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McGinnis KA, Justice AC, Marconi VC, Rodriguez-Barradas MC, Hauser RG, Oursler KK, Brown ST, Bryant KJ, Tate JP. Combining Charlson comorbidity and VACS indices improves prognostic accuracy for all-cause mortality for patients with and without HIV in the Veterans Health Administration. Front Med (Lausanne) 2024; 10:1342466. [PMID: 38356736 PMCID: PMC10864663 DOI: 10.3389/fmed.2023.1342466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/31/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction As people age with HIV (PWH), many comorbid diseases are more common than among age matched comparators without HIV (PWoH). While the Veterans Aging Cohort (VACS) Index 2.0 accurately predicts mortality in PWH using age and clinical biomarkers, the only included comorbidity is hepatitis C. We asked whether adding comorbid disease groupings from the Charlson Comorbidity Index (CCI) improves the accuracy of VACS Index. Methods To maximize our ability to model mortality among older age groups, we began with PWoH in Veterans Health Administration (VA) from 2007-2017, divided into development and validation samples. Baseline predictors included age, and components of CCI and VACS Index (excluding CD4 count and HIV RNA). Patients were followed until December 31, 2021. We used Cox models to develop the VACS-CCI score and estimated mortality using a parametric (gamma) survival model. We compared accuracy using C-statistics and calibration curves in validation overall and within subgroups (gender, age ≥65 years, race/ethnicity, and CCI score). We then applied VACS-CCI in PWH and compared its accuracy to age, VACS Index 2.0, CCI and VACS-CCI with CD4 and HIV RNA added. Results The analytic sample consisted of 6,588,688 PWoH and 30,539 PWH. Among PWoH/PWH, median age was 65/55 years; 6%/3% were women; 15%/48% were Black and 5%/7% Hispanic. VACS-CCI provided the best discrimination (C-statistic = 0.81) with excellent calibration (predicted and observed mortality largely overlapped) overall and within subgroups. When VACS-CCI was applied to PWH it demonstrated similar discrimination as VACS Index 2.0 (C-statistic = 0.77 for both) but superior calibration among those with CD4 < 200. Discrimination was improved when CD4 and HIV RNA were added VACS-CCI (C-statistic = 0.79). Liver and kidney disease, congestive heart failure, malignancy, and dementia were negatively associated with CD4 (p-trends all <0.0001). Discussion Among PWH and PWoH in VA care, age alone weakly discriminates risk of mortality. VACS Index 2.0, CCI, and VACS-CCI all provide better discrimination, but VACS-CCI is more consistently calibrated. The association of comorbid diseases with lower CD4 underscores the likely role of HIV in non-AIDS conditions. Future work will include adding CD4 and HIV RNA to VACS-CCI and validating it in independent data.
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Affiliation(s)
| | - Amy C. Justice
- VA Connecticut Healthcare System, West Haven, CT, United States
- Yale School of Medicine, New Haven, CT, United States
| | - Vincent C. Marconi
- The Atlanta Veterans Affairs Medical Center, Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA, United States
- VA Medical Center, Decatur, GA, United States
| | - Maria C. Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Ronald G. Hauser
- VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Krisann K. Oursler
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
- VA Salem Healthcare System, Salem, VA, United States
| | | | - Kendall J. Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - Janet P. Tate
- VA Connecticut Healthcare System, West Haven, CT, United States
- Yale School of Medicine, New Haven, CT, United States
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Janoff EN, Brown ST, Belitskaya-Levy I, Curtis JL, Bonomo RA, Miller EK, Goldberg AM, Zehm L, Wills A, Hutchinson C, Dumont LJ, Gleason T, Shih MC. Design of VA CoronavirUs Research and Efficacy Studies-1 (VA CURES-1): A double-blind, randomized placebo-controlled trial of COVID-19 convalescent plasma in hospitalized patients with early respiratory compromise. Contemp Clin Trials Commun 2023; 35:101190. [PMID: 37560085 PMCID: PMC10407261 DOI: 10.1016/j.conctc.2023.101190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 07/07/2023] [Accepted: 07/15/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Effective therapeutics for severe acute respiratory syndrome CoronaVirus-2 (SARS-CoV-2) infection are evolving. Under Emergency Use Authorization, COVID-19 convalescent plasma (CCP) was widely used in individuals hospitalized for COVID-19, but few randomized controlled trials supported its efficacy to limit respiratory failure or death. METHODS VA CoronavirUs Research and Efficacy Studies-1 (VA CURES-1) was a double-blind, multi-site, placebo-controlled, randomized clinical trial evaluating the efficacy and safety of CCP with conventional therapy in hospitalized Veterans with SARS-CoV-2 infection and early respiratory compromise (requirement for oxygen). Participants (planned sample size 702) were randomized 1:1 to receive CCP with high titer neutralizing activity or 0.9% saline, stratified by site and age (≥65 versus <65 years old). Participants were followed daily during initial hospitalization and at Days 15, 22 and 28. OUTCOMES The composite primary outcome was acute hypoxemic respiratory failure or all-cause death by Day 28. Secondary outcomes by day 28 included time-to-recovery, clinical severity, mortality, rehospitalization for COVID-19, and adverse events. Serial respiratory and blood samples were collected for safety, virologic and immunologic analyses and future studies. Key variables in predicting the success of CURES-1 were: (1) enrollment early in the course of severe infection; (2) use of plasma with high neutralizing activity; (3) reliance on unambiguous, clinically meaningful outcomes. CURES-1 was terminated for futility due to perceived inability to enroll in the lull between the Alpha and Delta waves of the SARS CoV-2 epidemic. CONCLUSIONS VA CURES-1 was a large multi-site trial designed to provide conclusive information about the efficacy of CCP in well-characterized patients at risk for progression of COVID-19. It utilized a rigorous study design with relevant initial timing, quality of product and outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04539275.
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Affiliation(s)
- Edward N. Janoff
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Sheldon T. Brown
- James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Ilana Belitskaya-Levy
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Palo Alto, CA, USA
| | - Jeffrey L. Curtis
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert A. Bonomo
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Case VA CARES, Case Western Reserve University School of Medicine, USA
| | - Elliott K. Miller
- Department of Veterans Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Alexa M. Goldberg
- Department of Veterans Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Lisa Zehm
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Palo Alto, CA, USA
| | - Ashlea Wills
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | | | - Larry J. Dumont
- University of Colorado Denver School of Medicine, Aurora, CO, USA
- Vitalant Research Institute, Denver, CO, USA
| | - Theresa Gleason
- Department of Veterans Affairs, Clinical Science Research and Development Service, Washington, DC, USA
| | - Mei-Chiung Shih
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Palo Alto, CA, USA
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - ADD Caitlin MS in CCTC website
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
- University of Colorado Denver School of Medicine, Aurora, CO, USA
- James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mt. Sinai, New York, NY, USA
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Palo Alto, CA, USA
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Case VA CARES, Case Western Reserve University School of Medicine, USA
- Department of Veterans Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
- Vitalant Research Institute, Denver, CO, USA
- Department of Veterans Affairs, Clinical Science Research and Development Service, Washington, DC, USA
- Stanford University School of Medicine, Palo Alto, CA, USA
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3
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Berg CJ, Patel B, Reynolds M, Tuzovic M, Chew KW, Sico JJ, Bhattacharya D, Butt AA, Lim JK, Bedimo RJ, Brown ST, Gottdiener JS, Warner AL, Freiberg MS, So-Armah KA, Nguyen KL. Left Atrial Mechanics and Diastolic Function Among People Living With Human Immunodeficiency Virus (from the Veterans Aging Cohort Study). Am J Cardiol 2023; 186:50-57. [PMID: 36343446 PMCID: PMC10193525 DOI: 10.1016/j.amjcard.2022.10.035] [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: 07/17/2022] [Revised: 09/27/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
Human immunodeficiency virus (HIV) infection is associated with subclinical cardiomyopathy, diastolic dysfunction, and increased risk of cardiovascular death. However, the relationship between left atrial (LA) mechanics and left ventricular (LV) diastolic function has not been evaluated in people living with HIV (PLWH) relative to HIV-uninfected (HIV-) controls. This is a multicenter, cross-sectional cohort analysis using the HIV Cardiovascular Disease substudy of the Veterans Aging Cohort Study database, which aimed to examine a cohort of PLWH and HIV- veterans without known cardiovascular disease. A total of 277 subjects (180 PLWH, 97 HIV-) with echocardiograms were identified. LV and LA phasic strain were derived and diastolic function was evaluated. Relationship between LA strain, LV strain, and the degree of diastolic dysfunction were assessed using analysis of variance and ordinal logistic regression with propensity weighting. In the PLWH cohort, 91.7% were on antiretroviral therapy and 86.1% had HIV viral loads <500 copies/ml. The mean (± SD) duration of infection was 9.7 ± 4.9 years. Relative to HIV- veterans, PLWH did not differ in LA mechanics and proportion of diastolic dysfunction (p = 0.31). Using logistic regression with propensity weighting, we found no association between HIV status and degree of diastolic dysfunction. In both cohorts, LA reservoir strain and LA conduit strain were inversely and independently associated with the degree of diastolic dysfunction. Compared with HIV- veterans, PLWH who are primarily virally suppressed and antiretroviral-treated did not differ in LA strain or LV diastolic dysfunction. If confirmed in other cohorts, HIV viral suppression may curtail adverse alterations in cardiac structure and function.
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Affiliation(s)
- Christopher J Berg
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Bobby Patel
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Maxwell Reynolds
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Mirela Tuzovic
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kara W Chew
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jason J Sico
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Center for Neuroepidemiology and Clinical Neurologic Research, Yale School of Medicine, New Haven, Connecticut; Neurology Service, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Debika Bhattacharya
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Adeel A Butt
- Weill Cornell Medical College, Doha Qatar and New York, New York; VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joseph K Lim
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Roger J Bedimo
- Department of Medicine, UT Southwestern Medical Center, Dallas, Texas; VA North Texas Healthcare System, Dallas, Texas
| | - Sheldon T Brown
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters VA Medical Center, Bronx, New York
| | | | - Alberta L Warner
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; GRECC VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | | | - Kim-Lien Nguyen
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California.
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4
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Harley JB, Pyarajan S, Partan ES, Epstein L, Wertheim JA, Diwan A, Woods CW, Davey V, Blair S, Clark DH, Kaufman KM, Khan S, Chepelev I, Devine A, Cameron P, McCann MF, Ammons MCB, Bolz DD, Battles JK, Curtis JL, Holodniy M, Marconi VC, Searles CD, Beenhouwer DO, Brown ST, Moorman JP, Yao ZQ, Rodriguez-Barradas MC, Mohapatra S, Molina De Rodriguez OY, Padiernos EB, McIndoo ER, Price E, Burgoyne HM, Robey I, Schwenke DC, Shive CL, Przygodzki RM, Ramoni RB, Krull HK, Bonomo RA. The US Department of Veterans Affairs Science and Health Initiative to Combat Infectious and Emerging Life-Threatening Diseases (VA SHIELD): A Biorepository Addressing National Health Threats. Open Forum Infect Dis 2022; 9:ofac641. [PMID: 36601554 PMCID: PMC9801224 DOI: 10.1093/ofid/ofac641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Indexed: 12/15/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has demonstrated the need to share data and biospecimens broadly to optimize clinical outcomes for US military Veterans. Methods In response, the Veterans Health Administration established VA SHIELD (Science and Health Initiative to Combat Infectious and Emerging Life-threatening Diseases), a comprehensive biorepository of specimens and clinical data from affected Veterans to advance research and public health surveillance and to improve diagnostic and therapeutic capabilities. Results VA SHIELD now comprises 12 sites collecting de-identified biospecimens from US Veterans affected by SARS-CoV-2. In addition, 2 biorepository sites, a data processing center, and a coordinating center have been established under the direction of the Veterans Affairs Office of Research and Development. Phase 1 of VA SHIELD comprises 34 157 samples. Of these, 83.8% had positive tests for SARS-CoV-2, with the remainder serving as contemporaneous controls. The samples include nasopharyngeal swabs (57.9%), plasma (27.9%), and sera (12.5%). The associated clinical and demographic information available permits the evaluation of biological data in the context of patient demographics, clinical experience and management, vaccinations, and comorbidities. Conclusions VA SHIELD is representative of US national diversity with a significant potential to impact national healthcare. VA SHIELD will support future projects designed to better understand SARS-CoV-2 and other emergent healthcare crises. To the extent possible, VA SHIELD will facilitate the discovery of diagnostics and therapeutics intended to diminish COVID-19 morbidity and mortality and to reduce the impact of new emerging threats to the health of US Veterans and populations worldwide.
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Affiliation(s)
- John B Harley
- Correspondence: John B. Harley, Cincinnati VA Medical Center, 3200 Vine St., John B. Harley (151), Cincinnati, OH 45220 ()
| | - Saiju Pyarajan
- Center for Data and Computational Sciences, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Elizabeth S Partan
- Center for Data and Computational Sciences, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Lauren Epstein
- Infectious Diseases, US Department of Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Jason A Wertheim
- Research & Development, Southern Arizona Veterans Affairs Healthcare System, US Department of Veterans Affairs, Tucson, Arizona, USA
| | - Abhinav Diwan
- Cardiology, Veterans Affairs Saint Louis Healthcare System, US Department of Veterans Affairs,Saint Louis, Missouri, USA
| | - Christopher W Woods
- Medicine, US Department of Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Victoria Davey
- Office of Research and Development, US Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Sharlene Blair
- Research Services, US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Dennis H Clark
- Research Services, US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Kenneth M Kaufman
- Research Services, US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Shagufta Khan
- Research Services, US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Iouri Chepelev
- Research Services, US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Alexander Devine
- Prometheus Federal Services, Titan Alpha, Washington, District of Columbia, USA
| | - Perry Cameron
- Customer Value Partners, Titan Alpha, Washington, District of Columbia, USA
| | - Monica F McCann
- Office of Research and Development, Chesapeake Medical Communications, Contractor for the US Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Mary Cloud B Ammons
- Research, US Department of Veterans Affairs Medical Center, Boise, Idaho, USA,Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
| | - Devin D Bolz
- Research, US Department of Veterans Affairs Medical Center, Boise, Idaho, USA
| | - Jane K Battles
- Office of Research and Development, US Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Jeffrey L Curtis
- Medicine Service, Veteran Affairs Ann Arbor Healthcare System, US Department of Veterans Affairs, Ann Arbor, Michigan, USA
| | - Mark Holodniy
- Public Health Surveillance, Veterans Affairs Palo Alto Healthcare System, US Department of Veterans Affairs, Palo Alto, California, USA
| | - Vincent C Marconi
- Infectious Diseases, US Department of Veterans Affairs Medical Center, Atlanta, Georgia, USA,Division of Infectious Diseases, Emory School of Medicine and Rollins School of Public Health, Atlanta, Georgia, USA
| | - Charles D Searles
- Infectious Diseases, US Department of Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - David O Beenhouwer
- Medicine, Veterans Affairs Greater Los Angeles Healthcare System, US Department of Veterans Affairs, Los Angeles, California, USA
| | - Sheldon T Brown
- Infectious Diseases, James J. Peters Veterans Affairs Medical Center, US Department of Veterans Affairs, Bronx, New York, USA
| | - Jonathan P Moorman
- Infectious Diseases, James H. Quillen Veterans Affairs Medical Center, US Department of Veterans Affairs, Mountain Home, Tennessee, USA,Center of Excellence in Inflammation, Infectious Diseases, and Immunity, East Tennessee State University, Johnson City, Tennessee, USA
| | - Zhi Q Yao
- Infectious Diseases, James H. Quillen Veterans Affairs Medical Center, US Department of Veterans Affairs, Mountain Home, Tennessee, USA,Center of Excellence in Inflammation, Infectious Diseases, and Immunity, East Tennessee State University, Johnson City, Tennessee, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center, US Department of Veterans Affairs, Houston, Texas, USA,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Shyam Mohapatra
- Medicine, James A. Haley Veterans Hospital, US Department of Veterans Affairs, Tampa, Florida, USA
| | - Osmara Y Molina De Rodriguez
- Research & Development, Southern Arizona Veterans Affairs Healthcare System, US Department of Veterans Affairs, Tucson, Arizona, USA
| | - Emerson B Padiernos
- Research, US Department of Veterans Affairs Medical Center, Boise, Idaho, USA
| | - Eric R McIndoo
- Research, US Department of Veterans Affairs Medical Center, Boise, Idaho, USA,Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
| | - Emily Price
- Research, US Department of Veterans Affairs Medical Center, Boise, Idaho, USA,Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
| | - Hailey M Burgoyne
- Research, US Department of Veterans Affairs Medical Center, Boise, Idaho, USA,Idaho Veterans Research and Education Foundation, Boise, Idaho, USA
| | - Ian Robey
- Research & Development, Southern Arizona Veterans Affairs Healthcare System, US Department of Veterans Affairs, Tucson, Arizona, USA
| | - Dawn C Schwenke
- Research & Development, Southern Arizona Veterans Affairs Healthcare System, US Department of Veterans Affairs, Tucson, Arizona, USA
| | - Carey L Shive
- Medicine, Veterans Affairs Northeast Ohio Healthcare System, US Department of Veterans Affairs, Cleveland, Ohio, USA
| | - Ronald M Przygodzki
- Office of Research and Development, US Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Rachel B Ramoni
- Office of Research and Development, US Department of Veterans Affairs, Washington, District of Columbia, USA
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Young-Xu Y, Zwain GM, Izurieta HS, Korves C, Powell EI, Smith J, Balajee A, Holodniy M, Beenhouwer DO, Rodriguez-Barradas MC, Brown ST, Marconi VC. Effectiveness of mRNA COVID-19 vaccines against Omicron and Delta variants in a matched test-negative case-control study among US veterans. BMJ Open 2022; 12:e063935. [PMID: 35922100 PMCID: PMC9352567 DOI: 10.1136/bmjopen-2022-063935] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To estimate the effectiveness of messenger RNA (mRNA) booster doses during the period of Delta and Omicron variant dominance. DESIGN We conducted a matched test-negative case-control study to estimate the vaccine effectiveness (VE) of three and two doses of mRNA vaccines against infection (regardless of symptoms) and against COVID-19-related hospitalisation and death. SETTING Veterans Health Administration. PARTICIPANTS We used electronic health record data from 114 640 veterans who had a SARS-CoV-2 test during November 2021-January 2022. Patients were largely 65 years or older (52%), male (88%) and non-Hispanic white (59%). MAIN OUTCOME MEASURES First positive result for a SARS-CoV-2 PCR or antigen test. RESULTS Against infection, booster doses had higher estimated VE (64%, 95% CI 63 to 65) than two-dose vaccination (12%, 95% CI 10 to 15) during the Omicron period. For the Delta period, the VE against infection was 90% (95% CI 88 to 92) among boosted vaccinees, higher than the VE among two-dose vaccinees (54%, 95% CI 50 to 57). Against hospitalisation, booster dose VE was 89% (95% CI 88 to 91) during Omicron and 94% (95% CI 90 to 96) during Delta; two-dose VE was 63% (95% CI 58 to 67) during Omicron and 75% (95% CI 69 to 80) during Delta. Against death, the VE with a booster dose was 94% (95% CI 90 to 96) during Omicron and 96% (95% CI 87 to 99) during Delta. CONCLUSIONS Among an older, mostly male, population with comorbidities, we found that an mRNA vaccine booster was highly effective against infection, hospitalisation and death. Although the effectiveness of booster vaccination against infection was moderately higher against Delta than against the Omicron SARS-CoV-2 variant, effectiveness against severe disease and death was similarly high against both variants.
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Affiliation(s)
- Yinong Young-Xu
- White River Junction VA Medical Center, US Department of Veterans Affairs, White River Junction, Vermont, USA
| | - Gabrielle M Zwain
- White River Junction VA Medical Center, US Department of Veterans Affairs, White River Junction, Vermont, USA
| | | | - Caroline Korves
- White River Junction VA Medical Center, US Department of Veterans Affairs, White River Junction, Vermont, USA
| | - Ethan I Powell
- White River Junction VA Medical Center, US Department of Veterans Affairs, White River Junction, Vermont, USA
| | - Jeremy Smith
- White River Junction VA Medical Center, US Department of Veterans Affairs, White River Junction, Vermont, USA
| | - Abirami Balajee
- White River Junction VA Medical Center, US Department of Veterans Affairs, White River Junction, Vermont, USA
| | - Mark Holodniy
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Public Health Program Office, Department of Veterans Affairs, Washington, District of Columbia, USA
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - David O Beenhouwer
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Maria C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Sheldon T Brown
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- James J. Peters Veterans Affairs Medical Center, New York City, New York, USA
| | - Vincent C Marconi
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Atlanta, Georgia, USA
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6
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Leuva H, Zhou M, Brau N, Brown ST, Mundi P, Rosenberg TCM, Luhrs C, Bates SE, Park YHA, Fojo T. Influence of cancer on COVID-19 incidence, outcomes, and vaccine effectiveness: A Prospective Cohort Study of U.S. Veterans. Semin Oncol 2022; 49:363-370. [PMID: 36055952 PMCID: PMC9353607 DOI: 10.1053/j.seminoncol.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
Purpose Coronavirus disease 2019 (COVID-19) has been a constant health threat since its emergence. Amongst risk factors proposed, a diagnosis of cancer has been worrisome. We report the impact of cancer and other risk factors in US Veterans receiving care at Veterans Administration (VA) Hospitals, their adjusted odds ratio (aOR) for infection and death, and report on the impact of vaccines on the incidence and severity of COVID-19 infections in Veterans without/with cancer. Methods We conducted a cohort study of US Veterans without/with cancer by mining VA COVID-19 Shared Data Resource (CSDR) data using the VA Informatics and Computing Infrastructure (VINCI). Our observation period includes index dates from 14DEC2020 to 25JAN2022, encompassing both the delta and omicron waves in the US. Results We identified 915,928 Veterans, 24% of whom were African Americans who had undergone COVID testing–688,541 were and 227,387 were not vaccinated. 157,072 had a cancer diagnosis in the preceding two years. Age emerged as the major risk factor, with gender, BMI, and (Elixhauser) comorbidity contributing less. Among veterans with solid tumors other than lung cancer, risks of infection and death within 60 days were comparable to Veterans without cancer. However, those with hematologic malignancies fared worse. Vaccination was highly effective across all cancer cohorts; the respective rates of infection and death after infection were 8% and 5% among the vaccinated compared to 47% and 10% in the unvaccinated. Amongst vaccinated, increased risk of infection was noted in both, Veterans with hematologic malignancy treated with chemotherapy (HR, 2.993, P < 0.0001) or targeted therapies (HR, 1.781, P < 0.0001), and in solid tumors treated with either chemotherapy (HR 2.328, 95%CI 2.075–2.611, P < 0.0001) or targeted therapies (HR 1.328, P < 0.0001) when compared to those not on treatment. Conclusions Risk for COVID-19 infection and death from infection vary based on cancer type and therapies administered. Importantly and encouragingly, the duration of protection from infection following vaccination in Veterans with a diagnosis of cancer was remarkably like those without a cancer diagnosis. Veterans with hematologic malignancies are especially vulnerable, with lower vaccine effectiveness (VE).
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Balachandran N, Cates J, Kambhampati AK, Marconi VC, Whitmire A, Morales E, Brown ST, Lama D, Rodriguez-Barradas MC, Moronez RG, Domiguez GR, Beenhouwer DO, Poteshkina A, Matolek ZA, Holodniy M, Lucero-Obusan C, Agarwal M, Cardemil C, Parashar U, Mirza SA. Risk Factors for Acute Gastroenteritis Among Patients Hospitalized in 5 Veterans Affairs Medical Centers, 2016-2019. Open Forum Infect Dis 2022; 9:ofac339. [PMID: 35949407 PMCID: PMC9356693 DOI: 10.1093/ofid/ofac339] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/22/2022] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND In the United States, ∼179 million acute gastroenteritis (AGE) episodes occur annually. We aimed to identify risk factors for all-cause AGE, norovirus-associated vs non-norovirus AGE, and severe vs mild/moderate AGE among hospitalized adults. METHODS We enrolled 1029 AGE cases and 624 non-AGE controls from December 1, 2016, to November 30, 2019, at 5 Veterans Affairs Medical Centers. Patient interviews and medical chart abstractions were conducted, and participant stool samples were tested using the BioFire Gastrointestinal Panel. Severe AGE was defined as a modified Vesikari score of ≥11. Multivariate logistic regression was performed to assess associations between potential risk factors and outcomes; univariate analysis was conducted for norovirus-associated AGE due to limited sample size. RESULTS Among 1029 AGE cases, 551 (54%) had severe AGE and 44 (4%) were norovirus positive. Risk factors for all-cause AGE included immunosuppressive therapy (adjusted odds ratio [aOR], 5.6; 95% CI, 2.7-11.7), HIV infection (aOR, 3.9; 95% CI, 1.8-8.5), severe renal disease (aOR, 3.1; 95% CI, 1.8-5.2), and household contact with a person with AGE (aOR, 2.9; 95% CI, 1.3-6.7). Household (OR, 4.4; 95% CI, 1.6-12.0) and non-household contact (OR, 5.0; 95% CI, 2.2-11.5) with AGE was associated with norovirus-associated AGE. Norovirus positivity (aOR, 3.4; 95% CI, 1.3-8.8) was significantly associated with severe AGE. CONCLUSIONS Patients with immunosuppressive therapy, HIV, and severe renal disease should be monitored for AGE and may benefit from targeted public health messaging regarding AGE prevention. These results may also direct future public health interventions, such as norovirus vaccines, to specific high-risk populations.
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Affiliation(s)
- Neha Balachandran
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Cherokee Nation Assurance, Arlington, Virginia, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia, USA
| | - Jordan Cates
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anita K Kambhampati
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Vincent C Marconi
- Atlanta VA Medical Center, Atlanta, Georgia, USA
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia, USA
| | | | | | - Sheldon T Brown
- James J. Peters VA Medical Center, Bronx, New York, USA
- Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Diki Lama
- James J. Peters VA Medical Center, Bronx, New York, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Rosalba Gomez Moronez
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Gilberto Rivera Domiguez
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David O Beenhouwer
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | | | - Mark Holodniy
- Department of Veterans Affairs, Public Health Surveillance and Research, Washington DC, USA
- VA Palo Alto Health Care System, Palo Alto California, USA
- Stanford University, Stanford, California, USA
| | - Cynthia Lucero-Obusan
- Department of Veterans Affairs, Public Health Surveillance and Research, Washington DC, USA
- VA Palo Alto Health Care System, Palo Alto California, USA
| | - Madhuri Agarwal
- Department of Veterans Affairs, Public Health Surveillance and Research, Washington DC, USA
| | - Cristina Cardemil
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Umesh Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sara A Mirza
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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8
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McGinnis KA, Skanderson M, Justice AC, Tindle HA, Akgün KM, Wrona A, Freiberg MS, Goetz MB, Rodriguez-Barradas MC, Brown ST, Crothers KA. Using the biomarker cotinine and survey self-report to validate smoking data from United States Veterans Health Administration electronic health records. JAMIA Open 2022; 5:ooac040. [DOI: 10.1093/jamiaopen/ooac040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/04/2022] [Accepted: 05/19/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
Tobacco use/smoking for epidemiologic studies is often derived from electronic health record (EHR) data, which may be inaccurate. We previously compared smoking from the United States Veterans Health Administration (VHA) EHR clinical reminder data with survey data and found excellent agreement. However, the smoking clinical reminder items changed October 1, 2018. We sought to use the biomarker salivary cotinine (cotinine ≥30) to validate current smoking from multiple sources.
Materials and Methods
We included 323 Veterans Aging Cohort Study participants with cotinine, clinical reminder, and self-administered survey smoking data from October 1, 2018 to September 30, 2019. We included International Classification of Disease (ICD)-10 codes F17.21 and Z72.0. Operating characteristics and kappa statistics were calculated.
Results
Participants were mostly male (96%), African American (75%) and mean age was 63 years. Of those identified as currently smoking based on cotinine, 86%, 85%, and 51% were identified as currently smoking based on clinical reminder, survey, and ICD-10 codes, respectively. Of those identified as not currently smoking based on cotinine, 95%, 97%, and 97% were identified as not currently smoking based on clinical reminder, survey, and ICD-10 codes. Agreement with cotinine was substantial for clinical reminder (kappa = .81) and survey (kappa = .83), but only moderate for ICD-10 (kappa = .50).
Discussion
To determine current smoking, clinical reminder, and survey agreed well with cotinine, whereas ICD-10 codes did not. Clinical reminders could be used in other health systems to capture more accurate smoking information.
Conclusions
Clinical reminders are an excellent source for self-reported smoking status and are readily available in the VHA EHR.
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Affiliation(s)
| | | | - Amy C Justice
- VA Connecticut Healthcare System , West Haven, Connecticut, USA
- Department of Medicine, Yale University , New Haven, Connecticut, USA
| | - Hilary A Tindle
- Department of Medicine, Vanderbilt University School of Medicine , Nashville, Tennessee, USA
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC) , Nashville, Tennessee, USA
| | - Kathleen M Akgün
- Department of Medicine, Yale University , New Haven, Connecticut, USA
| | - Aleksandra Wrona
- VA Connecticut Healthcare System , West Haven, Connecticut, USA
- Department of Medicine, Vanderbilt University School of Medicine , Nashville, Tennessee, USA
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC) , Nashville, Tennessee, USA
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University School of Medicine , Nashville, Tennessee, USA
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC) , Nashville, Tennessee, USA
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
- David Geffen School of Medicine at UCLA , Los Angeles, California, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Department of Medicine, Michael E. DeBakey VAMC, Baylor College of Medicine , Houston, Texas, USA
| | | | - Kristina A Crothers
- Department of Medicine, Harborview Medical Center, University of Washington , Seattle, Washington, USA
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9
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Johnson JA, Read TD, Petit RA, Marconi VC, Meagley KL, Rodriguez-Barradas MC, Beenhouwer DO, Brown ST, Holodniy M, Lucero-Obusan CA, Schirmer P, Ingersoll JM, Kraft CS, Neill FH, Atmar RL, Kambhampati AK, Cates JE, Mirza SA, Hall A, Cardemil CV, Lopman BA. Association of Secretor Status and Recent Norovirus Infection With Gut Microbiome Diversity Metrics in a Veterans Affairs Population. Open Forum Infect Dis 2022; 9:ofac125. [PMID: 35434176 PMCID: PMC9007923 DOI: 10.1093/ofid/ofac125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/08/2022] [Indexed: 11/12/2022] Open
Abstract
Norovirus infection causing acute gastroenteritis could lead to adverse effects on the gut microbiome. We assessed the association of microbiome diversity with norovirus infection and secretor status in patients from Veterans Affairs medical centers. Alpha diversity metrics were lower among patients with acute gastroenteritis but were similar for other comparisons.
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Affiliation(s)
- Jordan A Johnson
- Department of Epidemiology, Emory University Rollins School of Public Health, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Timothy D Read
- Department of Epidemiology, Emory University Rollins School of Public Health, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Robert A Petit
- Department of Epidemiology, Emory University Rollins School of Public Health, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Vincent C Marconi
- Department of Epidemiology, Emory University Rollins School of Public Health, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Kathryn L Meagley
- Department of Epidemiology, Emory University Rollins School of Public Health, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David O Beenhouwer
- Veterans Affairs Greater Los Angeles Health System, Los Angeles, California, USA
| | - Sheldon T Brown
- James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Mark Holodniy
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Office of Population Health, Public Health Surveillance and Research, Veterans Health Administration, Washington, DC, USA
- Division of Infectious Diseases & Geographic Medicine, Stanford University, Stanford, California, USA
| | - Cynthia A Lucero-Obusan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Office of Population Health, Public Health Surveillance and Research, Veterans Health Administration, Washington, DC, USA
| | - Patricia Schirmer
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Office of Population Health, Public Health Surveillance and Research, Veterans Health Administration, Washington, DC, USA
| | - Jessica M Ingersoll
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Colleen S Kraft
- Department of Epidemiology, Emory University Rollins School of Public Health, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Frederick H Neill
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Robert L Atmar
- Office of Population Health, Public Health Surveillance and Research, Veterans Health Administration, Washington, DC, USA
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Anita K Kambhampati
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jordan E Cates
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sara A Mirza
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Aron J Hall
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cristina V Cardemil
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Benjamin A Lopman
- Department of Epidemiology, Emory University Rollins School of Public Health, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
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10
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Miller EK, Goldberg AM, Janoff EN, Brown ST, Curtis JL, Bonomo RA, Shih MC, Gleason TC. Designing and implementing methodology for double-blind, placebo-controlled clinical trials using blood products within the Department of Veterans Affairs. Clin Trials 2022; 19:137-145. [PMID: 35229691 DOI: 10.1177/17407745211069703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Success in conducting clinical trials during the coronavirus disease of 2019 pandemic requires the ability to innovate and adapt. There are well-established procedures for the blinding of investigational agents, especially medications, in placebo-controlled randomized clinical trials within the Veterans Health Administration. However, these procedures, managed by research pharmacists, may not apply to investigational agents that are not exclusively managed by pharmacy, such as blood products, including coronavirus disease of 2019 convalescent plasma (plasma). In the absence of established blinding procedures, such studies require special design considerations to minimize uncertainty or bias. METHODS We describe the processes and procedures developed for blinding of plasma in "Veterans Affairs CoronavirUs Research and Efficacy Studies-1" as a prototypical study using this class of investigational therapeutic agents. Veterans Affairs CoronavirUs Research and Efficacy Studies-1 is an ongoing multicenter randomized clinical trial testing the efficacy of plasma added to conventional therapy for severe acute respiratory syndrome coronavirus-2 infection. RESULTS We report the design of procedures to supply investigational blood products or 0.9% normal saline (saline) control while ensuring the integrity of the blind. Key aspects include workflow considerations, physical blinding strategies, and methods for engaging stakeholders. These procedures leverage the well-established Veterans Affairs research pharmacist's research infrastructure, and Blood Bank Services, which is responsible for blood-based investigational products. CONCLUSION By describing the methods used to deliver blood products in a blinded manner in Veterans Affairs CoronavirUs Research and Efficacy Studies-1, we strive both to educate and to increase awareness to improve the implementation of these biological therapeutics for future, high-quality research studies.
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Affiliation(s)
- Elliott K Miller
- Department of Veterans Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Alexa M Goldberg
- Department of Veterans Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Edward N Janoff
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.,University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Sheldon T Brown
- James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY, USA
| | - Jeffrey L Curtis
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert A Bonomo
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,CWRU-VA Center for Antimicrobial Resistance and Epidemiology (VA CARES), Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mei-Chiung Shih
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Palo Alto, CA, USA.,Stanford University, Palo Alto, CA, USA
| | - Theresa C Gleason
- Department of Veterans Affairs, Clinical Science Research and Development Service, Washington, DC, USA
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11
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Bajema KL, Dahl RM, Evener SL, Prill MM, Rodriguez-Barradas MC, Marconi VC, Beenhouwer DO, Holodniy M, Lucero-Obusan C, Brown ST, Tremarelli M, Epperson M, Mills L, Park SH, Rivera-Dominguez G, Morones RG, Ahmadi-Izadi G, Deovic R, Mendoza C, Jeong C, Schrag SJ, Meites E, Hall AJ, Kobayashi M, McMorrow M, Verani JR, Thornburg NJ, Surie D. Comparative Effectiveness and Antibody Responses to Moderna and Pfizer-BioNTech COVID-19 Vaccines among Hospitalized Veterans - Five Veterans Affairs Medical Centers, United States, February 1-September 30, 2021. MMWR Morb Mortal Wkly Rep 2021; 70:1700-1705. [PMID: 34882654 PMCID: PMC8659185 DOI: 10.15585/mmwr.mm7049a2] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The mRNA COVID-19 vaccines (Moderna and Pfizer-BioNTech) provide strong protection against severe COVID-19, including hospitalization, for at least several months after receipt of the second dose (1,2). However, studies examining immune responses and differences in protection against COVID-19-associated hospitalization in real-world settings, including by vaccine product, are limited. To understand how vaccine effectiveness (VE) might change with time, CDC and collaborators assessed the comparative effectiveness of Moderna and Pfizer-BioNTech vaccines in preventing COVID-19-associated hospitalization at two periods (14-119 days and ≥120 days) after receipt of the second vaccine dose among 1,896 U.S. veterans at five Veterans Affairs medical centers (VAMCs) during February 1-September 30, 2021. Among 234 U.S. veterans fully vaccinated with an mRNA COVID-19 vaccine and without evidence of current or prior SARS-CoV-2 infection, serum antibody levels (anti-spike immunoglobulin G [IgG] and anti-receptor binding domain [RBD] IgG) to SARS-CoV-2 were also compared. Adjusted VE 14-119 days following second Moderna vaccine dose was 89.6% (95% CI = 80.1%-94.5%) and after the second Pfizer-BioNTech dose was 86.0% (95% CI = 77.6%-91.3%); at ≥120 days VE was 86.1% (95% CI = 77.7%-91.3%) for Moderna and 75.1% (95% CI = 64.6%-82.4%) for Pfizer-BioNTech. Antibody levels were significantly higher among Moderna recipients than Pfizer-BioNTech recipients across all age groups and periods since vaccination; however, antibody levels among recipients of both products declined between 14-119 days and ≥120 days. These findings from a cohort of older, hospitalized veterans with high prevalences of underlying conditions suggest the importance of booster doses to help maintain long-term protection against severe COVID-19.†.
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12
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Balachandran N, Cates J, Kambhampati A, Marconi V, Brown ST, Rodriguez–Barradas MC, Beenhouwer D, Holodniy M, Lucero-Obusan CA, Cardemil C, Parashar UD, Mirza S. 702. Risk Factors for Acute Gastroenteritis Among Patients Hospitalized in 5 Veterans Affairs Medical Centers, 2016–19. Open Forum Infect Dis 2021. [PMCID: PMC8644108 DOI: 10.1093/ofid/ofab466.899] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background In the United States, an estimated 179 million acute gastroenteritis (AGE) episodes occur each year. Identifying factors contributing to AGE susceptibility and severity is important to address the high disease burden of AGE among adults. The primary objective of this analysis was to identify risk factors for all-cause AGE, norovirus-associated AGE and severe AGE among hospitalized adults. Methods We analyzed data from 1029 inpatient AGE cases and 624 non-AGE controls enrolled prospectively from December 1, 2016 – November 30, 2019 from 5 Veterans Affairs Medical Centers (Atlanta, Bronx, Houston, Los Angeles, Palo Alto). Standardized patient interviews and medical chart abstractions were conducted to collect demographics, exposure history, and underlying medical conditions. Stool samples from participants were tested for 22 pathogens using the BioFire Gastrointestinal Panel. Severity of AGE was determined using a 20-point modified Vesikari score (MVS) and severe AGE was defined as a MVS score of ≥ 11. Multivariate logistic regression was performed to assess associations between potential risk factors and outcomes. Results Of the total AGE cases, 551 (54%) had severe AGE; 44 (4%) were norovirus positive. Risk factors for all-cause AGE vs. non-AGE controls included household contact with a person with AGE in the past 7 days (aOR=2.9, 95% CI:1.3-6.7), severe renal disease (aOR=3.1, 95% CI:1.8-5.2), human immunodeficiency virus (HIV) (aOR=3.9, 95% CI:1.8-8.5), and immunosuppressive therapy (aOR=5.6, 95% CI:2.7-11.7). Factors associated with norovirus positivity by univariate analysis were contact with a person with AGE outside (OR=4.4, 95% CI:1.6-12.0) and within (OR=5.0, 95% CI:2.2-11.5) the household in the past 7 days. Detection of any viral pathogen (aOR=4.0, 95% CI:1.7-9.5) was a risk factor for severe AGE. Conclusion Our findings suggest that inpatients with HIV or severe renal disease, on immunosuppressive therapy, or in contact with a person with AGE within household are at higher risk for all-cause AGE. Patients with these medical conditions should be monitored for AGE related hospitalizations and may benefit from targeted AGE prevention messaging. Disclosures Vincent Marconi, MD, Bayer (Consultant, Scientific Research Study Investigator)Eli Lilly (Consultant, Scientific Research Study Investigator)Gilead Sciences (Consultant, Scientific Research Study Investigator)ViiV (Consultant, Scientific Research Study Investigator)
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Affiliation(s)
- Neha Balachandran
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, Atlanta, GA
| | - Jordan Cates
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anita Kambhampati
- IHRC, Inc. contracting agency to the Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | | | | | | | - Cristina Cardemil
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Umesh D Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sara Mirza
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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13
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Bolton SJ, Levin SM, Guillot T, Li C, Kaspi Y, Orton G, Wong MH, Oyafuso F, Allison M, Arballo J, Atreya S, Becker HN, Bloxham J, Brown ST, Fletcher LN, Galanti E, Gulkis S, Janssen M, Ingersoll A, Lunine JL, Misra S, Steffes P, Stevenson D, Waite JH, Yadav RK, Zhang Z. Microwave observations reveal the deep extent and structure of Jupiter's atmospheric vortices. Science 2021; 374:968-972. [PMID: 34709937 DOI: 10.1126/science.abf1015] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- S J Bolton
- Southwest Research Institute, San Antonio, TX, USA
| | - S M Levin
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - T Guillot
- Université Côte d'Azur, Observatoire de la Côte d'Azur, Centre National de la Recherche Scientifique, Laboratoire Lagrange, Nice, France
| | - C Li
- Department of Climate and Space Sciences and Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Y Kaspi
- Weizmann Institute of Science, Rehovot, 76100, Israel
| | - G Orton
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - M H Wong
- Carl Sagan Center for Research, SETI Institute, Mountain View, CA, USA
| | - F Oyafuso
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - M Allison
- Goddard Institute for Space Studies, New York, NY, USA.,Department of Astronomy, Columbia University, New York, NY 10027, USA
| | - J Arballo
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - S Atreya
- Department of Climate and Space Sciences and Engineering, University of Michigan, Ann Arbor, MI, USA
| | - H N Becker
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - J Bloxham
- Department of Earth and Planetary Sciences, Harvard University, Cambridge, MA 02138, USA
| | - S T Brown
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - L N Fletcher
- School of Physics and Astronomy, University of Leicester, Leicester LE1 7RH, UK
| | - E Galanti
- Weizmann Institute of Science, Rehovot, 76100, Israel
| | - S Gulkis
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - M Janssen
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - A Ingersoll
- Department of Geological and Planetary Sciences, California Institute of Technology, Pasadena, CA, USA
| | - J L Lunine
- Department of Astronomy, Cornell University, Ithaca, NY, USA
| | - S Misra
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA, USA
| | - P Steffes
- Department of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - D Stevenson
- Department of Geological and Planetary Sciences, California Institute of Technology, Pasadena, CA, USA
| | - J H Waite
- Southwest Research Institute, San Antonio, TX, USA
| | - R K Yadav
- Department of Earth and Planetary Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Z Zhang
- Department of Geological and Planetary Sciences, California Institute of Technology, Pasadena, CA, USA
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14
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Meites E, Bajema KL, Kambhampati A, Prill M, Marconi VC, Brown ST, Rodriguez-Barradas MC, Beenhouwer DO, Holodniy M, Lucero-Obusan C, Cardemil C, Cates J, Surie D. Adapting the Surveillance Platform for Enteric and Respiratory Infectious Organisms at United States Veterans Affairs Medical Centers (SUPERNOVA) for COVID-19 Among Hospitalized Adults: Surveillance Protocol. Front Public Health 2021; 9:739076. [PMID: 34778173 PMCID: PMC8585926 DOI: 10.3389/fpubh.2021.739076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/05/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction: Early in the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) rapidly initiated COVID-19 surveillance by leveraging existing hospital networks to assess disease burden among hospitalized inpatients and inform prevention efforts. Materials and Methods: The Surveillance Platform for Enteric and Respiratory Infectious Organisms at Veterans Affairs Medical Centers (SUPERNOVA) is a network of five United States Veterans Affairs Medical Centers which serves nearly 400,000 Veterans annually and conducts laboratory-based passive and active monitoring for pathogens associated with acute gastroenteritis and acute respiratory illness among hospitalized Veterans. This paper presents surveillance methods for adapting the SUPERNOVA surveillance platform to prospectively evaluate COVID-19 epidemiology during a public health emergency, including detecting, characterizing, and monitoring patients with and without COVID-19 beginning in March 2020. To allow for case-control analyses, patients with COVID-19 and patients with non-COVID-19 acute respiratory illness were included. Results: SUPERNOVA included 1,235 participants with COVID-19 and 707 participants with other acute respiratory illnesses hospitalized during February through December 2020. Most participants were male (93.1%), with a median age of 70 years, and 45.8% non-Hispanic Black and 32.6% non-Hispanic White. Among those with COVID-19, 28.2% were transferred to an intensive care unit, 9.4% received invasive mechanical ventilation, and 13.9% died. Compared with controls, after adjusting for age, sex, and race/ethnicity, COVID-19 case-patients had significantly higher risk of mortality, respiratory failure, and invasive mechanical ventilation, and longer hospital stays. Discussion: Strengths of the SUPERNOVA platform for COVID-19 surveillance include the ability to collect and integrate multiple types of data, including clinical and illness outcome information, and SARS-CoV-2 laboratory test results from respiratory and serum specimens. Analysis of data from this platform also enables formal comparisons of participants with and without COVID-19. Surveillance data collected during a public health emergency from this key U.S. population of Veterans will be useful for epidemiologic investigations of COVID-19 spectrum of disease, underlying medical conditions, virus variants, and vaccine effectiveness, according to public health priorities and needs.
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Affiliation(s)
- Elissa Meites
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kristina L Bajema
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Anita Kambhampati
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Mila Prill
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Vincent C Marconi
- Atlanta VA Medical Center, Atlanta, GA, United States.,Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.,Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Sheldon T Brown
- James J. Peters VA Medical Center, Bronx, NY, United States.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Maria C Rodriguez-Barradas
- Michael E. DeBakey VA Medical Center, Houston, TX, United States.,Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - David O Beenhouwer
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Mark Holodniy
- VA Palo Alto Health Care System, Palo Alto, CA, United States.,Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC, United States.,Department of Medicine, Stanford University, Stanford, CA, United States
| | - Cynthia Lucero-Obusan
- VA Palo Alto Health Care System, Palo Alto, CA, United States.,Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC, United States
| | - Cristina Cardemil
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jordan Cates
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Diya Surie
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
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15
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Bajema KL, Dahl RM, Prill MM, Meites E, Rodriguez-Barradas MC, Marconi VC, Beenhouwer DO, Brown ST, Holodniy M, Lucero-Obusan C, Rivera-Dominguez G, Morones RG, Whitmire A, Goldin EB, Evener SL, Tremarelli M, Tong S, Hall AJ, Schrag SJ, McMorrow M, Kobayashi M, Verani JR, Surie D. Effectiveness of COVID-19 mRNA Vaccines Against COVID-19-Associated Hospitalization - Five Veterans Affairs Medical Centers, United States, February 1-August 6, 2021. MMWR Morb Mortal Wkly Rep 2021; 70:1294-1299. [PMID: 34529636 PMCID: PMC8445376 DOI: 10.15585/mmwr.mm7037e3] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
COVID-19 mRNA vaccines (Pfizer-BioNTech and Moderna) have been shown to be highly protective against COVID-19-associated hospitalizations (1-3). Data are limited on the level of protection against hospitalization among disproportionately affected populations in the United States, particularly during periods in which the B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, predominates (2). U.S. veterans are older, more racially diverse, and have higher prevalences of underlying medical conditions than persons in the general U.S. population (2,4). CDC assessed the effectiveness of mRNA vaccines against COVID-19-associated hospitalization among 1,175 U.S. veterans aged ≥18 years hospitalized at five Veterans Affairs Medical Centers (VAMCs) during February 1-August 6, 2021. Among these hospitalized persons, 1,093 (93.0%) were men, the median age was 68 years, 574 (48.9%) were non-Hispanic Black (Black), 475 were non-Hispanic White (White), and 522 (44.4%) had a Charlson comorbidity index score of ≥3 (5). Overall adjusted vaccine effectiveness against COVID-19-associated hospitalization was 86.8% (95% confidence interval [CI] = 80.4%-91.1%) and was similar before (February 1-June 30) and during (July 1-August 6) SARS-CoV-2 Delta variant predominance (84.1% versus 89.3%, respectively). Vaccine effectiveness was 79.8% (95% CI = 67.7%-87.4%) among adults aged ≥65 years and 95.1% (95% CI = 89.1%-97.8%) among those aged 18-64 years. COVID-19 mRNA vaccines are highly effective in preventing COVID-19-associated hospitalization in this older, racially diverse population of predominately male U.S. veterans. Additional evaluations of vaccine effectiveness among various age groups are warranted. To prevent COVID-19-related hospitalizations, all eligible persons should receive COVID-19 vaccination.
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16
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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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17
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Nguyen DC, Dousa KM, Kurz SG, Brown ST, Drusano G, Holland SM, Kreiswirth BN, Boom WH, Daley CL, Bonomo RA. "One-two Punch": Synergistic β-lactam Combinations for Mycobacterium abscessus and Target Redundancy in the Inhibition of Peptidoglycan Synthesis Enzymes. Clin Infect Dis 2021; 73:1532-1536. [PMID: 34113990 DOI: 10.1093/cid/ciab535] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 11/13/2022] Open
Abstract
Mycobacterium abscessus subsp. abscessus is one of the most difficult pathogens to treat and its incidence in disease is increasing. Dual β-lactam combinations act synergistically in vitro, but are not widely employed in practice. A recent study shows that a combination of imipenem and ceftaroline significantly lowers the minimum inhibitory concentration (MIC) of clinical isolates despite both drugs targeting the same peptidoglycan synthesis enzymes. The underlying mechanism of this effect provides a basis for further investigations of dual β-lactam combinations in the treatment of M. abscessus subsp. abscessus eventually leading to a clinical trial. Furthermore, dual β-lactam strategies may be explored for other difficult mycobacterial infections.
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Affiliation(s)
- David C Nguyen
- Division of Infectious Diseases & HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Division of Pediatric Infectious Diseases, Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Khalid M Dousa
- Department of Internal Medicine and Infectious Diseases, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA
| | - Sebastian G Kurz
- Mount Sinai National Jewish Respiratory Institute, New York City, NY, USA
| | - Sheldon T Brown
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Medicine, James J. Peters VA Medical Center, Bronx, NY, USA
| | - George Drusano
- Institute for Therapeutic Innovation, University of Florida, Orlando, FL, USA
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Barry N Kreiswirth
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - W Henry Boom
- Division of Infectious Diseases & HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Tuberculosis Research Unit, Case Western Reserve University, Cleveland, OH, USA
| | - Charles L Daley
- Division of Mycobacterial and Respiratory Infections, National Jewish Health, Denver, CO, USA
| | - Robert A Bonomo
- Department of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Medical Service, Research Service, and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, OH, USA
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18
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Greenstein RJ, Su L, Grant IR, Foddai ACG, Turner A, Nagati JS, Brown ST, Stabel JR. Comparison of a mycobacterial phage assay to detect viable Mycobacterium avium subspecies paratuberculosis with standard diagnostic modalities in cattle with naturally infected Johne disease. Gut Pathog 2021; 13:30. [PMID: 33957980 PMCID: PMC8103604 DOI: 10.1186/s13099-021-00425-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 04/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Mycobacterium avium subspecies paratuberculosis (MAP), the cause of Johne disease, is a slow growing mycobacterium. Viable MAP detection is difficult, inconstant and time-consuming. The purpose of this study was to compare a rapid phage/qPCR assay performed on peripheral blood mononuclear cells (PBMCs) with three standard methods of MAP detection: fecal MAP PCR; plasma antigen-specific IFN-γ & serum MAP ELISA hypothesizing that, if sensitive and specific, Johne animals would be positive and Control animals negative. We studied a well characterized herd of Holstein cattle that were naturally infected with MAP and their Controls. Results With phage/qPCR 72% (23/32) of Johne and 35% (6/17) of Controls were MAP positive. With fecal PCR 75% (24/32) of Johne and 0% (0/17) of Controls were MAP positive. With plasma antigen-specific IFN-γ 69% (22/32) of Johne and 12% (2/17) of Controls were MAP positive. With serum MAP ELISA, 31% (10/32) of Johne and 0% (0/17) of Controls were MAP positive. When phage / qPCR and fecal PCR results were combined, 100% (32/32) Johne and 35% (6/17) of Control animals were MAP positive. Younger Control animals (1–3 years) had significantly fewer plaques (25 ± 17 SEM) than older Controls (4–12 years) (309 ± 134 p = 0.04). The same trend was not observed in the Johne animals (p = 0.19). Conclusions In contrast to our hypothesis, using the phage/qPCR assay we find that viable circulating MAP can rapidly be detected from the blood of animals infected with, as well as those in the Control group evidently colonized by MAP. These data indicate that the presence of viable MAP in blood does not necessarily signify that an animal must of necessity be demonstrably ill or be MAP positive by standard diagnostic methods.
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Affiliation(s)
- Robert J Greenstein
- Department of Surgery, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA. .,Laboratory of Molecular Surgical Research, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA.
| | - Liya Su
- Laboratory of Molecular Surgical Research, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Irene R Grant
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Antonio C G Foddai
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Amy Turner
- Johne's Disease Research Project USDA-ARS-NADC, Ames, IA, USA
| | - Jason S Nagati
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Sheldon T Brown
- Infectious Disease Section, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Judith R Stabel
- Johne's Disease Research Project USDA-ARS-NADC, Ames, IA, USA
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19
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Berg C, Patel B, Reynolds M, Tuzovic M, Chew K, Sico J, Bhattacharya D, Butt AA, Lim JK, Bedimo RJ, Brown ST, Gottdiener J, Warner A, Freiberg M, So-Armah K, Nguyen KL. LEFT ATRIAL STRAIN AND DIASTOLIC DYSFUNCTION AMONGST HIV-POSITIVE INDIVIDUALS: INSIGHTS FROM THE VETERANS AGING COHORT STUDY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02780-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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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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21
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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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22
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Grytdal S, Browne H, Collins N, Vargas B, Rodriguez-Barradas MC, Rimland D, Beenhouwer DO, Brown ST, Goetz MB, Lucero-Obusan C, Holodniy M, Kambhampati A, Parashar U, Vinjé J, Lopman B, Hall AJ, Cardemil CV. Trends in Incidence of Norovirus-associated Acute Gastroenteritis in 4 Veterans Affairs Medical Center Populations in the United States, 2011-2015. Clin Infect Dis 2021; 70:40-48. [PMID: 30901024 DOI: 10.1093/cid/ciz165] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 02/25/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Norovirus is an important cause of epidemic acute gastroenteritis (AGE), yet the burden of endemic disease in adults has not been well documented. We estimated the prevalence and incidence of outpatient and community-acquired inpatient norovirus AGE at 4 Veterans Affairs Medical Centers (VAMC) (Atlanta, Georgia; Bronx, New York; Houston, Texas; and Los Angeles, California) and examined trends over 4 surveillance years. METHODS From November 2011 to September 2015, stool specimens collected within 7 days of AGE symptom onset for clinician-requested diagnostic testing were tested for norovirus, and positive samples were genotyped. Incidence was calculated by multiplying norovirus prevalence among tested specimens by AGE-coded outpatient encounters and inpatient discharges, and dividing by the number of unique patients served. RESULTS Of 1603 stool specimens, 6% tested were positive for norovirus; GII.4 viruses (GII.4 New Orleans [17%] and GII.4 Sydney [47%]) were the most common genotypes. Overall prevalence and outpatient and inpatient community-acquired incidence followed a seasonal pattern, with higher median rates during November-April (9.2%, 376/100 000, and 45/100 000, respectively) compared to May-October (3.0%, 131/100 000, and 13/100 000, respectively). An alternate-year pattern was also detected, with highest peak prevalence and outpatient and inpatient community-acquired norovirus incidence rates in the first and third years of surveillance (14%-25%, 349-613/100 000, and 43-46/100 000, respectively). CONCLUSIONS This multiyear analysis of laboratory-confirmed AGE surveillance from 4 VAMCs demonstrates dynamic intra- and interannual variability in prevalence and incidence of outpatient and inpatient community-acquired norovirus in US Veterans, highlighting the burden of norovirus disease in this adult population.
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Affiliation(s)
- Scott Grytdal
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hannah Browne
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.,Oak Ridge Institute for Science and Education, Tennessee
| | - Nikail Collins
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Blanca Vargas
- Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center.,Infectious Diseases Section, Baylor College of Medicine, Houston, Texas
| | | | - David O Beenhouwer
- Veterans Affairs Greater Los Angeles Healthcare System, California.,David Geffen School of Medicine, University of California, Los Angeles
| | - Sheldon T Brown
- James J. Peters Veterans Affairs Medical Center.,Mount Sinai School of Medicine, Bronx, New York
| | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System, California.,David Geffen School of Medicine, University of California, Los Angeles
| | - Cynthia Lucero-Obusan
- Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, California
| | - Mark Holodniy
- Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, California
| | - Anita Kambhampati
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.,IHRC, Inc
| | - Umesh Parashar
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jan Vinjé
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ben Lopman
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.,Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Aron J Hall
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cristina V Cardemil
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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23
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Wenger DS, Triplette M, Shahrir S, Akgun KM, Wongtrakool C, Brown ST, Kim JW, Soo Hoo GW, Rodriguez-Barradas MC, Huang L, Feemster LC, Zifodya J, Crothers K. Associations of marijuana with markers of chronic lung disease in people living with HIV. HIV Med 2020; 22:92-101. [PMID: 33022830 DOI: 10.1111/hiv.12966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/21/2020] [Accepted: 08/26/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The relationship between marijuana use and markers of chronic lung disease in people living with HIV (PLWH) is poorly understood. METHODS We performed a cross-sectional analysis of the Examinations of HIV-Associated Lung Emphysema (EXHALE) study, including 162 HIV-positive patients and 138 participants without HIV. We modelled marijuana exposure as: (i) current daily or weekly marijuana smoking vs. monthly or less often; or (ii) cumulative marijuana smoking (joint-years). Linear and logistic regression estimated associations between marijuana exposure and markers of lung disease, adjusted for tobacco smoking and other factors. RESULTS In PLWH, current daily or weekly marijuana use was associated with a larger forced vital capacity (FVC), larger total lung capacity and increased odds of radiographic emphysema compared with marijuana non-smokers in adjusted models; these associations were not statistically significant in participants without HIV. Marijuana joint-years were associated with higher forced expiratory volume in 1 s and FVC in PLWH but not with emphysema. CONCLUSIONS In PLWH, marijuana smoking was associated with higher lung volumes and potentially with radiographic emphysema. No consistently negative associations were observed between marijuana and measures of chronic lung health.
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Affiliation(s)
- D S Wenger
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - M Triplette
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - S Shahrir
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - K M Akgun
- Department of Internal Medicine, Veterans Affairs (VA) Connecticut Healthcare System and Yale University School of Medicine, New Haven, CT, USA
| | - C Wongtrakool
- Atlanta VA Medical Center and Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - S T Brown
- Department of Medicine, James J. Peters VA Medical Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - J W Kim
- Department of Medicine, James J. Peters VA Medical Center, Bronx, NY, USA
| | - G W Soo Hoo
- VA Greater Los Angeles Healthcare System and Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - M C Rodriguez-Barradas
- Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - L Huang
- Center for AIDS Research, University of California at San Francisco, San Francisco, CA, USA
| | - L C Feemster
- VA Puget Sound Healthcare System, University of Washington, Seattle, WA, USA
| | - J Zifodya
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - K Crothers
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.,VA Puget Sound Healthcare System, University of Washington, Seattle, WA, USA
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24
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Rodriguez-Barradas MC, McGinnis KA, Akgün K, Tate JP, Brown ST, Butt AA, Fine M, Goetz MB, Graber CJ, Huang L, Rimland D, Justice A, Crothers K. Validation for using electronic health records to identify community acquired pneumonia hospitalization among people with and without HIV. Pneumonia (Nathan) 2020; 12:6. [PMID: 32724760 PMCID: PMC7382068 DOI: 10.1186/s41479-020-00068-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 06/07/2020] [Indexed: 02/06/2023] Open
Abstract
Background Cohort studies identifying the incidence, complications and co-morbidities associated with community acquired pneumonia (CAP) are largely based on administrative datasets and rely on International Classification of Diseases (ICD) codes; however, the reliability of ICD codes for hospital admissions for CAP in people with HIV (PWH) has not been systematically assessed. Methods We used data from the Veterans Aging Cohort Study survey sample (N = 6824; 3410 PWH and 3414 uninfected) to validate the use of electronic health records (EHR) data to identify CAP hospitalizations when compared to chart review and to compare the performance in PWH vs. uninfected patients. We used different EHR algorithms that included a broad set of CAP ICD-9 codes, a set restricted to bacterial and viral CAP codes, and algorithms that included pharmacy data and/or other ICD-9 diagnoses frequently associated with CAP. We also compared microbiologic workup and etiologic diagnosis by HIV status among those with CAP. Results Five hundred forty-nine patients were identified as having an ICD-9 code compatible with a CAP diagnosis (13% of PWH and 4% of the uninfected, p < 0.01). The EHR algorithm with the best overall positive predictive value (82%) was obtained by using the restricted set of ICD-9 codes (480-487) in primary position or secondary only to selected codes as primary (HIV disease, respiratory failure, sepsis or bacteremia) with the addition of EHR pharmacy data; this algorithm yielded PPVs of 83% in PWH and 73% in uninfected (P = 0.1) groups. Adding aspiration pneumonia (ICD-9 code 507) to any of the ICD-9 code/pharmacy combinations increased the number of cases but decreased the overall PPV. Allowing COPD exacerbation in the primary position improved the PPV among the uninfected group only (to 76%). More PWH than uninfected patients underwent microbiologic evaluation or had respiratory samples submitted. Conclusions ICD-9 code-based algorithms perform similarly to identify CAP in PLWH and uninfected individuals. Adding antimicrobial use data and allowing as primary diagnoses ICD-9 codes frequently used in patients with CAP improved the performance of the algorithms in both groups of patients. The algorithms consistently performed better among PWH.
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Affiliation(s)
| | | | - Kathleen Akgün
- VA Connecticut Healthcare System, West Haven, CT USA.,Yale University, New Haven, CT USA
| | - Janet P Tate
- VA Connecticut Healthcare System, West Haven, CT USA.,Yale University, New Haven, CT USA
| | - Sheldon T Brown
- James J Peters VAMC, Bronx, NY USA.,Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Adeel A Butt
- VA Pittsburgh Healthcare System, Pittsburgh, PA USA.,Weill Cornell Medical College, New York, NY USA.,Weill Cornell Medical College, Doha, Qatar
| | - Michael Fine
- VA Pittsburgh Healthcare System, Pittsburgh, PA USA
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, and David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, and David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Laurence Huang
- San Francisco General Hospital and University of California San Francisco, San Francisco, CA USA
| | - David Rimland
- VAMC and Emory University School of Medicine, Atlanta, GA USA
| | - Amy Justice
- VA Connecticut Healthcare System, West Haven, CT USA.,Yale University, New Haven, CT USA
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25
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Ma R, Jung TH, Peduzzi PN, Brown ST, Kyriakides TC. Analysis of the Impact of Antiretroviral Drug Changes on Survival of Patients with Advanced-Stage AIDS with Multidrug-Resistant HIV Infection. J Int Assoc Provid AIDS Care 2020; 18:2325958219849101. [PMID: 31272313 PMCID: PMC6748500 DOI: 10.1177/2325958219849101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: This article aims to elucidate the relationship between antiretroviral (ARV) medication changes and all-cause mortality using a total of 368 patients recruited from the United States (78%), United Kingdom (11%), and Canada (11%). Methods: Data sources included demographic characteristics, ARV treatment history and modifications, and clinical biomarker data from the completed OPTions In Management with Antiretrovirals clinical trial. Descriptive analysis and graphical trajectory representation of ARV drug modifications and biomarker changes were undertaken. Three hypotheses aimed at assessing the impact of ARV modification parameters on clinical outcomes were tested. Kaplan-Meier survival techniques as well as Cox proportional hazard regression models were employed. Results: Results from the analyses suggest that (1) switching therapy strategy from an intensified ARV regimen to a less intense one or vice versa, (2) having a moderate number (up to 2) of ARV drug changes per 6 months, and (3) changes based on clinical/HIV-related reasons or nonclinical reasons compared to ARV drug regimen changes due to clinical non-HIV reasons improved survival. Conclusion: Modifications in the ARV regimens of HIV-infected patients with multidrug resistance are associated with improved survival.
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Affiliation(s)
- Rui Ma
- 1 Department of Biostatistics, Yale University, New Haven, CT, USA
| | - Tae Hyun Jung
- 1 Department of Biostatistics, Yale University, New Haven, CT, USA.,2 VA Cooperative Studies Program Coordinating Center, West Haven, CT, USA
| | - Peter N Peduzzi
- 1 Department of Biostatistics, Yale University, New Haven, CT, USA.,2 VA Cooperative Studies Program Coordinating Center, West Haven, CT, USA
| | - Sheldon T Brown
- 3 James J. Peters VA Medical Center, Bronx, NY, USA.,4 Icahn School of Medicine at Mount Sinai, NY, USA
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26
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Cardemil CV, Balachandran N, Kambhampati A, Grytdal S, Dahl RM, Rodriguez-Barradas MC, Vargas B, Beenhouwer DO, Evangelista KV, Marconi VC, Meagley KL, Brown ST, Perea A, Lucero-Obusan C, Holodniy M, Browne H, Gautam R, Bowen MD, Vinjé J, Parashar UD, Hall AJ. Incidence, etiology, and severity of acute gastroenteritis among prospectively enrolled patients in 4 Veterans Affairs hospitals and outpatient centers, 2016-18. Clin Infect Dis 2020; 73:e2729-e2738. [PMID: 32584956 DOI: 10.1093/cid/ciaa806] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute gastroenteritis (AGE) burden, etiology, and severity in adults is not well-characterized. We implemented a multisite AGE surveillance platform in 4 Veterans Affairs Medical Centers (Atlanta, Bronx, Houston and Los Angeles), collectively serving >320,000 patients annually. METHODS From July 1, 2016-June 30, 2018, we actively identified AGE inpatient cases and non-AGE inpatient controls through prospective screening of admitted patients and passively identified outpatient cases through stool samples submitted for clinical diagnostics. We abstracted medical charts and tested stool samples for 22 pathogens via multiplex gastrointestinal PCR panel followed by genotyping of norovirus- and rotavirus-positive samples. We determined pathogen-specific prevalence, incidence, and modified Vesikari severity scores. RESULTS We enrolled 724 inpatient cases, 394 controls, and 506 outpatient cases. Clostridioides difficile and norovirus were most frequently detected among inpatients (cases vs controls: C. difficile, 18.8% vs 8.4%; norovirus, 5.1% vs 1.5%; p<0.01 for both) and outpatients (norovirus: 10.7%; C. difficile: 10.5%). Incidence per 100,000 population was highest among outpatients (AGE: 2715; C. difficile: 285; norovirus: 291) and inpatients ≥65 years old (AGE: 459; C. difficile: 91; norovirus: 26). Clinical severity scores were highest for inpatient norovirus, rotavirus, and Shigella/EIEC cases. Overall, 12% of AGE inpatient cases had ICU stays and 2% died; 3 deaths were associated with C. difficile and 1 with norovirus. C. difficile and norovirus were detected year-round with a fall/winter predominance. CONCLUSIONS C. difficile and norovirus were leading AGE pathogens in outpatient and hospitalized US Veterans, resulting in severe disease. Clinicians should remain vigilant for bacterial and viral causes of AGE year-round.
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Affiliation(s)
- Cristina V Cardemil
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Neha Balachandran
- Cherokee Nation Assurance, Arlington, VA, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, GA
| | - Anita Kambhampati
- Cherokee Nation Assurance, Arlington, VA, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, GA
| | - Scott Grytdal
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Rebecca M Dahl
- Maximus Federal, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, GA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Blanca Vargas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX
| | - David O Beenhouwer
- VA Greater Los Angeles Healthcare System, Los Angeles, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Karen V Evangelista
- VA Greater Los Angeles Healthcare System, Los Angeles, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Vincent C Marconi
- Atlanta VA Medical Center, Atlanta, GA.,Emory University School of Medicine, Atlanta, GA
| | | | - Sheldon T Brown
- James J. Peters VA Medical Center, Bronx, NY.,Icahn School of Medicine at Mt. Sinai, NY, NY
| | | | - Cynthia Lucero-Obusan
- Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC.,VA Palo Alto Health Care System, Palo Alto, CA
| | - Mark Holodniy
- Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC.,VA Palo Alto Health Care System, Palo Alto, CA.,Stanford University, Stanford, CA
| | - Hannah Browne
- Cherokee Nation Assurance, Arlington, VA, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, GA
| | - Rashi Gautam
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Michael D Bowen
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jan Vinjé
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Umesh D Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Aron J Hall
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
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27
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Pindyck T, Hall AJ, Tate JE, Cardemil CV, Kambhampati AK, Wikswo ME, Payne DC, Grytdal S, Boom JA, Englund JA, Klein EJ, Halasa N, Selvarangan R, Staat MA, Weinberg GA, Beenhouwer DO, Brown ST, Holodniy M, Lucero-Obusan C, Marconi VC, Rodriguez-Barradas MC, Parashar U. Validation of Acute Gastroenteritis-related International Classification of Diseases, Clinical Modification Codes in Pediatric and Adult US Populations. Clin Infect Dis 2020; 70:2423-2427. [PMID: 31626687 PMCID: PMC7390357 DOI: 10.1093/cid/ciz846] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Received: 06/17/2019] [Accepted: 08/22/2019] [Indexed: 11/14/2022] Open
Abstract
International Classification of Diseases diagnostic codes are used to estimate acute gastroenteritis (AGE) disease burden. We validated AGE-related codes in pediatric and adult populations using 2 multiregional active surveillance platforms. The sensitivity of AGE codes was similar (54% and 58%) in both populations and increased with addition of vomiting-specific codes.
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Affiliation(s)
- Talia Pindyck
- Epidemic Intelligence Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Aron J Hall
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jacqueline E Tate
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cristina V Cardemil
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anita K Kambhampati
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- IHRC, Inc, Atlanta, Georgia, USA
| | - Mary E Wikswo
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Daniel C Payne
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Scott Grytdal
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | - Natasha Halasa
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Mary Allen Staat
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Geoffrey A Weinberg
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - David O Beenhouwer
- Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California, USA
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Sheldon T Brown
- James J. Peters VA Medical Center, Bronx, New York, USA
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mark Holodniy
- Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, California, USA
| | - Cynthia Lucero-Obusan
- Public Health Surveillance and Research, Department of Veterans Affairs, Palo Alto, California, USA
| | - Vince C Marconi
- Atlanta VA Medical Center, Decatur, Georgia, USA
- Rollins School of Public Health at Emory University, Atlanta, Georgia, USA
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Infectious Diseases Section, Baylor College of Medicine, Houston, Texas, USA
| | - Umesh Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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28
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Nosova EV, Japp E, Brown ST, Cohen AJ, Greenberg PD. SUN-518 Graves’ Disease Newly Diagnosed in the Setting of Hypokalemic Periodic Paralysis in an HIV+ Patient. J Endocr Soc 2020. [PMCID: PMC7209536 DOI: 10.1210/jendso/bvaa046.812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Relevance: A rare yet distinct cause of sudden onset paralysis is severe hypokalemia associated with thyrotoxicosis. This is thought to be associated with mutations in genes encoding cellular potassium channels. We report a case of acute onset paralysis with profound hypokalemia and a new diagnosis of Graves’ thyrotoxicosis in a previously asymptomatic African American, HIV+ man on highly active antiretroviral therapy (HAART) for over 8 years. Clinical case: A 49-year-old man with hypertension and HIV presented with acute paralysis of his bilateral upper and lower extremities. His initial potassium was 1.8 mEq/L (3.5-5.0). Prior to sudden onset loss of motor strength, he denied any preceding palpitations, tremor, anxiety, diaphoresis, hyper-defecation, weight loss, heat or cold intolerance, neck pain, increase in neck girth or difficulty swallowing, proptosis or other ocular symptoms. He has no family history of thyroid disease. He had an enlarged palpable thyroid without nodules and no audible bruit. There was no periorbital edema or proptosis, and no signs of dermopathy. A thyroid ultrasound showed a hyperemic and diffusely enlarged thyroid gland without nodules. Labs included a TSH of 0.007 mCU/mL (0.43-3.8), Free T4 2.1 ng/dL (0.71-1.85), Total T3 229.6 ng/dL (58-194), and thyrotropin receptor antibody 2.6 IU/L (0-1.75). The CD4+ count was 146 in 2010 with a slow gradual rise to 673 in 2019, and HIV viral load was undetectable. There were no offending medications or supplements identified. With aggressive potassium repletion, the serum potassium improved to 4.6 mEq/L and he regained normal strength within several hours. He was started on Methimazole 10mg daily and propranolol 10mg TID. At one month, the thyroid function tests normalized. Methimazole 10mg daily was continued and propranolol was tapered off. He remains euthyroid. Genetic testing is pending. Conclusions: Graves’ disease is the most common thyroid disease triggered by immune reconstitution in HIV + individuals on HAART. The incidence of thyroid disease in HIV patients on HAART is higher in women and Africans with a 1.5-2 fold increase compared with the general population [Muller et. al, Eur Thyroid J 2019;8:173-185]. Despite a higher incidence of hyperthyroidism in women, over 95% of cases of hypokalemic periodic paralysis have been reported in men, with a 10-fold higher incidence among Asians compared to Westerners. There has been one prior case report of Thyrotoxic Periodic Paralysis in an HIV + patient and this was in a Polynesian male (Brown JD et al. Hawaii Med J 2007). To our knowledge, this is the first case report of an African American HIV+ patient with this disorder. An association with mutations in the Kir2.6 gene (encodes a potassium channel, is expressed in skeletal muscle, and is transcriptionally regulated by thyroid hormone) has been proposed [Ryan et. al, Cell 2010 January 8; 140(1):88-98].
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Affiliation(s)
- Emily V Nosova
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Emily Japp
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Sheldon T Brown
- Division of Infectious Diseases, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Alan J Cohen
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Pietra D Greenberg
- Division of Endocrinology, James J Peters VA Medical Center, Bronx, NY, USA
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29
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Greenstein RJ, Su L, Fam PS, Gurland B, Endres P, Brown ST. Crohn's disease: failure of a proprietary fluorescent in situ hybridization assay to detect M. avium subspecies paratuberculosis in archived frozen intestine from patients with Crohn's disease. BMC Res Notes 2020; 13:96. [PMID: 32093770 PMCID: PMC7038517 DOI: 10.1186/s13104-020-04947-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 02/11/2020] [Indexed: 11/21/2022] Open
Abstract
Objectives Although controversial, there is increasing concern that Crohn’s disease may be a zoonotic infectious disease consequent to a mycobacterial infection. The most plausible candidate is M. avium subspecies paratuberculosis (MAP) that is unequivocally responsible for Johne’s disease in ruminants. The purpose of this study was to evaluate a proprietary (Affymetrix™ RNA view®) fluorescent in situ hybridization (FISH) assay for MAP RNA. Non-identifiable intestine from patients with documented Crohn’s disease was assayed according to the manufacturer’s instructions and with suggested modifications. Probes were custom designed for MAP and human β-actin (as the eukaryotic housekeeping gene) from published genomes. Results Repetitively, false positive signal was observed in our “No-Probe” negative control. Attempts were made to correct this according to the manufacturer’s suggestions (by modifying wash solutions, using recommended hydrochloric acid titration and different fluorescent filters). None prevented false positive signal in the “No-Probe” control. It is concluded that when performed according to manufactures instruction and with multiple variations on the manufactures recommended suggestions to correct for false positive signal, that the Affymetrix™ RNA view® cannot be used to detect MAP in pre-frozen resected intestine of humans with Crohn’s disease.
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Affiliation(s)
- Robert J Greenstein
- Department of Surgery, James J. Peters Veterans Affairs Medical Center Bronx, New York, USA. .,Laboratory of Molecular Surgical Research, James J. Peters Veterans Affairs Medical Center Bronx, New York, USA.
| | - Liya Su
- Laboratory of Molecular Surgical Research, James J. Peters Veterans Affairs Medical Center Bronx, New York, USA
| | - Peter S Fam
- Mental Illness Research Education and Clinical Center (MIRECC), James J. Peters, Veterans Affairs Medical Center Bronx, New York, USA
| | - Brooke Gurland
- Colorectal Surgery, Stanford University School of Medicine, Stanford CA, USA
| | - Paul Endres
- Department of Pathology, Icahn School of Medicine at Mount Sinai New York, New York, USA
| | - Sheldon T Brown
- Infectious Disease Section, James J. Peters Veterans Affairs Medical Center Bronx, New York, USA.,Department of Medicine, Icahn School of Medicine at Mt. Sinai. New York, New York, USA
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Bessesen MT, Doros G, Henrie AM, Harrington KM, Hermos JA, Bonomo RA, Ferguson RE, Huang GD, Brown ST. A multicenter randomized placebo controlled trial of rifampin to reduce pedal amputations for osteomyelitis in veterans with diabetes (VA INTREPID). BMC Infect Dis 2020; 20:23. [PMID: 31914940 PMCID: PMC6950878 DOI: 10.1186/s12879-019-4751-3] [Citation(s) in RCA: 12] [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: 11/01/2019] [Accepted: 12/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background The prevalence of diabetes mellitus continues to inexorably rise in the United States and throughout the world. Lower limb amputations are a devastating comorbid complication of diabetes mellitus. Osteomyelitis increases the risk of amputation fourfold and commonly presages death. Antimicrobial therapy for diabetic foot osteomyelitis (DFO) varies greatly, indicating that high quality data are needed to inform clinical decision making. Several small trials have indicated that the addition of rifampin to backbone antimicrobial regimens for osteomyelitis outside the setting of the diabetic foot results in 28 to 42% higher cure rates. Methods/design This is a prospective, randomized, double-blind investigation of the addition of 6 weeks of rifampin, 600 mg daily, vs. matched placebo (riboflavin) to standard-of-care, backbone antimicrobial therapy for DFO. The study population are patients enrolled in Veteran Health Administration (VHA), ages ≥18 and ≤ 89 years with diabetes mellitus and definite or probable osteomyelitis of the foot for whom an extended course of oral or intravenous antibiotics is planned. The primary endpoint is amputation-free survival. The primary hypothesis is that using rifampin as adjunctive therapy will lower the hazard rate compared with the group that does not use rifampin as adjunctive therapy. The primary hypothesis will be tested by means of a two-sided log-rank test with a 5% significance level. The test has 90% power to detect a hazard ratio of 0.67 or lower with a total of 880 study participants followed on average for 1.8 years. Discussion VA INTREPID will test if a rifampin-adjunctive antibiotic regimen increases amputation-free survival in patients seeking care in the VHA with DFO. A positive finding and its adoption by clinicians would reduce lower extremity amputations and their associated physical and emotional impact and reduce mortality for Veterans and for the general population with diabetic foot osteomyelitis. Given that rifampin-adjunctive regimens are currently employed for therapy for the majority of DFO cases in Europe, and only in a small minority of cases in the United States, the trial results will impact therapeutic decisions, even if the null hypothesis is not rejected. Trial registration Registered January 6, 2017 at ClinicalTrials.gov, NCT03012529.
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Affiliation(s)
- Mary T Bessesen
- Department of Veterans Affairs Eastern Colorado Healthcare System, Denver, CO, USA.,Division of Infectious Diseases, Department of Medicine, University of Colorado - Denver, Aurora, CO, USA
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Department of Biostatistics, Boston University, Boston, MA, USA
| | - Adam M Henrie
- Department of Veterans Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Office of Research and Development, Albuquerque, NM, USA
| | - Kelly M Harrington
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - John A Hermos
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Robert A Bonomo
- Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Ryan E Ferguson
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Grant D Huang
- Department of Veterans Affairs, Cooperative Studies Program Central Office, Washington, DC, USA
| | - Sheldon T Brown
- James J. Peters VA Medical Center, New York, NY, USA. .,Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA.
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Wilson BM, Bessesen MT, Doros G, Brown ST, Saade E, Hermos J, Perez F, Skalweit M, Spellberg B, Bonomo RA. Adjunctive Rifampin Therapy For Diabetic Foot Osteomyelitis in the Veterans Health Administration. JAMA Netw Open 2019; 2:e1916003. [PMID: 31755948 PMCID: PMC6902814 DOI: 10.1001/jamanetworkopen.2019.16003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Among patients diagnosed with diabetes, the lifetime incidence of foot ulcers is 15%. Infection is a common complication of foot ulcers, and 20% to 60% of infections result in diabetic foot osteomyelitis (DFO). Current treatment guidelines do not endorse any specific antibiotic agent for DFO, but small clinical trials suggest the addition of rifampin to antimicrobial regimens results in improved cure rates for osteomyelitis. OBJECTIVE To compare the clinical outcomes of patients treated for DFO in the Veterans Health Administration (VHA) with and without adjunctive rifampin. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study used VHA databases to identify index DFO cases from January 1, 2009, through December 31, 2013, and analyzed patients alive and without high-level amputation at 90 days after diagnosis in whom antibiotic therapy was initiated within 6 weeks of diagnosis. Patients with death or major amputation within 90 days of diagnosis, who were not treated with systemic antibiotics dispensed by the VHA within 6 weeks of diagnosis, or who were treated at facilities where rifampin was not dispensed for DFO were excluded. The retrospective cohort to inform the planning of a multisite randomized clinical trial was first investigated in spring 2015; retrospective analysis was performed from February 2017 through September 2019. EXPOSURES Patients initiating rifampin therapy within 6 weeks of the DFO diagnosis and receiving the drug for at least 14 days within 90 days of diagnosis were considered treated with rifampin. Patients not administered rifampin within 90 days of diagnosis served as the comparator group. MAIN OUTCOMES AND MEASURES A combined end point of mortality or amputation within 2 years of diagnosis was analyzed. Differences in times to event were evaluated using log-rank tests. Differences in event rates were compared using χ2 tests and multivariable logistic regression. RESULTS The analysis population included 130 patients treated with rifampin and 6044 treated without rifampin (total of 6174; 6085 men [98.6%]; mean [SD] age, 64.9 [9.7] years). Lower event rates were observed among the rifampin group (35 of 130 [26.9%] vs 2250 of 6044 [37.2%]; P = .02). Patients treated with rifampin were younger (mean [SD] age, 62.2 [9.4] vs 64.9 [9.6] years), had fewer comorbidities (mean [SD] Charlson comorbidity index score, 3.5 [1.8] vs 4.0 [2.2]), had more infectious disease specialty consultations (63 of 130 [48.5%] vs 1960 of 6044 [32.4%]), and more often had Staphylococcus aureus identified in cultures (55 of 130 [42.3%] vs 1755 of 6044 [29.0%]) than patients not treated with rifampin. A logistic regression estimating the odds of events and controlling for these and other covariates yielded a significant association of rifampin (odds ratio, 0.65; 95% CI, 0.43-0.96; P = .04). CONCLUSIONS AND RELEVANCE In this cohort study, patients administered rifampin experienced lower rates of death and amputation than patients not treated with rifampin, which remained significant after adjustment for confounders. These results coupled with existing evidence from small clinical trials suggest the addition of rifampin to current treatment regimens may be a useful antimicrobial option in the treatment of DFO.
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Affiliation(s)
- Brigid M. Wilson
- Research Service and Geriatric Research, Education, and Clinical Center (GRECC),VA Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mary T. Bessesen
- Division of Infectious Diseases, University of Colorado, Denver, School of Medicine, Department of Veterans Affairs Eastern Colorado Healthcare System, Aurora
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Boston University School of Medicine, Boston, Massachusetts
| | - Sheldon T. Brown
- James J. Peters Veterans Affairs Medical Center, Bronx, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elie Saade
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Service, VA Northeast Ohio Healthcare System, Cleveland
- University Hospitals of Cleveland, Cleveland, Ohio
| | - John Hermos
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of General Internal Medicine, Boston University, Boston, Massachusetts
| | - Federico Perez
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
| | - Marion Skalweit
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center, Los Angeles
- Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles
| | - Robert A. Bonomo
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- CWRU (Case Western Reserve University)–Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio
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Cardemil C, Balachandran N, Kambhampati A, Grytdal S, Rodriguez-Barradas MC, Vargas B, Beenhouwer D, Evangelista K, Marconi V, Meagley K, Brown ST, Perea A, Lucero-Obusan C, Holodniy M, Browne H, Gautam R, Bowen M, Vinje J, Parashar UD, Hall A. 2322. Etiology, Severity of Illness, and Risk Factors for Patients Hospitalized with Acute Gastroenteritis from Multi-Site Veteran’s Affairs (VA) Surveillance, 2016–2018: Results from SUPERNOVA. Open Forum Infect Dis 2019. [PMCID: PMC6809599 DOI: 10.1093/ofid/ofz360.2000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The severity of acute gastroenteritis (AGE) in adult populations and the relative contribution of specific pathogens is not well characterized. In 2016, we implemented a multisite AGE surveillance platform in 4 VA hospitals (Atlanta, Bronx, Houston and Los Angeles), collectively serving > 320,000 patients annually. Methods Inpatient AGE cases and age- and time-matched non-AGE controls were identified through prospective screening of admissions using standardized case definitions. Stool samples were tested for 22 pathogens using the FilmArray® Gastrointestinal Panel. Medical conditions were analyzed as risk factors for AGE by multivariate logistic regression. Results From July 2016 to June 2018, 731 cases and 399 controls were enrolled. Risk factors for AGE cases included HIV-positive status (adjusted odds ratio [aOR] 4.6; 95% confidence interval [CI] 1.6–12.9; P < 0.01), severe kidney disease (aOR 4.5; 95% CI 2.0–9.8; P < 0.01), and immunosuppressive therapy (aOR 4.0; 95% CI 1.2–13.3]; P = 0.02). Clostridioides difficile and norovirus were the most commonly detected pathogens in cases (18% and 5%, respectively); detection of these pathogens in cases was significantly higher than detection in controls (8% and 2%, respectively; P < 0.01 for both). The median duration of hospital stay was longer for C. difficile compared with norovirus cases (5 vs. 3 days; P < 0.01), and cases with both pathogens had intensive care unit (ICU) stays (C. difficile: 18%; norovirus: 8%; P = 0.2). Fourteen deaths occurred among AGE cases; 2 were associated with C. difficile and 1 with norovirus; the remainder did not have a clear etiology or pathogen detected. C. difficile and norovirus were detected year-round with a fall and winter predominance; C. difficile prevalence was highest in October, while norovirus prevalence was six times higher in December than in summer months. Conclusion This surveillance platform captured cases of severe AGE, including ICU stays and deaths, among hospitalized US Veterans. C. difficile and norovirus were leading pathogens in AGE cases. These findings can help guide appropriate clinical management of AGE patients and inform public health efforts to quantify and address the associated burden of disease through targeted interventions. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Neha Balachandran
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, Atlanta, Georgia
| | - Anita Kambhampati
- IHRC, Inc. contracting agency to the Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Scott Grytdal
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Kathryn Meagley
- Atlanta Veterans Affairs Health Care System, Atlanta, Georgia
| | | | - Adrienne Perea
- James J. Peters VA Medical Center, Bronx, New York, Bronx, New York
| | | | - Mark Holodniy
- Department of Veterans Affairs, Palo Alto, California
| | - Hannah Browne
- Oak Ridge Institute for Science and Education; Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Umesh D Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Aron Hall
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Freiberg MS, Chang CCH, Skanderson M, Patterson OV, DuVall SL, Brandt CA, So-Armah KA, Vasan RS, Oursler KA, Gottdiener J, Gottlieb S, Leaf D, Rodriguez-Barradas M, Tracy RP, Gibert CL, Rimland D, Bedimo RJ, Brown ST, Goetz MB, Warner A, Crothers K, Tindle HA, Alcorn C, Bachmann JM, Justice AC, Butt AA. Association Between HIV Infection and the Risk of Heart Failure With Reduced Ejection Fraction and Preserved Ejection Fraction in the Antiretroviral Therapy Era: Results From the Veterans Aging Cohort Study. JAMA Cardiol 2019; 2:536-546. [PMID: 28384660 DOI: 10.1001/jamacardio.2017.0264] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance With improved survival, heart failure (HF) has become a major complication for individuals with human immunodeficiency virus (HIV) infection. It is unclear if this risk extends to different types of HF in the antiretroviral therapy (ART) era. Determining whether HIV infection is associated with HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or both is critical because HF types differ with respect to underlying mechanism, treatment, and prognosis. Objectives To investigate whether HIV infection increases the risk of future HFrEF and HFpEF and to assess if this risk varies by sociodemographic and HIV-specific factors. Design, Setting, and Participants This study evaluated 98 015 participants without baseline cardiovascular disease from the Veterans Aging Cohort Study, an observational cohort of HIV-infected veterans and uninfected veterans matched by age, sex, race/ethnicity, and clinical site, enrolled on or after April 1, 2003, and followed up through September 30, 2012. The dates of the analysis were October 2015 to November 2016. Exposure Human immunodeficiency virus infection. Main Outcomes and Measures Outcomes included HFpEF (EF≥50%), borderline HFpEF (EF 40%-49%), HFrEF (EF<40%), and HF of unknown type (EF missing). Results Among 98 015 participants, the mean (SD) age at enrollment in the study was 48.3 (9.8) years, 97.0% were male, and 32.2% had HIV infection. During a median follow-up of 7.1 years, there were 2636 total HF events (34.6% were HFpEF, 15.5% were borderline HFpEF, 37.1% were HFrEF, and 12.8% were HF of unknown type). Compared with uninfected veterans, HIV-infected veterans had an increased risk of HFpEF (hazard ratio [HR], 1.21; 95% CI, 1.03-1.41), borderline HFpEF (HR, 1.37; 95% CI, 1.09-1.72), and HFrEF (HR, 1.61; 95% CI, 1.40-1.86). The risk of HFrEF was pronounced in veterans younger than 40 years at baseline (HR, 3.59; 95% CI, 1.95-6.58). Among HIV-infected veterans, time-updated HIV-1 RNA viral load of at least 500 copies/mL compared with less than 500 copies/mL was associated with an increased risk of HFrEF, and time-updated CD4 cell count less than 200 cells/mm3 compared with at least 500 cells/mm3 was associated with an increased risk of HFrEF and HFpEF. Conclusions and Relevance Individuals who are infected with HIV have an increased risk of HFpEF, borderline HFpEF, and HFrEF compared with uninfected individuals. The increased risk of HFrEF can manifest decades earlier than would be expected in a typical uninfected population. Future research should focus on prevention, risk stratification, and identification of the mechanisms for HFrEF and HFpEF in the HIV-infected population.
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Affiliation(s)
- Matthew S Freiberg
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee2Geriatric Research Education and Clinical Centers, Veterans Affairs Tennessee Valley Healthcare System, Nashville
| | - Chung-Chou H Chang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Melissa Skanderson
- Research Division, Veterans Affairs Connecticut Health Care System, West Haven Veterans Administration Medical Center, West Haven
| | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City6Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City6Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Cynthia A Brandt
- Research Division, Veterans Affairs Connecticut Health Care System, West Haven Veterans Administration Medical Center, West Haven7Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kaku A So-Armah
- Division of General Internal Medicine, Boston University, Boston, Massachusetts
| | - Ramachandran S Vasan
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Kris Ann Oursler
- Department of Medicine, University of Maryland School of Medicine, Baltimore11Division of Infectious Diseases, Baltimore Veterans Affairs Health Care System, Baltimore, Maryland12Division of Cardiology, Baltimore Veterans Affairs Health Care System, Baltimore, Maryland
| | - John Gottdiener
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Stephen Gottlieb
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - David Leaf
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Maria Rodriguez-Barradas
- Department of Medicine, Baylor College of Medicine, Houston, Texas15Division of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Russell P Tracy
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Burlington
| | - Cynthia L Gibert
- Department of Medicine, George Washington University School of Medicine, Washington, DC18Division of Infectious Diseases, Washington DC Veterans Affairs Medical Center, Washington, DC
| | - David Rimland
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia20Division of Infectious Diseases, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Roger J Bedimo
- Department of Medicine, Veterans Affairs North Texas Health Care System, Dallas
| | - Sheldon T Brown
- Division of Infectious Diseases, James J. Peters Veterans Affairs Medical Center, Bronx, New York23Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew Bidwell Goetz
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles24Division of Infectious Diseases, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
| | - Alberta Warner
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles25Division of Cardiology, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California
| | - Kristina Crothers
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Hilary A Tindle
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Charles Alcorn
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Justin M Bachmann
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amy C Justice
- Research Division, Veterans Affairs Connecticut Health Care System, West Haven Veterans Administration Medical Center, West Haven29Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Adeel A Butt
- Department of Medicine, Weill Cornell Medical College, New York, New York
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Edelman EJ, Moore BA, Holt SR, Hansen N, Kyriakides TC, Virata M, Brown ST, Justice AC, Bryant KJ, Fiellin DA, Fiellin LE. Efficacy of Extended-Release Naltrexone on HIV-Related and Drinking Outcomes Among HIV-Positive Patients: A Randomized-Controlled Trial. AIDS Behav 2019; 23:211-221. [PMID: 30073637 DOI: 10.1007/s10461-018-2241-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
We sought to test the efficacy of extended-release naltrexone (XR-NTX) on HIV-related and drinking outcomes. From April 2011-February 2015, we conducted a 4-site randomized double-blind placebo controlled clinical trial involving 51 HIV-positive patients with heavy drinking and < 95% antiretroviral (ART) adherence. All participants received counseling. The primary outcome was proportion with ≥ 95% ART adherence. Secondary outcomes included HIV biomarkers, VACS Index score, and past 30-day heavy drinking days. Based on receipt of ≥ 5 injections, 23 participants were retained at 24 weeks. We did not detect an effect of XR-NTX on ART adherence (p = 0.38); undetectable HIV viral load (p = 0.26); CD4 cell count (p = 0.75) or VACS Index score (p = 0.70). XR-NTX was associated with fewer heavy drinking days (p = 0.03). While XR-NTX decreases heavy drinking days, we did not detect improvements in ART adherence or HIV outcomes. Strategies to improve retention in alcohol treatment and HIV-related outcomes among heavy drinking HIV-positive patients are needed.
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Hawkins KL, Gordon KS, Levin MJ, Weinberg A, Battaglia C, Rodriguez-Barradas MC, Brown ST, Rimland D, Justice A, Tate J, Erlandson KM. Herpes Zoster and Herpes Zoster Vaccine Rates Among Adults Living With and Without HIV in the Veterans Aging Cohort Study. J Acquir Immune Defic Syndr 2018; 79:527-533. [PMID: 30179984 PMCID: PMC6203599 DOI: 10.1097/qai.0000000000001846] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Despite historically high rates of herpes zoster among people living with HIV (PLWH), comparative studies of herpes zoster by HIV serostatus are lacking since the advent of combination antiretroviral therapy and availability of zoster vaccine. METHODS Annual rates (2002-2015) of first-episode herpes zoster and zoster vaccination were calculated for PLWH and uninfected adults in the Veterans Aging Cohort Study and stratified by HIV serostatus and age. Herpes zoster was captured using ICD9 codes and vaccine receipt with procedural codes and pharmacy data. RESULTS Of 45,177 PLWH and 103,040 uninfected veterans, rates of herpes zoster decreased among PLWH (17.6-8.1/1000) over the study period but remained higher than uninfected adults (4.1/1000) at the end of study period. Rates were higher in PLWH with lower CD4 (<200 vs >500 cells/µL: 18.0 vs 6.8/1000) and unsuppressed vs suppressed HIV-1 RNA (21.8 vs 7.1/1000). Restricted to virologically suppressed participants with CD4 >350 cells per microliter, herpes zoster rates were similar among PLWH aged younger than 60 years and aged 60 years and older in 2015 (6.6 vs 6.7/1000) but higher than all uninfected age groups. At study end, cumulative receipt of zoster vaccine for PLWH aged 60 years and older was less than half that of uninfected veterans: 98.7 vs 215.2/1000. CONCLUSIONS Herpes zoster rates among PLWH have markedly decreased, but, even in cART-treated individuals, remain 50% higher than uninfected adults. Lower rates of zoster vaccine receipt combined with high rates of herpes zoster support the need for a safe and effective vaccine against herpes zoster for PLWH, formal zoster vaccine guidelines for PLWH, and consideration for expanded use at younger ages.
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Affiliation(s)
- Kellie L Hawkins
- Denver Public Health, Denver, CO
- Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Kirsha S Gordon
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Yale University Schools of Medicine and Public Health, New Haven, CT
| | - Myron J Levin
- Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Adriana Weinberg
- Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Catherine Battaglia
- Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Maria C Rodriguez-Barradas
- Department of Medicine, Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX
| | - Sheldon T Brown
- Department of Medicine, James J. Peters Veterans Affairs Medical Center, Mount Sinai School of Medicine, New York, NY
| | - David Rimland
- Division of Infectious Diseases, Atlanta Veterans Affairs Medical Center, Emory University School of Medicine, Atlanta, GA
| | - Amy Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Yale University Schools of Medicine and Public Health, New Haven, CT
| | - Janet Tate
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Yale University Schools of Medicine and Public Health, New Haven, CT
| | - Kristine M Erlandson
- Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado, Aurora, CO
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Kambhampati A, Atmar RL, Neill FH, Rodriguez-Barradas MC, Vargas B, Beenhouwer DO, Poteshkina A, Marconi VC, Meagley KL, Brown ST, Perea A, Browne H, Gautam R, Grytdal S, Bowen MD, Vinjé J, Parashar UD, Hall AJ, Cardemil CV. 652. What Is Blood Got to Do with It? Genetic Susceptibility to Norovirus and Rotavirus Infection: Results From the SUPERNOVA Network. Open Forum Infect Dis 2018. [PMCID: PMC6255288 DOI: 10.1093/ofid/ofy210.659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Histo-blood group antigens (HBGAs), whose expression is controlled in part by fucosyltransferase 2 (FUT2) and 3 (FUT3) genes, serve as receptors for norovirus and rotavirus. Individuals without functional FUT2 (nonsecretors) or FUT3 (Lewis-negative) genes may have decreased susceptibility to norovirus and rotavirus infections. As the prevalence of secretor and Lewis status can vary by race and ethnicity, we assessed this association in a US Veteran population. Methods Stool and saliva specimens were collected from acute gastroenteritis (AGE) cases and age- and time-matched controls through a multisite, active surveillance platform at four Veterans Affairs hospitals (Atlanta, Bronx, Houston, Los Angeles). Stool specimens were tested with the FilmArray Gastrointestinal Panel; norovirus and rotavirus positive specimens were genotyped. Saliva specimens were analyzed for HBGA expression by EIA using glycan-specific monoclonal antibodies and lectins. Chi-squared and Fisher’s exact tests were conducted to evaluate associations between secretor and Lewis status and infection with norovirus or rotavirus. Results From November 4, 2015–December 30, 2017, 670 AGE cases and 319 controls provided both stool and saliva specimens. Norovirus (21 GII.4 Sydney, 13 GII non-4, 7 GI, 10 untyped) and rotavirus (13 G12P[8], 1 G2P[4], 1 untyped) positive cases were more likely to be secretor positive (90% and 100%, respectively) compared with controls (76%) (P = 0.03 for both). Infections with GII.4 Sydney norovirus (P < 0.01) and G12P[8] rotavirus (P < 0.05) were significantly associated with secretor status. This association was not observed with other norovirus or rotavirus genotypes. No association was observed between Lewis status, race, or ethnicity and infection with norovirus or rotavirus. Conclusion Norovirus and rotavirus infections among a US Veteran population were associated with secretor status in a genotype-dependent manner, and with GII.4 Sydney norovirus and G12P[8] rotavirus, the most common strains. These associations are consistent with previously reported results, and suggest that the efficacy of interventions, such as vaccines, should include consideration of secretor status and predominantly circulating virus strains. Disclosures R. L. Atmar, Takeda Vaccines, Inc.: Investigator, Research grant. V. C. Marconi, ViiV: Investigator, Research support and Salary. Gilead: Investigator, Research support. Bayer: Investigator, Research support.
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Affiliation(s)
- Anita Kambhampati
- IHRC, Inc., Atlanta, Georgia
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Maria C Rodriguez-Barradas
- Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Blanca Vargas
- Baylor College of Medicine, Houston, Texas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - David O Beenhouwer
- David Geffen School of Medicine at UCLA, Los Angeles, California
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Vincent C Marconi
- Atlanta VA Medical Center, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Sheldon T Brown
- Icahn School of Medicine at Mt. Sinai, New York, New York
- James J. Peters VA Medical Center, Bronx, New York
| | | | - Hannah Browne
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Rashi Gautam
- IHRC, Inc., Atlanta, Georgia
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Scott Grytdal
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael D Bowen
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jan Vinjé
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Umesh D Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Aron J Hall
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cristina V Cardemil
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Rentsch CT, Cartwright EJ, Gandhi NR, Brown ST, Rodriguez-Barradas MC, Goetz MB, Marconi VC, Gibert CL, Re VL, Fiellin DA, Justice AC, Tate JP. Provider verification of electronic health record receipt and nonreceipt of direct-acting antivirals for the treatment of hepatitis C virus infection. Ann Epidemiol 2018; 28:808-811. [PMID: 30195616 PMCID: PMC6318448 DOI: 10.1016/j.annepidem.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/25/2018] [Accepted: 08/20/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Pharmacoepidemiologic studies using electronic health record data could serve an important role in assessing safety and effectiveness of direct-acting antiviral therapy for chronic hepatitis C virus (HCV) infection, but the validity of these data needs to be determined. We evaluated the accuracy of pharmacy fill records in the national Veterans Health Administration (VA) Corporate Data Warehouse (CDW) as compared to facility-level electronic health record. METHODS Patients prescribed a direct-acting antiviral regimen at five VA sites between 2014 and 2016 were randomly selected and reviewed. A random sample of patients with chronic HCV infection without evidence of HCV treatment during the study period also underwent chart review. We calculated positive predictive value and negative predictive value overall and by site. RESULTS Of the 501 patients who received a total of 2416 prescriptions, 494 were validated using data extracted from CDW 6 months after the study period, yielding a positive predictive value of 98.6% (95% confidence interval, 97.6%-99.6%). Of the 100 patients with chronic HCV infection without prescriptions for HCV treatment, 99 were confirmed not to have received antiviral treatment (negative predictive value, 99.0%; 95% confidence interval, 97.1%-100%). CONCLUSIONS These findings provide assurance to researchers who use national VA CDW data for retrospective cohort studies that the CDW contains accurate information on HCV therapies in the modern treatment era.
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Affiliation(s)
- Christopher T Rentsch
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA; Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - Emily J Cartwright
- Division of Infectious Diseases, Atlanta VA Medical Center, Decatur, GA, USA; School of Medicine, Emory University, Atlanta, GA, USA
| | - Neel R Gandhi
- School of Medicine, Emory University, Atlanta, GA, USA; Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sheldon T Brown
- Medicine, James J. Peters VA Medical Center, New York, NY, USA; Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Maria C Rodriguez-Barradas
- Medicine, Michael E. DeBakey VA Medical Center, Houston, TX, USA; Medicine-Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| | - Matthew Bidwell Goetz
- Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine, UCLA, CA, USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Atlanta VA Medical Center, Decatur, GA, USA; School of Medicine, Emory University, Atlanta, GA, USA; Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Vincent Lo Re
- Medicine (Division of Infectious Diseases) and Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David A Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; School of Public Health, Yale University, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
| | - Amy C Justice
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA; Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
| | - Janet P Tate
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA; Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Greenstein RJ, Su L, Fam PS, Stabel JR, Brown ST. Failure to detect M. avium subspecies paratuberculosis in Johne's disease using a proprietary fluorescent in situ hybridization assay. BMC Res Notes 2018; 11:498. [PMID: 30031406 PMCID: PMC6054717 DOI: 10.1186/s13104-018-3601-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/12/2018] [Indexed: 01/21/2023] Open
Abstract
Objectives Mycobacterium avium subspecies paratuberculosis (MAP) causes Johne’s disease in ruminants. The “gold standard” of MAP detection is by culture, DNA sequencing possibly supplemented by identification of Ziehl–Neelsen positive mycobacteria. The purpose of this study was to evaluate a proprietary (Affymetrix™ RNA view®) fluorescent in situ hybridization (FISH) assay for MAP RNA. Intestine from a steer with documented Johne’s disease was assayed according to the manufacturer’s instructions. Probes were custom designed for MAP and bovine β-actin (as the eukaryotic housekeeping gene) from published genomes. We attempt to prevent false positive signal in the “no-probe” control, by modifying wash solutions, using recommended hydrochloric acid titration and different fluorescent filters (TritC for Texas Red and “Hope” for Cy-5). Results Repetitively, false positive signal was observed in our “no probe” negative control. Attempts to correct this according to the manufacturers suggestions, and with multiple derivative techniques have been unsuccessful. It is concluded that when performed according to manufactures instruction and with multiple variations on the manufactures recommended suggestions to correct for false positive signal, that the Affymetrix™ RNA view® cannot be used to detect MAP in pre-frozen intestine of cattle with Johne’s disease. Electronic supplementary material The online version of this article (10.1186/s13104-018-3601-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert J Greenstein
- Department of Surgery, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA. .,Laboratory of Molecular Surgical Research, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA.
| | - Liya Su
- Laboratory of Molecular Surgical Research, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Peter S Fam
- Mental Illness Research Education and Clinical Center (MIRECC), James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Judy R Stabel
- Johne's Disease Research Project, USDA-ARS, National Animal Disease Center, Ames, IA, 50010, USA
| | - Sheldon T Brown
- Infectious Disease Section, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
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39
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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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40
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Byrne DD, Tate JP, Forde KA, Lim JK, Goetz MB, Rimland D, Rodriguez-Barradas MC, Butt AA, Gibert CL, Brown ST, Bedimo R, Freiberg MS, Justice AC, Kostman JR, Roy JA, Lo Re V. Risk of Acute Liver Injury After Statin Initiation by Human Immunodeficiency Virus and Chronic Hepatitis C Virus Infection Status. Clin Infect Dis 2018; 65:1542-1550. [PMID: 29020184 DOI: 10.1093/cid/cix564] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 06/27/2017] [Indexed: 12/15/2022] Open
Abstract
Background Patients with human immunodeficiency virus (HIV) and/or chronic hepatitis C virus (HCV) infection may be prescribed statins as treatment for metabolic/cardiovascular disease, but it remains unclear if the risk of acute liver injury (ALI) is increased for statin initiators compared to nonusers in groups classified by HIV/HCV status. Methods We conducted a cohort study to compare rates of ALI in statin initiators vs nonusers among 7686 HIV/HCV-coinfected, 8155 HCV-monoinfected, 17739 HIV-monoinfected, and 36604 uninfected persons in the Veterans Aging Cohort Study (2000-2012). We determined development of (1) liver aminotransferases >200 U/L, (2) severe ALI (coagulopathy with hyperbilirubinemia), and (3) death, all within 18 months. Cox regression was used to determine propensity score-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of outcomes in statin initiators compared to nonusers across the groups. Results Among HIV/HCV-coinfected patients, statin initiators had lower risks of aminotransferase levels >200 U/L (HR, 0.66 [95% CI, .53-.83]), severe ALI (HR, 0.23 [95% CI, .12-.46]), and death (HR, 0.36 [95% CI, .28-.46]) compared with statin nonusers. In the setting of chronic HCV alone, statin initiators had reduced risks of aminotransferase elevations (HR, 0.57 [95% CI, .45-.72]), severe ALI (HR, 0.15 [95% CI, .06-.37]), and death (HR, 0.42 [95% CI, .32-.54]) than nonusers. Among HIV-monoinfected patients, statin initiators had lower risks of aminotransferase increases (HR, 0.52 [95% CI, .40-.66]), severe ALI (HR, 0.26 [95% CI, .13-.55]), and death (HR, 0.19 [95% CI, .16-.23]) compared with nonusers. Results were similar among uninfected persons. Conclusions Regardless of HIV and/or chronic HCV status, statin initiators had a lower risk of ALI and death within 18 months compared with statin nonusers.
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Affiliation(s)
- Dana D Byrne
- Departments of Medicine, Penn Center for AIDS Research.,Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medicine, Cooper University Hospital, Camden, New Jersey
| | - Janet P Tate
- Veterans Affairs Connecticut Healthcare System, West Haven.,Yale University School of Medicine, New Haven, Connecticut
| | - Kimberly A Forde
- Departments of Medicine, Penn Center for AIDS Research.,Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joseph K Lim
- Veterans Affairs Connecticut Healthcare System, West Haven.,Yale University School of Medicine, New Haven, Connecticut
| | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California, Los Angeles
| | - David Rimland
- Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Georgia
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Adeel A Butt
- Veterans Affairs Pittsburgh Healthcare System, Pennsylvania.,Hamad Healthcare Quality Institute, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar and New York, New York
| | - Cynthia L Gibert
- Washington DC Veterans Affairs Medical Center and George Washington University Medical Center
| | - Sheldon T Brown
- James J. Peters Veterans Affairs Medical Center and Mount Sinai School of Medicine, New York, New York
| | - Roger Bedimo
- Medical Service, Veterans Affairs North Texas Healthcare System.,Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven.,Yale University School of Medicine, New Haven, Connecticut
| | - Jay R Kostman
- John Bell Health Center, Philadelphia Field Initiating Group for HIV Trials, Pennsylvania
| | - Jason A Roy
- Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Vincent Lo Re
- Departments of Medicine, Penn Center for AIDS Research.,Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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41
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Greenstein RJ, Brown ST. A data-based hypothesis explicating the observations that "Smoking is associated with risk for developing inflammatory bowel disease including late onset ulcerative colitis: a prospective study". Scand J Gastroenterol 2018; 53:505. [PMID: 29447017 DOI: 10.1080/00365521.2018.1440003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Robert J Greenstein
- a Department of Surgery , James J. Peters Veterans Affairs Medical Center , Bronx , NY , USA
| | - Sheldon T Brown
- b Department of Medicine , James J. Peters Veterans Affairs Medical Center , Bronx , NY , USA.,c Department of Medicine , Icahn School of Medicine at Mt. Sinai , New York , NY , USA
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42
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Joyce VR, Sun H, Barnett PG, Bansback N, Griffin SC, Bayoumi AM, Anis AH, Sculpher M, Cameron W, Brown ST, Holodniy M, Owens DK. Mapping MOS-HIV to HUI3 and EQ-5D-3L in Patients With HIV. MDM Policy Pract 2017; 2:2381468317716440. [PMID: 30288427 PMCID: PMC6125043 DOI: 10.1177/2381468317716440] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 09/14/2016] [Accepted: 05/10/2017] [Indexed: 12/25/2022] Open
Abstract
Objectives: The Medical Outcomes Study HIV Health Survey (MOS-HIV)
is frequently used in HIV clinical trials; however, scores generated from the
MOS-HIV are not suited for cost-effectiveness analyses as they do not assign
utility values to health states. Our objective was to estimate and externally
validate several mapping algorithms to predict Health Utilities Index Mark 3
(HUI3) and EQ-5D-3L utility values from the MOS-HIV. Methods: We
developed and validated mapping algorithms using data from two HIV clinical
trials. Data from the first trial (n = 367) formed the estimation data set for
the HUI3 (4,610 observations) and EQ-5D-3L (4,662 observations) mapping
algorithms; data from the second trial (n = 168) formed the HUI3 (1,135
observations) and EQ-5D-3L (1,152 observations) external validation data set. We
compared ordinary least squares (OLS) models of increasing complexity with the
more flexible two-part, beta regression, and finite mixture models. We assessed
model performance using mean absolute error (MAE) and mean squared error (MSE).
Results: The OLS model that used MOS-HIV dimension scores along
with squared terms gave the best HUI3 predictions (mean observed 0.84; mean
predicted 0.80; MAE 0.0961); the finite mixture model gave the best EQ-5D-3L
predictions (mean observed 0.90; mean predicted 0.88; MAE 0.0567). All models
produced higher prediction errors at the lower end of the HUI3 and EQ-5D-3L
score ranges (<0.40). Conclusions: The proposed mapping
algorithms can be used to predict HUI3 and EQ-5D-3L utility values from the
MOS-HIV, although greater error may pose a problem in samples where a
substantial proportion of patients are in poor health. These algorithms may be
useful for estimating utility values from the MOS-HIV for cost-effectiveness
studies when HUI3 or EQ-5D-3L data are not available.
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Affiliation(s)
- Vilija R Joyce
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Huiying Sun
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Paul G Barnett
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Nick Bansback
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Susan C Griffin
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Ahmed M Bayoumi
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Aslam H Anis
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Mark Sculpher
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - William Cameron
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Sheldon T Brown
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Mark Holodniy
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
| | - Douglas K Owens
- VA Palo Alto Health Care System, VA Cooperative Studies Program Coordinating Center, VA HSR&D Health Economics Resource Center, Menlo Park, California (VRJ, PGB).,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada (HS, NB, AHA).,Canadian HIV Trials Network, Vancouver, British Columbia, Canada (HS).,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (NB, AHA).,Centre for Health Economics, University of York, York, UK (SCG, MS).,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (AMB).,Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (AMB).,Division of Infectious Diseases, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada (WC).,James J. Peters VA Medical Center, Bronx, New York (STB).,VA Palo Alto Health Care System, Palo Alto, California (MH, DKO).,Center for Primary Care and Outcomes Research, Stanford University, Stanford, California (DKO)
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Triplette M, Attia EF, Akgün KM, Soo Hoo GW, Freiberg MS, Butt AA, Wongtrakool C, Goetz MB, Brown ST, Graber CJ, Huang L, Crothers K. A Low Peripheral Blood CD4/CD8 Ratio Is Associated with Pulmonary Emphysema in HIV. PLoS One 2017; 12:e0170857. [PMID: 28122034 PMCID: PMC5266287 DOI: 10.1371/journal.pone.0170857] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/11/2017] [Indexed: 12/17/2022] Open
Abstract
Objectives The prevalence of emphysema is higher among HIV-infected (HIV+) individuals compared to HIV-uninfected persons. While greater tobacco use contributes, HIV-related effects on immunity likely confer additional risk. Low peripheral blood CD4+ to CD8+ T-lymphocyte (CD4/CD8) ratio may reflect chronic inflammation in HIV and may be a marker of chronic lung disease in this population. Therefore, we sought to determine whether the CD4/CD8 ratio was associated with chronic obstructive pulmonary disease (COPD), particularly the emphysema subtype, in a cohort of HIV+ subjects. Methods We performed a cross-sectional analysis of 190 HIV+ subjects enrolled in the Examinations of HIV Associated Lung Emphysema (EXHALE) study. Subjects underwent baseline laboratory assessments, pulmonary function testing and chest computed tomography (CT) analyzed for emphysema severity and distribution. We determined the association between CD4/CD8 ratio and emphysema, and the association between CD4/CD8 ratio and pulmonary function markers of COPD. Results Mild or greater emphysema (>10% lung involvement) was present in 31% of subjects. Low CD4/CD8 ratio was associated with >10% emphysema in multivariable models, adjusting for risk factors including smoking, current and nadir CD4 count and HIV RNA level. Those with CD4/CD8 ratio <0.4 had 6.3 (1.1–39) times the odds of >10% emphysema compared to those with a ratio >1.0 in fully adjusted models. A low CD4/CD8 ratio was also associated with reduced diffusion capacity (DLCO). Conclusions A low CD4/CD8 ratio was associated with emphysema and low DLCO in HIV+ subjects, independent of other risk factors and clinical markers of HIV. The CD4/CD8 ratio may be a useful, clinically available, marker for risk of emphysema in HIV+ subjects in the antiretroviral therapy (ART) era.
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Affiliation(s)
- Matthew Triplette
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Engi F. Attia
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Kathleen M. Akgün
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Guy W. Soo Hoo
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Matthew S. Freiberg
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Adeel A. Butt
- Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
- Hamad Healthcare Quality Institute and Medical Corporation, Doha, Qatar
| | - Cherry Wongtrakool
- Department of Medicine, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, United States of America
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Matthew Bidwell Goetz
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Sheldon T. Brown
- Department of Medicine, James J. Peters Veterans Affairs Medical Center, New York, New York, United States of America
- Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, New York, United States of America
| | - Christopher J. Graber
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Laurence Huang
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Kristina Crothers
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
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Greenstein RJ, Cameron DW, Brown ST. A Data-Based Hypothesis Explicating Thiopurine Therapeutic Failure in Biologic-Naive UC. Dig Dis Sci 2017; 62:282-283. [PMID: 27812848 DOI: 10.1007/s10620-016-4360-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 10/19/2016] [Indexed: 12/09/2022]
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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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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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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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Edelman EJ, Tate JP, Fiellin DA, Brown ST, Bryant K, Gandhi N, Gibert CL, Goetz MB, Gordon KS, Rodriguez-Barradas MC, Braithwaite RS, Rimland D, Justice AC. Impact of defined clinical population and missing data on temporal trends in HIV viral load estimation within a health care system. HIV Med 2015; 16:346-54. [PMID: 25688937 PMCID: PMC4478104 DOI: 10.1111/hiv.12219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Community viral load (CVL) estimates vary based on analytic methods. We extended the CVL concept and used data from the Veterans Health Administration (VA) to determine trends in the health care system viral load (HSVL) and its sensitivity to varying definitions of the clinical population and assumptions regarding missing data. METHODS We included HIV-infected patients in the Veterans Aging Cohort Study, 2000-2010, with at least one documented CD4 count, HIV-1 RNA or antiretroviral prescription (n = 37 318). We created 6-month intervals including patients with at least one visit in the past 2 years. We assessed temporal trends in clinical population size, patient clinical status and mean HSVL and explored the impact of varying definitions of the clinical population and assumptions about missing viral load. RESULTS The clinical population size varied by definition, increasing from 16 000-19 000 patients in 2000 to 23 000-26 000 in 2010. The proportion of patients with suppressed HIV-1 RNA increased over time. Over 20% of patients had no viral load measured in a given interval or the past 2 years. Among patients with a current HIV-1 RNA, mean HSVL decreased from 97 800 HIV-1 RNA copies/mL in 2000 to 2000 copies/mL in 2010. When current HIV-1 RNA data were unavailable and the HSVL was recalculated using the last available HIV-1 RNA, HSVL decreased from 322 300 to 9900 copies/mL. HSVL was underestimated when using only current data in each interval. CONCLUSIONS The CVL concept can be applied to a health care system, providing a measure of health care quality. Like CVL, HSVL estimates depend on definitions of the clinical population and assumptions about missing data.
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Affiliation(s)
- E. Jennifer Edelman
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT
| | - Janet P. Tate
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - David A. Fiellin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT
| | - Sheldon T. Brown
- James J. Peters VA Medical Center, Bronx, NY and Department of Internal Medicine, The Ichann School of Medicine at Mt. Sinai, New York, NY
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD
| | - Neel Gandhi
- Veterans Affairs Medical Center and Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Cynthia L. Gibert
- Washington DC VA Medical Center and Department of Internal Medicine, George Washington University School of Medicine, Washington, D.C
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, Los Angeles, CA
| | | | - Maria C. Rodriguez-Barradas
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine and, Houston, TX
| | - R. Scott Braithwaite
- Department of Internal Medicine, New York University School of Medicine, New York, NY
| | - David Rimland
- Veterans Affairs Medical Center and Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Amy C. Justice
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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Affiliation(s)
- Robert J Greenstein
- 1 Department of Surgery, James J. Peters Veterans Affairs Medical Center , Bronx, New York
| | - D William Cameron
- 2 Department of Medicine, Ottawa Hospital Research Institute , Ottawa, Ontario, Canada
| | - Sheldon T Brown
- 3 Division of Infections Diseases, James J. Peters Veterans Affairs Medical Center , Bronx, New York.,4 Inchan School of Medicine at Mount Sinai , New York, New York
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