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Mezzacappa C, Larki NR, Skanderson M, Park LS, Brandt C, Hauser RG, Justice A, Yang YX, Wang L. Development and Validation of Case-Finding Algorithms to Identify Pancreatic Cancer in the Veterans Health Administration. Dig Dis Sci 2024; 69:1507-1513. [PMID: 38453743 DOI: 10.1007/s10620-024-08324-w] [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: 09/12/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Survival in pancreatic ductal adenocarcinoma (PDAC) remains poor due to late diagnosis. Electronic Health Records (EHRs) can be used to study this rare disease, but validated algorithms to identify PDAC in the United States EHRs do not currently exist. AIMS To develop and validate an algorithm using Veterans Health Administration (VHA) EHR data for the identification of patients with PDAC. METHODS We developed two algorithms to identify patients with PDAC in the VHA from 2002 to 2023. The algorithms required diagnosis of exocrine pancreatic cancer in either ≥ 1 or ≥ 2 of the following domains: (i) the VA national cancer registry, (ii) an inpatient encounter, or (iii) an outpatient encounter in an oncology setting. Among individuals identified with ≥ 1 of the above criteria, a random sample of 100 were reviewed by three gastroenterologists to adjudicate PDAC status. We also adjudicated fifty patients not qualifying for either algorithm. These patients died as inpatients and had alkaline phosphatase values within the interquartile range of patients who met ≥ 2 of the above criteria for PDAC. These expert adjudications allowed us to calculate the positive and negative predictive value of the algorithms. RESULTS Of 10.8 million individuals, 25,533 met ≥ 1 criteria (PPV 83.0%, kappa statistic 0.93) and 13,693 individuals met ≥ 2 criteria (PPV 95.2%, kappa statistic 1.00). The NPV for PDAC was 100%. CONCLUSIONS An algorithm incorporating readily available EHR data elements to identify patients with PDAC achieved excellent PPV and NPV. This algorithm is likely to enable future epidemiologic studies of PDAC.
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Affiliation(s)
- Catherine Mezzacappa
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Navid Rahimi Larki
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06520, USA
| | | | - Lesley S Park
- Department of Epidemiology and Population Health, Stanford School of Medicine, Stanford, CA, USA
| | - Cynthia Brandt
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Ronald G Hauser
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Amy Justice
- VA Connecticut Healthcare System, West Haven, CT, USA
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- School of Public Health, Yale University, New Haven, CT, USA
| | - Yu-Xiao Yang
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Louise Wang
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06520, USA.
- VA Connecticut Healthcare System, West Haven, CT, USA.
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Leeds IL, Park LS, Akgun K, Weintrob A, Justice AC, King JT. Postoperative Outcomes Associated with the Timing of Surgery After SARS-CoV-2 Infection. Ann Surg 2024:00000658-990000000-00773. [PMID: 38323413 DOI: 10.1097/sla.0000000000006227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVE Examine the association between prior SARS-CoV-2 infection, interval from infection to surgery, and adverse surgical outcomes. SUMMARY BACKGROUND DATA Earlier series have reported worse outcomes for surgery after COVID-19 illness, and these findings have led to routinely deferring surgery seven weeks after infection. METHODS We created a retrospective cohort of patients from US Veterans Health Administration facilities nationwide, April 2020-September 2022, undergoing surgical procedures. Primary outcomes were 90-day all-cause mortality and 30-day complications. Within surgical procedure groupings, SARS-CoV-2 infected and uninfected patients were matched in a 1:4 ratio. We categorized patients by two-week intervals from SARS-CoV-2 positive test to surgery. Hierarchical multilevel multivariable logistic regression models were used to estimate the association between infection to surgery interval versus no infection and primary endpoints. RESULTS We identified 82,815 veterans undergoing eligible operations (33% general, 27% orthopedic, 13% urologic, 9% vascular), of whom 16,563 (20%) had laboratory confirmed SARS-CoV-2 infection prior to surgery. The multivariable models demonstrated an association between prior SARS-CoV-2 infection and increased 90-day mortality (odds ratio (OR) 1.42, 95% CI 1.08, 1.86) and complications (OR 1.32, 95% CI 1.11, 1.57) only for patients having surgery within 14 days of infection. ASA-stratified multivariable models showed that the associations between increased 90-day mortality (OR 1.40, 95% CI 1.12, 1.75) and complications (OR 1.73, 95% CI 1.34, 2.24) for patients having surgery within 14 days of infection were confined to those with ASA 4-5. CONCLUSIONS In a contemporary surgical cohort, patients with prior SARS-CoV-2 infection only had increased post-operative mortality or complications when they had surgery within 14 days after positive test. These findings support revising timing recommendations between surgery and prior SARS-CoV-2 infection.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Yale University School of Medicine, New Haven, CT
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Lesley S Park
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Kathleen Akgun
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Amy Weintrob
- Veterans Affairs Washington DC Healthcare System, Washington, DC
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Department of Medicine, Yale University School of Medicine, New Haven, CT
- Department of Public Policy, School of Public Health, Yale University School of Medicine, New Haven, CT
| | - Joseph T King
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
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Lea AN, Leyden WA, Sofrygin O, Marafino BJ, Skarbinski J, Napravnik S, Agil D, Augenbraun M, Benning L, Horberg MA, Jefferson C, Marconi VC, Park LS, Gordon KS, Bastarache L, Gangireddy S, Althoff KN, Coburn SB, Gebo KA, Lang R, Williams C, Silverberg MJ. Human Immunodeficiency Virus Status, Tenofovir Exposure, and the Risk of Poor Coronavirus Disease 19 Outcomes: Real-World Analysis From 6 United States Cohorts Before Vaccine Rollout. Clin Infect Dis 2023; 76:1727-1734. [PMID: 36861341 PMCID: PMC10209434 DOI: 10.1093/cid/ciad084] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND People with human immunodeficiency virus (HIV) (PWH) may be at increased risk for severe coronavirus disease 2019 (COVID-19) outcomes. We examined HIV status and COVID-19 severity, and whether tenofovir, used by PWH for HIV treatment and people without HIV (PWoH) for HIV prevention, was associated with protection. METHODS Within 6 cohorts of PWH and PWoH in the United States, we compared the 90-day risk of any hospitalization, COVID-19 hospitalization, and mechanical ventilation or death by HIV status and by prior exposure to tenofovir, among those with severe acute respiratory syndrome coronavirus 2 infection between 1 March and 30 November 2020. Adjusted risk ratios (aRRs) were estimated by targeted maximum likelihood estimation, with adjustment for demographics, cohort, smoking, body mass index, Charlson comorbidity index, calendar period of first infection, and CD4 cell counts and HIV RNA levels (in PWH only). RESULTS Among PWH (n = 1785), 15% were hospitalized for COVID-19 and 5% received mechanical ventilation or died, compared with 6% and 2%, respectively, for PWoH (n = 189 351). Outcome prevalence was lower for PWH and PWoH with prior tenofovir use. In adjusted analyses, PWH were at increased risk compared with PWoH for any hospitalization (aRR, 1.31 [95% confidence interval, 1.20-1.44]), COVID-19 hospitalizations (1.29 [1.15-1.45]), and mechanical ventilation or death (1.51 [1.19-1.92]). Prior tenofovir use was associated with reduced hospitalizations among PWH (aRR, 0.85 [95% confidence interval, .73-.99]) and PWoH (0.71 [.62-.81]). CONCLUSIONS Before COVID-19 vaccine availability, PWH were at greater risk for severe outcomes than PWoH. Tenofovir was associated with a significant reduction in clinical events for both PWH and PWoH.
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Affiliation(s)
- Alexandra N Lea
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Wendy A Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Oleg Sofrygin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Ben J Marafino
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Deana Agil
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael Augenbraun
- Division of Infectious Diseases, State University of New York Health Sciences University, Brooklyn, USA
| | - Lorie Benning
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
| | - Celeena Jefferson
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
| | - Vincent C Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Lesley S Park
- Stanford Department of Epidemiology & Population Health, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kirsha S Gordon
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Srushti Gangireddy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sally B Coburn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kelly A Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raynell Lang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carolyn Williams
- Epidemiology Branch, Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Jefferson C, Watson E, Certa JM, Gordon KS, Park LS, D’Souza G, Benning L, Abraham AG, Agil D, Napravnik S, Silverberg MJ, Leyden WA, Skarbinski J, Williams C, Althoff KN, Horberg MA. Differences in COVID-19 testing and adverse outcomes by race, ethnicity, sex, and health system setting in a large diverse US cohort. PLoS One 2022; 17:e0276742. [PMID: 36417366 PMCID: PMC9683575 DOI: 10.1371/journal.pone.0276742] [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: 04/30/2022] [Accepted: 09/08/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Racial/ethnic disparities during the first six months of the COVID-19 pandemic led to differences in COVID-19 testing and adverse outcomes. We examine differences in testing and adverse outcomes by race/ethnicity and sex across a geographically diverse and system-based COVID-19 cohort collaboration. METHODS Observational study among adults (≥18 years) within six US cohorts from March 1, 2020 to August 31, 2020 using data from electronic health record and patient reporting. Race/ethnicity and sex as risk factors were primary exposures, with health system type (integrated health system, academic health system, or interval cohort) as secondary. Proportions measured SARS-CoV-2 testing and positivity; attributed hospitalization and death related to COVID-19. Relative risk ratios (RR) with 95% confidence intervals quantified associations between exposures and main outcomes. RESULTS 5,958,908 patients were included. Hispanic patients had the highest proportions of SARS-CoV-2 testing (16%) and positivity (18%), while Asian/Pacific Islander patients had the lowest portions tested (11%) and White patients had the lowest positivity rates (5%). Men had a lower likelihood of testing (RR = 0.90 [0.89-0.90]) and a higher positivity risk (RR = 1.16 [1.14-1.18]) compared to women. Black patients were more likely to have COVID-19-related hospitalizations (RR = 1.36 [1.28-1.44]) and death (RR = 1.17 [1.03-1.32]) compared with White patients. Men were more likely to be hospitalized (RR = 1.30 [1.16-1.22]) or die (RR = 1.70 [1.53-1.89]) compared to women. These racial/ethnic and sex differences were reflected in both health system types. CONCLUSIONS This study supports evidence of disparities by race/ethnicity and sex during the COVID-19 pandemic that persisted even in healthcare settings with reduced barriers to accessing care. Further research is needed to understand and prevent the drivers that resulted in higher burdens of morbidity among certain Black patients and men.
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Affiliation(s)
- Celeena Jefferson
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Rockville, Maryland, United States of America
| | - Eric Watson
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Rockville, Maryland, United States of America
- * E-mail:
| | - Julia M. Certa
- United Health Group, Fredrick, Maryland, United States of America
| | - Kirsha S. Gordon
- Yale School of Medicine, Department of General Internal Medicine, New Haven, Connecticut, United States of America
- VA Connecticut Healthcare System, West Haven, Connecticut, United States of America
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Gypsyamber D’Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lorie Benning
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Alison G. Abraham
- Department of Epidemiology, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, United States of America
| | - Deana Agil
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael J. Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Wendy A. Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Carolyn Williams
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, United States of America
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michael A. Horberg
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Rockville, Maryland, United States of America
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Lang R, Humes E, Coburn SB, Horberg MA, Fathi LF, Watson E, Jefferson CR, Park LS, Gordon KS, Akgün KM, Justice AC, Napravnik S, Edwards JK, Browne LE, Agil DM, Silverberg MJ, Skarbinski J, Leyden WA, Stewart C, Hogan BC, Gebo KA, Marconi VC, Williams CF, Althoff KN. Analysis of Severe Illness After Postvaccination COVID-19 Breakthrough Among Adults With and Without HIV in the US. JAMA Netw Open 2022; 5:e2236397. [PMID: 36227594 PMCID: PMC9561947 DOI: 10.1001/jamanetworkopen.2022.36397] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Understanding the severity of postvaccination SARS-CoV-2 (ie, COVID-19) breakthrough illness among people with HIV (PWH) can inform vaccine guidelines and risk-reduction recommendations. OBJECTIVE To estimate the rate and risk of severe breakthrough illness among vaccinated PWH and people without HIV (PWoH) who experience a breakthrough infection. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, the Corona-Infectious-Virus Epidemiology Team (CIVET-II) collaboration included adults (aged ≥18 years) with HIV who were receiving care and were fully vaccinated by June 30, 2021, along with PWoH matched according to date fully vaccinated, age group, race, ethnicity, and sex from 4 US integrated health systems and academic centers. Those with postvaccination COVID-19 breakthrough before December 31, 2021, were eligible. EXPOSURES HIV infection. MAIN OUTCOMES AND MEASURES The main outcome was severe COVID-19 breakthrough illness, defined as hospitalization within 28 days after a breakthrough SARS-CoV-2 infection with a primary or secondary COVID-19 discharge diagnosis. Discrete time proportional hazards models estimated adjusted hazard ratios (aHRs) and 95% CIs of severe breakthrough illness within 28 days of breakthrough COVID-19 by HIV status adjusting for demographic variables, COVID-19 vaccine type, and clinical factors. The proportion of patients who received mechanical ventilation or died was compared by HIV status. RESULTS Among 3649 patients with breakthrough COVID-19 (1241 PWH and 2408 PWoH), most were aged 55 years or older (2182 patients [59.8%]) and male (3244 patients [88.9%]). The cumulative incidence of severe illness in the first 28 days was low and comparable between PWoH and PWH (7.3% vs 6.7%; risk difference, -0.67%; 95% CI, -2.58% to 1.23%). The risk of severe breakthrough illness was 59% higher in PWH with CD4 cell counts less than 350 cells/μL compared with PWoH (aHR, 1.59; 95% CI, 0.99 to 2.46; P = .049). In multivariable analyses among PWH, being female, older, having a cancer diagnosis, and lower CD4 cell count were associated with increased risk of severe breakthrough illness, whereas previous COVID-19 was associated with reduced risk. Among 249 hospitalized patients, 24 (9.6%) were mechanically ventilated and 20 (8.0%) died, with no difference by HIV status. CONCLUSIONS AND RELEVANCE In this cohort study, the risk of severe COVID-19 breakthrough illness within 28 days of a breakthrough infection was low among vaccinated PWH and PWoH. PWH with moderate or severe immune suppression had a higher risk of severe breakthrough infection and should be included in groups prioritized for additional vaccine doses and risk-reduction strategies.
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Affiliation(s)
- Raynell Lang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Elizabeth Humes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sally B. Coburn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michael A. Horberg
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Lily F. Fathi
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Eric Watson
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Celeena R. Jefferson
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Palo Alto, California
| | - Kirsha S. Gordon
- VA Connecticut Healthcare System, West Haven
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Kathleen M. Akgün
- VA Connecticut Healthcare System, West Haven
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Amy C. Justice
- VA Connecticut Healthcare System, West Haven
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Sonia Napravnik
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Lindsay E. Browne
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Deana M. Agil
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Infectious Diseases, Oakland Medical Center, Oakland, California
| | - Wendy A. Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Cameron Stewart
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Brenna C. Hogan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kelly A. Gebo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Vincent C. Marconi
- Emory University School of Medicine, Atlanta, Georgia
- Rollins School of Public Health, Atlanta, Georgia
- Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Carolyn F. Williams
- Epidemiology Branch, Division of AIDS at National Institute of Allergy and Infectious Diseases, National Institute of Health, Rockville, Maryland
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Li G, Park LS, Lodi S, Logan RW, Cartwright EJ, Aoun-Barakat L, Casas JP, Dickerman BA, Rentsch CT, Justice AC, Hernán MA. Tenofovir disoproxil fumarate and coronavirus disease 2019 outcomes in men with HIV. AIDS 2022; 36:1689-1696. [PMID: 35848570 PMCID: PMC9444875 DOI: 10.1097/qad.0000000000003314] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare the risk of coronavirus disease 2019 (COVID-19) outcomes by antiretroviral therapy (ART) regimens among men with HIV. DESIGN We included men with HIV on ART in the Veterans Aging Cohort Study who, between February 2020 and October 2021, were 18 years or older and had adequate virological control, CD4 + cell count, and HIV viral load measured in the previous 12 months, and no previous COVID-19 diagnosis or vaccination. METHODS We compared the adjusted risks of documented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, COVID-19-related hospitalization, and intensive care unit (ICU) admission by baseline ART regimen: tenofovir alafenamide (TAF)/emtricitabine (FTC), tenofovir disoproxil fumarate (TDF)/FTC, abacavir (ABC)/lamivudine (3TC), and other. We fit pooled logistic regressions to estimate the 18-month risks standardized by demographic and clinical factors. RESULTS Among 20 494 eligible individuals, the baseline characteristics were similar across regimens, except that TDF/FTC and TAF/FTC had lower prevalences of chronic kidney disease and estimated glomerular filtration rate <60 ml/min. Compared with TAF/FTC, the estimated 18-month risk ratio (95% confidence interval) of documented SARS-CoV-2 infection was 0.65 (0.43, 0.89) for TDF/FTC, 1.00 (0.85, 1.18) for ABC/3TC, and 0.87 (0.70, 1.04) for others. The corresponding risk ratios for COVID-19 hospitalization were 0.43 (0.07, 0.87), 1.09 (0.79, 1.48), and 1.21 (0.88, 1.62). The risk of COVID-19 ICU admission was lowest for TDF/FTC, but the estimates were imprecise. CONCLUSION Our study suggests that, in men living with HIV, TDF/FTC may protect against COVID-19-related events. Randomized trials are needed to investigate the effectiveness of TDF as prophylaxis for, and early treatment of, COVID-19 in the general population.
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Affiliation(s)
- Guilin Li
- CAUSALab
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Sara Lodi
- CAUSALab
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Roger W Logan
- CAUSALab
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Emily J Cartwright
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta
- Atlanta VA Medical Center, North Druid Hills, Georgia
| | - Lydia Aoun-Barakat
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Juan P Casas
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System
- Department of Medicine, Division of Aging, Brigham & Women's Hospital
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Barbra A Dickerman
- CAUSALab
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Christopher T Rentsch
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, US Department of Veterans Affairs, Washington, DC, USA
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy C Justice
- VA Connecticut Healthcare System, US Department of Veterans Affairs, Washington, DC, USA
- Department of Medicine, Yale School of Medicine
- Division of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Miguel A Hernán
- CAUSALab
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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7
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Park LS, McGinnis KA, Gordon KS, Justice AC, Leyden W, Silverberg MJ, Skarbinski J, Jefferson C, Horberg M, Certa J, Napravnik S, Edwards JK, Westreich D, Bastarache L, Gangireddy S, Benning L, D'Souza G, Williams C, Althoff KN. SARS-CoV-2 Testing and Positivity Among Persons With and Without HIV in 6 US Cohorts. J Acquir Immune Defic Syndr 2022; 90:249-255. [PMID: 35195574 PMCID: PMC9203911 DOI: 10.1097/qai.0000000000002943] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 02/11/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is not definitively known if persons with HIV (PWH) are more likely to be SARS-CoV-2 tested or test positive than persons without HIV (PWoH). We describe SARS-CoV-2 testing and positivity in 6 large geographically and demographically diverse cohorts of PWH and PWoH in the United States. SETTING The Corona Infectious Virus Epidemiology Team comprises 5 clinical cohorts within a health system (Kaiser Permanente Northern California, Oakland, CA; Kaiser Permanente Mid-Atlantic States, Rockville, MD; University of North Carolina Health, Chapel Hill, NC; Vanderbilt University Medical Center, Nashville, TN; and Veterans Aging Cohort Study) and 1 interval cohort (Multicenter AIDS Cohort Study/Women's Interagency HIV Study Combined Cohort Study). METHODS We calculated the proportion of patients SARS-CoV-2 tested and the test positivity proportion by HIV status from March 1 to December 31, 2020. RESULTS The cohorts ranged in size from 1675 to 31,304 PWH and 1430 to 3,742,604 PWoH. The proportion of PWH who were tested for SARS-CoV-2 (19.6%-40.5% across sites) was significantly higher than PWoH (14.8%-29.4%) in the clinical cohorts. However, among those tested, the proportion of patients with positive SARS-CoV-2 tests was comparable by HIV status; the difference in proportion of SARS-CoV-2 positivity ranged from 4.7% lower to 1.4% higher. CONCLUSIONS Although PWH had higher testing proportions compared with PWoH, we did not find evidence of increased positivity in 6 large, diverse populations across the United States. Ongoing monitoring of testing, positivity, and COVID-19-related outcomes in PWH are needed, given availability, response, and durability of COVID-19 vaccines; emergence of SARS-CoV-2 variants; and latest therapeutic options.
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Affiliation(s)
- Lesley S Park
- Center for Population Health Sciences, Department of Epidemiology & Population Health, Stanford University School of Medicine, Stanford, CA
| | | | - Kirsha S Gordon
- Department of Internal Medicine, VA Connecticut Healthcare, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Amy C Justice
- Department of Internal Medicine, VA Connecticut Healthcare, West Haven, CT
- Yale University School of Medicine, New Haven, CT
- Yale University School of Public Health New Haven, CT
| | - Wendy Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Celeena Jefferson
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Michael Horberg
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Julia Certa
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Sonia Napravnik
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Daniel Westreich
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Srushti Gangireddy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Lorie Benning
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
| | - Gypsyamber D'Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
| | - Carolyn Williams
- Epidemiology Branch, Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
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8
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Coburn SB, Humes E, Lang R, Stewart C, Hogan BC, Gebo KA, Napravnik S, Edwards JK, Browne LE, Park LS, Justice AC, Gordon KS, Horberg MA, Certa JM, Watson E, Jefferson CR, Silverberg MJ, Skarbinski J, Leyden WA, Williams CF, Althoff KN. Analysis of Postvaccination Breakthrough COVID-19 Infections Among Adults With HIV in the United States. JAMA Netw Open 2022; 5:e2215934. [PMID: 35671054 PMCID: PMC9175076 DOI: 10.1001/jamanetworkopen.2022.15934] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/21/2022] [Indexed: 02/02/2023] Open
Abstract
Importance Recommendations for additional doses of COVID-19 vaccines for people with HIV (PWH) are restricted to those with advanced disease or unsuppressed HIV viral load. Understanding SARS-CoV-2 infection risk after vaccination among PWH is essential for informing vaccination guidelines. Objective To estimate the rate and risk of breakthrough infections among fully vaccinated PWH and people without HIV (PWoH) in the United States. Design, Setting, and Participants This cohort study used the Corona-Infectious-Virus Epidemiology Team (CIVET)-II (of the North American AIDS Cohort Collaboration on Research and Design [NA-ACCORD], which is part of the International Epidemiology Databases to Evaluate AIDS [IeDEA]), collaboration of 4 prospective, electronic health record-based cohorts from integrated health systems and academic health centers. Adult PWH who were fully vaccinated prior to June 30, 2021, were matched with PWoH on date of full vaccination, age, race and ethnicity, and sex and followed up through December 31, 2021. Exposures HIV infection. Main Outcomes and Measures COVID-19 breakthrough infections, defined as laboratory evidence of SARS-CoV-2 infection or COVID-19 diagnosis after a patient was fully vaccinated. Results Among 113 994 patients (33 029 PWH and 80 965 PWoH), most were 55 years or older (80 017 [70%]) and male (104 967 [92%]); 47 098 (41%) were non-Hispanic Black, and 43 218 (38%) were non-Hispanic White. The rate of breakthrough infections was higher in PWH vs PWoH (55 [95% CI, 52-58] cases per 1000 person-years vs 43 [95% CI, 42-45] cases per 1000 person-years). Cumulative incidence of breakthroughs 9 months after full vaccination was low (3.8% [95% CI, 3.7%-3.9%]), albeit higher in PWH vs PWoH (4.4% vs 3.5%; log-rank P < .001; risk difference, 0.9% [95% CI, 0.6%-1.2%]) and within each vaccine type. Breakthrough infection risk was 28% higher in PWH vs PWoH (adjusted hazard ratio, 1.28 [95% CI, 1.19-1.37]). Among PWH, younger age (<45 y vs 45-54 y), history of COVID-19, and not receiving an additional dose (aHR, 0.71 [95% CI, 0.58-0.88]) were associated with increased risk of breakthrough infections. There was no association of breakthrough with HIV viral load suppression, but high CD4 count (ie, ≥500 cells/mm3) was associated with fewer breakthroughs among PWH. Conclusions and Relevance In this study, COVID-19 vaccination, especially with an additional dose, was effective against infection with SARS-CoV-2 strains circulating through December 31, 2021. PWH had an increased risk of breakthrough infections compared with PWoH. Expansion of recommendations for additional vaccine doses to all PWH should be considered.
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Affiliation(s)
- Sally B. Coburn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Humes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Raynell Lang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Cameron Stewart
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Brenna C. Hogan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kelly A. Gebo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sonia Napravnik
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill
- Department of Epidemiology, University of North Carolina at Chapel Hill
| | - Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill
| | - Lindsay E. Browne
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Palo Alto, California
| | - Amy C. Justice
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven
| | - Kirsha S. Gordon
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven
| | - Michael A. Horberg
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Julia M. Certa
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Eric Watson
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Celeena R. Jefferson
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | | | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Infectious Diseases, Oakland Medical Center, Oakland, California
| | - Wendy A. Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Carolyn F. Williams
- Epidemiology Branch, Division of AIDS at National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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9
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Coburn SB, Humes E, Lang R, Stewart C, Hogan BC, Gebo KA, Napravnik S, Edwards JK, Browne LE, Park LS, Justice AC, Gordon K, Horberg MA, Certa JM, Watson E, Jefferson CR, Silverberg M, Skarbinski J, Leyden WA, Williams CF, Althoff KN. COVID-19 infections post-vaccination by HIV status in the United States. medRxiv 2021:2021.12.02.21267182. [PMID: 34909791 PMCID: PMC8669858 DOI: 10.1101/2021.12.02.21267182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Recommendations for additional doses of COVID vaccine are restricted to people with HIV who have advanced disease or unsuppressed HIV viral load. Understanding SARS-CoV-2 infection risk post-vaccination among PWH is essential for informing vaccination guidelines. OBJECTIVE Estimate the risk of breakthrough infections among fully vaccinated people with (PWH) and without (PWoH) HIV in the US. DESIGN SETTING AND PARTICIPANTS The Corona-Infectious-Virus Epidemiology Team (CIVET)-II cohort collaboration consists of 4 longitudinal cohorts from integrated health systems and academic health centers. Each cohort identified individuals ≥18 years old, in-care, and fully vaccinated for COVID-19 through 30 June 2021. PWH were matched to PWoH on date fully vaccinated, age group, race/ethnicity, and sex at birth. Incidence rates per 1,000 person-years and cumulative incidence of breakthrough infections with 95% confidence intervals ([,]) were estimated by HIV status. Cox proportional hazards models estimated adjusted hazard ratios (aHR) of breakthrough infections by HIV status adjusting for demographic factors, prior COVID-19 illness, vaccine type (BNT162b2, [Pfizer], mRNA-1273 [Moderna], Jansen Ad26.COV2.S [J&J]), calendar time, and cohort. Risk factors for breakthroughs among PWH, were also investigated. EXPOSURE HIV infection. OUTCOME COVID-19 breakthrough infections, defined as laboratory evidence of SARS-CoV-2 infection or COVID-19 diagnosis after an individual was fully vaccinated. RESULTS Among 109,599 individuals (31,840 PWH and 77,759 PWoH), the rate of breakthrough infections was higher in PWH versus PWoH: 44 [41, 48] vs. 31 [29, 33] per 1,000 person-years. Cumulative incidence at 210 days after date fully vaccinated was low, albeit higher in PWH versus PWoH overall (2.8% versus 2.1%, log-rank p<0.001, risk difference=0.7% [0.4%, 1.0%]) and within each vaccine type. Breakthrough infection risk was 41% higher in PWH versus PWoH (aHR=1.41 [1.28, 1.56]). Among PWH, younger age (18-24 versus 45-54), history of COVID-19 prior to fully vaccinated date, and J&J vaccination (versus Pfizer) were associated with increased risk of breakthroughs. There was no association of breakthrough with HIV viral load suppression or CD4 count among PWH. CONCLUSIONS AND RELEVANCE COVID-19 vaccination is effective against infection with SARS-CoV-2 strains circulating through 30 Sept 2021. PWH have an increased risk of breakthrough infections compared to PWoH. Recommendations for additional vaccine doses should be expanded to all PWH.
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Affiliation(s)
- Sally B Coburn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth Humes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Raynell Lang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Cameron Stewart
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brenna C Hogan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kelly A Gebo
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sonia Napravnik
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lindsay E Browne
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Palo Alto, CA, USA
| | - Amy C Justice
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Kirsha Gordon
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Michael A Horberg
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD, USA
| | - Julia M Certa
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD, USA
| | - Eric Watson
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD, USA
| | - Celeena R Jefferson
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD, USA
| | - Michael Silverberg
- Kaiser Permanente Northern California, Division of Research, Oakland CA, USA
| | - Jacek Skarbinski
- Kaiser Permanente Northern California, Division of Research, Oakland CA, USA
- Department of Infectious Diseases, Oakland Medical Center, Oakland CA, USA
| | - Wendy A Leyden
- Kaiser Permanente Northern California, Division of Research, Oakland CA, USA
| | - Carolyn F Williams
- Epidemiology Branch, Division of AIDS at National Institute of Allergy and Infectious Diseases (NIAID), National Institute of Health (NIH), Rockville, MD, USA
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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10
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Torgersen J, Newcomb CW, Carbonari DM, Rentsch CT, Park LS, Mezochow A, Mehta RL, Buchwalder L, Tate JP, Bräu N, Bhattacharya D, Lim JK, Taddei TH, Justice AC, Re VL. Protease inhibitor-based direct-acting antivirals are associated with increased risk of aminotransferase elevations but not hepatic dysfunction or decompensation. J Hepatol 2021; 75:1312-1322. [PMID: 34333102 PMCID: PMC8604762 DOI: 10.1016/j.jhep.2021.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Received: 12/23/2020] [Revised: 07/14/2021] [Accepted: 07/18/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Cases of acute liver injury (ALI) have been reported among chronic HCV-infected patients receiving protease inhibitor (PI)-based direct-acting antiviral (DAA) regimens, but no analyses have compared the risk of ALI in patients receiving PI- vs. non-PI-based DAAs. Thus, we compared the risk of 3 ALI outcomes between patients (by baseline Fibrosis-4 [FIB-4] group) receiving PI-based or non-PI-based DAAs. METHODS We conducted a cohort study of 18,498 patients receiving PI-based DAA therapy (paritaprevir/ritonavir/ombitasvir±dasabuvir, elbasvir/grazoprevir, glecaprevir/pibrentasvir) matched 1:1 on propensity score to those receiving non-PI-based DAAs (sofosbuvir/ledipasvir, sofosbuvir/velpatasvir) in the 1945-1965 Veterans Birth Cohort (2014-2019). During exposure to DAA therapy, we determined development of: i) alanine aminotransferase (ALT) >200 U/L, ii) severe hepatic dysfunction (coagulopathy with hyperbilirubinemia), and iii) hepatic decompensation. We used Cox regression to determine hazard ratios (HRs) with 95% CIs for each ALI outcome within groups defined by baseline FIB-4 (≤3.25; >3.25). RESULTS Among patients with baseline FIB-4 ≤3.25, those receiving PIs had a higher risk of ALT >200 U/L (HR 3.98; 95% CI 2.37-6.68), but not severe hepatic dysfunction (HR 0.67; 95% CI 0.19-2.39) or hepatic decompensation (HR 1.01; 95% CI 0.29-3.49), compared to those receiving non-PI-based regimens. For those with baseline FIB-4 >3.25, those receiving PIs had a higher risk of ALT >200 U/L (HR, 2.15; 95% CI 1.09-4.26), but not severe hepatic dysfunction (HR, 1.23 [0.64-2.38]) or hepatic decompensation (HR, 0.87; 95% CI 0.41-1.87), compared to those receiving non-PI-based regimens CONCLUSION: While risk of incident ALT elevations was increased in those receiving PI-based DAAs in both FIB-4 groups, the risk of severe hepatic dysfunction and hepatic decompensation did not differ between patients receiving PI- or non-PI-based DAAs in either FIB-4 group. LAY SUMMARY Cases of liver injury have been reported among patients treated with protease inhibitor-based direct-acting antivirals for hepatitis C infection, but it is not clear if the risk of liver injury among people starting these drugs is increased compared to those starting non-protease inhibitor-based therapy. In this study, patients receiving protease inhibitor-based treatment had a higher risk of liver inflammation than those receiving a non-protease inhibitor-based treatment, regardless of the presence of pre-treatment advanced liver fibrosis/cirrhosis. However, the risk of severe liver dysfunction and decompensation were not higher for patients treated with protease inhibitor-based regimens.
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Affiliation(s)
- Jessie Torgersen
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Craig W. Newcomb
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dena M. Carbonari
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher T. Rentsch
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Alyssa Mezochow
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rajni L. Mehta
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lynn Buchwalder
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Janet P. Tate
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Norbert Bräu
- James J. Peters VA Medical Center, Bronx, NY and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Debika Bhattacharya
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joseph K. Lim
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Amy C. Justice
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA,Division of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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11
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McGinnis KA, Skanderson M, Justice AC, Akgün KM, Tate JP, King JT, Rentsch CT, Marconi VC, Hsieh E, Ruser C, Kidwai-Khan F, Yousefzadeh R, Erdos J, Park LS. HIV care using differentiated service delivery during the COVID-19 pandemic: a nationwide cohort study in the US Department of Veterans Affairs. J Int AIDS Soc 2021; 24 Suppl 6:e25810. [PMID: 34713585 PMCID: PMC8554215 DOI: 10.1002/jia2.25810] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction The Department of Veterans Affairs (VA) is the largest provider of HIV care in the United States. Changes in healthcare delivery became necessary with the COVID‐19 pandemic. We compared HIV healthcare delivery during the first year of the COVID‐19 pandemic to a prior similar calendar period. Methods We included 27,674 people with HIV (PWH) enrolled in the Veterans Aging Cohort Study prior to 1 March 2019, with ≥1 healthcare encounter from 1 March 2019 to 29 February 2020 (2019) and/or 1 March 2020 to 28 February 2021 (2020). We counted monthly general medicine/infectious disease (GM/ID) clinic visits and HIV‐1 RNA viral load (VL) tests. We determined the percentage with ≥1 clinic visit (in‐person vs. telephone/video [virtual]) and ≥1 VL test (detectable vs. suppressed) for 2019 and 2020. Using pharmacy records, we summarized antiretroviral (ARV) medication refill length (<90 vs. ≥90 days) and monthly ARV coverage. Results Most patients had ≥1 GM/ID visit in 2019 (96%) and 2020 (95%). For 2019, 27% of visits were virtual compared to 64% in 2020. In 2019, 82% had VL measured compared to 74% in 2020. Of those with VL measured, 92% and 91% had suppressed VL in 2019 and 2020. ARV refills for ≥90 days increased from 39% in 2019 to 51% in 2020. ARV coverage was similar for all months of 2019 and 2020 ranging from 76% to 80% except for March 2019 (72%). Women were less likely than men to be on ARVs or to have a VL test in both years. Conclusions During the COVID‐19 pandemic, the VA increased the use of virtual visits and longer ARV refills, while maintaining a high percentage of patients with suppressed VL among those with VL measured. Despite decreased in‐person services during the pandemic, access to ARVs was not disrupted. More follow‐up time is needed to determine whether overall health was impacted by the use of differentiated service delivery and to evaluate whether a long‐term shift to increased virtual healthcare could be beneficial, particularly for PWH in rural areas or with transportation barriers. Programmes to increase ARV use and VL testing for women are needed.
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Affiliation(s)
- Kathleen A McGinnis
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA
| | - Melissa Skanderson
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA
| | - Amy C Justice
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kathleen M Akgün
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Janet P Tate
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joseph T King
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher T Rentsch
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Vincent C Marconi
- Emory University School of Medicine, Rollins School of Public Health, and the Atlanta VA Medical Center, Atlanta, Georgia, USA
| | - Evelyn Hsieh
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christopher Ruser
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Farah Kidwai-Khan
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roozbeh Yousefzadeh
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joseph Erdos
- VA CT Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, USA.,Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Department of Epidemiology and Population Health, Stanford School of Medicine, Stanford, California, USA
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12
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Makinson A, Park LS, Stone K, Tate J, Rodriguez-Barradas MC, Brown ST, Wadia R, Crothers K, Bedimo R, Goetz MB, Shebl F, Reynes J, Moing VL, Sigel KM. Risks of Opportunistic Infections in People With Human Immunodeficiency Virus With Cancers Treated With Chemotherapy. Open Forum Infect Dis 2021; 8:ofab389. [PMID: 34458394 PMCID: PMC8391784 DOI: 10.1093/ofid/ofab389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/17/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We ascertained incidence of opportunistic infections (OIs) in people with human immunodeficiency virus (PWH) with cancer undergoing chemotherapy with non-human immunodeficiency virus (HIV) comparators. METHODS We identified 2106 PWH and 2981 uninfected Veterans with cancer who received at least 1 dose of chemotherapy between 1996 and 2017 from the Veterans Aging Cohort Study. We ascertained incident OIs within 6 months of chemotherapy amongst zoster, cytomegalovirus, tuberculosis, Candida esophagitis, Pneumocystis jirovecii pneumonia (PCP), toxoplasmosis, Cryptococcosis, atypical Mycobacterium infection, Salmonella bacteremia, histoplasmosis, coccidioidomycosis, or progressive multifocal leukoencephalopathy. We used Poisson methods to calculate OI incidence rates by HIV status, stratifying for hematological and nonhematological tumors. We compared OI rates by HIV status, using inverse probability weights of HIV status, further adjusting for PCP prophylaxis. RESULTS We confirmed 106 OIs in 101 persons. Adjusted OI incidence rate ratios (IRRs) indicated higher risk in PWH for all cancers (IRR, 4.8; 95% confidence interval [CI], 2.8-8.2), hematological cancers (IRR, 8.2; 95% CI, 2.4-27.3), and nonhematological cancers (IRR, 3.9; 95% CI, 2.1-7.2). Incidence rate ratios were not significantly higher in those with CD4 >200 cells/mm3 and viral load <500 copies/mL (IRR, 1.8; 95% CI, 0.9-3.2). All PCP cases (n = 11) occurred in PWH, with 2 microbiologically unconfirmed cases among 1467 PWH with nonhematological cancers, no PCP prophylaxis, and CD4 counts >200/mm3. CONCLUSIONS Veterans with HIV undergoing chemotherapy had higher rates of OIs than uninfected Veterans, particularly those with hematological cancers, but not in PWH with HIV controlled disease. Our study does not support systematic PCP prophylaxis in solid tumors in PWH with HIV controlled disease.
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Affiliation(s)
- Alain Makinson
- University Hospital Montpellier, Institut National de Science et de Recherche Médicale U1175 and University of Montpellier, Montpellier, France
| | - Lesley S Park
- Stanford University School of Medicine, Stanford, California, USA
| | - Kimberly Stone
- Icahn School of Medicine at Mt Sinai, New York, New York, USA
| | - Janet Tate
- Veteran Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | | | | | - Roxanne Wadia
- Veteran Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Kristina Crothers
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - Roger Bedimo
- VA North Texas Health Care Center, Dallas, Texas, USA
| | | | - Fatma Shebl
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jacques Reynes
- University Hospital Montpellier, Institut National de Science et de Recherche Médicale U1175 and University of Montpellier, Montpellier, France
| | - Vincent Le Moing
- University Hospital Montpellier, Institut National de Science et de Recherche Médicale U1175 and University of Montpellier, Montpellier, France
| | - Keith M Sigel
- Icahn School of Medicine at Mt Sinai, New York, New York, USA
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13
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Torgersen J, Kallan MJ, Carbonari DM, Park LS, Mehta RL, D'Addeo K, Tate JP, Lim JK, Goetz MB, Rodriguez-Barradas MC, Gibert CL, Bräu N, Brown ST, Roy JA, Taddei TH, Justice AC, Lo Re V. HIV RNA, CD4+ Percentage, and Risk of Hepatocellular Carcinoma by Cirrhosis Status. J Natl Cancer Inst 2021; 112:747-755. [PMID: 31687755 DOI: 10.1093/jnci/djz214] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 09/19/2019] [Accepted: 10/25/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Despite increasing incidence of hepatocellular carcinoma (HCC) among HIV-infected patients, it remains unclear if HIV-related factors contribute to development of HCC. We examined if higher or prolonged HIV viremia and lower CD4+ cell percentage were associated with HCC. METHODS We conducted a cohort study of HIV-infected individuals who had HIV RNA, CD4+, and CD8+ cell counts and percentages assessed in the Veterans Aging Cohort Study (1999-2015). HCC was ascertained using Veterans Health Administration cancer registries and electronic records. Cox regression was used to determine hazard ratios (HR, 95% confidence interval [CI]) of HCC associated with higher current HIV RNA, longer duration of detectable HIV viremia (≥500 copies/mL), and current CD4+ cell percentage less than 14%, adjusting for traditional HCC risk factors. Analyses were stratified by previously validated diagnoses of cirrhosis prior to start of follow-up. RESULTS Among 35 659 HIV-infected patients, 302 (0.8%) developed HCC over 281 441 person-years (incidence rate = 107.3 per 100 000 person-years). Among patients without baseline cirrhosis, higher HIV RNA (HR = 1.25, 95% CI = 1.12 to 1.40, per 1.0 log10 copies/mL) and 12 or more months of detectable HIV (HR = 1.47, 95% CI = 1.02 to 2.11) were independently associated with higher risk of HCC. CD4+ percentage less than 14% was not associated with HCC in any model. Hepatitis C coinfection was a statistically significant predictor of HCC regardless of baseline cirrhosis status. CONCLUSION Among HIV-infected patients without baseline cirrhosis, higher HIV RNA and longer duration of HIV viremia increased risk of HCC, independent of traditional HCC risk factors. This is the strongest evidence to date that HIV viremia contributes to risk of HCC in this group.
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Affiliation(s)
- Jessie Torgersen
- Division of Infectious Diseases, Department of Medicine.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training
| | - Michael J Kallan
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training
| | - Dena M Carbonari
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training
| | - Lesley S Park
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA
| | - Rajni L Mehta
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Kathryn D'Addeo
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Janet P Tate
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Joseph K Lim
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Cynthia L Gibert
- Washington DC VA Medical Center and George Washington University Medical Center, Washington, DC
| | - Norbert Bräu
- James J. Peters VA Medical Center, Bronx, NY, and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sheldon T Brown
- James J. Peters VA Medical Center, Bronx, NY, and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jason A Roy
- Department of Biostatistics, Rutgers University School of Public Health, New Brunswick, NJ
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training
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14
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Bedimo RJ, Park LS, Shebl FM, Sigel K, Rentsch CT, Crothers K, Rodriguez-Barradas MC, Goetz MB, Butt AA, Brown ST, Gibert C, Justice AC, Tate JP. Statin exposure and risk of cancer in people with and without HIV infection. AIDS 2021; 35:325-334. [PMID: 33181533 PMCID: PMC7775280 DOI: 10.1097/qad.0000000000002748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine whether statin exposure is associated with decreased cancer and mortality risk among persons with HIV (PWH) and uninfected persons. Statins appear to have immunomodulatory and anti-inflammatory effects and may reduce cancer risk, particularly among PWH as they experience chronic inflammation and immune activation. DESIGN Propensity score-matched cohort of statin-exposed and unexposed patients from 2002 to 2017 in the Veterans Aging Cohort Study (VACS), a large cohort with cancer registry linkage and detailed pharmacy data. METHODS We calculated Cox regression hazard ratios (HRs) and 95% confidence intervals (CI) associated with statin use for all cancers, microbial cancers (associated with bacterial or oncovirus coinfection), nonmicrobial cancers, and mortality. RESULTS :The propensity score-matched sample (N = 47 940) included 23 970 statin initiators (31% PWH). Incident cancers were diagnosed in 1160 PWH and 2116 uninfected patients. Death was reported in 1667 (7.0%) statin-exposed, and 2215 (9.2%) unexposed patients. Statin use was associated with 24% decreased risk of microbial-associated cancers (hazard ratio 0.76; 95% CI 0.69-0.85), but was not associated with nonmicrobial cancer risk (hazard ratio 1.00; 95% CI 0.92-1.09). Statin use was associated with 33% lower risk of death overall (hazard ratio 0.67; 95% CI 0.63-0.72). Results were similar in analyses stratified by HIV status, except for non-Hodgkin lymphoma where statin use was associated with reduced risk (hazard ratio 0.56; 95% CI 0.38-0.83) for PWH, but not for uninfected (P interaction = 0.012). CONCLUSION In both PWH and uninfected, statin exposure was associated with lower risk of microbial, but not nonmicrobial cancer incidence, and with decreased mortality.
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Affiliation(s)
- Roger J Bedimo
- Veterans Affairs North Texas Healthcare System, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lesley S Park
- Stanford University School of Medicine, Palo Alto, California
| | - Fatima M Shebl
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keith Sigel
- Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | | | - Kristina Crothers
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, Washington
| | | | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Adeel A Butt
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvamia
- Weill Cornell Medical College, New York, New York, USA
- Weill Cornell Medical College, Doha, Qatar
| | - Sheldon T Brown
- James J. Peters Veterans Affairs Medical Center, Bronx
- Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Cynthia Gibert
- Washington DC Veterans Affairs Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Janet P Tate
- VA Connecticut Healthcare System, West Haven
- Yale School of Medicine, New Haven, Connecticut, USA
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15
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King JT, Yoon JS, Rentsch CT, Tate JP, Park LS, Kidwai-Khan F, Skanderson M, Hauser RG, Jacobson DA, Erdos J, Cho K, Ramoni R, Gagnon DR, Justice AC. Development and validation of a 30-day mortality index based on pre-existing medical administrative data from 13,323 COVID-19 patients: The Veterans Health Administration COVID-19 (VACO) Index. PLoS One 2020; 15:e0241825. [PMID: 33175863 PMCID: PMC7657526 DOI: 10.1371/journal.pone.0241825] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [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: 09/01/2020] [Accepted: 10/21/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Available COVID-19 mortality indices are limited to acute inpatient data. Using nationwide medical administrative data available prior to SARS-CoV-2 infection from the US Veterans Health Administration (VA), we developed the VA COVID-19 (VACO) 30-day mortality index and validated the index in two independent, prospective samples. METHODS AND FINDINGS We reviewed SARS-CoV-2 testing results within the VA between February 8 and August 18, 2020. The sample was split into a development cohort (test positive between March 2 and April 15, 2020), an early validation cohort (test positive between April 16 and May 18, 2020), and a late validation cohort (test positive between May 19 and July 19, 2020). Our logistic regression model in the development cohort considered demographics (age, sex, race/ethnicity), and pre-existing medical conditions and the Charlson Comorbidity Index (CCI) derived from ICD-10 diagnosis codes. Weights were fixed to create the VACO Index that was then validated by comparing area under receiver operating characteristic curves (AUC) in the early and late validation cohorts and among important validation cohort subgroups defined by sex, race/ethnicity, and geographic region. We also evaluated calibration curves and the range of predictions generated within age categories. 13,323 individuals tested positive for SARS-CoV-2 (median age: 63 years; 91% male; 42% non-Hispanic Black). We observed 480/3,681 (13%) deaths in development, 253/2,151 (12%) deaths in the early validation cohort, and 403/7,491 (5%) deaths in the late validation cohort. Age, multimorbidity described with CCI, and a history of myocardial infarction or peripheral vascular disease were independently associated with mortality-no other individual comorbid diagnosis provided additional information. The VACO Index discriminated mortality in development (AUC = 0.79, 95% CI: 0.77-0.81), and in early (AUC = 0.81 95% CI: 0.78-0.83) and late (AUC = 0.84, 95% CI: 0.78-0.86) validation. The VACO Index allows personalized estimates of 30-day mortality after COVID-19 infection. For example, among those aged 60-64 years, overall mortality was estimated at 9% (95% CI: 6-11%). The Index further discriminated risk in this age stratum from 4% (95% CI: 3-7%) to 21% (95% CI: 12-31%), depending on sex and comorbid disease. CONCLUSION Prior to infection, demographics and comorbid conditions can discriminate COVID-19 mortality risk overall and within age strata. The VACO Index reproducibly identified individuals at substantial risk of COVID-19 mortality who might consider continuing social distancing, despite relaxed state and local guidelines.
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Affiliation(s)
- Joseph T. King
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - James S. Yoon
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States of America
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Christopher T. Rentsch
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet P. Tate
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America
| | - Farah Kidwai-Khan
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Melissa Skanderson
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
| | - Ronald G. Hauser
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Daniel A. Jacobson
- Oak Ridge National Laboratory, Biosciences Division, Oak Ridge, Tennessee, United States of America
- The Bredesen Center for Interdisciplinary Research and Graduate Education, University of Tennessee Knoxville, Knoxville, Tennessee, United States of America
- Department of Psychology, University of Tennessee Knoxville, Knoxville, Tennesee, United States of America
| | - Joseph Erdos
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Kelly Cho
- VA Boston Healthcare System, U.S. Department of Veterans Affairs, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Rachel Ramoni
- Office of Research and Development, Veterans Health Administration, United States Department of Veterans Affairs, Washington, DC, United States of America
| | - David R. Gagnon
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Amy C. Justice
- VA Connecticut Healthcare System, U.S. Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Yale School of Public Health, New Haven, Connecticut, United States of America
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16
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Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Lo Re V, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. PLoS Med 2020; 17:e1003379. [PMID: 32960880 PMCID: PMC7508372 DOI: 10.1371/journal.pmed.1003379] [Citation(s) in RCA: 211] [Impact Index Per Article: 52.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). We investigated racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent mortality in the largest integrated healthcare system in the United States. METHODS AND FINDINGS This retrospective cohort study included 5,834,543 individuals receiving care in the US Department of Veterans Affairs; most (91%) were men, 74% were non-Hispanic White (White), 19% were non-Hispanic Black (Black), and 7% were Hispanic. We evaluated associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for a wide range of demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence. Between February 8 and July 22, 2020, 254,595 individuals were tested for COVID-19, of whom 16,317 tested positive and 1,057 died. Black individuals were more likely to be tested (rate per 1,000 individuals: 60.0, 95% CI 59.6-60.5) than Hispanic (52.7, 95% CI 52.1-53.4) and White individuals (38.6, 95% CI 38.4-38.7). While individuals from minority backgrounds were more likely to test positive (Black versus White: odds ratio [OR] 1.93, 95% CI 1.85-2.01, p < 0.001; Hispanic versus White: OR 1.84, 95% CI 1.74-1.94, p < 0.001), 30-day mortality did not differ by race/ethnicity (Black versus White: OR 0.97, 95% CI 0.80-1.17, p = 0.74; Hispanic versus White: OR 0.99, 95% CI 0.73-1.34, p = 0.94). The disparity between Black and White individuals in testing positive for COVID-19 was stronger in the Midwest (OR 2.66, 95% CI 2.41-2.95, p < 0.001) than the West (OR 1.24, 95% CI 1.11-1.39, p < 0.001). The disparity in testing positive for COVID-19 between Hispanic and White individuals was consistent across region, calendar time, and outbreak pattern. Study limitations include underrepresentation of women and a lack of detailed information on social determinants of health. CONCLUSIONS In this nationwide study, we found that Black and Hispanic individuals are experiencing an excess burden of SARS-CoV-2 infection not entirely explained by underlying medical conditions or where they live or receive care. There is an urgent need to proactively tailor strategies to contain and prevent further outbreaks in racial and ethnic minority communities.
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Affiliation(s)
- Christopher T. Rentsch
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Farah Kidwai-Khan
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Janet P. Tate
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America
| | - Joseph T. King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Melissa Skanderson
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
| | - Ronald G. Hauser
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Christopher I. Jarvis
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mark Holodniy
- VA Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California, United States of America
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kathleen M. Akgün
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Kristina Crothers
- VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington, United States of America
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Matthew S. Freiberg
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Amy C. Justice
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut, United States of America
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17
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Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Re VL, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Covid-19 by Race and Ethnicity: A National Cohort Study of 6 Million United States Veterans. medRxiv 2020. [PMID: 32511524 DOI: 10.1101/2020.05.12.20099135.] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of morbidity and mortality from symptomatic SARS-Cov-2 infection or coronavirus disease 2019 (Covid-19). Most studies investigating racial and ethnic disparities to date have focused on hospitalized patients or have not characterized who received testing or those who tested positive for Covid-19. OBJECTIVE To compare patterns of testing and test results for coronavirus 2019 (Covid-19) and subsequent mortality by race and ethnicity in the largest integrated healthcare system in the United States. DESIGN Retrospective cohort study. SETTING United States Department of Veterans Affairs (VA). PARTICIPANTS 5,834,543 individuals in care, among whom 62,098 were tested and 5,630 tested positive for Covid-19 between February 8 and May 4, 2020. Exposures: Self-reported race/ethnicity. MAIN OUTCOME MEASURES We evaluated associations between race/ethnicity and receipt of Covid-19 testing, a positive test result, and 30-day mortality, accounting for a wide range of demographic and clinical risk factors including comorbid conditions, site of care, and urban versus rural residence. RESULTS Among all individuals in care, 74% were non-Hispanic white (white), 19% non-Hispanic black (black), and 7% Hispanic. Compared with white individuals, black and Hispanic individuals were more likely to be tested for Covid-19 (tests per 1000: white=9.0, [95% CI 8.9 to 9.1]; black=16.4, [16.2 to 16.7]; and Hispanic=12.2, [11.9 to 12.5]). While individuals from minority backgrounds were more likely to test positive (black vs white: OR 1.96, 95% CI 1.81 to 2.12; Hispanic vs white: OR 1.73, 95% CI 1.53 to 1.96), 30-day mortality did not differ by race/ethnicity (black vs white: OR 0.93, 95% CI 0.64 to 1.33; Hispanic vs white: OR 1.07, 95% CI 0.61 to 1.87). CONCLUSIONS Black and Hispanic individuals are experiencing an excess burden of Covid-19 not entirely explained by underlying medical conditions or where they live or receive care. While there was no observed difference in mortality by race or ethnicity, our findings may underestimate risk in the broader US population as health disparities tend to be reduced in VA.
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Affiliation(s)
- Christopher T Rentsch
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Farah Kidwai-Khan
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Janet P Tate
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA, US, 94305
| | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, US, 06520
| | - Melissa Skanderson
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
| | - Ronald G Hauser
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516.,Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Christopher I Jarvis
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Mark Holodniy
- VA Palo Alto Healthcare System, US Department of Veterans Affairs, Palo Alto, CA, US, 94304.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, US, 94305
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US, 19104
| | - Kathleen M Akgün
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Kristina Crothers
- VA Puget Sound Health Care System and Department of Medicine, University of Washington School of Medicine, Seattle, WA, US, 98104
| | - Tamar H Taddei
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Matthew S Freiberg
- Geriatric Research Education and Clinical Center (GRECC), US Department of Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, US 37212.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, US, 37232
| | - Amy C Justice
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, US, 06511
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18
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Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Re VL, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Covid-19 by Race and Ethnicity: A National Cohort Study of 6 Million United States Veterans. medRxiv 2020:2020.05.12.20099135. [PMID: 32511524 PMCID: PMC7273292 DOI: 10.1101/2020.05.12.20099135] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of morbidity and mortality from symptomatic SARS-Cov-2 infection or coronavirus disease 2019 (Covid-19). Most studies investigating racial and ethnic disparities to date have focused on hospitalized patients or have not characterized who received testing or those who tested positive for Covid-19. OBJECTIVE To compare patterns of testing and test results for coronavirus 2019 (Covid-19) and subsequent mortality by race and ethnicity in the largest integrated healthcare system in the United States. DESIGN Retrospective cohort study. SETTING United States Department of Veterans Affairs (VA). PARTICIPANTS 5,834,543 individuals in care, among whom 62,098 were tested and 5,630 tested positive for Covid-19 between February 8 and May 4, 2020. Exposures: Self-reported race/ethnicity. MAIN OUTCOME MEASURES We evaluated associations between race/ethnicity and receipt of Covid-19 testing, a positive test result, and 30-day mortality, accounting for a wide range of demographic and clinical risk factors including comorbid conditions, site of care, and urban versus rural residence. RESULTS Among all individuals in care, 74% were non-Hispanic white (white), 19% non-Hispanic black (black), and 7% Hispanic. Compared with white individuals, black and Hispanic individuals were more likely to be tested for Covid-19 (tests per 1000: white=9.0, [95% CI 8.9 to 9.1]; black=16.4, [16.2 to 16.7]; and Hispanic=12.2, [11.9 to 12.5]). While individuals from minority backgrounds were more likely to test positive (black vs white: OR 1.96, 95% CI 1.81 to 2.12; Hispanic vs white: OR 1.73, 95% CI 1.53 to 1.96), 30-day mortality did not differ by race/ethnicity (black vs white: OR 0.93, 95% CI 0.64 to 1.33; Hispanic vs white: OR 1.07, 95% CI 0.61 to 1.87). CONCLUSIONS Black and Hispanic individuals are experiencing an excess burden of Covid-19 not entirely explained by underlying medical conditions or where they live or receive care. While there was no observed difference in mortality by race or ethnicity, our findings may underestimate risk in the broader US population as health disparities tend to be reduced in VA.
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Affiliation(s)
- Christopher T Rentsch
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Farah Kidwai-Khan
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Janet P Tate
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA, US, 94305
| | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, US, 06520
| | - Melissa Skanderson
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
| | - Ronald G Hauser
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Christopher I Jarvis
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Mark Holodniy
- VA Palo Alto Healthcare System, US Department of Veterans Affairs, Palo Alto, CA, US, 94304
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, US, 94305
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US, 19104
| | - Kathleen M Akgün
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Kristina Crothers
- VA Puget Sound Health Care System and Department of Medicine, University of Washington School of Medicine, Seattle, WA, US, 98104
| | - Tamar H Taddei
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Matthew S Freiberg
- Geriatric Research Education and Clinical Center (GRECC), US Department of Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, US 37212
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, US, 37232
| | - Amy C Justice
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, US, 06511
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19
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Edelman EJ, Li Y, Barry D, Braden JB, Crystal S, Kerns RD, Gaither JR, Gordon KS, Manhapra A, Merlin JS, Moore BA, Oldfield BJ, Park LS, Rentsch CT, Skanderson M, Williams EC, Justice AC, Tate JP, Becker WC, Marshall BD. Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study. J Acquir Immune Defic Syndr 2020; 84:26-36. [PMID: 32267658 PMCID: PMC7147724 DOI: 10.1097/qai.0000000000002310] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of self-reported opioid use and their correlates among a national sample of PWH engaged in care. SETTING Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at 8 US Veterans Health Administration (VA) sites. METHODS Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported "prescription painkillers" and/or heroin use at baseline and follow-up. We used group-based trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. RESULTS Among 3702 PWH, we identified 4 opioid use trajectories: (1) no lifetime use (25%); (2) stable, infrequent use (58%); (3) escalating use (7%); and (4) de-escalating use (11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications, and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. CONCLUSION Among PWH engaged in VA care, 1 in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.
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Affiliation(s)
- E. Jennifer Edelman
- Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Yu Li
- Brown University School of Public Health, Providence, RI
| | | | - Jennifer Brennan Braden
- University of Washington School of Medicine, Seattle, WA
- Valley Medical Center Psychiatry and Counseling, Behavioral Health Integration Program
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, Rutgers, NJ
| | - Robert D. Kerns
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Kirsha S. Gordon
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Ajay Manhapra
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Brent A. Moore
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Christopher T. Rentsch
- VA Connecticut Healthcare System, West Haven, CT
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Emily C. Williams
- VA Puget Sound Health Services Research and Development and Department of Health Services, University of Washington, Seattle, WA
| | - Amy C. Justice
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Janet P. Tate
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - William C. Becker
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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20
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Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Re VL, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Covid-19 Testing, Hospital Admission, and Intensive Care Among 2,026,227 United States Veterans Aged 54-75 Years. medRxiv 2020:2020.04.09.20059964. [PMID: 32511595 PMCID: PMC7276022 DOI: 10.1101/2020.04.09.20059964] [Citation(s) in RCA: 303] [Impact Index Per Article: 75.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
IMPORTANCE Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes coronavirus disease 2019 (Covid-19), an evolving pandemic. Limited data are available characterizing SARS-Cov-2 infection in the United States. OBJECTIVE To determine associations between demographic and clinical factors and testing positive for coronavirus 2019 (Covid-19+), and among Covid-19+ subsequent hospitalization and intensive care. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study including all patients tested for Covid-19 between February 8 and March 30, 2020, inclusive. We extracted electronic health record data from the national Veterans Affairs Healthcare System, the largest integrated healthcare system in the United States, on 2,026,227 patients born between 1945 and 1965 and active in care. Exposures: Demographic data, comorbidities, medication history, substance use, vital signs, and laboratory measures. Laboratory tests were analyzed first individually and then grouped into a validated summary measure of physiologic injury (VACS Index). Main Outcomes and Measures: We evaluated which factors were associated with Covid-19+ among all who tested. Among Covid-19+ we identified factors associated with hospitalization or intensive care. We identified independent associations using multivariable and conditional multivariable logistic regression with multiple imputation of missing values. RESULTS Among Veterans aged 54-75 years, 585/3,789 (15.4%) tested Covid-19+. In adjusted analysis (C-statistic=0.806) black race was associated with Covid-19+ (OR 4.68, 95% CI 3.79-5.78) and the association remained in analyses conditional on site (OR 2.56, 95% CI 1.89-3.46). In adjusted models, laboratory abnormalities (especially fibrosis-4 score [FIB-4] >3.25 OR 8.73, 95% CI 4.11-18.56), and VACS Index (per 5-point increase OR 1.62, 95% CI 1.43-1.84) were strongly associated with hospitalization. Associations were similar for intensive care. Although significant in unadjusted analyses, associations with comorbid conditions and medications were substantially reduced and, in most cases, no longer significant after adjustment. CONCLUSIONS AND RELEVANCE Black race was strongly associated with Covid-19+, but not with hospitalization or intensive care. Among Covid-19+, risk of hospitalization and intensive care may be better characterized by laboratory measures and vital signs than by comorbid conditions or prior medication exposure.
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Affiliation(s)
- Christopher T Rentsch
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Farah Kidwai-Khan
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Janet P Tate
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA, US, 94305
| | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, US, 06520
| | - Melissa Skanderson
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
| | - Ronald G Hauser
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Anna Schultze
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Christopher I Jarvis
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT
| | - Mark Holodniy
- VA Palo Alto Healthcare System, US Department of Veterans Affairs, Palo Alto, CA, US, 94304
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, US, 94305
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US, 19104
| | - Kathleen M Akgün
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Kristina Crothers
- VA Puget Sound Health Care System and Department of Medicine, University of Washington School of Medicine, Seattle, WA, US, 98104
| | - Tamar H Taddei
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
| | - Matthew S Freiberg
- Geriatric Research Education and Clinical Center (GRECC), US Department of Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, US 37212
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, US, 37232
| | - Amy C Justice
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, US, 06511
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21
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Torgersen J, Taddei TH, Park LS, Carbonari DM, Kallan MJ, Mitchell Richards K, Zhang X, Jhala D, Bräu N, Homer R, D'Addeo K, Mehta R, Skanderson M, Kidwai-Khan F, Justice AC, Lo Re V. Differences in Pathology, Staging, and Treatment between HIV + and Uninfected Patients with Microscopically Confirmed Hepatocellular Carcinoma. Cancer Epidemiol Biomarkers Prev 2019; 29:71-78. [PMID: 31575557 DOI: 10.1158/1055-9965.epi-19-0503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/21/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The incidence of hepatocellular carcinoma (HCC) is substantially higher among HIV-infected (HIV+) than uninfected persons. It remains unclear if HCC in the setting of HIV infection is morphologically distinct or more aggressive. METHODS We evaluated differences in tumor pathology in a cohort of HIV+ and uninfected patients with microscopically confirmed HCC in the Veterans Aging Cohort Study from 2000 to 2015. We reviewed pathology reports and medical records to determine Barcelona Clinic Liver Cancer stage (BCLC), HCC treatment, and survival by HIV status. Multivariable Cox regression was used to determine the hazard ratio [HR; 95% confidence interval (CI)] of death associated with HIV infection after microscopic confirmation. RESULTS Among 873 patients with HCC (399 HIV+), 140 HIV+ and 178 uninfected persons underwent liver tissue sampling and had microscopically confirmed HCC. There were no differences in histologic features of the tumor between HIV+ and uninfected patients, including tumor differentiation (well differentiated, 19% vs. 28%, P = 0.16) and lymphovascular invasion (6% vs. 7%, P = 0.17) or presence of advanced hepatic fibrosis (40% vs. 39%, P = 0.90). There were no differences in BCLC stage (P = 0.06) or treatment (P = 0.29) by HIV status. After adjustment for risk factors, risk of death was higher among HIV-infected than uninfected patients (HR = 1.37; 95% CI, 1.02-1.85). CONCLUSIONS We found no differences in HCC tumor characteristics or background hepatic parenchyma by HIV status, yet HIV was associated with poorer survival. Of note, pathology reports often omitted these characteristics. IMPACT Systematic evaluation of HCC pathology by HIV status is needed to understand tumor characteristics associated with improved survival.
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Affiliation(s)
- Jessie Torgersen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. .,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tamar H Taddei
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California
| | - Dena M Carbonari
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Xuchen Zhang
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Darshana Jhala
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Norbert Bräu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J. Peters VA Medical Center, Bronx, New York
| | - Robert Homer
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Kathryn D'Addeo
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Rajni Mehta
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Melissa Skanderson
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Farah Kidwai-Khan
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Amy C Justice
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Vincent Lo Re
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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22
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Waliany S, Sainani KL, Park LS, Zhang CA, Srinivas S, Witteles RM. Increase in Blood Pressure Associated With Tyrosine Kinase Inhibitors Targeting Vascular Endothelial Growth Factor. JACC CardioOncol 2019; 1:24-36. [PMID: 34396159 PMCID: PMC8352203 DOI: 10.1016/j.jaccao.2019.08.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/30/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
Objectives This study quantified the change in blood pressure (BP) during antivascular endothelial growth factor (VEGF) tyrosine kinase inhibitor (TKI) therapy, compared BPs between TKIs, and analyzed change in BP during antihypertensive therapy. Background TKIs targeting VEGF are associated with hypertension. The absolute change in BP during anti-VEGF TKI treatment is not well characterized outside clinical trials. Methods A retrospective single-center study included patients with metastatic renal cell carcinoma who received anti-VEGF TKIs between 2007 and 2018. Mixed models analyzed 3,088 BPs measured at oncology clinics. Results In 228 patients (baseline systolic blood pressure [SBP] 130.2 ± 16.3 mm Hg, diastolic blood pressure [DBP] 76.8 ± 9.3 mm Hg), anti-VEGF TKIs were associated with mean increases in SBP of 8.5 mm Hg (p < 0.0001) and DBP of 6.7 mm Hg (p <0.0001). Of the anti-VEGF TKIs evaluated, axitinib was associated with the greatest BP increase, with an increase in SBP of 12.6 mm Hg (p < 0.0001) and in DBP of 10.3 mm Hg (p < 0.0001) relative to baseline. In pairwise comparisons between agents, axitinib was associated with greater SBPs than cabozantinib by 8.4 mm Hg (p = 0.004) and pazopanib by 5.1 mm Hg (p = 0.01). Subsequent anti-VEGF TKI courses were associated with small increases in DBP, but not SBP, relative to the first course. During anti-VEGF TKI therapy, calcium-channel blockers and potassium-sparing diuretic agents were associated with the largest BP reductions, with decreases in SBP of 5.6 mm Hg (p < 0.0001) and 9.9 mm Hg (p = 0.007), respectively. Conclusions Anti-VEGF TKIs are associated with increased BP; greatest increases are observed with axitinib. Calcium-channel blockers and potassium-sparing diuretic agents were associated with the largest reductions in BP.
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Key Words
- ACE, angiotensin-converting enzyme
- ARB, angiotensin II receptor blocker
- BP, blood pressure
- CCB, calcium-channel blocker
- CTCAE, Common Terminology Criteria for Adverse Events
- DBP, diastolic blood pressure
- SBP, systolic blood pressure
- TKI, tyrosine kinase inhibitor
- VEGF, vascular endothelial growth factor
- antiangiogenic therapy
- antihypertensive agents
- blood pressure
- calcium-channel blockers
- diuretics
- eGFR, estimated glomerular filtration rate
- hypertension
- mRCC, metastatic renal cell carcinoma
- renal cell cancer
- treatment-related hypertension
- tyrosine kinase inhibitors
- vascular endothelial growth factor inhibitors
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Affiliation(s)
- Sarah Waliany
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kristin L Sainani
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Lesley S Park
- Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Chiyuan Amy Zhang
- Department of Urology, Stanford University School of Medicine, Stanford, California, USA
| | - Sandy Srinivas
- Division of Medical Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Ronald M Witteles
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
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23
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Hernández-Ramírez RU, Qin L, Lin H, Leyden W, Neugebauer RS, Althoff KN, Achenbach CJ, Hessol NA, D’Souza G, Gebo KA, Gill MJ, Grover S, Horberg MA, Li J, Mathews WC, Mayor AM, Park LS, Rabkin CS, Salters K, Justice AC, Moore RD, Engels EA, Silverberg MJ, Dubrow R. Association of immunosuppression and HIV viraemia with non-Hodgkin lymphoma risk overall and by subtype in people living with HIV in Canada and the USA: a multicentre cohort study. Lancet HIV 2019; 6:e240-e249. [PMID: 30826282 PMCID: PMC6531288 DOI: 10.1016/s2352-3018(18)30360-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Research is needed to better understand relations between immunosuppression and HIV viraemia and risk for non-Hodgkin lymphoma, a common cancer in people living with HIV. We aimed to identify key CD4 count and HIV RNA (viral load) predictors of risk for non-Hodgkin lymphoma, overall and by subtype. METHODS We studied people living with HIV during 1996-2014 from 21 Canadian and US cohorts participating in the North American AIDS Cohort Collaboration on Research and Design. To determine key independent predictors of risk for non-Hodgkin lymphoma, we assessed associations with time-updated recent, past, cumulative, and nadir or peak measures of CD4 count and viral load, using demographics-adjusted, cohort-stratified Cox models, and we compared models using Akaike's information criterion. FINDINGS Of 102 131 people living with HIV during the study period, 712 people developed non-Hodgkin lymphoma. The key independent predictors of risk for overall non-Hodgkin lymphoma were recent CD4 count (ie, lagged by 6 months; <50 cells per μL vs ≥500 cells per μL, hazard ratio [HR] 3·2, 95% CI 2·2-4·7) and average viral load during a 3-year window lagged by 6 months (a cumulative measure; ≥100 000 copies per mL vs ≤500 copies per mL, HR 9·6, 95% CI 6·5-14·0). These measures were also the key predictors of risk for diffuse large B-cell lymphoma (recent CD4 count <50 cells per μL vs ≥500 cells per μL, HR 2·4, 95% CI 1·4-4·2; average viral load ≥100 000 copies per mL vs ≤500 copies per mL, HR 7·5, 95% CI 4·5-12·7). However, recent CD4 count was the sole key predictor of risk for CNS non-Hodgkin lymphoma (<50 cells per μL vs ≥500 cells per μL, HR 426·3, 95% CI 58·1-3126·4), and proportion of time viral load was greater than 500 copies per mL during the 3-year window (a cumulative measure) was the sole key predictor for Burkitt lymphoma (100% vs 0%, HR 41·1, 95% CI 9·1-186·6). INTERPRETATION Both recent immunosuppression and prolonged HIV viraemia have important independent roles in the development of non-Hodgkin lymphoma, with likely subtype heterogeneity. Early and sustained antiretroviral therapy to decrease HIV replication, dampen B-cell activation, and restore overall immune function is crucial for preventing non-Hodgkin lymphoma. FUNDING National Institutes of Health, Centers for Disease Control and Prevention, US Agency for Healthcare Research and Quality, US Health Resources and Services Administration, Canadian Institutes of Health Research, Ontario Ministry of Health and Long Term Care, and the Government of Alberta.
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Affiliation(s)
- Raúl U. Hernández-Ramírez
- Corresponding author: Raúl U.
Hernández-Ramírez, Department of Biostatistics, Yale School of
Public Health, New Haven, CT 06520-8034, USA
| | - Li Qin
- Department of Internal Medicine, Yale School of Medicine, New
Haven, CT, USA
| | - Haiqun Lin
- Department of Biostatistics, Yale School of Public Health, Yale
School of Medicine, New Haven, CT, USA
| | - Wendy Leyden
- Division of Research, Kaiser Permanente Northern California,
Oakland, CA, USA
| | | | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins University Bloomberg
School of Public Health, Baltimore, MD, USA
| | - Chad J. Achenbach
- Division of Infectious Diseases, Northwestern University Feinberg
School of Medicine, Chicago, IL, USA
| | - Nancy A. Hessol
- Department of Clinical Pharmacy, University of California, San
Francisco, San Francisco, CA, USA
| | - Gypsyamber D’Souza
- Department of Epidemiology, Johns Hopkins University Bloomberg
School of Public Health, Baltimore, MD, USA
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - M. John Gill
- Department of Medicine, University of Calgary, Calgary, Alberta,
Canada
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania
Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente
Mid-Atlantic States, Rockville, MD, USA
| | - Jun Li
- Epidemiology Branch, Division of HIV/AIDS Prevention, Centers for
Disease Control and Prevention, Atlanta, GA, USA
| | | | - Angel M. Mayor
- Retrovirus Research Center, Universidad Central del Caribe School
of Medicine, Bayamon, Puerto Rico
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Stanford
University School of Medicine, Palo Alto, CA, USA
| | - Charles S. Rabkin
- Infections and Immunoepidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, Rockville, MD,
USA
| | - Kate Salters
- Epidemiology and Population Health, British Columbia Centre for
Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Amy C. Justice
- Department of Internal Medicine, Yale School of Medicine, New
Haven, CT, USA,Department of Health Policy and Management, Yale School of Public
Health, Yale School of Medicine, New Haven, CT, USA,Research Service, Veterans Affairs Connecticut Healthcare System,
West Haven, CT, USA
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Eric A. Engels
- Infections and Immunoepidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, Rockville, MD,
USA
| | | | - Robert Dubrow
- Department of Environmental Health Sciences, Yale School of Public
Health, Yale School of Medicine, New Haven, CT, USA
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Park LS, Tate JP, Sigel K, Brown ST, Crothers K, Gibert C, Goetz MB, Rimland D, Rodriguez-Barradas MC, Bedimo RJ, Justice AC, Dubrow R. Association of Viral Suppression With Lower AIDS-Defining and Non-AIDS-Defining Cancer Incidence in HIV-Infected Veterans: A Prospective Cohort Study. Ann Intern Med 2018; 169:87-96. [PMID: 29893768 PMCID: PMC6825799 DOI: 10.7326/m16-2094] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Viral suppression is a primary marker of HIV treatment success. Persons with HIV are at increased risk for AIDS-defining cancer (ADC) and several types of non-AIDS-defining cancer (NADC), some of which are caused by oncogenic viruses. Objective To determine whether viral suppression is associated with decreased cancer risk. Design Prospective cohort. Setting Department of Veterans Affairs. Participants HIV-positive veterans (n = 42 441) and demographically matched uninfected veterans (n = 104 712) from 1999 to 2015. Measurements Standardized cancer incidence rates and Poisson regression rate ratios (RRs; HIV-positive vs. uninfected persons) by viral suppression status (unsuppressed: person-time with HIV RNA levels ≥500 copies/mL; early suppression: initial 2 years with HIV RNA levels <500 copies/mL; long-term suppression: person-time after early suppression with HIV RNA levels <500 copies/mL). Results Cancer incidence for HIV-positive versus uninfected persons was highest for unsuppressed persons (RR, 2.35 [95% CI, 2.19 to 2.51]), lower among persons with early suppression (RR, 1.99 [CI, 1.87 to 2.12]), and lowest among persons with long-term suppression (RR, 1.52 [CI, 1.44 to 1.61]). This trend was strongest for ADC (unsuppressed: RR, 22.73 [CI, 19.01 to 27.19]; early suppression: RR, 9.48 [CI, 7.78 to 11.55]; long-term suppression: RR, 2.22 [CI, 1.69 to 2.93]), much weaker for NADC caused by viruses (unsuppressed: RR, 3.82 [CI, 3.24 to 4.49]; early suppression: RR, 3.42 [CI, 2.95 to 3.97]; long-term suppression: RR, 3.17 [CI, 2.78 to 3.62]), and absent for NADC not caused by viruses. Limitation Lower viral suppression thresholds, duration of long-term suppression, and effects of CD4+ and CD8+ T-cell counts were not thoroughly evaluated. Conclusion Antiretroviral therapy resulting in long-term viral suppression may contribute to cancer prevention, to a greater degree for ADC than for NADC. Patients with long-term viral suppression still had excess cancer risk. Primary Funding Source National Cancer Institute and National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health.
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Affiliation(s)
- Lesley S Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California (L.S.P.)
| | - Janet P Tate
- Veterans Affairs Connecticut Healthcare System, West Haven, and Yale School of Medicine, New Haven, Connecticut (J.P.T., A.C.J.)
| | - Keith Sigel
- Icahn School of Medicine at Mount Sinai, New York, New York (K.S.)
| | - Sheldon T Brown
- James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York, New York (S.T.B.)
| | - Kristina Crothers
- Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington (K.C.)
| | - Cynthia Gibert
- Washington DC Veterans Affairs Medical Center and George Washington University School of Medicine and Health Sciences, Washington, DC (C.G.)
| | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California (M.B.G.)
| | - David Rimland
- Atlanta Veterans Affairs Medical Center, Decatur, and Emory University School of Medicine, Atlanta, Georgia (D.R.)
| | - Maria C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas (M.C.R.)
| | - Roger J Bedimo
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas (R.J.B.)
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, and Yale School of Medicine, New Haven, Connecticut (J.P.T., A.C.J.)
| | - Robert Dubrow
- Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut (R.D.)
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Engels EA, Yanik EL, Wheeler W, Gill MJ, Shiels MS, Dubrow R, Althoff KN, Silverberg MJ, Brooks JT, Kitahata MM, Goedert JJ, Grover S, Mayor AM, Moore RD, Park LS, Rachlis A, Sigel K, Sterling TR, Thorne JE, Pfeiffer RM. Cancer-Attributable Mortality Among People With Treated Human Immunodeficiency Virus Infection in North America. Clin Infect Dis 2017; 65:636-643. [PMID: 29017269 PMCID: PMC5849088 DOI: 10.1093/cid/cix392] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/25/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cancer remains an important cause of morbidity and mortality in people with human immunodeficiency virus (PWHIV) on effective antiretroviral therapy (ART). Estimates of cancer-attributable mortality can inform public health efforts. METHODS We evaluated 46956 PWHIV receiving ART in North American HIV cohorts (1995-2009). Using information on incident cancers and deaths, we calculated population-attributable fractions (PAFs), estimating the proportion of deaths due to cancer. Calculations were based on proportional hazards models adjusted for age, sex, race, HIV risk group, calendar year, cohort, CD4 count, and viral load. RESULTS There were 1997 incident cancers and 8956 deaths during 267145 person-years of follow-up, and 11.9% of decedents had a prior cancer. An estimated 9.8% of deaths were attributable to cancer (cancer-attributable mortality rate 327 per 100000 person-years). PAFs were 2.6% for AIDS-defining cancers (ADCs, including non-Hodgkin lymphoma, 2.0% of deaths) and 7.1% for non-AIDS-defining cancers (NADCs: lung cancer, 2.3%; liver cancer, 0.9%). PAFs for NADCs were higher in males and increased strongly with age, reaching 12.5% in PWHIV aged 55+ years. Mortality rates attributable to ADCs and NADCs were highest for PWHIV with CD4 counts <100 cells/mm3. PAFs for NADCs increased during 1995-2009, reaching 10.1% in 2006-2009. CONCLUSIONS Approximately 10% of deaths in PWHIV prescribed ART during 1995-2009 were attributable to cancer, but this fraction increased over time. A large proportion of cancer-attributable deaths were associated with non-Hodgkin lymphoma, lung cancer, and liver cancer. Deaths due to NADCs will likely grow in importance as AIDS mortality declines and PWHIV age.
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Affiliation(s)
| | | | | | | | | | - Robert Dubrow
- Yale School of Public Health, New Haven, Connecticut
| | - Keri N Althoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - John T Brooks
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | | | | | - Anita Rachlis
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Keith Sigel
- Icahn School of Medicine at Mount Sinai, New York
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Sigel K, Wisnivesky J, Crothers K, Gordon K, Brown ST, Rimland D, Rodriguez-Barradas MC, Gibert C, Goetz MB, Bedimo R, Park LS, Dubrow R. Immunological and infectious risk factors for lung cancer in US veterans with HIV: a longitudinal cohort study. Lancet HIV 2016; 4:e67-e73. [PMID: 27916584 DOI: 10.1016/s2352-3018(16)30215-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 09/08/2016] [Accepted: 09/16/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND HIV infection is independently associated with risk of lung cancer, but few data exist for the relation between longitudinal measurements of immune function and lung-cancer risk in people living with HIV. METHODS We followed up participants with HIV from the Veterans Aging Cohort Study for a minimum of 3 years between Jan 1, 1998, and Dec 31, 2012, and used cancer registry data to identify incident cases of lung cancer. The index date for each patient was the later of the date HIV care began or Jan 1, 1998. We excluded patients with less than 3 years' follow-up, prevalent diagnoses of lung cancer, or incomplete laboratory data. We used Cox regression models to investigate the relation between different time-updated lagged and cumulative exposures (CD4 cell count, CD8 cell count, CD4/CD8 ratio, HIV RNA, and bacterial pneumonia) and risk of lung cancer. Models were adjusted for age, race or ethnicity, smoking, hepatitis C virus infection, alcohol use disorders, drug use disorders, and history of chronic obstructive pulmonary disease and occupational lung disease. FINDINGS We identified 277 cases of incident lung cancer in 21 666 participants with HIV. In separate models for each time-updated 12 month lagged, 24 month simple moving average cumulative exposure, increased risk of lung cancer was associated with low CD4 cell count (p trend=0·001), low CD4/CD8 ratio (p trend=0·0001), high HIV RNA concentration (p=0·004), and more cumulative bacterial pneumonia episodes (12 month lag only; p trend=0·0004). In a mutually adjusted model including these factors, CD4/CD8 ratio and cumulative bacterial pneumonia episodes remained significant (p trends 0·003 and 0·004, respectively). INTERPRETATION In our large HIV cohort in the antiretroviral therapy era, we found evidence that dysfunctional immune activation and chronic inflammation contribute to the development of lung cancer in the setting of HIV infection. These findings could be used to target lung-cancer prevention measures to high-risk groups. FUNDING US National Institutes of Health.
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Affiliation(s)
- Keith Sigel
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Juan Wisnivesky
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kristina Crothers
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Kirsha Gordon
- Department of Medicine, VA Connecticut Healthcare System and Yale Schools of Medicine and Public Health, New Haven, CT, USA
| | - Sheldon T Brown
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Infectious Diseases Section, James J Peters VA Medical Center, Bronx, NY, USA
| | - David Rimland
- Infectious Diseases Section, Atlanta VA Medical Center and Emory University School of Medicine, Decatur, GA, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Cynthia Gibert
- Department of Medicine, George Washington University School of Medicine and Washington DC Veterans Affairs Medical Center, Washington, DC, USA
| | - Matthew Bidwell Goetz
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Roger Bedimo
- Division of Infectious Diseases, VA North Texas Health Care System, Dallas, TX, USA
| | - Lesley S Park
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Robert Dubrow
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
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Pollom EL, Alagappan M, Park LS, Whittemore AS, Koong AC, Chang DT. Does radiotherapy still have a role in unresected biliary tract cancer? Cancer Med 2016; 6:129-141. [PMID: 27891822 PMCID: PMC5269698 DOI: 10.1002/cam4.975] [Citation(s) in RCA: 24] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 01/02/2023] Open
Abstract
The benefits of radiotherapy for inoperable biliary tract cancer remain unclear due to the lack of randomized data. We evaluated the impact of radiotherapy on survival in elderly patients using the SEER‐Medicare database. Patients in the SEER‐Medicare database with inoperable biliary tract tumors diagnosed between 1998 and 2011 were included. We used multivariate logistic regression to evaluate factors associated with treatment selection, and multivariate Cox regression and propensity score matching to evaluate treatment selection in relation to subsequent survival. Of the 2343 patients included, 451 (19%) received radiotherapy within 4 months of diagnosis. The use of radiotherapy declined over time, and was influenced by receipt of chemotherapy and patient age, race, marital status, poverty status, and tumor stage and type. Median survival was 9.3 (95% CI 8.7–9.7) months among patients who did not receive radiation and 10.0 (95% CI 9.1–11.3) months among those who received radiation, conditional on having survived 4 months. In patients who received chemotherapy (n = 1053), receipt of radiation was associated with improved survival, with an adjusted hazard ratio of 0.82 (95% 0.70–0.97, P = 0.02). In patients who did not receive chemotherapy (n = 1290), receipt of radiation was not associated with improved survival, with an adjusted hazard ratio of 1.09 (95% 0.91–1.30, P = 0.34). Propensity‐scored matched analyses showed similar results. Despite the survival benefit associated with the addition of radiotherapy to chemotherapy, the use of radiation for unresectable biliary tract cancers has declined over time.
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Affiliation(s)
- Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Muthuraman Alagappan
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Lesley S Park
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Alice S Whittemore
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Albert C Koong
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
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Park LS, Tate JP, Sigel K, Rimland D, Crothers K, Gibert C, Rodriguez-Barradas MC, Goetz MB, Bedimo RJ, Brown ST, Justice AC, Dubrow R. Time trends in cancer incidence in persons living with HIV/AIDS in the antiretroviral therapy era: 1997-2012. AIDS 2016; 30:1795-806. [PMID: 27064994 PMCID: PMC4925286 DOI: 10.1097/qad.0000000000001112] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [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: 02/07/2023]
Abstract
OBJECTIVE Utilizing the Veterans Aging Cohort Study, the largest HIV cohort in North America, we conducted one of the few comprehensive comparisons of cancer incidence time trends in HIV-infected (HIV+) versus uninfected persons during the antiretroviral therapy (ART) era. DESIGN Prospective cohort study. METHODS We followed 44 787 HIV+ and 96 852 demographically matched uninfected persons during 1997-2012. We calculated age-, sex-, and race/ethnicity-standardized incidence rates and incidence rate ratios (IRR, HIV+ versus uninfected) over four calendar periods with incidence rate and IRR period trend P values for cancer groupings and specific cancer types. RESULTS We observed 3714 incident cancer diagnoses in HIV+ and 5760 in uninfected persons. The HIV+ all-cancer crude incidence rate increased between 1997-2000 and 2009-2012 (P trend = 0.0019). However, after standardization, we observed highly significant HIV+ incidence rate declines for all cancer (25% decline; P trend <0.0001), AIDS-defining cancers (55% decline; P trend <0.0001), nonAIDS-defining cancers (NADC; 15% decline; P trend = 0.0003), and nonvirus-related NADC (20% decline; P trend <0.0001); significant IRR declines for all cancer (from 2.0 to 1.6; P trend <0.0001), AIDS-defining cancers (from 19 to 5.5; P trend <0.0001), and nonvirus-related NADC (from 1.4 to 1.2; P trend = 0.049); and borderline significant IRR declines for NADC (from 1.6 to 1.4; P trend = 0.078) and virus-related NADC (from 4.9 to 3.5; P trend = 0.071). CONCLUSION Improved HIV care resulting in improved immune function most likely contributed to the HIV+ incidence rate and the IRR declines. Further promotion of early and sustained ART, improved ART regimens, reduction of traditional cancer risk factor (e.g. smoking) prevalence, and evidence-based screening could contribute to future cancer incidence declines among HIV+ persons.
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Affiliation(s)
| | - Janet P. Tate
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Yale School of Medicine, New Haven, CT
| | - Keith Sigel
- Icahn School of Medicine at Mt. Sinai, New York, NY
| | - David Rimland
- Atlanta Veterans Affairs Medical Center, Atlanta, GA; Emory University School of Medicine, Atlanta, GA
| | | | - Cynthia Gibert
- Washington DC Veterans Affairs Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Roger J. Bedimo
- Veterans Affairs North Texas Healthcare System, Dallas, TX; University of Texas Southwestern Medical Center, Dallas, TX
| | - Sheldon T. Brown
- Icahn School of Medicine at Mt. Sinai, New York, NY
- James J. Peters Veterans Affairs Medical Center, New York, NY
| | - Amy C. Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Yale School of Medicine, New Haven, CT
| | - Robert Dubrow
- Yale School of Medicine, New Haven, CT
- Yale School of Public Health, New Haven, CT
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Park LS, Tate JP, Lo Re V, Butt AA, Gibert C, Goetz MB, Brown ST, Lim J, Rimland D, Lee JS, Justice AC, Dubrow R. Abstract 4308: Multiplicative interaction between HIV infection status and FIB-4 in prediction of hepatocellular carcinoma risk. Cancer Res 2016. [DOI: 10.1158/1538-7445.am2016-4308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: FIB-4 is an established marker of liver fibrosis and cirrhosis, calculated from platelet count, alanine transaminase, aspartate transaminase, and age. We previously found baseline FIB-4 to be strongly associated with hepatocellular carcinoma (HCC) risk among HIV-infected (HIV+) patients in the US; a similar finding was reported among persons who consume alcohol or are chronic hepatitis B virus (HBV) carriers in South Korea. Longitudinal associations between FIB-4 and HCC risk have not yet been explored. We aimed to expand our prior investigation by including uninfected patients, using time-updated FIB-4, and testing for multiplicative interaction between HIV status and FIB-4 in the prediction of HCC risk. We hypothesized that the relationship between FIB-4 and HCC risk would differ by HIV status.
Methods: We tested this hypothesis in the Veterans Aging Cohort Study, an open cohort that enrolls HIV+ veterans when they begin HIV care in the Veterans Health Administration and matches two uninfected patients by age, sex, race/ethnicity, and clinical site. We used proportional hazards regression models with time-varying covariates to calculate hazard ratios (HR) and 95% confidence intervals (CI) for FIB-4, adjusted for HCC risk factors (age, sex, race, hepatitis C virus (HCV) infection, HBV infection, smoking, alcohol, BMI, and diabetes). We used the counting process to create time-updated FIB-4 intervals and examined one-, three-, and five-year lagged FIB-4. We identified incident HCC cases from the VA Central Cancer Registry and determined hepatitis C virus and hepatitis B virus status from laboratory results. We defined low (3.25) as previously established.
Results: Between 2000 and 2012, among 37,158 HIV+ subjects, 202 developed HCC. Among 78,339 uninfected subjects, 207 developed HCC. There was a significant multiplicative interaction between HIV status and one-year lagged FIB-4 (interaction p = 0.0015). High FIB-4 was a stronger predictor of HCC in the uninfected than in HIV+. Among uninfected, the adjusted HR was 6.9 (95% CI: 3.4, 12.5) for intermediate FIB-4 and 40.0 (95% CI: 22.3, 71.8) for high FIB-4 compared to uninfected with low FIB-4. Among HIV+, with the same reference group (uninfected with low FIB-4), the adjusted HR was 2.1 (95% CI: 1.0, 4.4) for low FIB-4, 6.4 (95% CI: 3.5, 11.7) for intermediate FIB-4, and 23.7 (95% CI: 13.1, 42.9) for high FIB-4. There was no interaction between FIB-4 and HCV status (p = 0.92). Results were qualitatively similar using a three- or five-year lag.
Conclusions: Calculated from routine, non-invasive laboratory tests, FIB-4 is a strong, independent HCC risk factor in both HIV+ and uninfected subjects after adjustment for other HCC risk factors. FiB-4 appears to be a stronger risk factor in uninfected than in HIV+.
Citation Format: Lesley S. Park, Janet P. Tate, Vincent Lo Re, Adeel A. Butt, Cynthia Gibert, Matthew Bidwell Goetz, Sheldon T. Brown, Joseph Lim, David Rimland, Jennifer S. Lee, Amy C. Justice, Robert Dubrow. Multiplicative interaction between HIV infection status and FIB-4 in prediction of hepatocellular carcinoma risk. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4308.
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Affiliation(s)
| | - Janet P. Tate
- 2Veterans Affairs Connecticut Healthcare System, West Haven, CT; Yale School of Medicine , New Haven, CT
| | - Vincent Lo Re
- 3Perelman School of Medicine, University of Pennsylvania; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
| | - Adeel A. Butt
- 4Hamad Healthcare Quality Institute, Hamad Medical Corporation, Doha, Qatar; VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Cynthia Gibert
- 5Washington DC Veterans Affairs Medical Center; George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Matthew Bidwell Goetz
- 6Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Sheldon T. Brown
- 7James J. Peters Veterans Affairs Medical Center, Icahn School of Medicine at Mt. Sinai, New York, NY
| | | | - David Rimland
- 9Atlanta Veterans Affairs Medical Center; Emory University School of Medicine, Atlanta, GA
| | - Jennifer S. Lee
- 10Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA; Stanford University School of Medicine, Stanford, CA
| | - Amy C. Justice
- 2Veterans Affairs Connecticut Healthcare System, West Haven, CT; Yale School of Medicine , New Haven, CT
| | - Robert Dubrow
- 11Yale School of Public Health; Yale School of Medicine, New Haven, CT
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Wadia RJ, Park LS, Brandt C, Rose MG, Chao HH, Gibert C, Rimland D, Rodriguez-Barradas M, Justice A. Gleason grade in HIV+ versus uninfected prostate cancer patients in the Veterans Aging Cohort study. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e16560] [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: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Amy Justice
- Yale University School of Medicine, New Haven, CT
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Abstract
OBJECTIVE The burden of cancer among persons living with HIV/AIDS (PLWHA) is substantial and increasing. We assessed the prevalence of modifiable cancer risk factors among adult PLWHA in Western high-income countries since 2000. DESIGN Meta-analysis. METHODS We searched PubMed to identify articles published in 2011-2013 reporting prevalence of smoking, alcohol consumption, overweight/obesity, and infection with human papillomavirus (HPV), hepatitis C virus (HCV) and hepatitis B virus (HBV) among PLWHA. We conducted random effects meta-analyses of prevalence for each risk factor, including estimation of overall, sex-specific, and HIV-transmission-group-specific prevalence. We compared prevalence in PLWHA with published prevalence estimates in US adults. RESULTS The meta-analysis included 113 publications. Overall summary prevalence estimates were current smoking, 54% [95% confidence interval (CI) 49-59%] versus 20-23% in US adults; cervical high-risk HPV infection, 46% (95% CI 34-58%) versus 29% in US females; oral high-risk HPV infection, 16% (95% CI 10-23%) versus 4% in US adults; anal high-risk HPV infection (men who have sex with men), 68% (95% CI 57-79%), with no comparison estimate available; chronic HCV infection, 26% (95% CI 21-30%) versus 0.9% in US adults; and HBV infection, 5% (95% CI 4-5%) versus 0.3% in US adults. Overweight/obesity prevalence (53%; 95% CI 46-59%) was below that of US adults (68%). Meta-analysis of alcohol consumption prevalence was impeded by varying assessment methods. Overall, we observed considerable study heterogeneity in prevalence estimates. CONCLUSION Prevalence of smoking and oncogenic virus infections continues to be extraordinarily high among PLWHA, indicating a vital need for risk factor reduction efforts.
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Affiliation(s)
- Lesley S Park
- aDivision of Endocrinology, Gerontology, and Metabolism, Department of Medicine and Division of Epidemiology, Department of Health Policy and Research, Stanford University School of Medicine, Stanford, CaliforniabDepartment of Chronic Disease Epidemiology, Yale School of Public Health, Yale School of Medicine, New Haven, ConnecticutcDivision of Research, Kaiser Permanente, Oakland, CaliforniadDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA.*Lesley S. Park and Raúl U. Hernández-Ramírez contributed equally to this article
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Lo Re V, Kallan MJ, Tate JP, Lim JK, Goetz MB, Klein MB, Rimland D, Rodriguez-Barradas MC, Butt AA, Gibert CL, Brown ST, Park LS, Dubrow R, Reddy KR, Kostman JR, Justice AC, Localio AR. Predicting Risk of End-Stage Liver Disease in Antiretroviral-Treated Human Immunodeficiency Virus/Hepatitis C Virus-Coinfected Patients. Open Forum Infect Dis 2015; 2:ofv109. [PMID: 26284259 PMCID: PMC4536329 DOI: 10.1093/ofid/ofv109] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/05/2015] [Indexed: 12/15/2022] Open
Abstract
Background. End-stage liver disease (ESLD) is an important cause of morbidity among human immunodeficiency virus (HIV)/hepatitis C virus (HCV)-coinfected patients. Quantifying the risk of this outcome over time could help determine which coinfected patients should be targeted for risk factor modification and HCV treatment. We evaluated demographic, clinical, and laboratory variables to predict risk of ESLD in HIV/HCV-coinfected patients receiving antiretroviral therapy (ART). Methods. We conducted a retrospective cohort study among 6016 HIV/HCV-coinfected patients who received ART within the Veterans Health Administration between 1997 and 2010. The main outcome was incident ESLD, defined by hepatic decompensation, hepatocellular carcinoma, or liver-related death. Cox regression was used to develop prognostic models based on baseline demographic, clinical, and laboratory variables, including FIB-4 and aspartate aminotransferase-to-platelet ratio index, previously validated markers of hepatic fibrosis. Model performance was assessed by discrimination and decision curve analysis. Results. Among 6016 HIV/HCV patients, 532 (8.8%) developed ESLD over a median of 6.6 years. A model comprising FIB-4 and race had modest discrimination for ESLD (c-statistic, 0.73) and higher net benefit than alternative strategies of treating no or all coinfected patients at relevant risk thresholds. For FIB-4 >3.25, ESLD risk ranged from 7.9% at 1 year to 26.0% at 5 years among non-blacks and from 2.4% at 1 year to 14.0% at 5 years among blacks. Conclusions. Race and FIB-4 provided important predictive information on ESLD risk among HIV/HCV patients. Estimating risk of ESLD using these variables could help direct HCV treatment decisions among HIV/HCV-coinfected patients.
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Affiliation(s)
- Vincent Lo Re
- Departments of Medicine ; Biostatistics and Epidemiology and Center for Clinical Epidemiology and Biostatistics , Perelman School of Medicine, University of Pennsylvania , Philadelphia ; Medical Service , Philadelphia VA Medical Center , Pennsylvania
| | - Michael J Kallan
- Biostatistics and Epidemiology and Center for Clinical Epidemiology and Biostatistics , Perelman School of Medicine, University of Pennsylvania , Philadelphia
| | - Janet P Tate
- VA Connecticut Healthcare System , West Haven ; Yale University School of Medicine , New Haven, Connecticut
| | - Joseph K Lim
- VA Connecticut Healthcare System , West Haven ; Yale University School of Medicine , New Haven, Connecticut
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA , California
| | - Marina B Klein
- Chronic Viral Illness Service , McGill University Health Centre , Montreal , Canada
| | - David Rimland
- Atlanta VA Medical Center and Emory University School of Medicine , Georgia
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine , Baylor College of Medicine , Houston, Texas
| | - Adeel A Butt
- VA Pittsburgh Healthcare System , Pennsylvania ; Hamad Healthcare Quality Institute , Doha, Qatar ; Hamad Medical Corporation , Doha, Qatar
| | - Cynthia L Gibert
- Washington DC VA Medical Center , George Washington University Medical Center , Washington, District of Columbia
| | - Sheldon T Brown
- James J. Peters VA Medical Center and Mt. Sinai School of Medicine , New York, New York
| | - Lesley S Park
- Yale University School of Medicine , New Haven, Connecticut ; Yale School of Public Health , New Haven, Connecticut
| | - Robert Dubrow
- Yale University School of Medicine , New Haven, Connecticut ; Yale School of Public Health , New Haven, Connecticut
| | | | | | - Amy C Justice
- VA Connecticut Healthcare System , West Haven ; Yale University School of Medicine , New Haven, Connecticut
| | - A Russell Localio
- Biostatistics and Epidemiology and Center for Clinical Epidemiology and Biostatistics , Perelman School of Medicine, University of Pennsylvania , Philadelphia
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Althoff KN, McGinnis KA, Wyatt CM, Freiberg MS, Gilbert C, Oursler KK, Rimland D, Rodriguez-Barradas MC, Dubrow R, Park LS, Skanderson M, Shiels MS, Gange SJ, Gebo KA, Justice AC. Comparison of risk and age at diagnosis of myocardial infarction, end-stage renal disease, and non-AIDS-defining cancer in HIV-infected versus uninfected adults. Clin Infect Dis 2014; 60:627-38. [PMID: 25362204 DOI: 10.1093/cid/ciu869] [Citation(s) in RCA: 199] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Although it has been shown that human immunodeficiency virus (HIV)-infected adults are at greater risk for aging-associated events, it remains unclear as to whether these events happen at similar, or younger ages, in HIV-infected compared with uninfected adults. The objective of this study was to compare the median age at, and risk of, incident diagnosis of 3 age-associated diseases in HIV-infected and demographically similar uninfected adults. METHODS The study was nested in the clinical prospective Veterans Aging Cohort Study of HIV-infected and demographically matched uninfected veterans, from 1 April 2003 to 31 December 2010. The outcomes were validated diagnoses of myocardial infarction (MI), end-stage renal disease (ESRD), and non-AIDS-defining cancer (NADC). Differences in mean age at, and risk of, diagnosis by HIV status were estimated using multivariate linear regression models and Cox proportional hazards models, respectively. RESULTS A total of 98 687 (31% HIV-infected and 69% uninfected) adults contributed >450 000 person-years and 689 MI, 1135 ESRD, and 4179 NADC incident diagnoses. Mean age at MI (adjusted mean difference, -0.11; 95% confidence interval [CI], -.59 to .37 years) and NADC (adjusted mean difference, -0.10 [95% CI, -.30 to .10] years) did not differ by HIV status. HIV-infected adults were diagnosed with ESRD at an average age of 5.5 months younger than uninfected adults (adjusted mean difference, -0.46 [95% CI, -.86 to -.07] years). HIV-infected adults had a greater risk of all 3 outcomes compared with uninfected adults after accounting for important confounders. CONCLUSIONS HIV-infected adults had a higher risk of these age-associated events, but they occurred at similar ages than those without HIV.
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Affiliation(s)
| | | | | | | | - Cynthia Gilbert
- Veterans Affairs Medical Center and George Washington University Medical Center, Washington D.C
| | - Krisann K Oursler
- Salem Veterans Affairs Medical Center, Virginia University of Maryland School of Medicine, Baltimore
| | - David Rimland
- Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Georgia
| | | | - Robert Dubrow
- Veterans Affairs Connecticut Healthcare System and Yale Schools of Medicine and Public Health, New Haven, Connecticut
| | - Lesley S Park
- Veterans Affairs Connecticut Healthcare System and Yale Schools of Medicine and Public Health, New Haven, Connecticut
| | - Melissa Skanderson
- Veterans Affairs Connecticut Healthcare System and Yale Schools of Medicine and Public Health, New Haven, Connecticut
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | | | | | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System and Yale Schools of Medicine and Public Health, New Haven, Connecticut
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Park LS, Tate JP, Rodriguez-Barradas MC, Rimland D, Goetz MB, Gibert C, Brown ST, Kelley MJ, Justice AC, Dubrow R. Cancer Incidence in HIV-Infected Versus Uninfected Veterans: Comparison of Cancer Registry and ICD-9 Code Diagnoses. J AIDS Clin Res 2014; 5:1000318. [PMID: 25580366 PMCID: PMC4285627 DOI: 10.4172/2155-6113.1000318] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Given the growing interest in the cancer burden in persons living with HIV/AIDS, we examined the validity of data sources for cancer diagnoses (cancer registry versus International Classification of Diseases, Ninth Revision [ICD-9 codes]) and compared the association between HIV status and cancer risk using each data source in the Veterans Aging Cohort Study (VACS), a prospective cohort of HIV-infected and uninfected veterans from 1996 to 2008. METHODS We reviewed charts to confirm potential incident cancers at four VACS sites. In the entire cohort, we calculated cancer-type-specific age-, sex-, race/ethnicity-, and calendar-period-standardized incidence rates and incidence rate ratios (IRR) (HIV-infected versus uninfected). We calculated standardized incidence ratios (SIR) to compare VACS and Surveillance, Epidemiology, and End Results rates. RESULTS Compared to chart review, both Veterans Affairs Central Cancer Registry (VACCR) and ICD-9 diagnoses had approximately 90% sensitivity; however, VACCR had higher positive predictive value (96% versus 63%). There were 6,010 VACCR and 13,386 ICD-9 incident cancers among 116,072 veterans. Although ICD-9 rates tended to be double VACCR rates, most IRRs were in the same direction and of similar magnitude, regardless of data source. Using either source, all cancers combined, most viral-infection-related cancers, lung cancer, melanoma, and leukemia had significantly elevated IRRs. Using ICD-9, eight additional IRRs were significantly elevated, most likely due to false positive diagnoses. Most ICD-9 SIRs were significantly elevated and all were higher than the corresponding VACCR SIR. CONCLUSIONS ICD-9 may be used with caution for estimating IRRs, but should be avoided when estimating incidence or SIRs. Elevated cancer risk based on VACCR diagnoses among HIV-infected veterans was consistent with other studies.
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Affiliation(s)
- Lesley S Park
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
- Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, CT, USA
| | - Janet P Tate
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of General Internal Medicine, Veterans Affairs Healthcare System, West Haven, CT, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - David Rimland
- Medical Specialty Care Service Line, Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew Bidwell Goetz
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Cynthia Gibert
- Section of Infectious Diseases, Washington DC Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sheldon T Brown
- Department of Medicine, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
- Department of Medicine, Icahn School of Medicine, Mt. Sinai, New York, NY, USA
| | - Michael J Kelley
- Office of Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
- Hematology-Oncology Service, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - Amy C Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of General Internal Medicine, Veterans Affairs Healthcare System, West Haven, CT, USA
| | - Robert Dubrow
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
- Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, CT, USA
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Dubrow R, Darefsky AS, Jacobs DI, Park LS, Rose MG, Laurans MSH, King JT. Time trends in glioblastoma multiforme survival: the role of temozolomide. Neuro Oncol 2013; 15:1750-61. [PMID: 24046259 DOI: 10.1093/neuonc/not122] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In 2005, maximum safe surgical resection, followed by radiotherapy with concomitant temozolomide (TMZ), followed by adjuvant TMZ became the standard of care for glioblastoma (GBM). Furthermore, a modest, but meaningful, population-based survival improvement for GBM patients occurred in the US between 1999 (when TMZ was first introduced) and 2008. We hypothesized that TMZ usage explained this GBM survival improvement. METHODS We used national Veterans Health Administration (VHA) databases to construct a cohort of GBM patients, with detailed treatment information, diagnosed 1997-2008 (n = 1645). We compared survival across 3 periods of diagnosis (1997-2000, 2001-2004, and 2005-2008) using Kaplan-Meier curves. We used proportional hazards models to calculate period hazard rate ratios (HRs) and 95% confidence intervals (CIs), adjusted for demographic, clinical, and treatment covariates. RESULTS Survival increased over calendar time (stratified log-rank P < .0001). After adjusting for age and Charlson comorbidity score, for cases diagnosed in 2005-2008 versus 1997-2000, the HR was 0.72 (95% CI, 0.64-0.82; p-trend < .0001). Sequentially adding non-TMZ treatment variables (ie, surgery, radiotherapy, non-TMZ chemotherapy) to the model did not change this result. However, adding TMZ to the model containing age, Charlson comorbidity score, and all non-TMZ treatments eliminated the period effect entirely (HR = 1.01; 95% CI, 0.86-1.19; p-trend = 0.84). CONCLUSIONS The observed survival improvement among GBM patients diagnosed in the VHA system between 1997 and 2008 was completely explained by TMZ. Similar studies in other populations are warranted to test the generalizability of our finding to other patient cohorts and health care settings.
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Affiliation(s)
- Robert Dubrow
- Corresponding Author: Robert Dubrow, MD, PhD, Department of Chronic Disease Epidemiology, Yale School of Public Health, P.O. Box 208034, New Haven, CT 06520-8034.
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Sigel K, Wisnivesky J, Gordon K, Dubrow R, Justice A, Brown ST, Goulet J, Butt AA, Crystal S, Rimland D, Rodriguez-Barradas M, Gibert C, Park LS, Crothers K. HIV as an independent risk factor for incident lung cancer. AIDS 2012; 26:1017-25. [PMID: 22382152 DOI: 10.1097/qad.0b013e328352d1ad] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is unclear whether the elevated rate of lung cancer among HIV-infected persons is due to biological effects of HIV, surveillance bias, or excess smoking. We compared the incidence of lung cancer between HIV-infected and demographically similar HIV-uninfected patients, accounting for smoking and stage of lung cancer at diagnosis. DESIGN Data from the Veterans Aging Cohort Study Virtual Cohort were linked to data from the Veterans Affairs Central Cancer Registry, resulting in an analytic cohort of 37,294 HIV-infected patients and 75,750 uninfected patients. METHODS We calculated incidence rates of pathologically confirmed lung cancer by dividing numbers of cases by numbers of person-years at risk. We used Poisson regression to determine incidence rate ratios (IRRs), adjusting for age, sex, race/ethnicity, smoking prevalence, previous bacterial pneumonia, and chronic obstructive pulmonary disease. RESULTS The incidence rate of lung cancer in HIV-infected patients was 204 cases per 100,000 person-years [95% confidence interval (CI) 167-249] and among uninfected patients was 119 cases per 100,000 person-years (95% CI 110-129). The IRR of lung cancer associated with HIV infection remained significant after multivariable adjustment (IRR 1.7; 95% CI 1.5-1.9). Lung cancer stage at presentation did not differ between HIV-infected and uninfected patients. CONCLUSION In our cohort of demographically similar HIV-infected and uninfected patients, HIV infection was an independent risk factor for lung cancer after controlling for potential confounders including smoking. The similar stage distribution between the two groups indicated that surveillance bias was an unlikely explanation for this finding.
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Park LS, Tate JP, Justice AC, Lo Re V, Lim JK, Bräu N, Brown ST, Butt AA, Gibert C, Goetz MB, Rimland D, Rodriguez-Barradas MC, Dubrow R. FIB-4 index is associated with hepatocellular carcinoma risk in HIV-infected patients. Cancer Epidemiol Biomarkers Prev 2011; 20:2512-7. [PMID: 22028407 DOI: 10.1158/1055-9965.epi-11-0582] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Chronic inflammation caused by hepatitis B virus infection, hepatitis C virus infection, and/or heavy alcohol use can lead to fibrosis, cirrhosis, and eventually hepatocellular carcinoma (HCC). FIB-4 is an index score calculated from platelet count, alanine transaminase, aspartate transaminase, and age that predicts fibrosis and cirrhosis. We hypothesized that high FIB-4 would be associated with development of HCC in HIV-infected persons, who are at high risk due to high prevalence of viral hepatitis and alcohol consumption, and possibly due to HIV infection itself. METHODS Using proportional hazards models, we tested this hypothesis among 22,980 HIV-infected men from the Veterans Aging Cohort Study. We identified incident HCC cases from the Veterans Affairs Central Cancer Registry. RESULTS During follow-up, there were 112 incident HCC diagnoses. The age- and race/ethnic group-adjusted HR was 4.2 [95% confidence interval (CI), 2.4-7.4] for intermediate FIB-4 and 13.0 (95% CI, 7.2-23.4) for high FIB-4, compared with low FIB-4. After further adjustment for enrollment year, CD4 count, HIV-1 RNA level, antiretroviral therapy use, hepatitis B and C virus infection, alcohol abuse/dependency, and diabetes, FIB-4 remained a strong, significant, independent risk factor for HCC. The multivariate-adjusted HR was 3.6 (95% CI, 2.1-6.4) for intermediate FIB-4 and 9.6 (95% CI, 5.2-17.4) for high FIB-4. CONCLUSIONS Calculated from routine, noninvasive laboratory tests, FIB-4 is a strong, independent HCC risk factor in HIV-infected patients. IMPACT FIB-4 might prove valuable as an easily measured index to identify those at highest risk for HCC, even prior to development of clinical cirrhosis.
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Tuggle CT, Park LS, Roman S, Udelsman R, Sosa JA. Rehospitalization among elderly patients with thyroid cancer after thyroidectomy are prevalent and costly. Ann Surg Oncol 2010; 17:2816-23. [PMID: 20552406 DOI: 10.1245/s10434-010-1144-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Thyroid cancer increases in incidence and aggressiveness with age. The elderly are the fastest growing segment of the U.S. population. Reducing rates of rehospitalization would lower cost and improve quality of care. This is the first study to report population-level information characterizing rehospitalization after thyroidectomy among the elderly. METHODS The Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was used to identify patients older than aged 65 years with thyroid cancer who underwent thyroidectomy from 1997-2002. Patient and hospital characteristics were studied to predict the risk of rehospitalization. Outcomes were 30-day unplanned rehospitalization rate, cost, and length of stay (LOS) of readmission. RESULTS Of 2,127 patients identified, 69% were women, 84% had differentiated thyroid cancer, and 52% underwent total thyroidectomy. Mean age was 74 years. A total of 171 patients (8%) underwent 30-day unplanned rehospitalization. Rehospitalization was associated with increased comorbidity, advanced stage, number of lymph nodes examined, increased LOS of index admission, and small hospital size (all P < 0.05). Patients with a complication during index hospital stay were more likely to be readmitted (P < 0.001), whereas patients who saw an outpatient medical provider after index discharge returned less frequently (P < 0.001). Forty-seven percent of readmissions were for endocrine-related causes. Mean LOS and cost of rehospitalization were 3.5 days and $5,921, respectively. Unplanned rehospitalization was associated with death at 1 year compared with nonrehospitalized patients (18% vs. 6%; P < 0.001). DISCUSSION Rehospitalization among Medicare beneficiaries with thyroid cancer after thyroidectomy is prevalent and costly. Further study of predictors could identify high-risk patients for whom enhanced preoperative triage, improved discharge planning, and increased outpatient support might prove cost-effective.
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Affiliation(s)
- Charles T Tuggle
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Clifford DB, Smurzynski M, Park LS, Yeh TM, Zhao Y, Blair L, Arens M, Evans SR. Effects of active HCV replication on neurologic status in HIV RNA virally suppressed patients. Neurology 2009; 73:309-14. [PMID: 19636051 DOI: 10.1212/wnl.0b013e3181af7a10] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) is a frequent copathogen with HIV. Both viruses appear to replicate in the brain and both are implicated in neurocognitive and peripheral neuropathy syndromes. Interaction of the viruses is likely to be complicated and better understanding of the contributions of each virus will be necessary to make evidence-based therapeutic decisions. METHODS This study was designed to determine if active HCV infection, identified by quantitative HCV RNA determination, is associated with increased neurocognitive deficits or excess development of distal sensory peripheral neuropathy in HIV coinfected patients with stable HIV viral suppression. The AIDS Clinical Trials Group Longitudinal Linked Randomized Trials (ALLRT) study was the source of subjects with known HIV treatment status, neurocognitive and neuropathy evaluations, and HCV status. Subjects were selected based on HCV antibody status (249 positive; 310 negative). RESULTS HCV RNA viral loads were detectable in 172 participants with controlled HIV infection and available neurologic evaluations in the ALLRT. These participants were compared with 345 participants with undetectable HCV viral load and the same inclusion criteria from the same cohort. Neurocognitive performance measured by Trail-Making A or B and digit symbol testing was not dissimilar between the 2 groups. In addition, there was no significant association between active HCV replication and distal sensory neuropathy. CONCLUSION Clinically significant neurocognitive dysfunction and peripheral neuropathy were not exacerbated by active hepatitis C virus infection in the setting of optimally treated HIV infection.
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Affiliation(s)
- D B Clifford
- Washington University, St. Louis, MO 63110, USA.
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Cosman D, Kumaki S, Ahdieh M, Eisenman J, Grabstein KH, Paxton R, DuBose R, Friend D, Park LS, Anderson D. Interleukin 15 and its receptor. Ciba Found Symp 2007; 195:221-9; discussion 229-33. [PMID: 8724840 DOI: 10.1002/9780470514849.ch15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Interleukin 15 (IL-15) is a member of the four-helix bundle cytokine family that shares many in vitro biological activities with IL-2. Previous work demonstrated that IL-15 utilizes the beta and gamma chains of the IL-2 receptor (IL-2R), and that these are essential for IL-15-mediated signal transduction. However, several lines of evidence indicated the existence of an additional, IL-15-specific receptor component. An IL-15 binding chain was identified on a murine T cell clone, and direct expression cloning was used to isolate the corresponding cDNA. The predicted structure of this protein shows sequence similarity to the IL-2R alpha chain. Transfection of this cDNA into a murine, IL-3-dependent myeloid cell line, 32D-01, conferred IL-15 binding and, together with transfection of the IL-2R beta chain, rendered the cells responsive to IL-15 stimulation. This experiment confirmed that the IL-15 binding chain is part of the IL-15 receptor, and it is designated as the IL-15R alpha subunit. The expression pattern of the IL-15R alpha mRNA is distinct from that of IL-2R alpha mRNA. Recombinant expression of a soluble form of IL-15R alpha demonstrated that it is a potent inhibitor of IL-15 biological activity.
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Affiliation(s)
- D Cosman
- Immunex Research and Development Corporation, Seattle, WA 98101, USA
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Park LS, Sarnoff R, Bender C, Korenbrot C. Impact of recent welfare and immigration reforms on use of Medicaid for prenatal care by immigrants in California. ACTA ACUST UNITED AC 2006; 2:5-22. [PMID: 16228728 DOI: 10.1023/a:1009583205346] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study investigates the impact of the recent welfare and immigration changes on the use of Medicaid by low-income pregnant immigrant women in California. The study presents findings from interviews with government officials, safety-net prenatal care providers, and immigrant advocates who serve low-income pregnant Asian and Latina immigrants at the national, state, or local levels. These informants spoke of policy actions that affect immigrants' abilities to use Medicaid for coverage of prenatal care. These actions include (1) the sharing of information between the California Department of Health Services and the federal Immigration and Naturalization Service, (2) the slow and confusing implementation of the reforms, and (3) the intimidating Medicaid eligibility process. The findings demonstrate how the policies changed the immigrant women's relationship with safety-net prenatal care providers, and sparked intense actions on the part of their advocates to sustain the women's access to perinatal care.
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Affiliation(s)
- L S Park
- Ethnic Studies and Women's Studies Department, University of Colorado, Boulder, Colorado 80309, USA
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Guo XL, Yang KS, Hyun JY, Kim WS, Lee DH, Min KE, Park LS, Seo KH, Kim YI, Cho CS, Kang IK. Morphology and metabolism of Ba-alginate-encapsulated hepatocytes with galactosylated chitosan and poly(vinyl alcohol) as extracellular matrices. J Biomater Sci Polym Ed 2004; 14:551-65. [PMID: 12901437 DOI: 10.1163/15685620360674245] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Lactobionic acid, bearing a beta-galactose group, was coupled with chitosan to provide synthetic extracellular matrices together with poly(vinyl alcohol) (PVA). The hepatocytes encapsulated in Ba-alginate capsules with galactosylated chitosan (GC) and PVA as extracellular matrices showed aggregation morphologies as the incubation time increased. Ba-alginate-encapsulated hepatocytes with GC exhibited a higher metabolic function in albumin secretion compared to those entrapped in Ba-alginate beads and monolayer-cultured on a collagen-immobilized polystyrene dish. The ammonia removal ability of monolayer-cultured hepatocytes decreased with increasing culture time and disappeared completely after three days. In contrast, the ammonia removal ability of encapsulated and entrapped hepatocytes increased with increasing incubation time in the first seven and five days, respectively. Thereafter, the entrapped hepatocytes lost ammonia removal ability quickly while the encapsulated hepatocytes kept a relatively high ammonia removal ability up to 13 days. The trace amount of GC in the core matrices enabled encapsulated cells to enhance their ammonia removal and albumin secretion ability. The results obtained with 3-(3,4-dimethylthiazol-2yl)-2,5-diphenyltetrazolium bromide (MTT) also showed that the capsules incorporated with GC can provide a better microenvironment for cell aggregation along with nutrition and metabolite transfer. Due to the nature of the liquid core, the encapsulated hepatocytes showed very good mobility. This facilitated cell-cell interaction and cell-matrix interaction.
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Affiliation(s)
- X L Guo
- Department of Polymer Science, Kyungpook National University, Taegu 702-701, South Korea
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Brannan CI, Disteche CM, Park LS, Copeland NG, Jenkins NA. Autosomal telomere exchange results in the rapid amplification and dispersion of Csf2ra genes in wild-derived mice. Mamm Genome 2001; 12:882-6. [PMID: 11707773 DOI: 10.1007/s00335-001-2084-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2001] [Accepted: 08/07/2001] [Indexed: 11/30/2022]
Abstract
Common laboratory strains such as C57BL/6J carry a single Csf2ra gene that maps to the distal end of Chromosome (Chr) 19. Here we report that several species of wild mice contain multiple Csf2ra genes. Using interspecific backcross mapping and in situ hybridization, we demonstrate that one of these species, Mus spretus, carries four Csf2ra genes dispersed among the distal tips of Chrs 4, 10, 13, and 19. Our data further suggest that these additional Csf2ra genes are not generated by retrotransposition, but rather by nonhomologous subtelomeric exchanges that could be mediated in part by ribosomal genes located at the subtelomeric regions of Chrs 4, 13, and 19. Although we do not know whether these additional Csf2ra genes are functionally active, our studies suggest that subtelomeric exchange provides a potent means for rapid gene amplification in the mouse.
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Affiliation(s)
- C I Brannan
- Mouse Cancer Genetics Program, National Cancer Institute-Frederick, Frederick, Maryland 21702, USA.
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Yao Z, Garmestani K, Wong KJ, Park LS, Dadachova E, Yordanov A, Waldmann TA, Eckelman WC, Paik CH, Carrasquillo JA. Comparative cellular catabolism and retention of astatine-, bismuth-, and lead-radiolabeled internalizing monoclonal antibody. J Nucl Med 2001; 42:1538-44. [PMID: 11585870] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
Abstract
UNLABELLED Monoclonal antibodies (mAbs) labeled with alpha-emitting radionuclides such as (211)At, (212)Bi, (213)Bi, and (212)Pb (which decays by beta-emission to its alpha-emitting daughter, (212)Bi) are being evaluated for their potential applications for cancer therapy. The fate of these radionuclides after cells are targeted with mAbs is important in terms of dosimetry and tumor detection. METHODS In this study, we attached various radionuclides that result in alpha-emissions to T101, a rapidly internalizing anti-CD5 mAb. We then evaluated the catabolism and cellular retention and compared them with those of (125)I- and (111)In-labeled T101. T101 was labeled with (211)At, (125)I, (205,6)Bi, (111)In, and (203)Pb. CD5 antigen-positive cells, peripheral blood mononuclear cells (PBMNC), and MOLT-4 leukemia cells were used. The labeled T101 was incubated with the cells for 1 h at 4 degrees C for surface labeling. Unbound activity was removed and 1 mL medium added. The cells were then incubated at 37 degrees C for 0, 1, 2, 4, 8, and 24 h. The activity on the cell surface that internalized and the activity on the cell surface remaining in the supernatant were determined. The protein in the supernatant was further precipitated by methanol for determining protein-bound and non-protein-bound radioactivity. Sites of internal cellular localization of radioactivity were determined by Percoll gradient centrifugation. RESULTS All radiolabeled antibodies bound to the cells were internalized rapidly. After internalization, (205,6)Bi, (203)Pb, and (111)In radiolabels were retained in the cell, with little decrease of cell-associated radioactivity. However, (211)At and (125)I were released from cells rapidly ((211)At < (125)I) and most of the radioactivity in the supernatant was in a non-protein-bound form. Intracellular distribution of radioactivity revealed a transit of the radiolabel from the cell surface to the lysosome. The catabolism patterns of MOLT-4 cells and PBMNC were similar. CONCLUSION (211)At catabolism and release from cells were somewhat similar to that of (125)I, whereas (205,6)Bi and (203)Pb showed prolonged cell retention similar to that of (111)In. These catabolism differences may be important in the selection of alpha-radionuclides for radioimmunotherapy.
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Affiliation(s)
- Z Yao
- Department of Nuclear Medicine, Warren G. Magnuson Clinical Center, National Institutes of Health, 10 Center Dr., Bethesda, MD 20892-1180, USA
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Abstract
In this study, polyamine flocculants were synthesized and applied to Nak-dong river raw water in Korea to examine their efficiency in reducing turbidity, total organic carbon (TOC) and UV254. Synthesized polyamines were effective as flocculants for water treatment and the addition of organic polymer caused a reduction of 50-80% of the consumption of polyaluminium chloride (PAC). The effects of polyamine on the removal of turbidity, TOC and UV254 were investigated via both jar and pilot tests. The adsorption and separation mechanisms for the removal of turbidity and TOC by using the polymer flocculants were also observed.
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Affiliation(s)
- S H Lee
- Department of Environmental Engineering, KyungPook National University, Taegu, Korea
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Barile GR, Chang SS, Park LS, Reppucci VS, Schiff WM, Schmidt AM. Soluble cellular adhesion molecules in proliferative vitreoretinopathy and proliferative diabetic retinopathy. Curr Eye Res 1999; 19:219-27. [PMID: 10487959 DOI: 10.1076/ceyr.19.3.219.5314] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To measure vitreous levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cellular adhesion molecule-1 (sVCAM-1) in the eyes of patients with retinal detachment (RD) due to proliferative diabetic retinopathy (PDR) or proliferative vitreoretinopathy (PVR) and to determine whether the levels of these mediators correlated with clinical parameters of disease. METHODS Undiluted vitreous specimens were collected from 50 eyes of 48 patients undergoing vitrectomy for traction RD due to PDR (21 specimens) and recurrent RD due to PVR (19 specimens). Control vitreous specimens were obtained from patients undergoing macular hole repair (10 specimens). The levels of sICAM-1 and sVCAM-1 were measured in each sample by specific enzyme-linked immunoadsorbent assays. RESULTS Vitreous levels of sICAM-1 were significantly increased in vitreous specimens from both PVR (median +/- SD; 12.0 +/- 76.3 ng/ml; P < 0.01) and PDR (8.4 +/- 24.0 ng/ml; P < 0.01) when compared to vitreous from eyes with macular holes (0. 3 +/- 4.2 ng/ml). Vitreous levels of sVCAM-1 were significantly increased in both PVR (36.5 +/- 255.2 ng/ml; P < 0.001) and PDR (26. 2 +/- 93.5 ng/ml; P < 0.01) when compared to control vitreous (17.7 +/- 7.8 ng/ml). The vitreous levels of sICAM-1 were higher in cases of PDR which developed recurrent proliferative disease (P < 0.01) and recurrent RD (P = 0.01), whereas the levels of sICAM-1 in PVR and sVCAM-1 in PDR and PVR did not significantly correlate with these clinical parameters. CONCLUSIONS Soluble forms of ICAM-1 and VCAM-1 are increased in the vitreous cavity of patients with RD due to PDR or PVR, reflecting the inflammatory nature of these conditions and suggesting a possible role for these mediators in the pathogenesis of proliferative retinal disease. The vitreous levels of these sCAMs at the time of surgery may serve as a marker of inflammation, but their specific levels do not predict the likelihood of recurrent proliferation or surgical anatomic success in most cases of PVR and PDR.
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Affiliation(s)
- G R Barile
- The Edward S Harkness Eye Institute St Luke's-Roosevelt Hospital Center Columbia University College of Physicians & Surgeons Department of Ophthalmology NY, 10032, USA.
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Yao Z, Spriggs MK, Derry JM, Strockbine L, Park LS, VandenBos T, Zappone JD, Painter SL, Armitage RJ. Molecular characterization of the human interleukin (IL)-17 receptor. Cytokine 1997; 9:794-800. [PMID: 9367539 DOI: 10.1006/cyto.1997.0240] [Citation(s) in RCA: 191] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Human interleukin 17 (hIL-17) is a T-cell derived cytokine that exhibits 63% amino acid sequence identity to mouse IL-17 (mIL-17) and 57% identity to a viral protein encoded by the herpesvirus saimiri (HSV) gene 13 (HVS13). The IL-17 family of proteins binds to a unique mouse receptor (mIL-17R). Using nucleic acid hybridization techniques, a cDNA encoding a human homologue of the mIL-17R (hIL-17R) was isolated from a human T cell library. The predicted amino acid sequence of the hIL-17R is 69% identical to the mIL-17R, shares no homology with previously identified cytokine receptor families, and exhibits a broad tissue distribution. The hIL-17R gene was localized to chromosome 22. Monoclonal antibodies (mAbs) generated against the hIL-17R were able to block the IL-17-induced production of cytokine from human foreskin fibroblast (HFF) cells. Binding studies suggest that recombinant hIL-17 binds to the hIL-17R with low affinity.
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MESH Headings
- Amino Acid Sequence
- Animals
- Antibodies, Monoclonal
- Antigens, Differentiation, T-Lymphocyte/chemistry
- Cell Separation
- Chromosome Mapping
- Chromosomes, Human, Pair 22
- Electrophoresis, Polyacrylamide Gel
- Flow Cytometry
- Humans
- Interleukin-17
- Interleukin-6/biosynthesis
- Interleukins/antagonists & inhibitors
- Interleukins/metabolism
- Mice
- Molecular Sequence Data
- Molecular Weight
- RNA, Messenger/metabolism
- Receptors, Interleukin/genetics
- Receptors, Interleukin/immunology
- Receptors, Interleukin/metabolism
- Receptors, Interleukin-17
- Recombinant Proteins/genetics
- Recombinant Proteins/immunology
- Recombinant Proteins/metabolism
- Sequence Alignment
- Sequence Homology, Amino Acid
- T-Lymphocytes/chemistry
- Tissue Distribution
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Affiliation(s)
- Z Yao
- Department of Molecular Biology, Immunex Corporation, Seattle, WA 98101, USA
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Mosley B, De Imus C, Friend D, Boiani N, Thoma B, Park LS, Cosman D. Dual oncostatin M (OSM) receptors. Cloning and characterization of an alternative signaling subunit conferring OSM-specific receptor activation. J Biol Chem 1996; 271:32635-43. [PMID: 8999038 DOI: 10.1074/jbc.271.51.32635] [Citation(s) in RCA: 303] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Oncostatin M (OSM) is a cytokine whose structural and functional features are similar to other members of the interleukin (IL)-6 family of cytokines (IL-6, IL-11, leukemia inhibitory factor (LIF), granulocyte colonystimulating factor, ciliary neurotrophic factor, and cardiotrophin-1), many of which utilize gp130 as a common receptor subunit. A biologically active OSM receptor has been previously described that consists of a heterodimer of leukemia inhibitory factor receptor (LIFR) and gp130. This LIFR.gp130 complex is also a functional receptor for LIF. We have cloned and characterized an alternative subunit (OSMRbeta) for an OSM receptor complex (a heterodimer of gp130 and OSMRbeta) that is activated by OSM but not by LIF. The signaling capability of specific receptor subunit combinations was analyzed by independent assays measuring cell proliferation or induction of acute phase protein synthesis. Our results demonstrate that both LIF and OSM cause tyrosine phosphorylation and activation of the gp130.LIFR combination, but the gp130.OSMRbeta complex is activated by OSM only. OSM-induced cellular responses, initiated through low affinity binding to gp130, are mediated by two heterodimeric receptor complexes that utilize alternative signal transducing subunits that confer different cytokine specificities to the receptor complex.
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MESH Headings
- Acute-Phase Proteins/biosynthesis
- Alternative Splicing
- Amino Acid Sequence
- Base Sequence
- Carcinoma, Hepatocellular
- Cloning, Molecular
- Gene Expression
- Growth Inhibitors
- Humans
- Interleukin-6
- Leukemia Inhibitory Factor
- Leukemia Inhibitory Factor Receptor alpha Subunit
- Lymphokines
- Molecular Sequence Data
- RNA, Messenger/genetics
- Receptors, Cytokine/chemistry
- Receptors, Cytokine/classification
- Receptors, Cytokine/genetics
- Receptors, Cytokine/metabolism
- Receptors, Cytokine/physiology
- Receptors, OSM-LIF
- Receptors, Oncostatin M
- Sequence Homology, Amino Acid
- Signal Transduction
- Tissue Distribution
- Tumor Cells, Cultured
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Affiliation(s)
- B Mosley
- Immunex Corporation, Seattle, Washington 98101, USA
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Böhme B, VandenBos T, Cerretti DP, Park LS, Holtrich U, Rübsamen-Waigmann H, Strebhardt K. Cell-cell adhesion mediated by binding of membrane-anchored ligand LERK-2 to the EPH-related receptor human embryonal kinase 2 promotes tyrosine kinase activity. J Biol Chem 1996; 271:24747-52. [PMID: 8798744 DOI: 10.1074/jbc.271.40.24747] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Human embryonal kinase 2 (HEK2) is a protein-tyrosine kinase that is a member of the EPH family of receptors. Transcripts for HEK2 have a wide tissue distribution. Recently, a still growing family of ligands, which we have named LERKs, for ligands of the eph-related kinases, has been isolated. In order to analyze functional effects between the LERKs and the HEK2 receptor, we expressed HEK2 cDNA in an interleukin-3-dependent progenitor cell line 32D that grows as single cells in culture. Within the group of LERKs, LERK-2 and -5 were shown to bind to HEK2. Membrane-bound and soluble forms of LERK-2 were demonstrated to signal through HEK2 as judged by receptor phosphorylation. Coincubation of HEK2 and LERK-2 expressing cells induced cell-cell adhesion and formation of cell aggregates. This interaction could be inhibited by preincubation of HEK2 expressing cells with soluble LERK-2. Coexpression of HEK2 and LERK-2 in 32D cells showed reduced kinase activity and autophosphorylation of HEK2 compared with the juxtacrine stimulation, which seems to be due to a reduced sensitivity of the receptor.
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Affiliation(s)
- B Böhme
- Chemotherapeutisches Forschungsinstitut, Georg-Speyer-Haus, 60596 Frankfurt, Federal Republic of Germany
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Abstract
IL-15 interacts with a heterotrimeric receptor that consists of the beta and gamma subunits of the IL-2 receptor (IL-2R) as well as a specific, high-affinity IL-15-binding subunit, which is designated IL-15R alpha. Since both the beta and the gamma subunits of the IL-2R are required for signaling by either IL-2 or IL-15, it is not surprising that these cytokines share many activities in vitro. However, the differential expression of these cytokines and the alpha chains of their receptors within various tissues and cell types suggests that IL-2 and IL-15 may perform at least partially distinct physiological functions. The production of IL-15 by macrophages, and possibly other cell types, in response to environmental stimuli and infectious agents suggests that IL-15 may play a role in protective immune responses, allograft rejection, and the pathogenesis of autoimmune diseases.
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Affiliation(s)
- M K Kennedy
- Immunex Corporation, Seattle, Washington 98101-2936, USA
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