Abstract P542: Classifying COVID-19 Related Hospitalizations and Deaths in the Collaborative Cohort of Cohorts for COVID-19 Research (C4R) Study

Objectives: Administrative criteria are often used to define COVID-19 outcomes despite challenges in differentiating hospitalization “for” vs “with” COVID-19 and unknown reliability for identifying COVID-related cardiopulmonary complications. We implemented a protocol to adjudicate COVID-related events across 14 studies participating in C4R.

Methods: C4R cohorts ascertained COVID-related hospitalizations and deaths via questionnaires or ongoing surveillance. Medical records were reviewed by C4R physicians using a standardized protocol to assign COVID-related diagnoses as definite or probable. C4R diagnoses were compared against ICD codes assigned to the events. This report includes data from events centrally adjudicated by C4R as of September 2022.

Results: Among 144 events ascertained across 7 cohorts as potentially COVID-related, SARS-CoV-2 infection was confirmed in 107/117 (91%) non-fatal hospitalizations and 26/27 (96%) deaths. Of confirmed infections, COVID-19 illness was diagnosed as the cause of 101/107 (94%) hospitalizations and 24/26 (92%) deaths ( Table ). Of non-fatal hospitalizations with infection, 72% were diagnosed with severe or critical COVID-19, 78% with COVID-associated pneumonia, and 29% with renal failure; other complications were less common. C4R review did not validate diagnoses indicated by ICD codes for 1 COVID-19 infection, 5 pneumonias, 1 stroke, and 7 renal failure cases. C4R review did identify diagnoses that were not ICD-coded for 13 infections, 31 pneumonias, 6 myocardial infarctions, 5 venous thromboses, and 21 renal failure cases.

Conclusions: Protocolized medical records review by C4R confirmed COVID-19 as the cause of hospitalization or death in 87% of events ascertained as potentially COVID-related and 94% of those in which SARS-CoV-2 infection was confirmed. Both false-positive and false-negative misclassification by ICD criteria was observed. Protocolized review may be useful to identify and validate COVID-related events for epidemiologic research.

0475 Reducing Dysfunctional Sleep-Related Cognitions Improves Nighttime Sleep and Daytime Consequences in Older Adults with Insomnia

Introduction

The long-term impact of addressing sleep-related cognitions, which is an important component of cognitive behavioral therapy for insomnia (CBTI), has not been established, particularly in older adults. We examined whether specific changes in sleep-related cognitions predicted long-term changes in sleep and other outcomes following CBTI in older adults.

Methods

We analyzed data from a randomized controlled trial testing CBTI in older veterans with insomnia (N=159, mean age 72 years). Sleep-related cognitions were assessed with the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS, subscales: Consequences, Worry/Helplessness, Sleep Expectations, Medication). Outcome measures included the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), sleep diary variables, Flinders Fatigue Scale (FFS), and Short Form-12 health-related quality of life (QOL). Analyses completed slope of change in DBAS subscales (baseline to post-treatment: T1) between CBTI and control with respect to slope of change in sleep and other outcomes from post-treatment to 6-months (T2).

Results

Compared to controls, the CBTI group had significantly stronger associations between improvement (T1) in DBAS-Consequences and subsequent (T2) improvement in PSQI (difference in slopes [DIS]=0.9, 95%CI=[.29, 1.43], p=0.004), ISI (DIS=1.1, 95%CI=[.18, 2.0], p=0.019), ESS (DIS=0.6, 95%CI=[.10, 1.18], p=0.020), and FFS (DIS=1.9, 95%CI=[.76, 3.09], p=0.001). The CBTI group also had significantly stronger associations between improvement in DBAS-Worry/Helplessness and subsequent improvements in PSQI, ISI, and FFS; improvement in DBAS-Medication and PSQI and ISI; and improvement in DBAS-Sleep Expectations and improved FFS. Slopes were not different between groups for sleep diary variables or QOL.

Conclusion

Significant improvements in sleep-related cognitions with CBTI across DBAS subscales in older adults predicted improvement in several outcomes of nighttime sleep and daytime consequences. These findings suggest the importance of addressing dysfunctional sleep-related cognitions for sustained improvement with CBTI in older adults

Support

The study was supported by VA Health Services, Research and Development (Alessi, IIR 08-295), National Institute on Aging (K23AG055668, Song), National Heart, Lung, and Blood Institute (K24HL 143055, Martin) of the National Institutes of Health and VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center.

0537 Cognitive Functioning Before and After Insomnia Treatment in Women Veterans

Introduction

Women are at higher risk for cognitive impairment and dementia compared to men. Identifying potentially treatable risk factors such as insomnia is an important clinical goal. In a trial comparing two behavioral treatments for insomnia in women veterans, we hypothesized that 1) worse baseline insomnia severity would be associated with poorer cognitive function, and 2) improvement in insomnia severity with treatment would be associated with improvement in cognitive functioning.

Methods

347 women veterans with insomnia disorder [mean age 48.3 (12.9) years] completed baseline testing. Of these, 149 women were randomized to receive cognitive behavioral therapy for insomnia (CBT-I) or acceptance and commitment (ACT) based insomnia treatment (both treatments included sleep restriction, stimulus control, and sleep hygiene). Insomnia Severity Index (ISI) was assessed at baseline, post-treatment, and 3-month follow-up. Cognitive functioning was measured with Symbol Digit Coding (SDC) and Trail Making Test A and B (TMTA and TMTB). Pearson correlations were used to examine associations between insomnia severity and cognitive functioning at baseline and changes in both insomnia severity and cognitive functioning from before to after treatment.

Results

At baseline (N=347), mean ISI was 14.1 (5.3). Worse baseline ISI was associated with worse baseline cognitive functioning on TMTA (r=-.15, p<.01) and SDC (r=-.12, p<.05). In the randomized sample (N=149), ISI scores improved at post-treatment (mean ISI change= -9.0; p<.001) and 3-month follow-up (mean change= -8.0; p<.001) relative to baseline. Improvement in ISI from baseline to post-treatment was significantly associated with improvement in SDC from baseline to post-treatment (r=-.18, p<.05), but not improvement in TMTA and TMTB. Change in ISI was not significantly related to change in cognitive tasks from baseline to 3-month follow-up.

Conclusion

More severe insomnia is associated with worse cognitive functioning in women veterans. The magnitude of improvement in insomnia symptoms may be associated with improvement in cognition.

Support

NIH/NIA K23AG049955 (PI: Dzierzewski); VA/HSR&D IIR-HX002300 (PI: Martin), NIH/NHLBI K24HL143055 (PI: Martin).

0467 Benefits of CBT-I for Women Veterans with and without PTSD

Introduction

A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of CBT-I in women with insomnia plus PTSD. The current analyses examined changes in sleep symptoms, quality of life (QoL), and mental health symptoms from pre- to post-CBT-I in WVs with and without PTSD.

Methods

This was a secondary analysis of 75 WVs with insomnia (32 with probable PTSD), who received CBT-I within a behavioral sleep intervention study (NCT02076165). Measures completed at baseline, posttreatment, and 3-month follow-up included: insomnia severity (Insomnia Severity Index, ISI), sleep quality (Pittsburgh Sleep Quality Index, PSQI), PTSD symptoms (PTSD Checklist-5, PCL-5; probable PTSD=total score ≥33), depressive symptoms (Patient Health Qestionnaire-9, PHQ-9), and mental and physical quality of life (Short Form Health Survey, SF-12). One sample T-tests examined changes in ISI, PSQI, PHQ-9, PCL-5, and SF-12 from baseline to posttreatment and baseline to follow-up. Two samples T-tests compared change scores in ISI, PSQI, PHQ-9, and SF-12 between participants with and without PTSD.

Results

There were significant improvements in ISI (p≤.001), PSQI (p≤.001), PHQ-9 (p≤.001), PCL-5 (p=.001), and SF-12 mental (p≤.001) and physical (p=.03) from baseline to posttreatment and 3-month follow-up (p≤.001-.01). There were no significant change score differences between WVs with and without PTSD from baseline to posttreatment (p=.06-.98) or 3-month follow-up (p=.09-.93).

Conclusion

CBT-I appears to be an effective treatment to improve insomnia symptoms among WVs with and without PTSD, and may reduce psychiatric symptoms as well. These findings suggest WVs with comorbid insomnia and PTSD benefit from CBT-I. The appropriate sequencing of CBT-I and PTSD treatments remains potentially important, but unstudied.

Support

VA/HSR&D IIR-HX002300; NIH/NHLBI K24HL14305; VA Office of Academic Affiliations through the Advanced Fellowship Programs in HSR&D and Women’s Health

0131 Decreased Habitual Sleep Efficiency is Associated with Increased Insulin Resistance in Healthy Adult Men

Introduction

Partial sleep deprivation is associated with increased insulin resistance (IR), a metabolic disease risk marker. Little is known about habitual sleep patterns and IR in the absence of acute sleep restriction. We anticipated greater change in habitual sleep over one month would be associated with increased IR.

Methods

24 males (age=33.6±6.4 years; BMI=25.7±2.5kg/m2) completed baseline (T1) and follow-up (T2; ≥4 weeks post-T1) study procedures: actigraphy (one week) followed by polysomnography (PSG; one 10h sleep opportunity) and a next morning oral glucose tolerance test (OGTT; homeostatic model assessment insulin resistance [HOMA-IR], β-cell function [HOMA-β], and Matsuda Index). Weekly average actigraphy total sleep time (aTST; 291-511min) and sleep efficiency (aSE; 72–93%) were computed at T1 and T2, as well as across the 1, 2, and 3 days prior to PSG/OGTT. Pearson and Spearman correlations assessed the change (T1-T2) in actigraphy (aSEΔ, aTSTΔ, PSGΔ) or PSG sleep (PSG-TSTΔ, PSG-SEΔ, sleep stages) versus change in metabolic risk (HOMA-IRΔ, HOMA-βΔ, MatsudaΔ).

Results

There were significant correlations between HOMA-IRΔ and aSEΔ [r(22)=-0.42, p=0.01; rs=-0.45, p=0.03], PSG TSTΔ [r(22)=0.50, p=0.012; rs=0.41, p=.045], and PSG-SEΔ [r(22)=0.49, p=0.015; rs=0.43, p=.037]. No significant associations emerged between change in metabolic risk versus aTSTΔ one week prior to PSG/OGTT, aSEΔ or aTSTΔ across 1–3 days prior to PSG/OGTT, or PSG sleep stages.

Conclusion

Within-subject T1-T2 decrease in habitual sleep quality, but not TST, was associated with increased IR. T1-T2 PSG TST and SE were associated with following day IR. At home sleep 1–3 days beforehand were not correlated with IR. Although preceding night sleep quality and TST are associated with IR, habitual sleep quality, rather than TST, may be a more important determinant of metabolic risk in community dwelling middle-aged men.

Support

This work was supported by NIH/NHLBI R01HL124211, NIH/NHLBI K24HL138632, NIH National Center for Advancing Translational Sciences (NCATS) UCLA CTSI Grant UL1TR001881 (PI: Liu); and NIH/NHLBI K24HL143055 (PI: Martin). Dr. Kelly is supported by the VA Office of Academic Affiliations through the Advanced Fellowship Programs in Geriatrics.

Can physicians identify inappropriate nuclear stress tests? An examination of inter-rater reliability for the 2009 appropriate use criteria for radionuclide imaging

BACKGROUND

We sought to determine inter-rater reliability of the 2009 Appropriate Use Criteria for radionuclide imaging and whether physicians at various levels of training can effectively identify nuclear stress tests with inappropriate indications.

METHODS AND RESULTS

Four hundred patients were randomly selected from a consecutive cohort of patients undergoing nuclear stress testing at an academic medical center. Raters with different levels of training (including cardiology attending physicians, cardiology fellows, internal medicine hospitalists, and internal medicine interns) classified individual nuclear stress tests using the 2009 Appropriate Use Criteria. Consensus classification by 2 cardiologists was considered the operational gold standard, and sensitivity and specificity of individual raters for identifying inappropriate tests were calculated. Inter-rater reliability of the Appropriate Use Criteria was assessed using Cohen κ statistics for pairs of different raters. The mean age of patients was 61.5 years; 214 (54%) were female. The cardiologists rated 256 (64%) of 400 nuclear stress tests as appropriate, 68 (18%) as uncertain, 55 (14%) as inappropriate; 21 (5%) tests were unable to be classified. Inter-rater reliability for noncardiologist raters was modest (unweighted Cohen κ, 0.51, 95% confidence interval, 0.45-0.55). Sensitivity of individual raters for identifying inappropriate tests ranged from 47% to 82%, while specificity ranged from 85% to 97%.

CONCLUSIONS

Inter-rater reliability for the 2009 Appropriate Use Criteria for radionuclide imaging is modest, and there is considerable variation in the ability of raters at different levels of training to identify inappropriate tests.

Epigallocatechin gallate protects U937 cells against nitric oxide-induced cell cycle arrest and apoptosis

Ingesting phenolic phytochemicals in many plant products may promote health, but the effects of phenolic phytochemicals at the cellular level have not been fully examined. Thus, it was determined if the tea phenolic phytochemical, epigallocatechin gallate (EGCG), protects U937 human pro-monocytic cells against the nitrogen free radical, nitric oxide (*NO). Cells were incubated for 4-6 h with 500 microM S-nitrosoglutathione (GSNO), which generates *NO, but this did not induce single-strand breaks in DNA. Nevertheless, 82 +/- 4% of GSNO-treated cells, compared to only 39 +/- 1% of untreated cells, were arrested in the G(1)-phase of the cell cycle. However, dosing the GSNO-treated cells with 9, 14, or 18 microg/ml of EGCG resulted in only 74 +/- 8%, 66 +/- 1%, and 43 +/- 3% of the cells, respectively, in the G(1)-phase. Exposing cells to GSNO also resulted in the emergence of a sub-G(1) apoptotic cell population numbering 14 +/- 3%, but only 5 +/- 2%, 5 +/- 1%, and 2 +/- 0% upon dosing of the GSNO-treated cells with 9, 14, and 18 microg/ml of EGCG, respectively. Furthermore, exposing cells to GSNO resulted in greater cell surface binding of annexin V-FITC, but binding was 41-89% lower in GSNO-treated cells dosed with EGCG. Collectively, these data suggest that *NO or downstream products induced cell cycle arrest and apoptosis that was not due to single-strand breaks in DNA, and that EGCG scavenged cytotoxic *NO or downstream products, thus reducing the number of cells in a state of cell cycle arrest or apoptosis.

Disparate effects of similar phenolic phytochemicals as inhibitors of oxidative damage to cellular DNA

Phenolic phytochemicals are natural plant substances whose cellular effects have not been completely determined. Nordihydroguaiaretic acid (NDGA) and curcumin are two phenolic phytochemicals with similar molecular structures, suggesting that they possess comparable chemical properties particularly in terms of antioxidant activity. To examine this possibility in a cellular system, this study evaluated the capacities of NDGA and curcumin to function as antioxidants in inhibiting oxidative damage to DNA. Jurkat T-lymphocytes were pre-incubated for 30 min with 0-25 microM of either NDGA or curcumin to allow for uptake. The phenolic phytochemical-treated cells were then oxidatively challenged with 25 microM hydrogen peroxide (H2O2). Afterwards, cells were subjected to alkaline micro-gel electrophoresis (i.e. comet assay) to assess the extent of single-strand breaks in DNA. In a concentration-dependent manner, NDGA inhibited H2O2-induced DNA damage, whereas curcumin did not. In fact, incubating Jurkat T-lymphocytes with curcumin alone actually induced DNA damage. This effect of curcumin on DNA did not appear to reflect the DNA fragmentation associated with apoptosis because there was no proteolytic cleavage of poly-(ADP-ribose)-polymerase, which is considered an early marker of apoptosis. Curcumin-induced damage to DNA was prevented by pre-treatment of the cells with the lipophilic antioxidant, alpha-tocopherol, suggesting that curcumin damaged DNA through oxygen radicals. Therefore, it is concluded that NDGA has antioxidant activity but curcumin has prooxidant activity in cultured cells based on their opposite effects on DNA.

Melatonin inhibits oxidative modification of human low-density lipoprotein

An important property of melatonin is that it is a free-radical scavenger or antioxidant. Since free radicals can induce oxidative modification of low-density lipoprotein (LDL), a process believed to be involved in atherogenesis, we were prompted to evaluate the capacity of melatonin to prevent oxidative modification of LDL. To induce oxidation, human LDL (0.4 mg protein/ml) was incubated at 37 degrees C with either 10 microM cupric chloride or 10 mM 2,2'-azo-bis-(2-amidinopropane) dihydrochloride (AAPH) for 3 hr or 24 hr, respectively. Several assays were then performed to unequivocally determine the extent of LDL oxidation. Compared to native LDL, oxidized LDL had increased agarose gel electrophoretic mobility and weaker immunoreactivity with a murine monoclonal antibody to human apolipoprotein B-100. Measurement of thiobarbituric acid-reactive substances (TBARS) revealed that native LDL contained 1.8 +/- 0.6 nmoles TBARS/mg protein, whereas copper-oxidized LDL contained 53 +/- 4 nmoles TBARS/mg protein. However, when present during incubation, melatonin (0.125-4 mM) inhibited in a concentration-dependent manner the increase in electrophoretic mobility, decrease in immunoreactivity of LDL, and increase in formation of TBARS caused by either copper or AAPH. In a fourth assay, phospholipid analysis of LDL was performed. Native LDL contained 420 +/- 9 nmoles phosphatidylcholine (PC)/mg LDL protein and 30 +/- 20 nmoles lysophosphatidylcholine (LysPC)/mg LDL protein. LDL incubated with copper had a decreased PC content (276 +/- 48 nmoles PC/mg LDL protein) and increased LysPC content (76 +/- 22 nmoles LysPC/mg LDL protein). But when present during the incubation of LDL with copper, melatonin attenuated in a concentration-dependent manner the degradation of PC to LysPC. Therefore, we conclude that melatonin can inhibit oxidative modification of LDL in vitro.

Gastrocolic fistulas: the increasing role of aspirin

Eight patients had gastrocolic fistulas depicted on barium studies at the authors' hospital during a 10-year period between 1982 and 1992. Seven of those patients (88%) had benign disease, including aspirin-induced gastric ulcers of the greater curvature (n = 4), granulomatous colitis (n = 1), tuberculosis (n = 1), and a penetrating anastomotic ulcer after partial gastrectomy (n = 1). The remaining patient had a malignant gastrocolic fistula caused by carcinoma of the transverse colon. Two patients (25%) experienced classic symptoms of gastrocolic fistulas (ie, feculent vomiting or foul-smelling eructations), but the other six (75%) experienced abdominal pain or other nonspecific clinical findings. In the four patients who were taking aspirin, upper gastrointestinal examinations revealed giant penetrating ulcers of the greater curvature that communicated with the superior border of the transverse colon via a fistula. Three of these patients exhibited marked clinical improvement after conservative medical treatment and did not need surgery. This experience suggests that aspirin-induced gastric ulcers of the greater curvature have become a more common cause of gastrocolic fistulas than is carcinoma of the stomach or transverse colon.

A modern argument against legalizing active euthanasia

A Seattle nephrologist cautions against making euthanasia a public policy, citing contemporary concerns over the ethical, legal, medical and societal questions that the issue raises.

Double-blind comparison of standard Sinemet and Sinemet CR in patients with mild-to-moderate Parkinson's disease

The combination of carbidopa and levodopa (Sinemet) is a highly effective treatment for the symptoms of Parkinson's disease. However, side effects, such as abnormal involuntary movements, fluctuations in motor performance, and "wearing off" phenomena limit its long-term usefulness in some patients. Open-label studies show that controlled-release Sinemet CR is effective in reducing motor fluctuations. This report discusses the results of a 14-week double-blind crossover study comparing the efficacy and tolerability of standard Sinemet with controlled-release Sinemet CR. Overall, there were no statistically significant differences in efficacy between Sinemet CR and standard Sinemet on any of the major efficacy measures, suggesting a clinical equivalence in terms of treating the symptoms of Parkinson's disease. The study also supports the tolerability of Sinemet CR. In summary, Sinemet CR holds the promise of reducing some disturbing side effects of long-term levodopa therapy, thus achieving optimal control of parkinsonian symptoms.

Treatment of the anemia of progressive renal failure with recombinant human erythropoietin

To examine the effects of erythropoietin on the anemia of chronic renal disease and on the rate of renal deterioration, we administered recombinant human erythropoietin to 17 patients with anemia and progressive renal failure who did not yet require dialysis (serum creatinine level, 353 to 972 mumol per liter [4.0 to 11.0 mg per deciliter]). The dose of erythropoietin (50 to 150 units per kilogram of body weight) was adjusted according to the hematocrit response. In all 17 patients the anemia responded to erythropoietin. The median hematocrit increased from 0.27 to 0.37. The rate of the response depended on the initial erythropoietin dose and was similar to that observed in patients who were on dialysis. Hypertension was present in 14 patients before therapy, developed during therapy in 2 of the normotensive patients, and worsened in 9 patients, who required additional antihypertensive medications. The rate of the decline in renal function, as measured by serial determination of the reciprocal of the serum creatinine level, did not change significantly as the hematocrit rose (P = 0.78 by the paired t-test) during erythropoietin therapy. All the patients reported improvements in appetite, activity level, and sense of well-being. We conclude that erythropoietin therapy is effective in correcting the anemia of patients with progressive renal failure without affecting renal function, although it may be associated with an increase in blood pressure.

Cefadroxil kinetics in patients with renal insufficiency

Kinetic parameters and bioavailability of cefadroxil were studied in 20 subjects with differing renal function as measured by endogenous creatinine clearance (CCr). Two subjects were on hemodialysis. After an overnight fast, each subject ingested two 500-mg capsules of cefadroxil. The peak serum concentration was variable (12 to 57 mg/L) and correlated inversely with the CCr. All but one patient had maximum absorption within 4 hr of ingestion and in most patients the peak was reached within the 2-hr sample. Urinary recovery within 48 hr was 45% to 106% when CCr greater than 8 ml/min. Even in patients with the most severe renal failure (CCr less than 10 ml/min), urine concentrations of cefadroxil were adequate to treat susceptible bacteria. The rate of oral absorption ka, was not affected by the state of renal function and was 0.76 +/- 0.50 hr-1. The apparent distribution volume (V d ext) was 0.28 +/- 0.09 L/kg. The plasma elimination rate was dependent on CCr wih a small fraction of drug being removed by nonrenal routes. Except in advanced renal failure, tubular secretion was present since renal clearance of cefadroxil exceeded CCr. The data suggest that little drug accumulation will occur with the usual 8- to 12-hr dosing schedule except when the CCr is less than 25 ml/min.

Increased prolactin levels during reserpine treatment of hypertensive patients

Serum prolactin levels are significantly greater among hypertensive patients receiving reserpine as compared to levels six weeks after discontinuing the treatment (P less than .005). This association between regular, long-term reserpine use and greater prolactin levels may be clinically significant, since an increased incidence of breast cancer has been reported among hypertensive patients receiving reserpine.