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Hoogendoorn CJ, Krause-Steinrauf H, Uschner D, Wen H, Presley CA, Legowski EA, Naik AD, Golden SH, Arends VL, Brown-Friday J, Krakoff JA, Suratt CE, Waltje AH, Cherrington AL, Gonzalez JS. Emotional Distress Predicts Reduced Type 2 Diabetes Treatment Adherence in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). Diabetes Care 2024; 47:629-637. [PMID: 38227900 PMCID: PMC10973907 DOI: 10.2337/dc23-1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/18/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations. RESULTS At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%-15.5%) of the longitudinal link between emotional distress and adherence. CONCLUSIONS Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence.
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Affiliation(s)
- Claire J. Hoogendoorn
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | - Heidi Krause-Steinrauf
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Diane Uschner
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Hui Wen
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Caroline A. Presley
- General Internal and Preventive Medicine, Department of Medicine, University of Alabama, Birmingham, Birmingham, AL
| | - Elizabeth A. Legowski
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX
- University of Texas Health Science Center (UTHealth) School of Public Health, Houston, TX
- Consortium on Aging, University of Texas Health Science Center (UTHealth), Houston, TX
| | - Sherita Hill Golden
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Valerie L. Arends
- Advanced Research and Diagnostic Laboratory, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Janet Brown-Friday
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Jonathan A. Krakoff
- Obesity and Diabetes Clinical Research Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ
| | - Colleen E. Suratt
- Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | | | - Andrea L. Cherrington
- General Internal and Preventive Medicine, Department of Medicine, University of Alabama, Birmingham, Birmingham, AL
| | - Jeffrey S. Gonzalez
- Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
- New York-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, NY
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Trief PM, Wen H, Burke B, Uschner D, Anderson BJ, Liu X, Bulger J, Weinstock RS. Psychosocial Factors and Glycemic Control in Young Adults With Youth-Onset Type 2 Diabetes. JAMA Netw Open 2024; 7:e245620. [PMID: 38587841 PMCID: PMC11002701 DOI: 10.1001/jamanetworkopen.2024.5620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 04/09/2024] Open
Abstract
Importance Youth-onset type 2 diabetes is associated with poor glycemic control and early onset of complications. Identification of psychosocial factors associated with poor glycemic control is needed to inform efficacious interventions. Objective To identify psychosocial factors associated with glycated hemoglobin (HbA1c) levels in young adults with youth-onset type 2 diabetes. Design, Setting, and Participants For the iCount cohort study, HbA1c levels were measured twice (at baseline [T1] and at 1 year [T2]) during the last years (2017-2019) of the observational phase of the multicenter Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY2) study. Participants were young adults who had been diagnosed with type 2 diabetes during childhood or adolescence. Data were analyzed from December 2021 to September 2023. Main Outcomes and Measures Glycemic control was examined categorically (high [≥8.0%] vs low [<8.0%] HbA1c), continuously (HbA1c level), and over time (change in HbA1c: decreased ≥0.5%, remained stable, or increased ≥0.5%). Psychosocial measures included beliefs about medicines, depression and anxiety symptoms, diabetes distress, diabetes self-efficacy, self-management support, and unmet material needs. Multivariable logistic and linear regression models evaluated the association of each psychosocial factor with the probability of T2 HbA1c of 8.0% or greater, T2 HbA1c level, and change in HbA1c. Results Of the 411 TODAY2 participants approached, 381 enrolled in the iCount study, and 348 with T1 and T2 HbA1c data comprised the analysis group. The 348 participants had a mean (SD) age of 26.1 (2.5) years and a mean (SD) HbA1c of 9.4% (2.8%). Most participants (229 [65.8%]) were women. In adjusted multivariable regressions, greater beliefs that diabetes medicines are necessary (odds ratio [OR], 1.19 [95% CI, 1.03-1.37]; P = .02), concerns about medicines (OR, 1.20 [95% CI, 1.00-1.45]; P = .049), diabetes distress (OR, 1.08 [95% CI, 1.02-1.15]; P = .006), and high distress (OR, 2.18 [95% CI, 1.15-4.13]; P = .02) increased the odds of high HbA1c at T2. Greater support (OR, 0.67 [95% CI, 0.46-0.97]; P = .04) and diabetes self-efficacy (OR, 0.91 [95% CI, 0.84-0.99]; P = .02) decreased the odds of high HbA1c at T2. Diabetes distress was associated with higher HbA1c level at T2 (coefficient, 0.08 [95% CI, 0.02-0.13]; P = .01). Beliefs that diabetes medicines are necessary (OR, 1.20 [95% CI, 1.03-1.39]; P = .02) and concerns about medicines (OR, 1.22 [95% CI, 1.00-1.47]; P = .048) increased the odds of an HbA1c decrease of at least 0.5% over 1 year. Conclusions and Relevance In this cohort study of young adults with youth-onset type 2 diabetes, beliefs about medicines, high diabetes distress, low diabetes self-efficacy, and self-management support were associated with high HbA1c over time. Future research should assess whether interventions that address these factors result in improved glycemic control in this at-risk group.
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Affiliation(s)
- Paula M. Trief
- Department of Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, Syracuse
| | - Hui Wen
- Biostatistics Center, George Washington University, Rockville, Maryland
| | - Brian Burke
- Biostatistics Center, George Washington University, Rockville, Maryland
| | - Diane Uschner
- Biostatistics Center, George Washington University, Rockville, Maryland
| | - Barbara J. Anderson
- Department of Pediatrics-Psychology, Baylor College of Medicine, Houston, Texas
| | - Xun Liu
- Biostatistics Center, George Washington University, Rockville, Maryland
| | - Jane Bulger
- Department of Medicine, State University of New York Upstate Medical University, Syracuse
| | - Ruth S. Weinstock
- Department of Medicine, State University of New York Upstate Medical University, Syracuse
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Dantuluri KL, Buahin A, Uschner D, DeWitt ME, Rossman W, Dunn CO, Hetherington TC, Priem J, Castri P, Lagarde WH, Gibbs M, Ahmed A. Association of social vulnerability index and masking adherence among children enrolled in COVID-19 community research partnership study. BMC Public Health 2024; 24:410. [PMID: 38331791 PMCID: PMC10854168 DOI: 10.1186/s12889-024-17931-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Individuals with high social vulnerability index (SVI) have poorer outcomes with COVID-19. Masking reduces transmission of COVID-19 among children, but how SVI plays a role in masking behavior is unknown. We aimed to measure the association of SVI with masking adherence among children during the COVID-19 pandemic. METHODS We conducted a multi-site, prospective syndromic surveillance study among children aged 2 - 17 years in the Southeastern United States by daily electronic surveys which solicited symptoms of COVID-19-like illness, infection with or exposure to SARS-CoV-2, masking habits, and any receipt of COVID-19 vaccines. Parents/guardians submitted surveys for their children; adolescents 13 years and older could opt to submit their own surveys. Multivariable and univariate linear models were used to measure the associations of different predictors such as SVI with masking adherence. RESULTS One thousand four hundred sixty-one children from 6 states and 55 counties predominately from North and South Carolina were included in the analysis. Most children in the cohort were 5 - 11 years old, non-Hispanic White, from urban counties, and with low-moderate SVI. Overall masking adherence decreased over time, and older children had higher masking adherence throughout the study period compared with younger children. Children who resided in urban counties had greater masking adherence throughout the study period than those who resided in suburban or rural counties. Masking adherence was higher among children with both low and medium SVI than those with high SVI. CONCLUSIONS Despite being at risk for more severe outcomes with COVID-19, children with high SVI had lower levels of masking adherence compared to those with low SVI. Our findings highlight opportunities for improved and targeted messaging in these vulnerable communities.
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Affiliation(s)
- Keerti L Dantuluri
- Department of Pediatrics (Infectious Diseases) at Levine Children's Hospital and Wake Forest University School of Medicine, Atrium Health, 1001 Blythe Blvd, Medical Education Building, P.O. Box 32861, Charlotte, NC, 28203, USA.
| | - Asare Buahin
- Department of Biostatistics and Bioinformatics and The Biostatistics Center at The George Washington University, Washington, D.C., USA
| | - Diane Uschner
- Department of Biostatistics and Bioinformatics and The Biostatistics Center at The George Washington University, Washington, D.C., USA
| | - Michael E DeWitt
- Section on Infectious Diseases, Department of Medicine at Wake Forest University School of Medicine and the Department of Biology, Wake Forest University, Winston-Salem, NC, USA
| | - Whitney Rossman
- Center for Outcomes Research and Evaluation at Atrium Health, Charlotte, NC, USA
| | - Connell O Dunn
- Department of Emergency Medicine Research at Atrium Health, Charlotte, NC, USA
| | | | - Jennifer Priem
- Center for Outcomes Research and Evaluation at Atrium Health, Charlotte, NC, USA
| | - Paola Castri
- Department of Neurology (Pediatric Neurology) at Wake Forest Baptist, Winston Salem, NC, USA
| | - William H Lagarde
- Department of Pediatrics (Endocrinology) at WakeMed, Raleigh, NC, USA
| | - Michael Gibbs
- Department of Emergency Medicine at Atrium Health, Charlotte, NC, USA
| | - Amina Ahmed
- Department of Pediatrics (Infectious Diseases) at Levine Children's Hospital and Wake Forest University School of Medicine, Atrium Health, 1001 Blythe Blvd, Medical Education Building, P.O. Box 32861, Charlotte, NC, 28203, USA
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Berry AA, Tjaden AH, Renteria J, Friedman-Klabanoff D, Hinkelman AN, Gibbs MA, Ahmed A, Runyon MS, Schieffelin J, Santos RP, Oberhelman R, Bott M, Correa A, Edelstein SL, Uschner D, Wierzba TF. Persistence of antibody responses to COVID-19 vaccines among participants in the COVID-19 Community Research Partnership. Vaccine X 2023; 15:100371. [PMID: 37649617 PMCID: PMC10462856 DOI: 10.1016/j.jvacx.2023.100371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023] Open
Abstract
Introduction High levels of immunity to SARS-CoV-2 in the community correlate with protection from COVID-19 illness. Measuring COVID-19 antibody seroprevalence and persistence may elucidate the level and length of protection afforded by vaccination and infection within a population. Methods We measured the duration of detectable anti-spike antibodies following COVID-19 vaccination in a multistate, longitudinal cohort study of almost 13,000 adults who completed daily surveys and submitted monthly dried blood spots collected at home. Results Overall, anti-spike antibodies persisted up to 284 days of follow-up with seroreversion occurring in only 2.4% of the study population. In adjusted analyses, risk of seroreversion increased with age (adults aged 55-64: adjusted hazard ratio [aHR] 2.19 [95% confidence interval (CI): 1.22, 3.92] and adults aged > 65: aHR 3.59 [95% CI: 2.07, 6.20] compared to adults aged 18-39). Adults with diabetes had a higher risk of seroreversion versus nondiabetics (aHR 1.77 [95% CI: 1.29, 2.44]). Decreased risk of seroreversion was shown for non-Hispanic Black versus non-Hispanic White (aHR 0.32 [95% CI: 0.13, 0.79]); college degree earners versus no college degree (aHR 0.61 [95% CI: 0.46, 0.81]); and those who received Moderna mRNA-1273 vaccine versus Pfizer-BioNTech BNT162b2 (aHR 0.35 [95% CI: 0.26, 0.47]). An interaction between healthcare worker occupation and sex was detected, with seroreversion increased among male, non-healthcare workers. Conclusion We established that a remote, longitudinal, multi-site study can reliably detect antibody durability following COVID-19 vaccination. The survey platform and measurement of antibody response using at-home collection at convenient intervals allowed us to explore sociodemographic factors and comorbidities and identify predictors of antibody persistence, which has been demonstrated to correlate with protection against disease. Our findings may help inform public health interventions and policies to protect those at highest risk for severe illness and assist in determining the optimal timing of booster doses.Clinical trials registry: NCT04342884.
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Affiliation(s)
- Andrea A. Berry
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashley H. Tjaden
- The Biostatistics Center, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA
| | - Jone Renteria
- The Biostatistics Center, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA
| | - DeAnna Friedman-Klabanoff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amy N. Hinkelman
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, NC, USA
| | | | | | | | - John Schieffelin
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Richard Oberhelman
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA
| | - Matthew Bott
- The Biostatistics Center, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA
| | - Adolfo Correa
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Sharon L. Edelstein
- The Biostatistics Center, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA
| | - Diane Uschner
- The Biostatistics Center, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA
| | - Thomas F. Wierzba
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
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El Ghormli L, Wen H, Uschner D, Haymond MW, Hughan KS, Kutney K, Laffel L, Tollefsen SE, Escaname EN, Lynch J, Bjornstad P. Trajectories of eGFR and risk of albuminuria in youth with type 2 diabetes: results from the TODAY cohort study. Pediatr Nephrol 2023; 38:4137-4144. [PMID: 37434027 PMCID: PMC10875681 DOI: 10.1007/s00467-023-06044-3] [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: 02/10/2023] [Revised: 04/28/2023] [Accepted: 05/17/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND We conducted exploratory analyses to identify distinct trajectories of estimated glomerular filtration rate (eGFR) and their relationship with hyperfiltration, subsequent rapid eGFR decline, and albuminuria in participants with youth-onset type 2 diabetes enrolled in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study. METHODS Annual serum creatinine, cystatin C, urine albumin, and creatinine measurements were obtained from 377 participants followed for ≥ 10 years. Albuminuria and eGFR were calculated. Hyperfiltration peak is the greatest eGFR inflection point during follow-up. Latent class modeling was applied to identify distinct eGFR trajectories. RESULTS At baseline, participants' mean age was 14 years, type 2 diabetes duration was 6 months, mean HbA1c was 6%, and mean eGFR was 120 ml/min/1.73 m2. Five eGFR trajectories associated with different rates of albuminuria were identified, including a "progressive increasing eGFR" group (10%), three "stable eGFR" groups with varying starting mean eGFR, and an "eGFR steady decline" group (1%). Participants who exhibited the greatest peak eGFR also had the highest levels of elevated albuminuria at year 10. This group membership was characterized by a greater proportion of female and Hispanic participants. CONCLUSIONS Distinct eGFR trajectories that associate with albuminuria risk were identified, with the eGFR trajectory characterized by increasing eGFR over time associating with the highest level of albuminuria. These descriptive data support the current recommendations to estimate GFR annually in young persons with type 2 diabetes and provide insight into eGFR-related factors which may contribute to predictive risk strategies for kidney disease therapies in youth with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00081328, date registered 2002. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Laure El Ghormli
- The Biostatistics Center, George Washington University, 6110 Executive Boulevard, Suite 750, Rockville, MD, 20852, USA.
| | - Hui Wen
- The Biostatistics Center, George Washington University, 6110 Executive Boulevard, Suite 750, Rockville, MD, 20852, USA
| | - Diane Uschner
- The Biostatistics Center, George Washington University, 6110 Executive Boulevard, Suite 750, Rockville, MD, 20852, USA
| | - Morey W Haymond
- Baylor College of Medicine Children's Nutrition Research Center, Houston, TX, USA
| | - Kara S Hughan
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Katherine Kutney
- UH Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | | | - Sherida E Tollefsen
- Department of Pediatrics, Saint Louis University Health Sciences Center, St. Louis, MO, USA
| | - Elia N Escaname
- The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Jane Lynch
- The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Petter Bjornstad
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
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Trief PM, Uschner D, Anderson BJ, Wen H, Bulger JD, Weinstock RS. Psychosocial Factors Predicting Healthcare Usage in Young Adults with Youth-Onset Type 2 Diabetes: The TODAY2 iCount Observational Study. J Gen Intern Med 2023; 38:3152-3161. [PMID: 37507549 PMCID: PMC10651562 DOI: 10.1007/s11606-023-08305-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Established diabetes care ("diabetes home") and regular healthcare visits are important to achieve optimal health. Nothing is known about psychosocial factors that predict healthcare usage (HCU) in young adults with youth-onset type 2 diabetes, at risk for early complications. OBJECTIVE To identify psychosocial predictors of HCU in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort. DESIGN Longitudinal, measured at T1 (baseline) and T2 (1 year later). Logistic and linear regressions, adjusted for potential confounders, identified predictors of sub-optimal HCU (defined as no diabetes home, 0 visits for routine care, or ≥ 1 urgent care visit in prior 6 months). PARTICIPANTS N = 366 TODAY2 participants with T1 and T2 data (381 consented). Mean age = 26.0 years, 67.8% female, 37.7% non-Hispanic Black, 35.8% Hispanic, 20.2% non-Hispanic white, 6.3% "other," mean HbA1c = 9.4%. MAIN MEASURES HCU survey; reliable and valid measures of diabetes self-efficacy, depressive symptoms, anxiety symptoms, diabetes distress, beliefs about medicines, diabetes attitudes, material need insecurities, self-management support. KEY RESULTS 25.4% had no diabetes home, 23.7% had 0 routine care visits, 46% had ≥ 1 urgent care visit (prior 6 months). Beliefs in the necessity of (adjusted odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.12, 1.46, p < 0.001), and concerns about (OR = 1.29;CI = 1.08,1.54, p = 0.004), diabetes medicines, and its negative psychosocial impacts (OR = 1.57;CI = 1.04, 2.38, p = 0.03), predicted higher odds of having a diabetes home at T2. Beliefs that medicines are harmful predicted lower odds of a diabetes home (OR = 0.56;CI = 0.37,0.85, p = 0.006). Necessity beliefs (OR = 1.2;CI = 1.06,1.36, p = 0.004), and self-management support (OR = 1.5;CI = 1.08,2.07, p = 0.01) predicted higher odds of having ≥ 1 diabetes care visit, harm beliefs predicted lower odds (OR = 0.6;CI = 0.41,0.88, p = 0.01). CONCLUSIONS Sub-optimal healthcare usage, common in young adults with youth-onset type 2 diabetes, is predicted by beliefs about medicines, diabetes impact, and self-management support. We must address these factors to help this vulnerable group establish stable diabetes care.
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Affiliation(s)
- Paula M Trief
- Department of Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, NY, Syracuse, USA.
| | - Diane Uschner
- The Biostatistics Center, George Washington University, Washington, DC, USA
| | - Barbara J Anderson
- Department of Pediatrics-Psychology, Baylor College of Medicine, Houston, TX, USA
| | - Hui Wen
- The Biostatistics Center, George Washington University, Washington, DC, USA
| | - Jane D Bulger
- Department of Medicine, State University of New York Upstate Medical University, NY, Syracuse, USA
| | - Ruth S Weinstock
- Department of Medicine, State University of New York Upstate Medical University, NY, Syracuse, USA
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Ahmed A, DeWitt ME, Dantuluri KL, Castri P, Buahin A, LaGarde WH, Weintraub WS, Rossman W, Santos RP, Gibbs M, Uschner D. Characterisation of infection-induced SARS-CoV-2 seroprevalence amongst children and adolescents in North Carolina. Epidemiol Infect 2023; 151:e63. [PMID: 37009915 PMCID: PMC10154644 DOI: 10.1017/s0950268823000481] [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: 12/15/2022] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 04/04/2023] Open
Abstract
Few prospective studies have documented the seropositivity among those children infected with severe acute respiratory syndrome coronavirus 2. From 2 April 2021 to 24 June 2021, we prospectively enrolled children between the ages of 2 and 17 years at three North Carolina healthcare systems. Participants received at least four at-home serological tests detecting the presence of antibodies against, but not differentiating between, the nucleocapsid or spike antigen. A total of 1,058 participants were enrolled in the study, completing 2,709 tests between 1 May 2021 and 31 October 2021. Using multilevel regression with poststratification techniques and considering our assay sensitivity and sensitivity, we estimated that the seroprevalence of infection-induced antibodies among unvaccinated children and adolescents aged 2-17 years in North Carolina increased from 15.2% (95% credible interval, CrI 9.0-22.0) in May 2021 to 54.1% (95% CrI 46.7-61.1) by October 2021, indicating an average infection-to-reported-case ratio of 5. A rapid rise in seropositivity was most pronounced in those unvaccinated children aged 12-17 years, based on our estimates. This study underlines the utility of serial, serological testing to inform a broader understanding of the regional immune landscape and spread of infection.
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Affiliation(s)
- Amina Ahmed
- Levine Children’s Hospital, Atrium Health, Charlotte, NC, USA
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Michael E. DeWitt
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Paola Castri
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Asare Buahin
- Milken School of Public Health, George Washington University, Washington, DC, USA
| | - William H. LaGarde
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - William S. Weintraub
- MedStar Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA
- MedStar Healthcare Delivery Research Network, Georgetown University, Washington, DC, USA
| | - Whitney Rossman
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | | | - Michael Gibbs
- Department of Emergency Medicine, Atrium Health, Charlotte, NC, USA
| | - Diane Uschner
- Milken School of Public Health, George Washington University, Washington, DC, USA
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Plumb ID, Fette LM, Tjaden AH, Feldstein L, Saydah S, Ahmed A, Link-Gelles R, Wierzba TF, Berry AA, Friedman-Klabanoff D, Larsen MP, Runyon MS, Ward LM, Santos RP, Ward J, Weintraub WS, Edelstein S, Uschner D. Estimated COVID-19 vaccine effectiveness against seroconversion from SARS-CoV-2 Infection, March-October, 2021. Vaccine 2023; 41:2596-2604. [PMID: 36932031 PMCID: PMC9995303 DOI: 10.1016/j.vaccine.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Monitoring the effectiveness of COVID-19 vaccines against SARS-CoV-2 infections remains important to inform public health responses. Estimation of vaccine effectiveness (VE) against serological evidence of SARS-CoV-2 infection might provide an alternative measure of the benefit of vaccination against infection. METHODS We estimated mRNA COVID-19 vaccine effectiveness (VE) against development of SARS-CoV-2 anti-nucleocapsid antibodies in March-October 2021, during which the Delta variant became predominant. Participants were enrolled from four participating healthcare systems in the United States, and completed electronic surveys that included vaccination history. Dried blood spot specimens collected on a monthly basis were analyzed for anti-spike antibodies, and, if positive, anti-nucleocapsid antibodies. We used detection of new anti-nucleocapsid antibodies to indicate SARS-CoV-2 infection, and estimated VE by comparing 154 case-participants with new detection of anti-nucleocapsid antibodies to 1,540 seronegative control-participants matched by calendar period. Using conditional logistic regression, we estimated VE ≥ 14 days after the 2nd dose of an mRNA vaccine compared with no receipt of a COVID-19 vaccine dose, adjusting for age group, healthcare worker occupation, urban/suburban/rural residence, healthcare system region, and reported contact with a person testing positive for SARS-CoV-2. RESULTS Among individuals who completed a primary series, estimated VE against seroconversion from SARS-CoV-2 infection was 88.8% (95% confidence interval [CI], 79.6%-93.9%) after any mRNA vaccine, 87.8% (95% CI, 75.9%-93.8%) after BioNTech vaccine and 91.7% (95% CI, 75.7%-97.2%) after Moderna vaccine. VE was estimated to be lower ≥ 3 months after dose 2 compared with < 3 months after dose 2, and among participants who were older or had underlying health conditions, although confidence intervals overlapped between subgroups. CONCLUSIONS VE estimates generated using infection-induced antibodies were consistent with published estimates from clinical trials and observational studies that used virologic tests to confirm infection during the same period. Our findings support recommendations for eligible adults to remain up to date with COVID-19 vaccination.
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Affiliation(s)
- Ian D Plumb
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA.
| | - Lida M Fette
- Biostatistics Center, Milken Institute School of Public Health, The George Washington University, 6110 Executive Blvd., Suite 750, Rockville, MD 20852, USA
| | - Ashley H Tjaden
- Biostatistics Center, Milken Institute School of Public Health, The George Washington University, 6110 Executive Blvd., Suite 750, Rockville, MD 20852, USA
| | - Leora Feldstein
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Sharon Saydah
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Amina Ahmed
- Atrium Health Levine Children's Hospital, 1000 Blythe Blvd, Charlotte, NC 28203, USA
| | - Ruth Link-Gelles
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Thomas F Wierzba
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Andrea A Berry
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore Street, Room 480, Baltimore, MD 21201, USA
| | - DeAnna Friedman-Klabanoff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, 685 W. Baltimore Street, Room 480, Baltimore, MD 21201, USA
| | - Moira P Larsen
- Medstar Health Research Institute, 6525 Belcrest Road, Suite 700, Hyattsville, MD 20782, USA
| | - Michael S Runyon
- Department of Emergency Medicine, Atrium Health Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC 28203, USA
| | - Lori M Ward
- University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Roberto P Santos
- University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Johnathan Ward
- Vysnova Partners, 8400 Corporate Drive Suite 130, Landover, MD 20785, USA
| | - William S Weintraub
- Medstar Health Research Institute, 6525 Belcrest Road, Suite 700, Hyattsville, MD 20782, USA
| | - Sharon Edelstein
- Biostatistics Center, Milken Institute School of Public Health, The George Washington University, 6110 Executive Blvd., Suite 750, Rockville, MD 20852, USA
| | - Diane Uschner
- Biostatistics Center, Milken Institute School of Public Health, The George Washington University, 6110 Executive Blvd., Suite 750, Rockville, MD 20852, USA
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9
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Trief PM, Uschner D, Kalichman S, Anderson BJ, Fette LM, Wen H, Bulger JD, Weinstock RS. Psychosocial factors predict medication adherence in young adults with youth-onset type 2 diabetes: Longitudinal results from the TODAY2 iCount study. Diabet Med 2023; 40:e15062. [PMID: 36751994 DOI: 10.1111/dme.15062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/13/2023] [Accepted: 02/06/2023] [Indexed: 02/09/2023]
Abstract
AIM To identify psychosocial predictors of medication adherence in young adults with youth-onset type 2 diabetes in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort. METHODS Participants (mean age: 26 years) completed validated psychosocial measures. Unannounced telephone pill counts were completed at T1 (baseline) and T2 (follow-up, approximately 1 year later) to assess adherence to oral hypoglycaemia agents (OHAs). Adherence to insulin was assessed by self-report. Logistic and linear regressions identified factors that predicted 'low adherence' (<80% of pills/insulin) and per cent adherence, adjusted for potential confounders. RESULTS Of 171 participants with OHA adherence scores at T1 and T2 (65% women, 43% Hispanic and 35% non-Hispanic Black), 65.4% were low adherent. After adjustment (including T1 adherence), concerns about diabetes medicines (adverse effects, dependence) at T1 predicted higher odds of being low adherent (categorical) at T2 (p = 0.019). Housing insecurity (p = 0.045) and reporting ≥2 need insecurities (p = 0.027) at T1 predicted lower per cent adherence (continuous) at T2. Of 157 participants with insulin adherence scores at T1 and T2 (69% women, 38% Hispanic and 38% non-Hispanic Black), 36.3% were low adherent. After adjustment (including T1 adherence), beliefs that medicines are overused predicted higher odds of insulin low adherence at T2 (p = 0.013), and beliefs that medicines are harmful (p = 0.004) and overused (p = 0.010) predicted lower per cent insulin adherence at T2. CONCLUSIONS Suboptimal medication adherence, common in young adults with youth-onset type 2 diabetes, is predicted by interfering beliefs about medicines and social factors. We must address these beliefs and unmet needs to develop tailored interventions for this vulnerable group.
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Affiliation(s)
- Paula M Trief
- Department of Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Diane Uschner
- The Biostatistics Center, George Washington University, Washington, DC, USA
| | - Seth Kalichman
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Barbara J Anderson
- Department of Pediatrics-Psychology, Baylor College of Medicine, Houston, Texas, USA
| | - Lida M Fette
- The Biostatistics Center, George Washington University, Washington, DC, USA
| | - Hui Wen
- The Biostatistics Center, George Washington University, Washington, DC, USA
| | - Jane D Bulger
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Ruth S Weinstock
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, New York, USA
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10
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Uschner D, Bott M, Strylewicz GB, Edelstein S, Miller K, Lagarde WH, Keating J, Schieffelin J, Weintraub W, Yukich J, Ahmed A, Berry AA, Seals AL, Fette L, Burke B, Tapp H, Herrington DM, Sanders JW, Runyon MS. 1049. Breakthrough SARS-CoV-2 Infections after Vaccination in the North Carolina COVID-19 Community Research Partnership (NC-CCRP). Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.890] [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: 12/23/2022] Open
Abstract
Abstract
Background
We characterize the incidence and risk factors of SARS-CoV-2 breakthrough infections in the NC-CCRP.
Cumulative Incidence of Breakthrough infections after Self-reported Symptomatic SARS-CoV-2 Test
Cumulative incidence curves (1 minus the unadjusted Kaplan–Meier risk), number at risk at each time point for the first self-reported symptomatic positive SARS-CoV-2 test, starting from full vaccination among participants who reported full vaccination.
Methods
The NC-CCRP is an observational cohort study assessing COVID-19 symptoms, test results, vaccination status, and risk behavior via daily email or text surveys. Cox models were used to estimate hazard rates. Fixed covariates were age at enrollment, race/ethnicity, sex, county of residence classification, vaccine product, and healthcare worker status. Time varying covariates were vaccination rate in county of residence, mask usage in the week prior, the Delta time frame, the Omicron time frame, and receipt of a vaccine booster.
Results
Among 15,808 eligible adult participants, 638 (4.0%) reported a positive SARS-CoV-2 test after vaccination from 01/15/2021 to 01/03/2022. The breakthrough rate increased with time from vaccination (Figure), with a cumulative incidence of 6.95% over 45 weeks of follow-up. Factors associated with a lower risk of breakthrough infection (p< 0.05) included older age (HR 0.7 for participants 45-64 years and 0.41 for those > 65 years compared to those 18-44 years), prior SARS-CoV-2 infection (HR 0.58), higher rates of mask use (HR 0.66), and receipt of a booster vaccination (HR 0.33). Higher rates of breakthrough infection were reported by participants vaccinated with BNT162b2 (HR 1.35) or Ad26.COV2.S (1.74) compared to mRNA-1273, those residing in suburban (HR 1.33) or rural (1.24) counties compared to urban counties, and during circulation of the Delta (3.54) and Omicron (16.68) variants compared to earlier time periods. There was no association of breakthrough infection with sex, race/ethnicity, healthcare worker status, or vaccination rate in the county of residence.
Conclusion
In this real-world analysis, risk of breakthrough infections increased with time since vaccination, with some variability among the specific vaccine products. Risk increased dramatically during the Omicron surge. Higher rates among younger individuals may reflect more frequent, or higher risk exposures, including those related to childcare. Significantly lower rates of breakthrough associated with mask wearing and receipt of a booster highlight specific measures that individuals can take to minimize the risk for COVID-19.
Disclosures
Michael S. Runyon, MD, MPH, Abbott Laboratories: Grant/Research Support|Roche Diagnostics Operations, Inc: Grant/Research Support.
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Affiliation(s)
- Diane Uschner
- The George Washington University , Rockville, Maryland
| | - Matthew Bott
- George Washington University , Bethesda, Maryland
| | | | - Sharon Edelstein
- George Washington Univ Biostatistics Center , Rockville, Maryland
| | - Kristen Miller
- MedStar Health National Center for Human Factors in Healthcare , Washington, District of Columbia
| | | | | | | | - William Weintraub
- MedStar Health Research Institute and Georgetown University , Washington, District of Columbia
| | - Joshua Yukich
- Tulane University School of Public Health and Tropical Medicine , New Orleans, Louisiana
| | - Amina Ahmed
- Levine Children's Hospital at Atrium Health , Charlotte, North Carolina
| | - Andrea A Berry
- University of Maryland School of Medicine , Baltimore, Maryland
| | | | - Lida Fette
- George Washington University , Bethesda, Maryland
| | - Brian Burke
- George Washington University , Bethesda, Maryland
| | - Hazel Tapp
- Atrium Health , Charlotte, North Carolina
| | - David M Herrington
- Wake Forest university School of Medicne , Winston Salem, North Carolina
| | - John W Sanders
- Wake Forest University School of Medicine , Winston-Salem, North Carolina
| | - Michael S Runyon
- Atrium Health Department of Emergency Medicine , Charlotte, North Carolina
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11
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Ahmed A, DeWitt ME, Uschner D, Lagarde WH, Friedman-Klabanoff DJ, Santos RP, Gibbs MA, Tapp H, Dantuluri KL. 2299. Longitudinal Serological Surveillance of SARS-CoV-2 in Children and Adolescents Using Serial At-Home Testing. Open Forum Infect Dis 2022. [PMCID: PMC9751902 DOI: 10.1093/ofid/ofac492.137] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Longitudinal serological surveillance is critical to understand dynamics of SARS-CoV-2 infections in children, a substantial portion of whom are asymptomatic. We describe trends in seroprevalence using at-home testing and evaluate demographic and clinical characteristics associated with seroconversion. Methods Children 2–17 years old enrolled at 3 North Carolina sites (Figure 1) were followed April 2- December 31, 2021. Daily electronic surveys solicited symptoms and vaccination status. Four fingerprick lateral flow immunoassay tests were shipped to participants to be completed monthly; sensitivity and specificity were 84.5% and 99.0%, respectively. We defined an infection window as 30 days before a positive antibody test (IgG), excluding results after any vaccine. Asymptomatic was defined as absence of “new” symptoms in the window; “new” was defined as not occurring the 14 days preceding the first observation of the symptom in the window. Univariate logistic regression was used to compare participants with and without infection-induced antibodies. For estimated seroprevalence, we used Bayesian inference accounting for sensitivity and specificity, modeling IgG positives from a binomial distribution. Results Of 1,501 participants, 9.1% developed infection-induced antibody (Table 1). Blacks were more likely to seroconvert (OR 1.95 [95% CI 1.05–3.45]) as were those in a 5-or-more person household (OR 4.25 [CI 1.47–12.1]). Cumulative seroprevalence of SARS-CoV-2 increased from 12.7% in May to 32.4% in October (Figure 2); 61% of those seropositive were asymptomatic (Table 2). Adolescents had the highest seroconversion rates and were significantly more likely than 2–4-year olds to be asymptomatic. Bayesian seroprevalence estimates accounting for assay sensitivity and specificity. Error bars represent 95% credible intervals. Conclusion Prior SARS-CoV-2 seroprevalence data in children are limited by cross sectional design and use of convenience samples. With serial testing, we demonstrate rising SARS-CoV-2 seroprevalence, with highest rates of seroconversion in adolescents. Although prior findings suggest that asymptomatic infections occur most frequently in young children, we found a high proportion among adolescents. Our findings underscore the importance of serosurveillance to optimize public health efforts aimed at children and adolescents. Disclosures Roberto P. Santos, MD, MSCS, American Board of Pediatrics - Sub-Board Infectious Diseases: Honoraria|Eli Lilly and Company: Grant/Research Support|Eli Lilly and Company: Eli Lilly and Company awarded to the University of Mississippi Medical Center with Roberto P. Santos as the Site PI|Health Resources and Services Administration (HRSA): Grant/Research Support|Health Resources and Services Administration (HRSA): Program Director & Principal Investigator|Janssen Pharmaceutical Companies of Johnson & Johnson (JNJ): Grant/Research Support|Janssen Pharmaceutical Companies of Johnson & Johnson (JNJ): Janssen Pharmaceutical Companies of Johnson & Johnson (JNJ) awarded to the University of Mississippi Medical Center with Roberto P. Santos as the Site|Merck Sharp & Dohme (MSD): Grant/Research Support|Merck Sharp & Dohme (MSD): Merck Sharp & Dohme (MSD) awarded to the University of Mississippi Medical Center with Roberto P. Santos as the Site PI.
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Affiliation(s)
- Amina Ahmed
- Levine Children's Hospital at Atrium Health, Charlotte, North Carolina
| | - Michael E DeWitt
- Atrium Wake Forest Baptist Health/ Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Diane Uschner
- The George Washington University, Rockville, Maryland
| | | | | | | | - Michael A Gibbs
- Atrium Health - Carolinas Medical Center, Charlotte, North Carolina
| | - Hazel Tapp
- Atrium Health, Charlotte, North Carolina
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12
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Williamson JC, Strylewicz GB, DeWitt ME, Uschner D, Soni A, Mongraw-Chaffin M, Dantuluri KL, Hinkelman A, Gibbs MA, Lagarde WH, Weintraub W, Bott M, Ostasiewski B, Miller K, McCurdy L, Sanders JW, Herrington DM. 781. COVID-19 Outcomes in the Immunocompromised Population of the COVID-19 Community Research Partnership. Open Forum Infect Dis 2022. [PMCID: PMC9752374 DOI: 10.1093/ofid/ofac492.042] [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: 12/23/2022] Open
Abstract
Background The COVID-19 Community Research Partnership (CCRP) is a large multicenter healthcare system-based study of the COVID-19 pandemic, including factors impacting risk of infection and hospitalization. The CCRP includes a subset of immunocompromised (IC) participants with varying vaccination status over time. Methods We conducted an observational cohort study of 2,515 IC and 41,941 non-IC CCRP participants who contributed electronic health record data and daily electronic surveys to self-report COVID-19 symptoms, test results, and vaccinations from April 2020 to March 2022. The IC population included those with stem cell transplant, HIV, cancer, autoimmune disease, or solid organ transplant. The latter 3 must have also had an active systemic therapy to meet the IC condition (e.g. chemotherapy, immune modulator, steroid). Logistic regression was used to investigate risk of COVID-19 and hospitalization among IC participants and according to vaccine status within viral variant time periods (pre-delta, delta, omicron). Results IC conditions included cancer (51%), autoimmune (41%), solid organ/stem cell transplant (9%), and HIV (7%). The IC group was older and had more comorbidities. 95% of vaccine recipients received an mRNA vaccine. More vaccine breakthrough infections occurred in the IC group than non-IC group (36.1% vs 29.5%, p< 0.001). IC participants were less likely to remain COVID-19 free over time if vaccinated but not boosted (Fig 1A). However, after receiving a booster there was no difference in COVID-19 cases between the groups (Fig 1B). IC participants were more likely to be hospitalized with COVID-19 (OR 2.85; 95% CI 1.69–4.76), but vaccination reduced risk for hospitalization (OR 0.26; 95% CI 0.08–0.8). Receipt of a booster dose reduced risk of COVID-19 among IC participants during the delta wave (IRR 0.52; 95% CI 0.28–0.94) but not during omicron. However, during omicron risk of hospitalization in the IC group was reduced by a booster dose (OR 0.13; 95% CI 0.02–0.72). Conclusion IC individuals were at increased risk for COVID-19 hospitalizations and breakthrough infections. After receiving a booster, IC participants were conferred the same level of protection from infection as their non-IC counterparts, highlighting the importance of boosters for these individuals. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
| | | | - Michael E DeWitt
- Atrium Wake Forest Baptist Health/ Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Ashvi Soni
- The Biostatistics Center, The George Washington University, Washington, District of Columbia
| | | | | | - Amy Hinkelman
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina
| | - Michael A Gibbs
- Atrium Health - Carolinas Medical Center, Charlotte, North Carolina
| | | | - William Weintraub
- MedStar Health Research Institute and Georgetown University, Washington, District of Columbia
| | - Matthew Bott
- George Washington University, Bethesda, Maryland
| | | | - Kristen Miller
- MedStar Health National Center for Human Factors in Healthcare, Washington, District of Columbia
| | | | - John W Sanders
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
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13
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Mongraw-Chaffin M, Tjaden AH, Seals AL, Miller K, Ahmed N, Espeland MA, Gibbs M, Thomas D, Uschner D, Weintraub WS, Edelstein SL. Association of Obesity and Diabetes with SARS-Cov-2 Infection and Symptoms in the COVID-19 Community Research Partnership. J Clin Endocrinol Metab 2022; 108:dgac715. [PMID: 36482096 DOI: 10.1210/clinem/dgac715] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Obesity and diabetes are established risk factors for severe SARS-CoV-2 outcomes, but less is known about their impact on susceptibility to COVID-19 infection and general symptom severity. We hypothesized that those with obesity or diabetes would be more likely to self-report a positive SARS-CoV-2 test, and among those with a positive test, have greater symptom severity and duration. METHODS Among 44,430 COVID-19 Community Research Partnership participants, we evaluated the association of self-reported and electronic health record obesity and diabetes with a self-reported positive COVID-19 test at any time. Among the 2,663 participants with a self-reported positive COVID-19 test during the study, we evaluated the association of obesity and diabetes with self-report of symptom severity, duration, and hospitalization. Logistic regression models were adjusted for age, sex, race/ethnicity, socioeconomic status, and healthcare worker status. RESULTS We found a positive graded association between Body Mass Index (BMI) category and positive COVID-19 test (Overweight OR = 1.14 [1.05-1.25]; Obesity I OR = 1.29 [1.17-2.42]; Obesity II OR = 1.34 [1.19-1.50]; Obesity III OR = 1.53 [1.35-1.73]), and a similar but weaker association with COVID-19 symptoms and severity among those with a positive test. Diabetes was associated with COVID-19 infection but not symptoms after adjustment, with some evidence of an interaction between obesity and diabetes. CONCLUSIONS While the limitations of this health system convenience sample include generalizability and selection around test-seeking, the strong graded association of BMI and diabetes with self-reported COVID-19 infection suggests that obesity and diabetes may play a role in risk for symptomatic SARS-CoV-2 beyond co-occurrence with socioeconomic factors.
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Affiliation(s)
| | | | | | - Kristen Miller
- MedStar Health Research Institute, Georgetown University Washington, District of Columbia
| | | | | | | | - Dorey Thomas
- Wake Forest School of Medicine, Winston-Salem, NC
| | - Diane Uschner
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - William S Weintraub
- MedStar Health Research Institute, Georgetown University Washington, District of Columbia
| | - Sharon L Edelstein
- The Biostatistics Center, George Washington University, Rockville, Maryland
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14
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Trief PM, Kalichman S, Uschner D, Tung M, Drews KL, Anderson BJ, Fette LM, Wen H, Bulger JD, Weinstock RS. Association of psychosocial factors with medication adherence in emerging adults with youth-onset type 2 diabetes: The iCount study. Pediatr Diabetes 2022; 23:1695-1706. [PMID: 36220788 DOI: 10.1111/pedi.13431] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/13/2022] [Accepted: 10/05/2022] [Indexed: 12/29/2022] Open
Abstract
AIMS To assess associations of psychosocial factors with medication adherence in young adults with youth-onset type 2 diabetes in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort. METHODS Participants (mean age 26 years) completed validated psychosocial measures. Adherence to oral hypoglycemia agents (OHAs) was assessed with 3-monthly unannounced phone pill counts; insulin adherence by self-report. Logistic and linear regressions identified factors associated with "low-adherence" (<80% of pills/insulin) controlling for confounders. RESULTS Of 212 participants taking OHAs (67% female, 39% Hispanic, 36% non-Hispanic Black), 69.8% were low-adherent. After adjustment, beliefs that medicines are necessary was associated with lower odds of low-adherence (p = 0.040, dichotomous). Less self-management support (p = 0.008), no healthcare coverage (p = 0.001), ≥1 (p = 0.008)/≥2 (p = 0.045) need insecurities were associated with higher odds of low-adherence. Factors associated with lower % adherence (continuous) were beliefs that medicines are harmful (p < 0.001)/overused (p = 0.007)/less necessary (p = 0.022), low self-management support (p = 0.003), food insecurity (p = 0.036), no healthcare coverage (p < 0.001), ≥1 (p = 0.003)/≥2 (p = 0.018) need insecurities. Of 192 taking insulin (69% female, 36% Hispanic, 41% non-Hispanic Black, 16% non-Hispanic white), 37.0% were low-adherent. Beliefs that medicines are overused (p = 0.009), that diabetes is not serious (p = 0.010), low diabetes self-efficacy (p = 0.035), high distress (p = 0.027), low self-management support (p = 0.001), food insecurity (p = 0.020), ≥1 (p = 0.011)/≥2 (p = 0.015) insecurities increased odds of insulin low-adherence. CONCLUSIONS Poor medication adherence, common in young adults with youth-onset type 2 diabetes, is associated with interfering beliefs, diabetes distress and social factors. We must address these factors to develop tailored interventions for this vulnerable group.
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Affiliation(s)
- Paula M Trief
- Department of Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Seth Kalichman
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Diane Uschner
- Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Melinda Tung
- Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Kimberly L Drews
- Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Barbara J Anderson
- Department of Pediatrics, Psychology Section, Baylor College of Medicine, Houston, Texas, USA
| | - Lida M Fette
- Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Hui Wen
- Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Jane D Bulger
- Department of Medicine, Division of Endocrinology, State University of New York Upstate Medical University, Syracuse New York, USA
| | - Ruth S Weinstock
- Department of Medicine, Division of Endocrinology, State University of New York Upstate Medical University, Syracuse New York, USA
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15
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Mititelu M, Uschner D, Doherty L, Bjornstad P, Domalpally A, Drews KL, Gubitosi-Klug R, Levitsky LL, Pak JW, White NH, Blodi BA. Retinal Thickness and Morphology Changes on OCT in Youth with Type 2 Diabetes: Findings from the TODAY Study. Ophthalmol Sci 2022; 2:100191. [PMID: 36531589 PMCID: PMC9754955 DOI: 10.1016/j.xops.2022.100191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/13/2022] [Accepted: 06/22/2022] [Indexed: 06/17/2023]
Abstract
Objective To evaluate changes in retinal thickness and morphology using OCT in youth with type 2 diabetes (T2D) and to identify systemic biomarkers correlating with these changes. Design Retrospective subgroup analysis of a prospective study. Participants Participants who underwent OCT imaging in the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) trial and its follow-up study TODAY2. Methods In 2010-2011 (TODAY) and 2017-2018 (TODAY2), 6 × 6-mm macular volume OCT scans were acquired, segmented, and analyzed to generate total retinal thickness, inner retinal thickness, and outer retinal thickness. The main retinal morphologies graded were intraretinal cystoid spaces, subretinal fluid, and posterior vitreous detachment (PVD). Main Outcome Measures Changes in total and individual retinal layer thickness and development of abnormal vitreomacular morphology between TODAY and TODAY2. Results Participants had a mean age of 17.9 ± 2.4 years and glycated hemoglobin (HbA1c) of 8.2 ± 2.8% in TODAY and a mean age of 25.0 ± 2.4 years and mean HbA1c of 9.5 ± 2.8% in TODAY2. Longitudinally between assessments, there were overall decreases in outer retinal thickness from 167.2 ± 11.5 microns to 158.4 ± 12.8 microns (P < 0.001) and in photoreceptor thickness from 30.3 ± 2.9 microns to 29.8 ± 4.1 microns (P = 0.04) in the central subfield, while in the inner subfield, we noted a decrease in outer retinal thickness from 150.5 ± 10.1 microns to 144.9 ± 10.5 microns (P < 0.001) and an increase in inner retinal thickness from 136.9 ± 11.5 microns to 137.4 ± 12.6 microns (P = 0.01). Multivariate analysis showed that in the center subfield, HbA1c increases were associated with increases in total retinal thickness (r: 0.67, P = 0.001), whereas fasting glucose was positively correlated with inner retinal thickness (r: 0.02, P = 0.02). In the inner subfield, both systolic (r: -0.22, P < 0.001) and diastolic (r: -0.22, P = 0.003) blood pressures were negatively correlated with total retinal thickness. There was an increase in PVD (18.9%) and cystoid spaces (4.2%). Conclusions Youth with T2D develop retinal thickness changes on OCT, including increases in total retinal and inner retinal thickness in the center subfield that correlate with HbA1c and fasting glucose, respectively. Taken together with the increased prevalence of abnormal vitreomacular morphology in this cohort at risk, these findings emphasize the importance of controlling risk factors to prevent the development of sight-threatening retinal complications.
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Key Words
- DR, diabetic retinopathy
- EZ, ellipsoid zone
- Glycemic control
- HbA1c, glycated hemoglobin
- ILM, internal limiting membrane
- INL, inner nuclear layer
- Macular morphology
- NPDR, nonproliferative DR
- OPL, outer plexiform layer
- PVD, posterior vitreous detachment
- Posterior vitreous detachment
- RPE, retinal pigment epithelium
- Retinal thickening
- SD-OCT, spectral-domain OCT
- T2D, type 2 diabetes
- TD-OCT, time-domain OCT
- TODAY, Treatment Options for Type 2 Diabetes in Adolescents and Youth
- Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study
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Affiliation(s)
- Mihai Mititelu
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Diane Uschner
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Lindsay Doherty
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Petter Bjornstad
- University of Colorado, School of Medicine, Department of Pediatrics, Section of Endocrinology, Department of Medicine, Division of Renal Diseases and Hypertension, Denver, Colorado
| | - Amitha Domalpally
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kimberly L. Drews
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | | | - Lynne L. Levitsky
- MassGeneral for Children, Harvard Medical School, Boston, Massachusetts
| | - Jeong W. Pak
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Neil H. White
- School of Medicine, Washington University, St. Louis, Missouri
| | - Barbara A. Blodi
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
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Wierzba TF, Sanders JW, Herrington D, Espeland MA, Williamson J, Mongraw-Chaffin M, Bertoni A, Alexander-Miller MA, Castri P, Mathews A, Munawar I, Seals AL, Ostasiewski B, Ballard CAP, Gurcan M, Ivanov A, Zapata GM, Westcott M, Blinson K, Blinson L, Mistysyn M, Davis D, Doomy L, Henderson P, Jessup A, Lane K, Levine B, McCanless J, McDaniel S, Melius K, O’Neill C, Pack A, Rathee R, Rushing S, Sheets J, Soots S, Wall M, Wheeler S, White J, Wilkerson L, Wilson R, Wilson K, Burcombe D, Saylor G, Lunn M, Ordonez K, O’Steen A, Wagner L, Runyon MS, McCurdy LH, Gibbs MA, Taylor YJ, Calamari L, Tapp H, Ahmed A, Brennan M, Munn L, Dantuluri KL, Hetherington T, Lu LC, Dunn C, Hogg M, Price A, Leonidas M, Manning M, Rossman W, Gohs FX, Harris A, Priem JS, Tochiki P, Wellinsky N, Silva C, Ludden T, Hernandez J, Spencer K, McAlister L, Weintraub W, Miller K, Washington C, Moses A, Dolman S, Zelaya-Portillo J, Erkus J, Blumenthal J, Barrientos RER, Bennett S, Shah S, Mathur S, Boxley C, Kolm P, Franklin E, Ahmed N, Larsen M, Oberhelman R, Keating J, Kissinger P, Schieffelin J, Yukich J, Beron A, Teigen J, Kotloff K, Chen WH, Friedman-Klabanoff D, Berry AA, Powell H, Roane L, Datar R, Reilly C, Correa A, Navalkele B, Min YI, Castillo A, Ward L, Santos RP, Anugu P, Gao Y, Green J, Sandlin R, Moore D, Drake L, Horton D, Johnson KL, Stover M, Lagarde WH, Daniel L, Maguire PD, Hanlon CL, McFayden L, Rigo I, Hines K, Smith L, Harris M, Lissor B, Cook V, Eversole M, Herrin T, Murphy D, Kinney L, Diehl P, Abromitis N, Pierre TS, Heckman B, Evans D, March J, Whitlock B, Moore W, Arthur S, Conway J, Gallaher TR, Johanson M, Brown S, Dixon T, Reavis M, Henderson S, Zimmer M, Oliver D, Jackson K, Menon M, Bishop B, Roeth R, King-Thiele R, Hamrick TS, Ihmeidan A, Hinkelman A, Okafor C, Bray Brown RB, Brewster A, Bouyi D, Lamont K, Yoshinaga K, Vinod P, Peela AS, Denbel G, Lo J, Mayet-Khan M, Mittal A, Motwani R, Raafat M, Schultz E, Joseph A, Parkeh A, Patel D, Afridi B, Uschner D, Edelstein SL, Santacatterina M, Strylewicz G, Burke B, Gunaratne M, Turney M, Zhou SQ, Tjaden AH, Fette L, Buahin A, Bott M, Graziani S, Soni A, Diao G, Renteria J, Mores C, Porzucek A, Laborde R, Acharya P, Guill L, Lamphier D, Schaefer A, Satterwhite WM, McKeague A, Ward J, Naranjo DP, Darko N, Castellon K, Brink R, Shehzad H, Kuprianov D, McGlasson D, Hayes D, Edwards S, Daphnis S, Todd B, Goodwin A, Berkelman R, Hanson K, Zeger S, Hopkins J, Reilly C, Minnesota UO, Edwards K, Gayle H, Redd S. The COVID-19 Community Research Partnership: a multistate surveillance platform for characterizing the epidemiology of the SARS-CoV-2 pandemic. Biol Methods Protoc 2022; 7:bpac033. [PMID: 36589317 PMCID: PMC9789889 DOI: 10.1093/biomethods/bpac033] [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: 09/29/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/29/2022] Open
Abstract
The COVID-19 Community Research Partnership (CCRP) is a multisite surveillance platform designed to characterize the epidemiology of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) pandemic. This article describes the CCRP study design and methodology. The CCRP includes two prospective cohorts, one with six health systems in the mid-Atlantic and southern USA, and the other with six health systems in North Carolina. With enrollment beginning in April 2020, sites invited persons within their healthcare systems as well as community members to participate in daily surveillance for symptoms of COVID-like illnesses, testing, and risk behaviors. Participants with electronic health records (EHRs) were also asked to volunteer data access. Subsets of participants, representative of the general population and including oversampling of populations of interest, were selected for repeated at-home serology testing. By October 2021, 65 739 participants (62 261 adult and 3478 pediatric) were enrolled, with 89% providing syndromic data, 74% providing EHR data, and 70% participating in one of the two serology sub-studies. An average of 62% of the participants completed a daily survey at least once a week, and 55% of the serology kits were returned. The CCRP provides rich regional epidemiologic data and the opportunity to more fully characterize the risks and sequelae of SARS-CoV-2 infection.
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Uschner D, Bott M, Lagarde WH, Keating J, Tapp H, Berry AA, Seals AL, Munawar I, Schieffelin J, Yukich J, Santacatterina M, Gunaratne M, Fette LM, Burke B, Strylewicz G, Edelstein SL, Ahmed A, Miller K, Sanders JW, Herrington D, Weintraub WS, Runyon MS. Breakthrough SARS-CoV-2 Infections after Vaccination in North Carolina. Vaccines (Basel) 2022; 10:1922. [PMID: 36423018 PMCID: PMC9695352 DOI: 10.3390/vaccines10111922] [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: 10/05/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 10/01/2023] Open
Abstract
We characterize the overall incidence and risk factors for breakthrough infection among fully vaccinated participants in the North Carolina COVID-19 Community Research Partnership cohort. Among 15,808 eligible participants, 638 reported a positive SARS-CoV-2 test after vaccination. Factors associated with a lower risk of breakthrough in the time-to-event analysis included older age, prior SARS-CovV-2 infection, higher rates of face mask use, and receipt of a booster vaccination. Higher rates of breakthrough were reported by participants vaccinated with BNT162b2 or Ad26.COV2.S compared to mRNA-1273, in suburban or rural counties compared to urban counties, and during circulation of the Delta and Omicron variants.
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Affiliation(s)
- Diane Uschner
- The Biostatistics Center, George Washington University, Rockville, MD 20852, USA
| | - Matthew Bott
- The Biostatistics Center, George Washington University, Rockville, MD 20852, USA
| | - William H. Lagarde
- Division of Pediatric Endocrinology, Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC 27610, USA
| | - Joseph Keating
- Department of Tropical Medicine, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70118, USA
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC 28262, USA
| | - Andrea A. Berry
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Austin L. Seals
- Division of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27109, USA
| | - Iqra Munawar
- Division of Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27109, USA
| | - John Schieffelin
- Section of Infectious Disease, Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Joshua Yukich
- Department of Tropical Medicine, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70118, USA
| | | | - Mihili Gunaratne
- The Biostatistics Center, George Washington University, Rockville, MD 20852, USA
| | - Lida M. Fette
- The Biostatistics Center, George Washington University, Rockville, MD 20852, USA
| | - Brian Burke
- The Biostatistics Center, George Washington University, Rockville, MD 20852, USA
| | - Greg Strylewicz
- The Biostatistics Center, George Washington University, Rockville, MD 20852, USA
| | - Sharon L. Edelstein
- The Biostatistics Center, George Washington University, Rockville, MD 20852, USA
| | - Amina Ahmed
- Department of Pediatrics, Atrium Health Levine Children’s Hospital, Charlotte, NC 28203, USA
| | - Kristen Miller
- MedStar Health Research Institute, Georgetown University, Washington, DC 20007, USA
| | - John W. Sanders
- Division of Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27109, USA
| | - David Herrington
- Division of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27109, USA
| | - William S. Weintraub
- MedStar Health Research Institute, Georgetown University, Washington, DC 20007, USA
| | - Michael S. Runyon
- Department of Emergency Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC 28262, USA
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18
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Trief PM, Uschner D, Tung M, Marcus MD, Rayas M, MacLeish S, Farrell R, Keady J, Chao L, Weinstock RS. Diabetes Distress in Young Adults With Youth-Onset Type 2 Diabetes: TODAY2 Study Results. Diabetes Care 2022; 45:529-537. [PMID: 35015056 PMCID: PMC8918198 DOI: 10.2337/dc21-1689] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/29/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the prevalence of high diabetes distress and associated factors in the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY2) study cohort of young adults with youth-onset type 2 diabetes. RESEARCH DESIGN AND METHODS Participants completed the Diabetes Distress Scale (DDS) at end-of-study visits. Factors examined for association with high distress were demographic (sex, race/ethnicity, age, education, income), medical (HbA1c, BMI, complications), psychological (depressive and anxiety symptoms), and social (number in household, offspring, health care coverage, established with diabetes care provider). Univariate logistic regression identified factors associated with high distress that were controlled for in multivariate logistic regressions. RESULTS Of 438 participants, 66% were female (mean age 26.8 years, 18% non-Hispanic White, 37% non-Hispanic Black, 38% Hispanic). High distress (DDS ≥2) was reported by 105 (24%) participants. Subscales identified 40% with high regimen distress and 29.7% with high emotional burden. A greater percentage of those with high distress were female (P = 0.002), diagnosed with hypertension (P = 0.037) and retinopathy (P = 0.005), treated with insulin, had higher HbA1c, and had moderate to severe depressive and anxiety symptoms (all P < 0.001). In multivariate analyses, female sex (P < 0.001), HbA1c (P < 0.001), anxiety symptoms (P = 0.036), and lack of health care coverage (P = 0.019) were associated with high distress, after controlling for potential confounders. Moderate to severe depressive symptoms were associated with high regimen distress (P = 0.018) and emotional burden (P < 0.001); insulin treatment was associated with high emotional burden (P = 0.027). CONCLUSIONS Future research should identify modifiable factors associated with high diabetes distress in young adults with youth-onset type 2 diabetes that may inform distress interventions with this medically vulnerable group.
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Affiliation(s)
- Paula M Trief
- State University of New York Upstate Medical University, Syracuse, NY
| | - Diane Uschner
- The Biostatistics Center, George Washington University, Rockville, MD
| | - Melinda Tung
- The Biostatistics Center, George Washington University, Rockville, MD
| | | | - Maria Rayas
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Sarah MacLeish
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ryan Farrell
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Lily Chao
- Children's Hospital Los Angeles, Los Angeles, CA
| | - Ruth S Weinstock
- State University of New York Upstate Medical University, Syracuse, NY
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19
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Herrington DM, Sanders JW, Wierzba TF, Alexander-Miller M, Espeland M, Bertoni AG, Mathews A, Seals AL, Munawar I, Runyon MS, McCurdy LH, Gibbs MA, Kotloff K, Friedman-Klabanoff D, Weintraub W, Correa A, Uschner D, Edelstein S, Santacatterina M. Duration of SARS-CoV-2 sero-positivity in a large longitudinal sero-surveillance cohort: the COVID-19 Community Research Partnership. BMC Infect Dis 2021; 21:889. [PMID: 34461847 PMCID: PMC8404407 DOI: 10.1186/s12879-021-06517-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 07/30/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Estimating population prevalence and incidence of prior SARS-CoV-2 infection is essential to formulate public health recommendations concerning the COVID-19 pandemic. However, interpreting estimates based on sero-surveillance requires an understanding of the duration of elevated antibodies following SARS-CoV-2 infection, especially in the large number of people with pauci-symptomatic or asymptomatic disease. METHODS We examined > 30,000 serology assays for SARS-CoV-2 specific IgG and IgM assays acquired longitudinally in 11,468 adults between April and November 2020 in the COVID-19 Community Research Partnership. RESULTS Among participants with serologic evidence for infection but few or no symptoms or clinical disease, roughly 50% sero-reverted in 30 days of their initial positive test. Sero-reversion occurred more quickly for IgM than IgG and for antibodies targeting nucleocapsid protein compared with spike proteins, but was not associated with age, sex, race/ethnicity, or healthcare worker status. CONCLUSIONS The short duration of antibody response suggests that the true population prevalence of prior SARS-CoV-2 infection may be significantly higher than presumed based on earlier sero-surveillance studies. The impact of the large number of minimally symptomatic COVID-19 cases with only a brief antibody response on population immunity remains to be determined.
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Berger VW, Bour LJ, Carter K, Chipman JJ, Everett CC, Heussen N, Hewitt C, Hilgers RD, Luo YA, Renteria J, Ryeznik Y, Sverdlov O, Uschner D. A roadmap to using randomization in clinical trials. BMC Med Res Methodol 2021; 21:168. [PMID: 34399696 PMCID: PMC8366748 DOI: 10.1186/s12874-021-01303-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/14/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Randomization is the foundation of any clinical trial involving treatment comparison. It helps mitigate selection bias, promotes similarity of treatment groups with respect to important known and unknown confounders, and contributes to the validity of statistical tests. Various restricted randomization procedures with different probabilistic structures and different statistical properties are available. The goal of this paper is to present a systematic roadmap for the choice and application of a restricted randomization procedure in a clinical trial. METHODS We survey available restricted randomization procedures for sequential allocation of subjects in a randomized, comparative, parallel group clinical trial with equal (1:1) allocation. We explore statistical properties of these procedures, including balance/randomness tradeoff, type I error rate and power. We perform head-to-head comparisons of different procedures through simulation under various experimental scenarios, including cases when common model assumptions are violated. We also provide some real-life clinical trial examples to illustrate the thinking process for selecting a randomization procedure for implementation in practice. RESULTS Restricted randomization procedures targeting 1:1 allocation vary in the degree of balance/randomness they induce, and more importantly, they vary in terms of validity and efficiency of statistical inference when common model assumptions are violated (e.g. when outcomes are affected by a linear time trend; measurement error distribution is misspecified; or selection bias is introduced in the experiment). Some procedures are more robust than others. Covariate-adjusted analysis may be essential to ensure validity of the results. Special considerations are required when selecting a randomization procedure for a clinical trial with very small sample size. CONCLUSIONS The choice of randomization design, data analytic technique (parametric or nonparametric), and analysis strategy (randomization-based or population model-based) are all very important considerations. Randomization-based tests are robust and valid alternatives to likelihood-based tests and should be considered more frequently by clinical investigators.
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Affiliation(s)
| | | | - Kerstine Carter
- Boehringer-Ingelheim Pharmaceuticals Inc, Ridgefield, CT USA
| | - Jonathan J. Chipman
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City UT, USA
- Cancer Biostatistics, University of Utah Huntsman Cancer Institute, Salt Lake City UT, USA
| | | | - Nicole Heussen
- RWTH Aachen University, Aachen, Germany
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | | | - Jone Renteria
- Open University of Catalonia (UOC) and the University of Barcelona (UB), Barcelona, Spain
- Department of Human Development and Quantitative Methodology, University of Maryland, College Park, MD USA
| | - Yevgen Ryeznik
- BioPharma Early Biometrics & Statistical Innovations, Data Science & AI, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Oleksandr Sverdlov
- Early Development Analytics, Novartis Pharmaceuticals Corporation, NJ East Hanover, USA
| | - Diane Uschner
- Biostatistics Center & Department of Biostatistics and Bioinformatics, George Washington University, DC Washington, USA
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Uschner D. Randomization-based inference in the presence of selection bias. Stat Med 2021; 40:2212-2229. [PMID: 33561882 DOI: 10.1002/sim.8898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 12/24/2020] [Accepted: 01/16/2021] [Indexed: 11/05/2022]
Abstract
For the analysis of clinical trials, the study participants are usually assumed to be representative sample of a target population. This assumption is rarely fulfilled in clinical trials, and particularly not if the sample size is small. In addition, covariate imbalances may affect the trial. Randomization tests provide a nonparametric analysis method of the treatment effect that does not rely on population-based assumptions. We propose a nonparametric statistical model that yields a formal basis for randomization tests. We adapt the model for the presence of covariate imbalance in the form of selection bias and investigate the effects of bias on the rejection probability of the randomization test using Monte Carlo simulations. Finally, we show that ancillary statistics can be used to control for the influence of bias. We show that covariate imbalance leads to an inflation of the type I error probability. The proposed nonparametric model allows for the use of ancillary statistics that yield an unbiased adjusted randomization test.
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Affiliation(s)
- Diane Uschner
- The Biostatistics Center, George Washington University, Rockville, Maryland, USA
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22
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Gubitosi-Klug RA, Braffett BH, Hitt S, Arends V, Uschner D, Jones K, Diminick L, Karger AB, Paterson AD, Roshandel D, Marcovina S, Lachin JM, Steffes M, Palmer JP. Residual β cell function in long-term type 1 diabetes associates with reduced incidence of hypoglycemia. J Clin Invest 2021; 131:143011. [PMID: 33529168 PMCID: PMC7843223 DOI: 10.1172/jci143011] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUNDWe investigated residual β cell function in Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study participants with an average 35-year duration of type 1 diabetes mellitus (T1DM).METHODSSerum C-peptide was measured during a 4-hour mixed-meal tolerance test. Associations with metabolic outcomes and complications were explored among nonresponders (all C-peptide values after meal <0.003 nmol/L) and 3 categories of responders, classified by peak C-peptide concentration (nmol/L) as high (>0.2), intermediate (>0.03 to ≤0.2), and low (≥ 0.003 to ≤0.03).RESULTSOf the 944 participants, 117 (12.4%) were classified as responders. Residual C-peptide concentrations were associated with higher DCCT baseline concentrations of stimulated C-peptide (P value for trend = 0.0001). Residual C-peptide secretion was not associated with current or mean HbA1c, HLA high-risk haplotypes for T1DM, or the current presence of T1DM autoantibodies. The proportion of subjects with a history of severe hypoglycemia was lower with high (27%) and intermediate (48%) residual C-peptide concentrations than with low (74%) and no (70%) residual C-peptide concentrations (P value for trend = 0.0001). Responders and nonresponders demonstrated similar rates of advanced microvascular complications.CONCLUSIONβ Cell function can persist in long-duration T1DM. With a peak C-peptide concentration of >0.03 nmol/L, we observed clinically meaningful reductions in the prevalence of severe hypoglycemia.TRIAL REGISTRATIONClinicalTrials.gov NCT00360815 and NCT00360893.FUNDINGDivision of Diabetes Endocrinology and Metabolic Diseases of the National Institute of Diabetes and Digestive and Kidney Diseases (DP3-DK104438, U01 DK094176, and U01 DK094157).
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Affiliation(s)
- Rose A. Gubitosi-Klug
- Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Barbara H. Braffett
- The Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Susan Hitt
- University of Missouri, Columbia, Missouri, USA
| | | | - Diane Uschner
- The Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | | | - Lisa Diminick
- The Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Amy B. Karger
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew D. Paterson
- Genetics and Genome Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Divisions of Epidemiology and Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Delnaz Roshandel
- Genetics and Genome Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - John M. Lachin
- The Biostatistics Center, George Washington University, Rockville, Maryland, USA
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23
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Wang Y, Rosenberger WF, Uschner D. Randomization tests for multiarmed randomized clinical trials. Stat Med 2019; 39:494-509. [DOI: 10.1002/sim.8418] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 10/04/2019] [Accepted: 10/07/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Yanying Wang
- Department of StatisticsGeorge Mason University Fairfax Virginia
| | | | - Diane Uschner
- Biostatistics Center, The George Washington University Rockville Maryland
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Rosenberger WF, Uschner D, Wang Y. Rejoinder. Stat Med 2019; 38:27-30. [PMID: 30537122 DOI: 10.1002/sim.7978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | - Diane Uschner
- Department for Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Yanying Wang
- Department of Statistics, George Mason University, Fairfax, Virginia
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Rosenberger WF, Uschner D, Wang Y. Randomization: The forgotten component of the randomized clinical trial. Stat Med 2018; 38:1-12. [DOI: 10.1002/sim.7901] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/31/2018] [Accepted: 06/13/2018] [Indexed: 11/10/2022]
Affiliation(s)
| | - Diane Uschner
- Department of StatisticsGeorge Mason University Fairfax Virginia
- Department of Medical StatisticsRWTH Aachen University Aachen Germany
| | - Yanying Wang
- Department of StatisticsGeorge Mason University Fairfax Virginia
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Bergrath S, Müller M, Rossaint R, Beckers SK, Uschner D, Brokmann JC. Guideline adherence in acute coronary syndromes between telemedically supported paramedics and conventional on-scene physician care: A longitudinal pre-post intervention cohort study. Health Informatics J 2018; 25:1528-1537. [PMID: 29865891 DOI: 10.1177/1460458218775157] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Health informatics applications reduce time intervals in acute coronary syndromes, but their impact on guideline adherence is unknown. This pre-post intervention study compared guideline adherence between telemedically supported (n = 101, April 2014-July 2015) and conventional on-scene care (n = 120, January 2014-March 2014) in acute coronary syndrome. A multivariate logistic regression was performed for dependent variables: adverse events 0 versus 0, p = NA; electrocardiogram 101 versus 120, p = NA; acetylic salicylic acid 91 versus 102, p = 0.21; heparin 92 versus 112, p = 0.99; morphine 96 versus 107, p = 0.33; oxygen 83 versus 102, p = 0.92; glyceroltrinitrate 55 versus 90, p = 0.038; correct destination: 100 versus 119, p = 1.0. The time from ambulance arrival to hospital arrival was prolonged with telemedicine: 48.7 ± 11 min versus 35.5 ± 8.1 min, p < 0.001. Guideline adherence showed no differences except for glyceroltrinitrate. Prolonged time requirements are critical, though explainable. However, this approach enables a timely and high-quality backup strategy if only paramedics are on-scene.
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Abstract
The impact of selection bias on the results of clinical trials has been analyzed extensively for trials of two treatments, yet its impact in multi-arm trials is still unknown. In this paper, we investigate selection bias in multi-arm trials by its impact on the type I error probability. We propose two models for selection bias, so-called biasing policies, that both extend the classic guessing strategy by Blackwell and Hodges. We derive the distribution of the F-test statistic under the misspecified outcome model and provide a formula for the type I error probability under selection bias. We apply the presented approach to quantify the influence of selection bias in multi-arm trials with increasing number of treatment groups using a permuted block design for different assumptions and different biasing strategies. Our results confirm previous findings that smaller block sizes lead to a higher proportion of sequences with inflated type I error probability. Astonishingly, our results also show that the proportion of sequences with inflated type I error probability remains constant when the number of treatment groups is increased. Realizing that the impact of selection bias cannot be completely eliminated, we propose a bias adjusted statistical model and show that the power of the statistical test is only slightly deflated for larger block sizes.
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Affiliation(s)
- Diane Uschner
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
- * E-mail:
| | | | - Nicole Heussen
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
- Center of Biostatistics and Epidemiology, Department of Evidence Based Medicine, Sigmund Freund University, Vienna, Austria
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Uschner D, Schindler D, Hilgers RD, Heussen N. randomizeR: An R Package for the Assessment and Implementation of Randomization in Clinical Trials. J Stat Softw 2018. [DOI: 10.18637/jss.v085.i08] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Hilgers RD, Uschner D, Rosenberger WF, Heussen N. ERDO - a framework to select an appropriate randomization procedure for clinical trials. BMC Med Res Methodol 2017; 17:159. [PMID: 29202708 PMCID: PMC5715815 DOI: 10.1186/s12874-017-0428-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/15/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Randomization is considered to be a key feature to protect against bias in randomized clinical trials. Randomization induces comparability with respect to known and unknown covariates, mitigates selection bias, and provides a basis for inference. Although various randomization procedures have been proposed, no single procedure performs uniformly best. In the design phase of a clinical trial, the scientist has to decide which randomization procedure to use, taking into account the practical setting of the trial with respect to the potential of bias. Less emphasis has been placed on this important design decision than on analysis, and less support has been available to guide the scientist in making this decision. METHODS We propose a framework that weights the properties of the randomization procedure with respect to practical needs of the research question to be answered by the clinical trial. In particular, the framework assesses the impact of chronological and selection bias on the probability of a type I error. The framework is applied to a case study with a 2-arm parallel group, single center randomized clinical trial with continuous endpoint, with no-interim analysis, 1:1 allocation and no adaptation in the randomization process. RESULTS In so doing, we derive scientific arguments for the selection of an appropriate randomization procedure and develop a template which is illustrated in parallel by a case study. Possible extensions are discussed. CONCLUSION The proposed ERDO framework guides the investigator through a template for the choice of a randomization procedure, and provides easy to use tools for the assessment. The barriers for the thorough reporting and assessment of randomization procedures could be further reduced in the future when regulators and pharmaceutical companies employ similar, standardized frameworks for the choice of a randomization procedure.
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Affiliation(s)
- Ralf-Dieter Hilgers
- Department of Medical Statistics, RWTH Aachen University Aachen, Pauwelsstrasse 19, Aachen, Germany
| | - Diane Uschner
- Department of Medical Statistics, RWTH Aachen University Aachen, Pauwelsstrasse 19, Aachen, Germany
| | - William F. Rosenberger
- Department of Statistics, George Mason University, 4400 University Drive, Fairfax, 22030 VA USA
| | - Nicole Heussen
- Department of Medical Statistics, RWTH Aachen University Aachen, Pauwelsstrasse 19, Aachen, Germany
- Center of Biostatistics and Epidemiology, Sigmund Freud University, Freudplatz 1, Vienna, 1020 Austria
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Gohmann RF, Heckner F, Uschner D, Katharina Kuhl C, Daniel Reinartz S. Body Pushers: Low-Dose CT, Always the Best Choice? A Study of the Diagnostic Performance of CT Scout View. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/ojrad.2017.72013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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