total CVD, acute myocardial infarction, heart failure, and ischemic stroke events after adjusting for known risk factors. Future studies should investigate how this apparently protective effect of elevated bilirubin could be harnessed to reduce CVD risk or improve risk estimation among HIV+ individuals.
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Affiliation(s)
- Vincent C Marconi
- Atlanta VA Medical Center, Atlanta, GA
- Emory University School of Medicine, Atlanta, GA
- Emory University Rollins School of Public Health, Atlanta, GA
| | - Meredith S Duncan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Vincent Lo Re
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Joseph K Lim
- Yale University School of Medicine, New Haven, CT
| | - Adeel A Butt
- Weill Cornell Medical College, Mars, PA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Charles W Alcorn
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | | | - Joshua A Beckman
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | - Amy Justice
- Yale University School of Medicine, New Haven, CT
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Matthew Freiberg
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
- Tennessee Valley Health Care System Nashville VA, Nashville, TN
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40
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Sico JJ, Kundu S, So-Armah K, Gupta S, Chang J, Freiberg M, Stewart J. Abstract 111: Depression as a Risk Factor for Incident Ischemic Stroke Among HIV-infected Veterans. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.111] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
HIV infection (HIV+) and major depressive disorder (MDD) are each associated with an increased risk of ischemic stroke. While depressive disorders are common among HIV+ people, it is not known if MDD is a risk factor for ischemic stroke in the HIV population.
Methods and Results:
We analyzed data on 106,363 (33,544 HIV+; 72,819 HIV-) participants who were free of baseline cardiovascular disease from the Veterans Aging Cohort Study, an observational cohort of HIV+ and matched uninfected veterans in care from April 1
st
, 2003 through September 30, 2012. International Classification of Diseases, Ninth Revision codes from medical records were used to determine baseline MDD and the primary outcome, incident ischemic stroke. The prevalence of MDD was similar for HIV+ and HIV- veterans (20.0% and 18.8%, respectively). After a median of 9.2 years of follow-up, stroke rates per 1000 person-years were highest among HIV+/MDD+ veterans (5.8; 95% CI:5.2-6.5), followed by HIV+/MDD- veterans (5.3; 95% CI:5.0-5.6), HIV-/MDD+ (5.1; 95% CI: 4.7-5.5), and HIV-/MDD- (4.8; 95% CI: 4.6-5.0). In Cox proportional hazard models, MDD was associated with an increased risk of ischemic stroke for both HIV+ and HIV- veterans, even after adjusting for sociodemographic adjusting for sociodemographic characteristics and cerebrovascular risk factors (Table). The risk persisted among HIV+ people after further adjusting for HIV factors (Table). These associations were modestly attenuated with the addition of cocaine and alcohol abuse/dependence.
Conclusions:
In the VACS, MDD was associated with an increased risk of ischemic stroke in HIV+ veterans after adjustment for sociodemographic characteristics, traditional cerebrovascular risk factors, and HIV factors; however, this association was modestly attenuated after adjustment for cocaine and alcohol abuse/dependence. Future research is necessary to: (a) fully elucidate the relationships among MDD, cocaine/alcohol use, and stroke risk and (b) determine whether intervening on MDD reduces stroke risk in HIV+ and HIV- people. Clinical providers should be aware of the increased stroke risk among HIV+ adults with MDD.
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Affiliation(s)
| | | | | | - Samir Gupta
- Indiana Univ Sch of Medicine, Indianapolis, IN
| | - Joyce Chang
- Univ of Pittsburgh Sch of Medicine, Pittsburgh, PA
| | - Matthew Freiberg
- Vanderbilt Cntr for Clinical Cardiovascular Outcomes Rsch and Trials Evaluation, Nashville, TN
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41
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Beckman JA, Duncan MS, Alcorn CW, So-Armah K, Butt AA, Goetz MB, Tindle HA, Sico JJ, Tracy RP, Justice AC, Freiberg MS. Association of Human Immunodeficiency Virus Infection and Risk of Peripheral Artery Disease. Circulation 2018. [PMID: 29535090 DOI: 10.1161/circulationaha.117.032647] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The effect of human immunodeficiency virus (HIV) on the development of peripheral artery disease (PAD) remains unclear. We investigated whether HIV infection is associated with an increased risk of PAD after adjustment for traditional atherosclerotic risk factors in a large cohort of HIV-infected (HIV+) and demographically similar HIV-uninfected veterans. METHODS We studied participants in the Veterans Aging Cohort Study from April 1, 2003 through December 31, 2014. We excluded participants with known prior PAD or prevalent cardiovascular disease (myocardial infarction, stroke, coronary heart disease, and congestive heart failure) and analyzed the effect of HIV status on the risk of incident PAD events after adjusting for demographics, PAD risk factors, substance use, CD4 cell count, HIV-1 ribonucleic acid, and antiretroviral therapy. The primary outcome is incident peripheral artery disease events. Secondary outcomes include mortality and amputation in subjects with incident PAD events by HIV infection status, viral load, and CD4 count. RESULTS Among 91 953 participants, over a median follow up of 9.0 years, there were 7708 incident PAD events. Rates of incident PAD events per 1000 person-years were higher among HIV+ (11.9; 95% confidence interval [CI], 11.5-12.4) than uninfected veterans (9.9; 95% CI, 9.6-10.1). After adjustment for demographics, PAD risk factors, and other covariates, HIV+ veterans had an increased risk of incident PAD events compared with uninfected veterans (hazard ratio [HR], 1.19; 95% CI, 1.13-1.25). This risk was highest among those with time-updated HIV viral load >500 copies/mL (HR, 1.51; 95% CI, 1.38-1.65) and CD4 cell counts <200 cells/mm3 (HR, 1.91; 95% CI, 1.71-2.13). In contrast, HIV+ veterans with time updated CD4 cell count ≥500 cells/mm3 had no increased risk of PAD (HR, 1.03; 95% CI, 0.96-1.11). Mortality rates after incident PAD events are high regardless of HIV status. HIV infection did not affect rates of amputation after incident PAD events. CONCLUSIONS Infection with HIV is associated with a 19% increased risk of PAD beyond that explained by traditional atherosclerotic risk factors. However, for those with sustained CD4 cell counts <200 cells/mm3, the risk of incident PAD events is nearly 2-fold higher whereas for those with sustained CD4 cell counts ≥500 cells/mm3 there is no excess risk of incident PAD events compared with uninfected people.
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Affiliation(s)
- Joshua A Beckman
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.A.B., M.S.D., M.S.F.).
| | - Meredith S Duncan
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.A.B., M.S.D., M.S.F.)
| | - Charles W Alcorn
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA (C.W.A.)
| | - Kaku So-Armah
- Section of General Internal Medicine, Boston University School of Medicine, MA (K.S.-A.)
| | - Adeel A Butt
- Department of Medicine, Weill Cornell Medical College, New York, NY (A.A.B.).,Veterans Association Pittsburgh Healthcare System, PA (A.A.B.)
| | - Matthew Bidwell Goetz
- Department of Medicine, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California (M.B.G.)
| | - Hilary A Tindle
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN (H.A.T.).,Geriatric Research Education and Clinical Centers, Veterans Affairs Tennessee Valley Healthcare System, Nashville (H.A.T., M.S.F.)
| | - Jason J Sico
- Veterans Affairs Connecticut Health Care System, West Haven Veterans Administration Medical Center (J.J.S, A.C.J.)
| | - Russel P Tracy
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Burlington (R.P.T.)
| | - Amy C Justice
- Veterans Affairs Connecticut Health Care System, West Haven Veterans Administration Medical Center (J.J.S, A.C.J.).,Yale University Schools of Medicine and Public Health, New Haven, CT (A.C.J.)
| | - Matthew S Freiberg
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.A.B., M.S.D., M.S.F.).,Geriatric Research Education and Clinical Centers, Veterans Affairs Tennessee Valley Healthcare System, Nashville (H.A.T., M.S.F.)
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Bedimo R, Drechsler H, So-Armah K. Long-term Low-Density Lipoprotein–Cholesterol (LDL-c) Trajectories in Virologically Suppressed HIV Patients: Effect of Liver Fibrosis and Statin Use. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Roger Bedimo
- Medicine, Veterans Affairs North Texas Health Care Systems, University of Texas, Dallas, Texas
| | - Henning Drechsler
- Infectious Diseases, University of Texas Southwestern Medical School, Dallas, Texas
| | - Kaku So-Armah
- School of Public Health, Boston University, Boston, Massachusetts
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43
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Gupta S, So-Armah K, Stewart J, Chang J, Goulet JL, Freiberg M. Depression and HIV Infection Are Associated With Higher Risks of All-Cause Mortality in US Veterans: A Cohort Study. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Samir Gupta
- Medicine/Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kaku So-Armah
- School of Public Health, Boston University, Boston, Massachusetts
| | - Jesse Stewart
- Indiana University–Purdue University Indianapolis, Indianapolis, Indiana
| | - Joyce Chang
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph L. Goulet
- Psychiatry, Yale School of Medicine/Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Matthew Freiberg
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
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Cannon AR, Morris NL, Hammer AM, Curtis B, Remick DG, Yeligar SM, Poole L, Burnham EL, Wyatt TA, Molina PE, So-Armah K, Cisneros T, Wang G, Lang CH, Mandrekar P, Kovacs EJ, Choudhry MA. Alcohol and inflammatory responses: Highlights of the 2015 Alcohol and Immunology Research Interest Group (AIRIG) meeting. Alcohol 2016; 54:73-7. [PMID: 27522326 DOI: 10.1016/j.alcohol.2016.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 06/24/2016] [Indexed: 01/04/2023]
Abstract
On September 27, 2015 the 20th annual Alcohol and Immunology Research Interest Group (AIRIG) meeting was held as a satellite symposium at the annual meeting of the Society for Leukocyte Biology in Raleigh, NC. The 2015 meeting focused broadly on adverse effects of alcohol and alcohol-use disorders in multiple organ systems. Divided into two plenary sessions, AIRIG opened with the topic of pulmonary inflammation as a result of alcohol consumption, which was followed by alcohol's effect on multiple organs, including the brain and liver. With presentations showing the diverse range of underlying pathology and mechanisms associated with multiple organs as a result of alcohol consumption, AIRIG emphasized the importance of continued alcohol research, as its detrimental consequences are not limited to one or even two organs, but rather extend to the entire host as a whole.
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Freiberg MS, Bebu I, Tracy R, So-Armah K, Okulicz J, Ganesan A, Armstrong A, O’Bryan T, Rimland D, Justice AC, Agan BK. D-Dimer Levels before HIV Seroconversion Remain Elevated Even after Viral Suppression and Are Associated with an Increased Risk of Non-AIDS Events. PLoS One 2016; 11:e0152588. [PMID: 27088215 PMCID: PMC4835105 DOI: 10.1371/journal.pone.0152588] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [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: 02/05/2016] [Accepted: 03/16/2016] [Indexed: 01/04/2023] Open
Abstract
The mechanism underlying the excess risk of non-AIDS diseases among HIV infected people is unclear. HIV associated inflammation/hypercoagulability likely plays a role. While antiretroviral therapy (ART) may return this process to pre-HIV levels, this has not been directly demonstrated. We analyzed data/specimens on 249 HIV+ participants from the US Military HIV Natural History Study, a prospective, multicenter observational cohort of >5600 active duty military personnel and beneficiaries living with HIV. We used stored blood specimens to measure D-dimer and Interleukin-6 (IL-6) at three time points: pre-HIV seroconversion, ≥6 months post-HIV seroconversion but prior to ART initiation, and ≥6 months post-ART with documented HIV viral suppression on two successive evaluations. We evaluated the changes in biomarker levels between time points, and the association between these biomarker changes and future non-AIDS events. During a median follow-up of 3.7 years, there were 28 incident non-AIDS diseases. At ART initiation, the median CD4 count was 361cells/mm3; median duration of documented HIV infection 392 days; median time on ART was 354 days. Adjusted mean percent increase in D-dimer levels from pre-seroconversion to post-ART was 75.1% (95% confidence interval 24.6–148.0, p = 0.002). This increase in D-dimer was associated with a significant 22% increase risk of future non-AIDS events (p = 0.03). Changes in IL-6 levels across time points were small and not associated with future non-AIDS events. In conclusion, ART initiation and HIV viral suppression does not eliminate HIV associated elevation in D-dimer levels. This residual pathology is associated with an increased risk of future non-AIDS diseases.
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Affiliation(s)
- Matthew S. Freiberg
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine and Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America
- * E-mail:
| | - Ionut Bebu
- The Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Rockville, MD, United States of America
| | - Russell Tracy
- Department of Pathology, University of Vermont College of Medicine, Burlington, VT, United States of America
| | - Kaku So-Armah
- Division of General Internal Medicine, Boston University, Boston, MA, United States of America
| | - Jason Okulicz
- Infectious Disease Clinical Research Program (IDCRP), Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
- Infectious Disease Service, San Antonio Military Medical Center, San Antonio, TX, United States of America
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program (IDCRP), Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
- Infectious Disease Clinic, Walter Reed National Military Medical Center, Bethesda, MD, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States of America
| | - Adam Armstrong
- Infectious Disease Clinical Research Program (IDCRP), Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
- U.S. Naval Medical Research Unit No. 6 Peru, Lima, Peru
| | - Thomas O’Bryan
- Infectious Disease Clinical Research Program (IDCRP), Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
- Infectious Disease Service, San Antonio Military Medical Center, San Antonio, TX, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States of America
| | - David Rimland
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine and VA Medical Center, Atlanta, Georgia, United States of America
| | - Amy C. Justice
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, and VA Connecticut Healthcare System West Haven affiliation, New Haven, CT, United States of America
| | - Brian K. Agan
- Infectious Disease Clinical Research Program (IDCRP), Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States of America
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Affiliation(s)
- Matthew S Freiberg
- Vanderbilt University Medical Center, VA Tennessee Valley Health Care System, Nashville, TN Geriatric Research Education and Clinical Care Service, VA Tennessee Valley Health Care System, Nashville, TN
| | - Kaku So-Armah
- Vanderbilt University Medical Center, VA Tennessee Valley Health Care System, Nashville, TN Geriatric Research Education and Clinical Care Service, VA Tennessee Valley Health Care System, Nashville, TN
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Feinstein MJ, Bahiru E, Achenbach C, Longenecker CT, Hsue P, So-Armah K, Freiberg MS, Lloyd-Jones DM. Patterns of Cardiovascular Mortality for HIV-Infected Adults in the United States: 1999 to 2013. Am J Cardiol 2016; 117:214-20. [PMID: 26639041 DOI: 10.1016/j.amjcard.2015.10.030] [Citation(s) in RCA: 218] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/22/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
Abstract
With widespread availability and the use of antiretroviral therapy, patients with human immunodeficiency virus (HIV) in the United States are living long enough to experience non-AIDS-defining illnesses. HIV is associated with an increased risk for cardiovascular disease (CVD) because of traditional CVD risk factors, residual virally mediated inflammation despite HIV treatment, and side effects of antiretroviral therapy. No United States population-wide studies have evaluated patterns of CVD mortality for HIV-infected subjects. Our central hypothesis was that the proportionate mortality from CVD (CVD mortality/total mortality) in the HIV-infected population increased from 1999 to 2013. We used the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research online database of the United States public health data to assess proportionate CVD mortality from 1999 to 2013 in the HIV-infected, general, and inflammatory polyarthropathy populations; the inflammatory polyarthropathy population was included as a positive control group. Total mortality in the HIV-infected population decreased from 15,739 in 1999 to 8,660 in 2013; however, CVD mortality increased from 307 to 400 during the same period. Thus, proportionate CVD mortality for the HIV-infected population increased significantly from 1999 to 2013 (p <0.0001); this pattern was consistent across races, particularly for men. In contrast, proportionate CVD mortality decreased for the general and inflammatory polyarthropathy populations from 1999 to 2013. In conclusion, CVD has become an increasingly common cause of death in HIV-infected subjects since 1999; understanding evolving mortality risks in the HIV-infected population is essential to inform routine clinical care of HIV-infected subjects as well as CVD prevention and treatment.
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O'bryan T, Freiberg M, Tracy R, So-Armah K, Okulicz J, Ganesan A, Lalani T, Armstrong A, Rimland D, Deiss R, Agan B. Racial Comparison of D-Dimer Levels in Adults Before and After HIV Infection. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sico JJ, Chang CCH, So-Armah K, Justice AC, Hylek E, Skanderson M, McGinnis K, Kuller LH, Kraemer KL, Rimland D, Bidwell Goetz M, Butt AA, Rodriguez-Barradas MC, Gibert C, Leaf D, Brown ST, Samet J, Kazis L, Bryant K, Freiberg MS. HIV status and the risk of ischemic stroke among men. Neurology 2015; 84:1933-40. [PMID: 25862803 DOI: 10.1212/wnl.0000000000001560] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 01/29/2015] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Given conflicting data regarding the association of HIV infection and ischemic stroke risk, we sought to determine whether HIV infection conferred an increased ischemic stroke risk among male veterans. METHODS The Veterans Aging Cohort Study-Virtual Cohort consists of HIV-infected and uninfected veterans in care matched (1:2) for age, sex, race/ethnicity, and clinical site. We analyzed data on 76,835 male participants in the Veterans Aging Cohort Study-Virtual Cohort who were free of baseline cardiovascular disease. We assessed demographics, ischemic stroke risk factors, comorbid diseases, substance use, HIV biomarkers, and incidence of ischemic stroke from October 1, 2003, to December 31, 2009. RESULTS During a median follow-up period of 5.9 (interquartile range 3.5-6.6) years, there were 910 stroke events (37.4% HIV-infected). Ischemic stroke rates per 1,000 person-years were higher for HIV-infected (2.79, 95% confidence interval 2.51-3.10) than for uninfected veterans (2.24 [2.06-2.43]) (incidence rate ratio 1.25 [1.09-1.43]; p < 0.01). After adjusting for demographics, ischemic stroke risk factors, comorbid diseases, and substance use, the risk of ischemic stroke was higher among male veterans with HIV infection compared with uninfected veterans (hazard ratio 1.17 [1.01-1.36]; p = 0.04). CONCLUSIONS HIV infection is associated with an increased ischemic stroke risk among HIV-infected compared with demographically and behaviorally similar uninfected male veterans.
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Affiliation(s)
- Jason J Sico
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN.
| | - Chung-Chou H Chang
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Kaku So-Armah
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Amy C Justice
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Elaine Hylek
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Melissa Skanderson
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Kathleen McGinnis
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Lewis H Kuller
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Kevin L Kraemer
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - David Rimland
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Matthew Bidwell Goetz
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Adeel A Butt
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Maria C Rodriguez-Barradas
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Cynthia Gibert
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - David Leaf
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Sheldon T Brown
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Jeffrey Samet
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Lewis Kazis
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Kendall Bryant
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
| | - Matthew S Freiberg
- From the VA Connecticut Health Care System (J.J.S., A.C.J., M.S., K.M.), West Haven Veterans Administration Medical Center, West Haven; Yale University School of Medicine (J.J.S., K.S.-A., A.C.J.), New Haven, CT; University of Pittsburgh School of Medicine (C.-C.H.C., K.L.K., A.A.B.); University of Pittsburgh Graduate School of Public Health (C.-C.H.C., L.H.K.), Pittsburgh, PA; Boston Medical Center (E.H.), MA; Emory University School of Medicine and Atlanta Veterans Administration Medical Center (D.R.), Atlanta, GA; David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Health Care System (M.B.G., D.L.), Los Angeles, CA; VA Pittsburgh Health Care System (A.A.B.), Pittsburgh, PA; Michael E. DeBakey Veterans Administration Medical Center and Baylor College of Medicine (M.C.R.-B.), Houston, TX; Washington DC Veterans Administration Medical Center and George Washington University School of Medicine (C.G.), Washington, DC; James J. Peters VA (S.T.B.), Bronx; Mount Sinai School of Medicine (S.T.B.), New York, NY; Boston University School of Medicine (J.S.), MA; Center for the Assessment of Pharmaceutical Practices (L.K.), Department of Health Policy and Management, Boston University School of Public Health; Center for Healthcare Organization and Implementation Research (L.K.), a Center for Innovation, Veterans Administration Medical Center, Bedford, MA; National Institute on Alcohol Abuse and Alcoholism (K.B.), Bethesda, MD; and Vanderbilt University School of Medicine and the Nashville Veterans Affairs Medical Center (M.S.F.), Nashville, TN
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