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Adler AJ, Wroe EB, Atzori A, Bay N, Bekele W, Bhambhani VM, Nkwiro RB, Boudreaux C, Calixte D, Chiwanda Banda J, Coates MM, Dagnaw WW, Domingues K, Drown L, Dusabeyezu S, Fenelon D, Gupta N, Ssinabulya I, Jain Y, Kalkonde Y, Kamali I, Karekezi C, Karmacharya BM, Koirala B, Makani J, Manenti F, Mangwiro A, Manuel B, Masiye JK, Goma FM, Mayige MT, McLaughlin A, Mensah E, Salipa NM, Mutagaywa R, Mutengerere A, Ngoga G, Patiño M, Putoto G, Ruderman T, Salvi D, Sesay S, Taero F, Tostão E, Toussaint S, Bukhman G, Mocumbi AO. Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries. BMJ Open 2024; 14:e074182. [PMID: 38296295 PMCID: PMC10828858 DOI: 10.1136/bmjopen-2023-074182] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 12/21/2023] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION The Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. In the PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up. METHODS AND ANALYSIS Guided by Proctor outcomes for implementation research, we are conducting a mixed-method evaluation consisting of 10 components to understand outcomes in clinical implementation, training and policy development. Data will be collected through a mix of quantitative surveys, routine reporting, routine clinical data and qualitative interviews. ETHICS AND DISSEMINATION This protocol has been considered exempt or covered by central and local institutional review boards. Findings will be disseminated throughout the project's course, including through quarterly M&E discussions, semiannual formative assessments, dashboard mapping of progress, quarterly newsletters, regular feedback loops with national stakeholders and publication in peer-reviewed journals.
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Affiliation(s)
- Alma J Adler
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily B Wroe
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | | | - Neusa Bay
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Wondu Bekele
- Mathiwos Wondu-Ye Ethiopia Cancer Society, Addis Ababa, Ethiopia
| | - Victoria M Bhambhani
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Chantelle Boudreaux
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Matthew M Coates
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Katia Domingues
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Laura Drown
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Neil Gupta
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Yogesh Jain
- NCDI Poverty Network, Surguja, Chhattisgarh, India
| | | | | | | | - Biraj Man Karmacharya
- Cardiovascular Health Research Unit, University of Washington, Seattle, Washington, USA
- School of Medical Sciences, Kathmandu University, Kathmandu, Nepal
| | | | - Julie Makani
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Beatriz Manuel
- Department of Community Health, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jones K Masiye
- Noncommunicable Diseases and Mental Health Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
| | | | | | | | - Emmanuel Mensah
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Reuben Mutagaywa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | | | - Gedeon Ngoga
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Marta Patiño
- Partners In Health Sierra Leone, Kono, Sierra Leone
| | | | | | - Devashri Salvi
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Santigie Sesay
- Noncommunicable Diseases and Mental Health, Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Fameti Taero
- Mozambique Institute for Health Education and Research, Maputo, Mozambique
| | - Emílio Tostão
- Department of Agricultural Economics and Development, Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Gene Bukhman
- Center for Integration Science, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Ana Olga Mocumbi
- Universidade Eduardo Mondlane, Maputo, Mozambique
- Instituto Nacional de Saúde, Maputo, Mozambique
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Ngo D, Pratte KA, Flexeder C, Petersen H, Dang H, Ma Y, Keyes MJ, Gao Y, Deng S, Peterson BD, Farrell LA, Bhambhani VM, Palacios C, Quadir J, Gillenwater L, Xu H, Emson C, Gieger C, Suhre K, Graumann J, Jain D, Conomos MP, Tracy RP, Guo X, Liu Y, Johnson WC, Cornell E, Durda P, Taylor KD, Papanicolaou GJ, Rich SS, Rotter JI, Rennard SI, Curtis JL, Woodruff PG, Comellas AP, Silverman EK, Crapo JD, Larson MG, Vasan RS, Wang TJ, Correa A, Sims M, Wilson JG, Gerszten RE, O’Connor GT, Barr RG, Couper D, Dupuis J, Manichaikul A, O’Neal WK, Tesfaigzi Y, Schulz H, Bowler RP. Systemic Markers of Lung Function and Forced Expiratory Volume in 1 Second Decline across Diverse Cohorts. Ann Am Thorac Soc 2023; 20:1124-1135. [PMID: 37351609 PMCID: PMC10405603 DOI: 10.1513/annalsats.202210-857oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 06/13/2023] [Indexed: 06/24/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) is a complex disease characterized by airway obstruction and accelerated lung function decline. Our understanding of systemic protein biomarkers associated with COPD remains incomplete. Objectives: To determine what proteins and pathways are associated with impaired pulmonary function in a diverse population. Methods: We studied 6,722 participants across six cohort studies with both aptamer-based proteomic and spirometry data (4,566 predominantly White participants in a discovery analysis and 2,156 African American cohort participants in a validation). In linear regression models, we examined protein associations with baseline forced expiratory volume in 1 second (FEV1) and FEV1/forced vital capacity (FVC). In linear mixed effects models, we investigated the associations of baseline protein levels with rate of FEV1 decline (ml/yr) in 2,777 participants with up to 7 years of follow-up spirometry. Results: We identified 254 proteins associated with FEV1 in our discovery analyses, with 80 proteins validated in the Jackson Heart Study. Novel validated protein associations include kallistatin serine protease inhibitor, growth differentiation factor 2, and tumor necrosis factor-like weak inducer of apoptosis (discovery β = 0.0561, Q = 4.05 × 10-10; β = 0.0421, Q = 1.12 × 10-3; and β = 0.0358, Q = 1.67 × 10-3, respectively). In longitudinal analyses within cohorts with follow-up spirometry, we identified 15 proteins associated with FEV1 decline (Q < 0.05), including elafin leukocyte elastase inhibitor and mucin-associated TFF2 (trefoil factor 2; β = -4.3 ml/yr, Q = 0.049; β = -6.1 ml/yr, Q = 0.032, respectively). Pathways and processes highlighted by our study include aberrant extracellular matrix remodeling, enhanced innate immune response, dysregulation of angiogenesis, and coagulation. Conclusions: In this study, we identify and validate novel biomarkers and pathways associated with lung function traits in a racially diverse population. In addition, we identify novel protein markers associated with FEV1 decline. Several protein findings are supported by previously reported genetic signals, highlighting the plausibility of certain biologic pathways. These novel proteins might represent markers for risk stratification, as well as novel molecular targets for treatment of COPD.
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Affiliation(s)
- Debby Ngo
- Cardiovascular Research Institute
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | | | - Claudia Flexeder
- Institute of Epidemiology and
- Comprehensive Pneumology Center Munich (CPC-M) as member of the German Center for Lung Research (DZL), Munich, Germany
- Institute and Clinic for Occupational, Social, and Environmental Medicine, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Hans Petersen
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico
| | - Hong Dang
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Yanlin Ma
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia
| | | | - Yan Gao
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi; and
- Institute and Clinic for Occupational, Social, and Environmental Medicine, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | | | | | | | | | | | | | - Hanfei Xu
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Claire Emson
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Christian Gieger
- Institute of Epidemiology and
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München – German Research Center for Environmental Health, Neuherberg, Germany
| | - Karsten Suhre
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
| | | | - Deepti Jain
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Matthew P. Conomos
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Russell P. Tracy
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Xiuqing Guo
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA (University of California, Los Angeles) Medical Center, Torrance, California
| | - Yongmei Liu
- Division of Cardiology, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina
| | - W. Craig Johnson
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Elaine Cornell
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Peter Durda
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Kent D. Taylor
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA (University of California, Los Angeles) Medical Center, Torrance, California
| | - George J. Papanicolaou
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Stephen S. Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia
| | - Jerome I. Rotter
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA (University of California, Los Angeles) Medical Center, Torrance, California
| | - Steven I. Rennard
- Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Prescott G. Woodruff
- Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | | | | | - Martin G. Larson
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
- The National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, Massachusetts
| | - Ramachandran S. Vasan
- The National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, Massachusetts
- Division of Preventive Medicine and
- Division of Cardiology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Thomas J. Wang
- Department of Medicine, UT (University of Texas) Southwestern Medical Center, Dallas, Texas
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adolfo Correa
- Jackson Heart Study, Department of Medicine, and
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi; and
| | - Mario Sims
- Jackson Heart Study, Department of Medicine, and
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi; and
| | - James G. Wilson
- Cardiovascular Research Institute
- Jackson Heart Study, Department of Medicine, and
| | - Robert E. Gerszten
- Cardiovascular Research Institute
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - George T. O’Connor
- The National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, Massachusetts
- Pulmonary Center, Department of Medicine, Boston University, Boston, Massachusetts
| | - R. Graham Barr
- Department of Medicine and
- Department of Epidemiology, Columbia University, New York, New York
| | - David Couper
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Josée Dupuis
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Ani Manichaikul
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia
| | - Wanda K. O’Neal
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Yohannes Tesfaigzi
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Holger Schulz
- Institute of Epidemiology and
- Comprehensive Pneumology Center Munich (CPC-M) as member of the German Center for Lung Research (DZL), Munich, Germany
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Mi MY, Whitlock M, Shi X, Farrell LA, Bhambhani VM, Quadir J, Blatnik M, Wald KP, Tierney B, Kim A, Loudon P, Chen ZZ, Correa A, Gao Y, Carson AP, Bertoni AG, Roth Flach RJ, Gerszten RE. Mixed meal tolerance testing highlights in diabetes altered branched-chain ketoacid metabolism and pathways associated with all-cause mortality. Am J Clin Nutr 2023; 117:529-539. [PMID: 36811472 PMCID: PMC10356557 DOI: 10.1016/j.ajcnut.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Elevated BCAA levels are strongly associated with diabetes, but how diabetes affects BCAA, branched-chain ketoacids (BCKAs), and the broader metabolome after a meal is not well known. OBJECTIVE To compare quantitative BCAA and BCKA levels in a multiracial cohort with and without diabetes after a mixed meal tolerance test (MMTT) as well as to explore the kinetics of additional metabolites and their associations with mortality in self-identified African Americans. METHODS We administered an MMTT to 11 participants without obesity or diabetes and 13 participants with diabetes (treated with metformin only) and measured the levels of BCKAs, BCAAs, and 194 other metabolites at 8 time points across 5 h. We used mixed models for repeated measurements to compare between group metabolite differences at each timepoint with adjustment for baseline. We then evaluated the association of top metabolites with different kinetics with all-cause mortality in the Jackson Heart Study (JHS) (N = 2441). RESULTS BCAA levels, after adjustment for baseline, were similar at all timepoints between groups, but adjusted BCKA kinetics were different between groups for α-ketoisocaproate (P = 0.022) and α-ketoisovalerate (P = 0.021), most notably diverging at 120 min post-MMTT. An additional 20 metabolites had significantly different kinetics across timepoints between groups, and 9 of these metabolites-including several acylcarnitines-were significantly associated with mortality in JHS, irrespective of diabetes status. The highest quartile of a composite metabolite risk score was associated with higher mortality (HR:1.57; 1.20, 2.05, P = 0.00094) than the lowest quartile. CONCLUSIONS BCKA levels remained elevated after an MMTT among participants with diabetes, suggesting that BCKA catabolism may be a key dysregulated process in the interaction of BCAA and diabetes. Metabolites with different kinetics after an MMTT may be markers of dysmetabolism and associated with increased mortality in self-identified African Americans.
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Affiliation(s)
- Michael Y Mi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | | | - Xu Shi
- Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Laurie A Farrell
- Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Juweria Quadir
- Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Kyle P Wald
- Early Clinical Development, Pfizer, Groton, CT, USA
| | | | - Albert Kim
- Internal Medicine Research Unit, Pfizer, Cambridge, MA, USA; Cytel, Cambridge, MA, USA
| | - Peter Loudon
- Early Clinical Development, Pfizer, Cambridge, UK; Tenpoint Therapeutics, Cambridge, UK
| | - Zsu-Zsu Chen
- Division of Endocrinology, Diabetes, and Metabolism, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Adolfo Correa
- Department of Population Health Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Yan Gao
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - April P Carson
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Alain G Bertoni
- Department of Epidemiology & Prevention, Wake Forest School of Medicine, Winston Salem, NC, USA
| | | | - Robert E Gerszten
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
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