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Alvarez CA, Hall RG, Lin S, Perkins AR, Mortensen EM. Compliance with recommended pneumococcal vaccination schedule in patients treated for rheumatoid arthritis: A retrospective cohort study in the Veterans Affairs population. Vaccine 2024; 42:489-495. [PMID: 38177030 DOI: 10.1016/j.vaccine.2023.12.075] [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: 09/15/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Invasive pneumococcal disease (IPD) is a leading cause of death. Rheumatoid arthritis (RA) patients are at risk of IPD due to immunosuppressant medications. Up until 2022, two pneumococcal vaccines, the 13-valent Pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23), were recommended. Despite the recommendation change to give a single 20-valent PCV vaccine (PCV20), some still require multiple vaccinations. There is a need to identify barriers to vaccine uptake. METHODS We conducted a retrospective cohort study to assess the on-time vaccination rates for PCV13 and PPSV23 in treated RA patients between 2010 and 2018 using national Veterans Affairs data. Patients > 18 years of age diagnosed with RA and newly initiated on RA treatment were included. Pneumococcal vaccine compliance was assessed by measuring on-time receipt of PCV13 and PPSV23 vaccinations. We identified factors using multivariate logistic regression and described the occurrence of these factors using descriptive statistics. RESULTS A total of 39,243 patients were included in the study. Most patients were white (75.8 %), male (85.4 %), on methotrexate therapy (41.4 %). The average age was 62.3 years. The proportion of patients considered vaccine compliant is 43.9 %. The primary independent risk factors for vaccine non-compliance were black/African American race (Odds Ratio [OR] 1.26, 95 % Confidence Interval [CI] 1.19-1.34) or missing/unknown race (OR 1.45, 95 % CI 1.31-1.61), missing/unknown ethnicity (OR 1.21, 1.02-1.43), never married (OR 1.10, 95 % CI 1.02-1.19) or widowed (OR 1.23, 95 % CI 1.12-1.34), diagnosed with congestive heart failure (OR 1.10, 95 % CI 1.00-1.22), or dementia (OR 1.48, 95 % CI 1.16-1.91). The proportion of patients who were non-compliant in patients who were vaccine naïve was 32.1 % and the non-compliance rate for non-naïve patients was 65.3 %. CONCLUSIONS Providers should identify barriers to pneumococcal vaccination in RA patients to improve compliance. Efforts to increase vaccination should be tailored to specific high-risk groups.
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Affiliation(s)
- Carlos A Alvarez
- Jerry H Hodge School of Pharmacy Texas Tech University Health Sciences Center, Dallas, TX, United States; Center of Excellence in Real World Evidence, Dallas, TX, United States; VA North Texas Health Sciences Center, Dallas, TX, United States.
| | - Ronald G Hall
- Jerry H Hodge School of Pharmacy Texas Tech University Health Sciences Center, Dallas, TX, United States; Center of Excellence in Real World Evidence, Dallas, TX, United States
| | - Suzy Lin
- Jerry H Hodge School of Pharmacy Texas Tech University Health Sciences Center, Dallas, TX, United States
| | - Aaron R Perkins
- Jerry H Hodge School of Pharmacy Texas Tech University Health Sciences Center, Dallas, TX, United States; Center of Excellence in Real World Evidence, Dallas, TX, United States; VA North Texas Health Sciences Center, Dallas, TX, United States
| | - Eric M Mortensen
- VA North Texas Health Sciences Center, Dallas, TX, United States; UCONN School of Medicine, Farmington, CT, United States
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Perez MF, Yurieva M, Poddutoori S, Mortensen EM, Crotty Alexander LE, Williams A. Transcriptomic responses in the blood and sputum of cigarette smokers compared to e-cigarette vapers. Respir Res 2023; 24:134. [PMID: 37208747 PMCID: PMC10196320 DOI: 10.1186/s12931-023-02438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 04/27/2023] [Indexed: 05/21/2023] Open
Abstract
RATIONALE Electronic (e)-cigarettes are popular among youth and cigarette smokers attempting to quit. Studies to date have focused on the utility of e-cigarettes as a smoking cessation tool, but the biological effects are largely unknown. OBJECTIVES To identify transcriptomic differences in the blood and sputum of e-cigarette users compared to conventional cigarettes smokers and healthy controls and describe biological pathways affected by these tobacco products. METHODS Cross-sectional analysis of whole blood and sputum RNA-sequencing data from 8 smokers, 9 e-cigarette users (e-cigs) and 4 controls. Weighted gene co-network analysis (WGCNA) identified gene module associations. Ingenuity Pathway Analysis (IPA) identified canonical pathways associated with tobacco products. MAIN RESULTS In blood, a three-group comparison showed 16 differentially expressed genes (DEGs); pair-wise comparison showed 7 DEGs between e-cigs and controls, 35 DEGs between smokers and controls, and 13 DEGs between smokers and e-cigs. In sputum, 438 DEGs were in the three-group comparison. In pair-wise comparisons, there were 2 DEGs between e-cigs and controls, 270 DEGs between smokers and controls, and 468 DEGs between smokers and e-cigs. Only 2 genes in the smokers vs. control comparison overlapped between blood and sputum. Most gene modules identified through WGCNA associated with tobacco product exposures also were associated with cotinine and exhaled CO levels. IPA showed more canonical pathways altered by conventional cigarette smoking than by e-cigarette use. CONCLUSION Cigarette smoking and e-cigarette use led to transcriptomic changes in both blood and sputum. However, conventional cigarettes induced much stronger transcriptomic responses in both compartments.
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Affiliation(s)
- Mario F Perez
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Marina Yurieva
- The Jackson Laboratory for Genomic Medicine, Farmington, CT, USA
| | | | - Eric M Mortensen
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Laura E Crotty Alexander
- Division of Pulmonary Critical Care, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Adam Williams
- The Jackson Laboratory for Genomic Medicine, Farmington, CT, USA
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Mohammed T, Bowe M, Plant A, Perez M, Alvarez CA, Mortensen EM. Metformin Use Is Associated With Lower Mortality in Veterans With Diabetes Hospitalized With Pneumonia. Clin Infect Dis 2023; 76:1237-1244. [PMID: 36575139 PMCID: PMC10319762 DOI: 10.1093/cid/ciac900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recent studies suggest that metformin use may be associated with improved infectious disease-related outcomes, whereas other papers suggest potentially worse outcomes in serious bacterial infections. Our purpose was to examine the association of prior outpatient prescription of metformin on 30- and 90-day mortality for older veterans with pre-existing diabetes hospitalized with pneumonia. METHODS We conducted a retrospective cohort study using national Department of Veterans Affairs data of patients ≥65 years with a prior history of diabetes who were hospitalized with pneumonia over a 10-year period (fiscal years 2002-2012.) For our primary analysis, we created a propensity score and matched metformin users to nonusers 1:1. RESULTS We identified 34 759 patients who met the inclusion criteria, 20.3% of whom were prescribed metformin. Unadjusted 30-day mortality was 9.6% for those who received metformin versus 13.9% in nonusers (P < .003), and 90-day mortality was 15.8% for those who received metformin versus 23.0% for nonusers (P < .0001). For the propensity score model, we matched 6899 metformin users to 6899 nonusers. After propensity matching, both 30-day (relative risk [RR]: .86; 95% confidence interval [CI]: .78-.95) and 90-day (RR: .85; 95% CI: .79-.92) mortality was significantly lower for metformin users. CONCLUSIONS Prior receipt of metformin was associated with significantly lower mortality after adjusting for potential confounders. Additional research is needed to examine the safety and potential benefits of metformin use in patients with respiratory infections.
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Affiliation(s)
- Turab Mohammed
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Michael Bowe
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Alexandria Plant
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mario Perez
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Carlos A Alvarez
- Department of Medicine, VA North Texas Health Care System, Dallas, Texas, USA
- Department of Medicine, Texas Tech University Health Sciences Centre, Jerry H. Hodge School of Pharmacy, Dallas, Texas, USA
| | - Eric M Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
- Department of Medicine, VA North Texas Health Care System, Dallas, Texas, USA
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Atuegwu NC, Mortensen EM, Krishnan-Sarin S, Laubenbacher RC, Litt MD. Prospective predictors of electronic nicotine delivery system initiation in tobacco naive young adults: A machine learning approach. Prev Med Rep 2023; 32:102148. [PMID: 36865398 PMCID: PMC9971268 DOI: 10.1016/j.pmedr.2023.102148] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/11/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
The use of electronic nicotine delivery systems (ENDS) is increasing among young adults. However, there are few studies regarding predictors of ENDS initiation in tobacco-naive young adults. Identifying the risk and protective factors of ENDS initiation that are specific to tobacco-naive young adults will enable the creation of targeted policies and prevention programs. This study used machine learning (ML) to create predictive models, identify risk and protective factors for ENDS initiation for tobacco-naive young adults, and the relationship between these predictors and the prediction of ENDS initiation. We used nationally representative data of tobacco-naive young adults in the U.S drawn from the Population Assessment of Tobacco and Health (PATH) longitudinal cohort survey. Respondents were young adults (18-24 years) who had never used any tobacco products in Wave 4 and who completed Waves 4 and 5 interviews. ML techniques were used to create models and determine predictors at 1-year follow-up from Wave 4 data. Among the 2,746 tobacco-naive young adults at baseline, 309 initiated ENDS use at 1-year follow-up. The top five prospective predictors of ENDS initiation were susceptibility to ENDS, increased days of physical exercise specifically designed to strengthen muscles, frequency of social media use, marijuana use and susceptibility to cigarettes. This study identified previously unreported and emerging predictors of ENDS initiation that warrant further investigation and provided comprehensive information on the predictors of ENDS initiation. Furthermore, this study showed that ML is a promising technique that can aid ENDS monitoring and prevention programs.
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Affiliation(s)
- Nkiruka C. Atuegwu
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA
- Corresponding author at: University of Connecticut, Department of Medicine, 263 Farmington Avenue, Farmington, CT 06030, USA.
| | - Eric M. Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA
| | - Suchitra Krishnan-Sarin
- Department of Psychiatry, Yale University School of Medicine, Connecticut Mental Health Center, 34 Park Street, New Haven, CT 06519, USA
| | - Reinhard C. Laubenbacher
- Laboratory for Systems Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mark D. Litt
- Division of Behavioral Sciences and Community Health, University of Connecticut Health Center, Farmington, CT 06030, USA
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Uddin M, Mohammed T, Metersky M, Anzueto A, Alvarez CA, Mortensen EM. Effectiveness of Beta-Lactam plus Doxycycline for Patients Hospitalized with Community-Acquired Pneumonia. Clin Infect Dis 2021; 75:118-124. [PMID: 34751745 DOI: 10.1093/cid/ciab863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite clinical practice guideline recommendations to use doxycycline as part of combination therapy for some patients hospitalized with pneumonia, there is minimal evidence supporting this recommendation. Our aim was to examine the association between beta-lactam plus doxycycline and mortality for patients hospitalized with community-acquired pneumonia. METHODS We identified patients > 65 years of age admitted to any United States Department of Veterans Affairs hospital in fiscal years 2002-2012 with a discharge diagnosis of pneumonia. We excluded those patients who did not receive antibiotic therapy concordant with the 2019 ATS/IDSA clinical practice guidelines. Using propensity score matching, we examined the association of doxycycline with 30- and 90-day mortality. RESULTS Our overall cohort was comprised of 70,533 patients and 5,282 (7.49%) received doxycycline. Unadjusted 30-day mortality was 6.4% for those who received a beta-lactam plus doxycycline vs. 9.1% in those who did not (p<0.0001), and 90-day mortality was 13.8% for those who received a beta-lactam + doxycycline vs. 16.8% for those who did not (p<0.0001). In the propensity score matched models, both 30- (odds ratio 0.72, 95% confidence interval, 0.63-0.84) and 90-day (0.83, 0.74-0.92) mortality were significantly lower for those who received doxycycline. CONCLUSIONS In this retrospective observational cohort study, we found that doxycycline use, as part of guideline-concordant antibiotic therapy, was associated with lower 30- and 90-day mortality than regimens without doxycycline. While this supports the safety and effectiveness of antibiotic regimes that include doxycycline, additional studies, especially randomized clinical trials, are needed to confirm this.
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Affiliation(s)
- Moe Uddin
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Turab Mohammed
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mark Metersky
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Antonio Anzueto
- Department of Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA.,Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Carlos A Alvarez
- VA North Texas Health Care System, Dallas, Texas, USA.,Department of Pharmacy Practice, Texas Tech University Health Sciences Center Jerry H. Hodge School of Pharmacy, Dallas, Texas, USA
| | - Eric M Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA.,VA North Texas Health Care System, Dallas, Texas, USA
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Atuegwu NC, Litt MD, Krishnan-Sarin S, Laubenbacher RC, Perez MF, Mortensen EM. E-Cigarette Use in Young Adult Never Cigarette Smokers with Disabilities: Results from the Behavioral Risk Factor Surveillance System Survey. Int J Environ Res Public Health 2021; 18:5476. [PMID: 34065407 PMCID: PMC8160823 DOI: 10.3390/ijerph18105476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/13/2021] [Accepted: 05/16/2021] [Indexed: 12/29/2022]
Abstract
Young adult never cigarette smokers with disabilities may be at particular risk for adopting e-cigarettes, but little attention has been paid to these people. This study examines the associations between different types of disability and e-cigarette use in this population. Young adult never-smokers from the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) survey who were either never or current e-cigarette users (n = 79,177) were selected for the analysis. The Least Absolute Shrinkage and Selection Operator (LASSO) algorithm was used to select confounders for multivariable logistic regression models. Multivariable logistic regression models were used to determine the associations between current e-cigarette use and different types of disability after incorporating BRFSS survey design and adjusting for confounders. Young adult never-smokers who reported any disability had increased odds (OR 1.44, 95% CI 1.18-1.76) of e-cigarette use compared to those who reported no disability. Young adult never-smokers who reported self-care, cognitive, vision, and independent living disabilities had higher odds of e-cigarette use compared to those who reported no disability. There was no statistically significant difference in the odds of e-cigarette use for those reporting hearing and mobility disabilities compared to those who reported no disability. This study highlights the need for increased public education and cessation programs for this population.
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Affiliation(s)
- Nkiruka C. Atuegwu
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA; (M.F.P.); (E.M.M.)
| | - Mark D. Litt
- Division of Behavioral Sciences and Community Health, University of Connecticut School of Medicine, Farmington, CT 06030, USA;
| | | | - Reinhard C. Laubenbacher
- Laboratory for Systems Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - Mario F. Perez
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA; (M.F.P.); (E.M.M.)
| | - Eric M. Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA; (M.F.P.); (E.M.M.)
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Perez MF, Mead EL, Atuegwu NC, Mortensen EM, Goniewicz M, Oncken C. Biomarkers of Toxicant Exposure and Inflammation Among Women of Reproductive Age Who Use Electronic or Conventional Cigarettes. J Womens Health (Larchmt) 2021; 30:539-550. [PMID: 33534627 DOI: 10.1089/jwh.2019.8075] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Electronic cigarettes (e-cigarettes) generally have a more favorable toxicant profile than conventional cigarettes; however, limited information exists for women of reproductive age (WRA). Our aim was to compare biomarkers of toxicant exposure, inflammation, and oxidative stress among WRA who self-report exclusive e-cigarette use, exclusive cigarette smoking, or never tobacco use (controls). Methods: Multivariable linear regression models were used to compare the geometric means of urinary biomarkers of toxicant exposure and their metabolites, serum markers of inflammation [highly sensitive C-reactive protein, soluble intercellular adhesion molecule (sICAM), interleukin 6, fibrinogen], and a measurement of oxidative stress [prostaglandin F2a-8-isoprostane (F2PG2a)] among WRA from the Population Assessment of Tobacco and Health survey. Results: E-cigarette users had higher levels of lead, tobacco-specific nitrosamines, nicotine metabolites, and some volatile organic compounds (VOCs) than controls. Except for cadmium and lead, e-cigarette users had lower levels of the analyzed urinary toxicant biomarkers compared with cigarette smokers. Cigarette smokers had higher levels of all the biomarkers of toxicant exposure than controls. There were no significant differences in the levels of markers of inflammation and oxidative stress between e-cigarette users and controls. E-cigarette users and controls had lower levels of sICAM and F2PG2a than cigarette smokers. Conclusion: WRA who use e-cigarettes had lower levels of some of the evaluated urinary biomarkers of toxicant exposure and serum biomarkers of inflammation and oxidative stress than those who smoke cigarettes, but higher lead, nicotine metabolites, and some VOCs than controls, which can increase health risks.
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Affiliation(s)
- Mario F Perez
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, UConn Health, Farmington, Connecticut, USA
| | - Erin L Mead
- Department of Medicine, UConn Health, Farmington, Connecticut, USA
| | | | - Eric M Mortensen
- Department of Medicine, UConn Health, Farmington, Connecticut, USA
| | - Maciej Goniewicz
- Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Cheryl Oncken
- Department of Medicine, UConn Health, Farmington, Connecticut, USA
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Perez MF, Atuegwu NC, Mortensen EM, Oncken C. The inflammatory biomarker YKL-40 is elevated in the serum, but not the sputum, of E-cigarette users. Exp Lung Res 2021; 47:55-66. [PMID: 33200966 PMCID: PMC8168626 DOI: 10.1080/01902148.2020.1847216] [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: 03/27/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
METHODS We conducted a cross-sectional study of adults between 18 and 55 years old. Inclusion criteria were: exclusive e-cigarette use or cigarette smoking for ≥ 1 year or no history of tobacco use. Participants with a history of pulmonary illness, atopy, medications (except birth control pills), marijuana, and illegal substance use were excluded. Custom Multiplex ELISA was used to measure YKL-40 and other biomarker levels in the serum and induced sputum of the participants. Multivariable linear regression was used to compare the levels of YLK-40 in healthy participants, e-cigarette, and cigarette users after adjusting for age, sex, and BMI. RESULTS We recruited 20 healthy controls, 23 cigarette smokers, and 22 exclusive e-cigarette users. Serum YKL-40 (ng/ml) was significantly higher in e-cigarette users (Median 21.2 [IQR 12.1-24.0] ng/ml) when compared to controls (12.2 [IQR 8.7-18.1] ng/ml, p = 0.016) but comparable to cigarette smokers (21.6 [IQR 11.62-51.7] ng/ml, p = 0.31). No significant differences were found in the serum or sputum of the other biomarkers tested. CONCLUSION The inflammatory biomarker, YKL-40 is elevated in the serum but not the sputum of e-cigarette users with no reported pulmonary disease. Further research is necessary to characterize this association.
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Affiliation(s)
- Mario F Perez
- Pulmonary, Critical Care and Sleep Medicine, Deparment of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Nkiruka C Atuegwu
- Pulmonary, Critical Care and Sleep Medicine, Deparment of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Eric M Mortensen
- Pulmonary, Critical Care and Sleep Medicine, Deparment of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Cheryl Oncken
- Pulmonary, Critical Care and Sleep Medicine, Deparment of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
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Bentivegna K, Atuegwu NC, Oncken C, DiFranza JR, Mortensen EM. Electronic Cigarettes Associated With Incident and Polysubstance Use Among Youth. J Adolesc Health 2021; 68:123-129. [PMID: 32641242 DOI: 10.1016/j.jadohealth.2020.05.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 10/23/2019] [Revised: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 01/29/2023]
Abstract
PURPOSE Electronic cigarette (e-cigarette) use has increased exponentially among the youth in the United States and may increase the incidence of substance use. METHODS Youth participants (12-17 years) were surveyed through the Population Assessment of Tobacco and Health study over a three-year time period. Youth with any baseline substance use or diagnosis of an attention deficit disorder were excluded from the analysis. Multivariable logistic regressions were used to assess the association between e-cigarette use at Wave 1 and incident substance use (marijuana, painkillers, sedatives, or tranquilizers and Ritalin/Adderall) and polysubstance use at Wave 2 or 3, and marijuana use in the electronic nicotine device at Wave 3. RESULTS Baseline ever e-cigarette users who had no history of marijuana, nonprescribed drugs and illicit substance use in Wave 1 had increased odds of reporting incident use of marijuana (odds ratio 2.59, 95% confidence interval: 1.90-3.52), nonprescribed Ritalin/Adderall use (1.89, 1.09-3.28), or polysubstance use (2.09, 1.43-3.05) in Wave 2 or 3 compared to never e-cigarette users. They were also more likely to report use of marijuana in the electronic nicotine product (2.26, 1.56-3.27) in Wave 3 compared to never e-cigarette users. There was no statistically significant association between baseline e-cigarette use and incident use of painkillers, sedatives, or tranquilizers in Wave 2 or 3 (1.21, .79-1.87). CONCLUSIONS E-cigarette use is associated with incident use of marijuana, marijuana in electronic nicotine devices, Ritalin/Adderall, and polysubstance use but not painkillers, sedatives, or tranquilizers. Results indicate that e-cigarettes are associated with subsequent additional risky health behaviors in youth.
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Affiliation(s)
- Kathryn Bentivegna
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - Nkiruka C Atuegwu
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | - Cheryl Oncken
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut
| | | | - Eric M Mortensen
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut.
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Alvarez CA, Halm EA, Pugh MJV, McGuire DK, Hennessy S, Miller RT, Lingvay I, Vouri SM, Zullo AR, Yang H, Chansard M, Mortensen EM. Lactic acidosis incidence with metformin in patients with type 2 diabetes and chronic kidney disease: A retrospective nested case-control study. Endocrinol Diabetes Metab 2021; 4:e00170. [PMID: 33532612 PMCID: PMC7831229 DOI: 10.1002/edm2.170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 05/28/2020] [Accepted: 06/27/2020] [Indexed: 12/12/2022] Open
Abstract
Objective Compare rates of lactic acidosis (LA) among metformin-exposed and unexposed patients with type 2 diabetes mellitus and varying degrees of chronic kidney disease (CKD). Research Design and Methods Retrospective, nested case-control study using data from national VA Corporate Data Warehouse. All adult patients with type 2 diabetes and CKD newly dispensed any antihyperglycaemic medication during FY 2003-13 were included. The outcome was LA hospitalization or serum lactate >5 mEq/L. Exposure to metformin was evaluated in the three months prior to event. Estimates were adjusted for 31 covariates, including demographics, comorbidities and medications. Results Overall, 320 882 patients were included, contributing a total of 1 331 784 person-years of follow-up. LA occurred in 2 665 patients, generating an overall incidence rate of 2.00 (95% CI 1.93-2.08) per 1000 person-years. Metformin exposure in the prior 3 months was associated with an elevated adjusted hazard of LA (HR 1.97, 95% CI 1.69-2.29). No association was evident in patients with CKD stage 1 or 2 (HR 1.05, 95% CI 0.71-1.57), but associations were present and progressively greater in patients with CKD stage 3a through 5: HR 3.09, 95% CI 2.19-4.35 in CKD 3a, HR 3.34, 95% CI 1.95-5.72 in CKD 3b, HR 7.87, 95% CI 3.51-17.61 in CKD stage 4&5. Conclusion Metformin was not associated with an elevated risk of LA in persons with stage 1-2 CKD, but was associated with a progressively higher risk at more advanced stages of CKD.
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Affiliation(s)
- Carlos A. Alvarez
- Texas Tech University Health Sciences CenterSchool of PharmacyDallasTXUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
- Veterans Affairs North Texas Health Care SystemDallasTXUSA
| | - Ethan A. Halm
- University of Texas Southwestern Medical CenterDallasTXUSA
| | | | | | - Sean Hennessy
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Richard T. Miller
- University of Texas Southwestern Medical CenterDallasTXUSA
- Veterans Affairs North Texas Health Care SystemDallasTXUSA
| | - Ildiko Lingvay
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - Scott M. Vouri
- University of Florida College of PharmacyGainesvilleFLUSA
| | - Andrew R. Zullo
- Brown University School of Public Health and Providence Veterans Affairs Medical CenterProvidenceRIUSA
| | - Hui Yang
- Texas Tech University Health Sciences CenterSchool of PharmacyDallasTXUSA
| | - Matt Chansard
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - Eric M. Mortensen
- University of Texas Southwestern Medical CenterDallasTXUSA
- Veterans Affairs North Texas Health Care SystemDallasTXUSA
- University of Connecticut School of MedicineFarmingtonCTUSA
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Atuegwu NC, Oncken C, Laubenbacher RC, Perez MF, Mortensen EM. Factors Associated with E-Cigarette Use in U.S. Young Adult Never Smokers of Conventional Cigarettes: A Machine Learning Approach. Int J Environ Res Public Health 2020; 17:ijerph17197271. [PMID: 33027932 PMCID: PMC7579019 DOI: 10.3390/ijerph17197271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 02/08/2023]
Abstract
E-cigarette use is increasing among young adult never smokers of conventional cigarettes, but the awareness of the factors associated with e-cigarette use in this population is limited. The goal of this work was to use machine learning (ML) algorithms to determine the factors associated with current e-cigarette use among US young adult never cigarette smokers. Young adult (18-34 years) never cigarette smokers from the 2016 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) who reported current or never e-cigarette use were used for the analysis (n = 79,539). Variables associated with current e-cigarette use were selected by two ML algorithms (Boruta and Least absolute shrinkage and selection operator (LASSO)). Odds ratios were calculated to determine the association between e-cigarette use and the variables selected by the ML algorithms, after adjusting for age, gender and race/ethnicity and incorporating the BRFSS complex design. The prevalence of e-cigarette use varied across states. Factors previously reported in the literature, such as age, race/ethnicity, alcohol use, depression, as well as novel factors associated with e-cigarette use, such as disabilities, obesity, history of diabetes and history of arthritis were identified. These results can be used to generate further hypotheses for research, increase public awareness and help provide targeted e-cigarette education.
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Affiliation(s)
- Nkiruka C. Atuegwu
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA; (C.O.); (M.F.P.); (E.M.M.)
- Correspondence: ; Tel.: +1-860-0679-2372; Fax: +1-860-0679-8087
| | - Cheryl Oncken
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA; (C.O.); (M.F.P.); (E.M.M.)
| | | | - Mario F. Perez
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA; (C.O.); (M.F.P.); (E.M.M.)
| | - Eric M. Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA; (C.O.); (M.F.P.); (E.M.M.)
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12
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Nayfe R, Chansard M, Hynan LS, Mortensen EM, Annaswamy T, Fraenkel L, Makris UE. Comparison of patient-reported outcomes measurement information system and legacy instruments in multiple domains among older veterans with chronic back pain. BMC Musculoskelet Disord 2020; 21:598. [PMID: 32900386 PMCID: PMC7487821 DOI: 10.1186/s12891-020-03587-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 08/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic low back pain (cLBP) results in significant physical, psycho-social and socioeconomic burden. Identifying efficient and reliable patient reported outcome measures is critical for research and clinical purposes. The NIH's Patient Reported Outcomes Measurement Information System (PROMIS) instruments have not been compared to validated "legacy" instruments in older adults with cLBP. This study evaluates construct (convergent and discriminant) validity and time to complete (TTC) PROMIS as compared to legacy instruments. METHODS We enrolled older Veterans (age 60+) with cLBP with/without leg pain scheduled for lumbar epidural steroid injections. Subjects completed PROMIS computer adaptive test item banks and corresponding legacy instruments in the following domains: pain intensity, interference, and behavior; functional status; depression and anxiety; fatigue; sleep and social functioning. Convergent and discriminant validity between PROMIS and legacy instruments was evaluated using Spearman rank order correlations; Mann-Whitney U tests compared TTC. RESULTS Of the 71 Veterans recruited, the median (IQR) age was 67 (63-71) years old, 94% were men, 76% were White, 17% Black, and 96% were Non-Hispanic. Spearman correlations between PROMIS and legacy instruments showed moderate to very strong convergent validity in all domains (r = 0.4-1.0), except for social functioning and pain behavior (PROMIS Pain Behavior with Fear Avoidance Belief Questionnaire). The total median TTC for all PROMIS items was significantly shorter than legacy items, 8 min 50 s vs 29 min 14 s respectively, p < 0.001. CONCLUSIONS Given time efficiency of using PROMIS, along with strong construct validity, PROMIS instruments are a practical choice for measuring multidimensional PROs in older Veterans with cLBP for both research and clinical purposes.
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Affiliation(s)
- Rabih Nayfe
- Department of Internal Medicine, UT Southwestern (UTSW) Medical Center, Dallas, TX, USA
| | | | - Linda S Hynan
- Department of Population and Data Sciences, UTSW, Dallas, TX, USA
- Department of Psychiatry, UTSW, Dallas, TX, USA
| | - Eric M Mortensen
- Department of Population and Data Sciences, UTSW, Dallas, TX, USA
- Department of Medicine, University of Connecticut, Farmington, CT, USA
- Department of Medicine, VA North Texas Health Care System, Dallas, TX, USA
| | - Thiru Annaswamy
- Department of Physical Medicine & Rehabilitation, VA North Texas Health Care System, Dallas, TX, USA
| | - Liana Fraenkel
- Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Una E Makris
- Department of Internal Medicine, UT Southwestern (UTSW) Medical Center, Dallas, TX, USA.
- Department of Population and Data Sciences, UTSW, Dallas, TX, USA.
- Department of Medicine, VA North Texas Health Care System, Dallas, TX, USA.
- Department of Internal Medicine, Division of Rheumatic Diseases, VA North Texas Health Care System, 4500 S Lancaster Rd., Dallas, TX, 75216, USA.
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Mansi IA, English JL, Alvarez CA, Mortensen EM, Pugh M. Statins in survivors of traumatic brain injury: a propensity score-matched analysis. Brain Inj 2020; 34:1367-1374. [DOI: 10.1080/02699052.2020.1802663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Ishak A. Mansi
- Medical Service, VA North Texas Health System, Dallas, Texas, USA
- Departments of Internal Medicine and Population and Data Sciences, University of Texas Southwestern, Dallas, Texas, USA
| | | | - Carlos A. Alvarez
- Medical Service, VA North Texas Health System, Dallas, Texas, USA
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Dallas, Texas, USA
| | - Eric M. Mortensen
- Medical Service, VA North Texas Health System, Dallas, Texas, USA
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - M.J Pugh
- Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake city, Utah, USA
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14
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Katz M, Silverstein N, Coll P, Sullivan G, Mortensen EM, Sachs A, Gross JB, Girard E, Liang J, Ristau BT, Stevenson C, Smith PP, Shames BD, Millea R, Ali I, Poulos CM, Ramaraj AB, Otukoya AO, McFadden DW. Erratum to ``Surgical care of the geriatric patient'' [YMSG 56(7) (2019) 260-329]. Curr Probl Surg 2019; 56:100647. [PMID: 31837715 DOI: 10.1016/j.cpsurg.2019.100647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Marilyn Katz
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT
| | | | - Patrick Coll
- University of Connecticut School of Medicine, Farmington, CT
| | - Gail Sullivan
- University of Connecticut School of Medicine, Farmington, CT
| | | | - Adam Sachs
- Department of Anesthesiology, University of Connecticut School of Medicine, Farmington, CT
| | - Jeffrey B Gross
- Department of Anesthesiology, University of Connecticut School of Medicine, Farmington, CT
| | - Eric Girard
- Department of Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Joy Liang
- Department of Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Benjamin T Ristau
- Department of Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Christina Stevenson
- Neag Cancer Center, Department of Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Phillip P Smith
- Department of Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Brian D Shames
- Department of Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Ryan Millea
- Department of Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Irfan Ali
- University of Connecticut School of Medicine, Farmington, CT
| | | | - Akila B Ramaraj
- University of Connecticut School of Medicine, Farmington, CT
| | - Azuka Onye Otukoya
- Department of Anesthesiology, University of Connecticut School of Medicine, Farmington, CT
| | - David W McFadden
- Department of Surgery, University of Connecticut School of Medicine, Farmington, CT; Department of Neuroscience, University of Connecticut School of Medicine, Farmington, CT; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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15
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Atuegwu NC, Perez MF, Oncken C, Mead EL, Maheshwari N, Mortensen EM. E-cigarette use is associated with a self-reported diagnosis of prediabetes in never cigarette smokers: Results from the behavioral risk factor surveillance system survey. Drug Alcohol Depend 2019; 205:107692. [PMID: 31707269 PMCID: PMC6893144 DOI: 10.1016/j.drugalcdep.2019.107692] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of e-cigarettes is increasing in the US but there is still a paucity of research on the metabolic effects of e-cigarette use. The goal of this work was to determine the association between e-cigarette use and self-reported prediabetes in adult never cigarette smokers. METHOD The 2017 cross sectional Behavioral Risk Factor Surveillance System (BRFSS) survey data was used for the analysis. Current e-cigarette users reported daily or someday use of e-cigarettes and former e-cigarette users reported no current use of e-cigarettes. Participants who reported a history of diabetes, gestational prediabetes/ diabetes were excluded. Odds ratios were calculated to determine the association between e-cigarette use and self-reported prediabetes in never cigarette smokers after adjusting for potential confounders. RESULTS There were a total of 154,404 participants that met the inclusion criteria. Of those participants, there were 143,952 never, 1339 current and 7625 former e-cigarette users. Current e-cigarette users had an increased odds of reporting a diagnosis of prediabetes 1.97 (95% CI 1.25-3.10) compared to never e-cigarette users. After stratifying by gender, men and women had an increased odds ratio of reporting a diagnosis of prediabetes 2.36 (95% CI 1.26-4.40) and 1.88 (95% CI 1.00-3.53) respectively when compared to never e-cigarette users. There was no association between former e-cigarette use and a self-reported diagnosis of prediabetes. CONCLUSION Our findings show that e-cigarette use may be associated with self-reported prediabetes. Further evaluation is needed in prospective studies.
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Affiliation(s)
- Nkiruka C Atuegwu
- Department of Medicine, University of Connecticut, Farmington, CT 06030, USA.
| | - Mario F Perez
- Department of Medicine, University of Connecticut, Farmington, CT 06030, USA.
| | - Cheryl Oncken
- Department of Medicine, University of Connecticut, Farmington, CT 06030, USA.
| | - Erin L Mead
- Department of Medicine, University of Connecticut, Farmington, CT 06030, USA.
| | - Narinder Maheshwari
- Department of Medicine, University of Connecticut, Farmington, CT 06030, USA.
| | - Eric M Mortensen
- Department of Medicine, University of Connecticut, Farmington, CT 06030, USA.
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16
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Boivin Z, Perez MF, Atuegwu NC, Metersky M, Alvarez CA, Anzueto A, Mortensen EM. Association of atypical antipsychotics and mortality for patients hospitalised with pneumonia. ERJ Open Res 2019; 5:00223-2018. [PMID: 31720299 PMCID: PMC6826252 DOI: 10.1183/23120541.00223-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/11/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction Atypical antipsychotics are commonly used in patients with psychiatric conditions and dementia. They are also frequently used in patients being admitted with pneumonia; however, there are few safety data. The purpose of this study was to examine whether atypical antipsychotic use prior to admission is associated with increased mortality in patients with pneumonia. Methods We conducted a retrospective cohort study of hospitalised patients with pneumonia over a 10-year period. We included patients 65 years or older and hospitalised with pneumonia. For our primary analysis, we used propensity score matching to balance confounders between atypical antipsychotic users and nonusers. Results There were 102 897 patients and 5977 were taking atypical antipsychotics. After matching there were 5513 users and 5513 nonusers. Atypical antipsychotic use was associated with increased odds of 30-day (OR 1.20, 95% CI 1.11–1.31) and 90-day mortality (1.19, 1.09–1.30). Conclusion In patients 65 years or older that are hospitalised with pneumonia, we found an association between atypical antipsychotic use and increased odds of mortality. This was particularly pronounced for patients with pre-existing psychiatric or cardiac conditions. We suggest closely monitoring patients who use these medications and minimising their use in older adult patients. When hospitalised with pneumonia, older patients who use atypical antipsychotics should be monitored closely and their use of these drugs should be minimised as much as possiblehttp://bit.ly/2JEevHV
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Affiliation(s)
- Zachary Boivin
- University of Connecticut Medical Center, Farmington, CT, USA
| | - Mario F Perez
- University of Connecticut Medical Center, Farmington, CT, USA
| | | | - Mark Metersky
- University of Connecticut Medical Center, Farmington, CT, USA
| | - Carlos A Alvarez
- VA North Texas Health Care System, Dallas, TX, USA.,Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, TX, USA.,University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Eric M Mortensen
- University of Connecticut Medical Center, Farmington, CT, USA.,VA North Texas Health Care System, Dallas, TX, USA
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17
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Obodozie-Ofoegbu OO, Teng C, Mortensen EM, Frei CR. Antipseudomonal monotherapy or combination therapy for older adults with community-onset pneumonia and multidrug-resistant risk factors: a retrospective cohort study. Am J Infect Control 2019; 47:1053-1058. [PMID: 30904374 PMCID: PMC6710104 DOI: 10.1016/j.ajic.2019.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Infectious Diseases Society of America guidelines recommend empiric antipseudomonal combination therapy when Pseudomonas is suspected. However, combination antipseudomonal therapy is controversial. This study compares all-cause 30-day mortality in older patients who received antipseudomonal monotherapy (PMT) or antipseudomonal combination therapy (PCT) for the treatment of community-onset pneumonia. METHODS This population-based, retrospective cohort study used data from over 150 Veterans Health Administration hospitals. Patients were classified as being at low, medium, or high risk of drug-resistant pathogens. In total, 31,027 patients were assigned to PCT or PMT treatment arms based on antibiotics received in the first 48 hours of hospital admission. RESULTS The unadjusted 30-day mortality difference between PCT and PMT was most pronounced in the low-risk group (18% vs 8%), followed by the medium-risk group (24% vs 18%) and then the high-risk group (39% vs 33%). PCT was associated with higher 30-day mortality than PMT overall (adjusted odds ratio [aOR], 1.54; 95% confidence interval [CI], 1.43-1.66) in all 3 risk groups: low (aOR, 1.69; 95% CI, 1.50-1.89), medium (aOR, 1.30; 95% CI, 1.14-1.48), and high (aOR, 1.21; 95% CI, 1.04-1.40). CONCLUSIONS Older adults who received combination antipseudomonal therapy for community-onset pneumonia fared worse than those who received monotherapy. Empiric combination antipseudomonal therapy should not be routinely offered to all patients suspected of having pseudomonal pneumonia.
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Affiliation(s)
- Obiageri O Obodozie-Ofoegbu
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX
| | - Chengwen Teng
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX
| | - Eric M Mortensen
- Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX.
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18
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Katz M, Silverstein N, Coll P, Sullivan G, Mortensen EM, Sachs A, Gross JB, Girard E, Liang J, Ristau BT, Stevenson C, Smith PP, Shames BD, Millea R, Ali I, Poulos CM, Ramaraj AB, Otukoya AO, Nolan J, Wahla Z, Hardy C, Al-Naggar I, Bliss LA, McFadden DW. In brief. Curr Probl Surg 2019. [DOI: 10.1067/j.cpsurg.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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19
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Katz M, Silverstein N, Coll P, Sullivan G, Mortensen EM, Sachs A, Gross JB, Girard E, Liang J, Ristau BT, Stevenson C, Smith PP, Shames BD, Millea R, Ali I, Poulos CM, Ramaraj AB, Otukoya AO, Nolan J, Wahla Z, Hardy C, Al-Naggar I, Bliss LA, McFadden DW. Surgical care of the geriatric patient. Curr Probl Surg 2019; 56:260-329. [DOI: 10.1067/j.cpsurg.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 03/13/2019] [Indexed: 12/15/2022]
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20
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Boivin Z, Perez MF, Atuegwu NC, Anzueto A, Mortensen EM. Impact of Cirrhosis on Pneumonia-Related Outcomes in Hospitalized Older Veterans. Am J Med Sci 2019; 357:296-301. [PMID: 30904044 DOI: 10.1016/j.amjms.2019.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 08/10/2018] [Revised: 12/09/2018] [Accepted: 01/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prior research has demonstrated high mortality rates in patients with cirrhosis who contract bacterial infections. The purpose of our study was to explore clinical outcomes such as 90-day mortality, rehospitalization, and intensive care unit (ICU) admission in older veterans with pneumonia and cirrhosis. METHODS We conducted a retrospective cohort study of hospitalized patients with community-acquired pneumonia at any Departments of Veterans Affairs (VA) hospital over a 10-year period. We included patients 65 years or older who consistently received VA care and who were diagnosed with community-acquired pneumonia. There were 103,997 patients who met the inclusion criteria, and 1,246 patients with cirrhosis. We used multilevel regression models to examine the association between cirrhosis and the outcomes of interest after controlling for potential confounders. RESULTS Cirrhosis was associated with significantly increased odds of 90-day mortality (odds ratio 1.79, 95% confidence interval, 1.57-2.04). There were also significantly increased odds of rehospitalization within 90-days (1.30, 1.16-1.47). No significant association was found with ICU admission (1.00, 0.83-1.19). CONCLUSIONS We found an association between cirrhosis and 90-day mortality and rehospitalization in older patients with pneumonia. We suggest that physicians should carefully monitor patients with cirrhosis who develop pneumonia.
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Affiliation(s)
- Zachary Boivin
- UConn Health, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Mario F Perez
- UConn Health, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Nkiruka C Atuegwu
- UConn Health, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Antonio Anzueto
- University of Texas Health Science Center at San Antonio, San Antonio, Texas; South Texas Veterans Health Care System, San Antonio, Texas
| | - Eric M Mortensen
- UConn Health, University of Connecticut School of Medicine, Farmington, Connecticut; VA North Texas Health Care System, Dallas, Texas.
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21
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Obodozie-Ofoegbu O, Teng C, Mortensen EM, Frei CR. 1881. Empiric Pseudomonal Monotherapy vs. Combination Therapy for Community-Onset Pneumonia in Older Adults. Open Forum Infect Dis 2018. [PMCID: PMC6253437 DOI: 10.1093/ofid/ofy210.1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Patients with pseudomonal pneumonia have a poor prognosis; therefore, IDSA guidelines recommend empiric antipseudomonal combination therapy when Pseudomonas is suspected, at least until treatment can be adjusted based on susceptibilities. However, combination antipseudomonal therapy is controversial. This study compared all-cause 30-day mortality in older patients who received antipseudomonal monotherapy (PMT) or antipseudomonal combination therapy (PCT) for the treatment of community-onset pneumonia. Methods This population-based cohort study used data from over 150 Veteran Health Administration hospitals. Patients were classified as low, medium, or high risk of drug-resistant pathogens according to a published rule. Patients were assigned to PCT or PMT groups based on antibiotics received in the first 48 hours of hospital admission. Separate multivariable logistic regression models were constructed to determine whether the choice of PCT or PMT was associated with 30-day mortality, after accounting for divergent baseline characteristics. Adjusted odds ratios (aORs) and 95% confidence intervals (95% CI) were calculated for the overall, low, medium, and high-risk groups. Results Of the 31,027 patients who met study criteria, 23% received PCT and 77% received PMT. Patients belonged to low (59%), medium (24%), and high (18%) risk groups. 30-day mortality was 18% overall, and increased among the groups: low (13%), medium (21%), and high (36%). Patient age (median of 78 years), race (>80% white), and sex (>98% male) were similar for patients receiving PCT and PMT. The unadjusted mortality difference between PCT and PMT was most pronounced in the low-risk group (18% vs. 8%, 10% absolute risk difference), followed by the medium (24% vs. 18%, 6% difference) and high (39% vs. 33%, 6% difference) risk groups. PCT was associated with higher 30-day mortality than PMT overall (aOR, 1.54; 95% CI, 1.43–1.66), and in all three groups: low (aOR, 1.69; 95% CI, 1.50–1.89), medium (aOR, 1.30; 95% CI, 1.14–1.48), and high (aOR, 1.21; 95% CI, 1.04–1.40). Conclusion Older adults who received empiric combination antipseudomonal therapy for community-onset pneumonia fared worse than those who received monotherapy. Empiric combination antipseudomonal therapy should not be routinely offered to all patients suspected of having pseudomonal pneumonia. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Obiageri Obodozie-Ofoegbu
- The University of Texas at Austin College of Pharmacy and University of Texas Health Science Center Long School of Medicine, San Antonio, Texas
| | - Chengwen Teng
- The University of Texas at Austin College of Pharmacy and University of Texas Health Science Center Long School of Medicine, San Antonio, Texas
| | - Eric M Mortensen
- University of Connecticut Medical Center, Farmington, Connecticut
| | - Christopher R Frei
- The University of Texas at Austin College of Pharmacy and University of Texas Health Science Center Long School of Medicine, San Antonio, Texas
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22
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Hall RG, Yoo E, Faust A, Smith T, Goodman E, Mortensen EM, Raza J, Dehmami F, Alvarez CA. Impact of piperacillin/tazobactam on nephrotoxicity in patients with Gram-negative bacteraemia. Int J Antimicrob Agents 2018; 53:343-346. [PMID: 30415001 DOI: 10.1016/j.ijantimicag.2018.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/30/2018] [Accepted: 11/04/2018] [Indexed: 01/23/2023]
Abstract
Piperacillin/tazobactam (TZP) has been associated with nephrotoxicity in patients receiving vancomycin. Its impact on nephrotoxicity in patients with Gram-negative bacteraemia (GNB) is unclear. This study evaluated the impact of TZP on nephrotoxicity in patients with GNB. This retrospective cohort included patients aged ≥18 years receiving ≥48 h of therapy for bacteraemia due to Escherichia coli, Pseudomonas aeruginosa, Enterobacter, Klebsiella, Acinetobacter or Stenotrophomonas maltophilia from 1/01/2008-8/31/2011. Patients with baseline serum creatinine (SCr) ≥3.5 mg/dL, polymicrobial infection or recurrent bacteraemia were excluded. Nephrotoxicity was defined as a ≥0.5 mg/dL increase in SCr or ≥50% increase from baseline for ≥2 consecutive days. Any variable demonstrating a 10% change in exposure effect was retained in the final model. All variables biologically reasonable causes of nephrotoxicity were also considered for inclusion. The median age of the cohort (n = 292) was 76 years; 38.0% had a cancer diagnosis and ICU residence was common (21.9%). There was no difference in nephrotoxicity incidence based on days of TZP received (0 days, 13.6%; 1-2 days, 14.7%; 3-4 days, 6.9%; ≥5 days, 16.7%; P = 0.71). In multivariable analysis, baseline SCr, total body weight and vasopressor use were independently associated with nephrotoxicity. Duration of TZP was not associated with nephrotoxicity in multivariable analysis (1-2 days, OR = 0.91, 95% CI 0.39-2.12; 3-4 days, OR = 0.48, 95% CI 0.10-2.46; ≥5 days, OR = 0.57, 95% CI 0.11-3.02). In this cohort of GNB patients, duration of TZP was not associated with nephrotoxicity.
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Affiliation(s)
- Ronald G Hall
- Texas Tech University Health Sciences Center, Department of Pharmacy Practice, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA; VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA; Dose Optimization and Outcomes Research (DOOR) Program, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA.
| | - Eunice Yoo
- Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - Andrew Faust
- Texas Health Presbyterian Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231, USA
| | - Terri Smith
- Texas Health Presbyterian Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231, USA
| | - Edward Goodman
- Texas Health Presbyterian Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231, USA
| | - Eric M Mortensen
- VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA; Division of General Internal Medicine, University of Connecticut, 263 Farmington Avenue, Farmington, CT, USA
| | - Jaffar Raza
- Texas Tech University Health Sciences Center, Department of Pharmacy Practice, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA
| | - Farbod Dehmami
- Texas Tech University Health Sciences Center, Department of Pharmacy Practice, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA
| | - Carlos A Alvarez
- Texas Tech University Health Sciences Center, Department of Pharmacy Practice, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA; VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
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Abstract
INTRODUCTION Musculoskeletal conditions, including osteoarthritis (OA), result in tremendous disability and cost. Statins are among the most commonly prescribed medications and their use for primary prevention in many otherwise healthy individuals, including those who are physically active, is increasing. There is conflicting evidence regarding the relationship of statin use and musculoskeletal conditions. Given the rising disability associated with musculoskeletal conditions, understanding predisposing factors, including medication-related exposures, deserves further attention. OBJECTIVES We examined the association between statin use and the risk of being diagnosed with non-traumatic arthropathies, use-related injury, and undergoing rehabilitation in a cohort with longitudinal follow-up. METHODS Patients enrolled in a regional military healthcare system between 2003 and 2012 were evaluated in this retrospective cohort study. A propensity score was generated to match statin-users and nonusers using 115 baseline characteristics. Outcomes included ICD-9 diagnoses codes for Agency for Healthcare Research and Quality disease categories of: non-traumatic arthropathies, use-related injury and undergoing rehabilitation. Primary analysis examined the outcomes in statin-users and nonusers after propensity score matching using conditional logistic regression analysis. RESULTS Initially, 60,455 patients were identified. We propensity score-matched 6728 statin users with 6728 nonusers (52 years of age, ~ 47% women). In the propensity score-matched cohort, non-traumatic arthropathies occurred in 59.8% of statin users and 56.0% of nonusers [odds ratio (OR) 1.17, 95% confidence interval (95% CI) 1.09-1.25] and use related injury occurred in 31.9% of statin users and 29.8% of nonusers (OR 1.11, 95% CI 1.03-1.19). There was no difference between statin users and nonusers undergoing rehabilitation (22.6% among statin users, 21.9% among nonusers, OR 1.04, 95% CI 0.96-1.13). CONCLUSION Statin use was associated with a significant increased risk of non-traumatic arthropathies and use-related injury. Our results provide additional data that can inform patient and clinician conversations about the benefits and risks of statin use.
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Affiliation(s)
- Una E Makris
- Medical Service, VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX, USA
- Division of Outcomes and Health Services Research, Departments of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Carlos A Alvarez
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Eric M Mortensen
- Division of Outcomes and Health Services Research, Departments of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
- University of Connecticut Medical Center, Farmington, CT, USA
| | - Ishak A Mansi
- Medical Service, VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX, USA.
- Division of Outcomes and Health Services Research, Departments of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
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Beg MS, Gupta A, Sher D, Ali S, Khan S, Gao A, Stewart T, Ahn C, Berry J, Mortensen EM. Impact of Concurrent Medication Use on Pancreatic Cancer Survival-SEER-Medicare Analysis. Am J Clin Oncol 2018; 41:766-771. [PMID: 28079594 PMCID: PMC5503814 DOI: 10.1097/coc.0000000000000359] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Preclinical studies have suggested that non-antineoplastic medication use may impact pancreatic cancer biology. We examined the association of several medication classes on pancreatic cancer survival in a large medical claims database. MATERIALS AND METHODS Histologically confirmed pancreatic adenocarcinoma diagnosed between 2006 and 2009 were analyzed from the Surveillance, Epidemiology, and End Results-Medicare database with available part D data. Drug use was defined as having 2 prescriptions filled within 12 months of pancreatic cancer diagnosis. The following medication classes/combinations were analyzed: β-blocker, statin, insulin, metformin, thiazolidinedione, warfarin, heparin, β-blocker/statin, metformin/statin, and β-blocker/metformin. Multivariable Cox proportional hazard models adjusting for age, sex, race, stage at diagnosis, site of cancer, and Charlson comorbidity index were constructed to test the association between medication classes and overall survival. RESULTS A total of 13,702 patients were included in the study; median age 76 years, 42.5% males, 77.1% white. The most common anatomic site and stage at diagnosis were head of the pancreas (49.9%) and stage 4 (49.6%), respectively. Ninety-four percent of patients died in the follow-up period (median overall survival 5.3 mo). Multivariable Cox regression analysis showed that use of β-blockers, heparin, insulin, and warfarin were significantly associated with improved survival (P<0.05 for each one), whereas metformin, thiazolidinedione, statin, and combination therapies were not. CONCLUSIONS In this study, use of β-blockers, heparin, insulin, and warfarin were associated with improved survival in patients with pancreatic cancer. Additional studies are needed to validate these findings in the clinical setting.
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Affiliation(s)
- Muhammad Shaalan Beg
- Division of Hematology/Oncology, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390-8852
- Harold C. Simmons Cancer Center, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - Arjun Gupta
- Department of Internal Medicine, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - David Sher
- Harold C. Simmons Cancer Center, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
- Department of Radiation Oncology, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - Sadia Ali
- Division of Endocrinology and Metabolism, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - Saad Khan
- Division of Hematology/Oncology, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390-8852
- Harold C. Simmons Cancer Center, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - Ang Gao
- Department of Clinical Sciences, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - Tyler Stewart
- Department of Internal Medicine, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - Chul Ahn
- Harold C. Simmons Cancer Center, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
- Department of Clinical Sciences, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - Jarett Berry
- Division of Cardiology, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
| | - Eric M. Mortensen
- Department of Internal Medicine, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
- Department of Clinical Sciences, University of Texas- Southwestern Medical Center. 5323 Harry Hines Blvd Dallas, TX 75390
- VA North Texas Health Care System, 4500 South Lancaster, Dallas, TX 75216
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25
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Hall RG, Yoo E, Faust A, Smith T, Goodman E, Mortensen EM, Felder V, Alvarez CA. Impact of total body weight on acute kidney injury in patients with gram-negative bacteremia. Expert Rev Clin Pharmacol 2018; 11:651-654. [PMID: 29718754 DOI: 10.1080/17512433.2018.1471984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The impact of total body weight (TBW) on the development of acute kidney injury (AKI) associated with gram-negative bacteremia has not been previously evaluated. METHODS The cohort included 323 patients >/ = 18 years old with gram-negative bacteremia (1/1/2008-8/31/2011) who received >/ = 48 hours of antibiotics. We compared the incidence of AKI in patients with a TBW </ = 80kg vs. >80kg with a multivariable stepwise logistic regression adjusting for age >/ = 70 years, baseline serum creatinine of > 2.0 mg/dl, and receipt of a vasopressor. AKI was defined as an increase of 0.5 mg/dL or a > 50% increase from baseline for at least two consecutive days. RESULTS The cohort was 62% TBW </ = 80kg and 38% TBW >80kg. TBW >80kg patients had higher risk of AKI (24% vs. 9%, p < 0.001), which was significant in the multivariable analysis (OR 3.41, 95% CI 1.73-6.73). A baseline serum creatinine of > 2.0 mg/dl and vasopressor use were also independently associated with AKI. CONCLUSIONS TBW >80kg was associated with the development of AKI. However, the mechanism for this association is not clear.
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Affiliation(s)
- Ronald G Hall
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas , TX , USA.,b Department of Medical Service for RGH, EMM; Department of Pharmacy Service for CAA , VA North Texas Health Care System , Dallas , TX , USA.,c Department of Surgery for RGH; Department of General Internal Medicine for EMM, CAA , University of Texas Southwestern Medical Center , Dallas , TX , USA.,d Dose Optimization and Outcomes Research (DOOR) program , Dallas , TX , USA
| | - Eunice Yoo
- e Department of Pharmacy , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Andrew Faust
- f Department of Pharmacy for AF, TS; Department of Internal Medicine for ELG , Texas Health Presbyterian , Dallas , TX , USA
| | - Terri Smith
- f Department of Pharmacy for AF, TS; Department of Internal Medicine for ELG , Texas Health Presbyterian , Dallas , TX , USA
| | - Edward Goodman
- f Department of Pharmacy for AF, TS; Department of Internal Medicine for ELG , Texas Health Presbyterian , Dallas , TX , USA
| | - Eric M Mortensen
- b Department of Medical Service for RGH, EMM; Department of Pharmacy Service for CAA , VA North Texas Health Care System , Dallas , TX , USA.,c Department of Surgery for RGH; Department of General Internal Medicine for EMM, CAA , University of Texas Southwestern Medical Center , Dallas , TX , USA.,g Division of General Internal Medicine , University of Connecticut , Farmington , CT , USA
| | - Victoria Felder
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Carlos A Alvarez
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas , TX , USA.,b Department of Medical Service for RGH, EMM; Department of Pharmacy Service for CAA , VA North Texas Health Care System , Dallas , TX , USA.,c Department of Surgery for RGH; Department of General Internal Medicine for EMM, CAA , University of Texas Southwestern Medical Center , Dallas , TX , USA
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26
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Reveles KR, Pugh MJV, Lawson KA, Mortensen EM, Koeller JM, Argamany JR, Frei CR. Shift to community-onset Clostridium difficile infection in the national Veterans Health Administration, 2003-2014. Am J Infect Control 2018; 46:431-435. [PMID: 29126751 DOI: 10.1016/j.ajic.2017.09.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 08/17/2017] [Revised: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) occurs frequently in inpatient settings; however, community-onset cases have been reported more frequently in recent years. This study evaluated hospital-onset and community-onset CDI in the national Veterans Health Administration (VHA) population over a 12-year period. METHODS This was a retrospective cohort study of all adult VHA beneficiaries with CDI between October 1, 2002, and September 30, 2014. Data were obtained from the Veterans Affairs Informatics and Computing Infrastructure. CDI was categorized into community-associated CDI (CA-CDI); community-onset, health care facility-associated CDI; and health care facility-onset CDI (HCFO-CDI). Each type was described longitudinally and was assessed as an independent risk factor for health outcomes using multivariable logistic regression. RESULTS Overall, 30,326 patients with a first CDI episode were included. HCFO-CDI was the predominant type (60.2%), followed by CO-HCFA-CDI (20.6%) and CA-CDI (19.2%). The proportion of patients with HCFO-CDI decreased from 73.5% during fiscal year 2003 to 53.2% during fiscal year 2014, whereas CA-CDI increased from 8.3% to 26.7%. HCFO-CDI was a positive predictor of severe CDI (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.59-1.84) and 30-day mortality (OR, 1.46; 95% CI, 1.32-1.61), but a negative predictor of 60-day recurrence (OR, 0.41; 95% CI, 0.37-0.46). CONCLUSIONS HCFO-CDI was the predominant CDI type. The proportion of patients with CA-CDI increased and HCFO-CDI decreased in recent years. Patients with HCFO-CDI experienced higher rates of severe CDI and mortality.
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Affiliation(s)
- Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX.
| | - Mary Jo V Pugh
- South Texas Veterans Health Care System, San Antonio, TX; Department of Epidemiology and Biostatistics, UT Health San Antonio, San Antonio, TX
| | - Kenneth A Lawson
- College of Pharmacy, The University of Texas at Austin, Austin, TX
| | - Eric M Mortensen
- Department of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX; Department of General Internal Medicine, VA North Texas Health Care System, Dallas, TX
| | - Jim M Koeller
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, TX
| | - Jacqueline R Argamany
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, TX
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX
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Reveles KR, Mortensen EM, Koeller JM, Lawson KA, Pugh MJV, Rumbellow SA, Argamany JR, Frei CR. Derivation and Validation of a Clostridium difficile Infection Recurrence Prediction Rule in a National Cohort of Veterans. Pharmacotherapy 2018; 38:349-356. [PMID: 29393522 DOI: 10.1002/phar.2088] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE Prior studies have identified risk factors for recurrent Clostridium difficile infection (CDI), but few studies have integrated these factors into a clinical prediction rule that can aid clinical decision-making. The objectives of this study were to derive and validate a CDI recurrence prediction rule to identify patients at risk for first recurrence in a national cohort of veterans. DESIGN Retrospective cohort study. DATA SOURCE Veterans Affairs Informatics and Computing Infrastructure. PATIENTS A total of 22,615 adult Veterans Health Administration beneficiaries with first-episode CDI between October 1, 2002, and September 30, 2014; of these patients, 7538 were assigned to the derivation cohort and 15,077 to the validation cohort. MEASUREMENTS AND MAIN RESULTS A 60-day CDI recurrence prediction rule was created in a derivation cohort using backward logistic regression. Those variables significant at p<0.01 were assigned an integer score proportional to the regression coefficient. The model was then validated in the derivation cohort and a separate validation cohort. Patients were then split into three risk categories, and rates of recurrence were described for each category. The CDI recurrence prediction rule included the following predictor variables with their respective point values: prior third- and fourth-generation cephalosporins (1 point), prior proton pump inhibitors (1 point), prior antidiarrheals (1 point), nonsevere CDI (2 points), and community-onset CDI (3 points). In the derivation cohort, the 60-day CDI recurrence risk for each score ranged from 7.5% (0 points) to 57.9% (8 points). The risk score was strongly correlated with recurrence (R2 = 0.94). Patients were split into low-risk (0-2 points), medium-risk (3-5 points), and high-risk (6-8 points) classes and had the following recurrence rates: 8.9%, 20.2%, and 35.0%, respectively. Findings were similar in the validation cohort. CONCLUSION Several CDI and patient-specific factors were independently associated with 60-day CDI recurrence risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were strongly correlated with CDI recurrence. This clinical prediction rule can be used by providers to identify patients at high risk for CDI recurrence and help guide preventive strategy decisions, while accounting for clinical judgment.
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Affiliation(s)
- Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas.,South Texas Veterans Health Care System, San Antonio, Texas
| | - Eric M Mortensen
- Department of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.,VA North Texas Health Care System, Dallas, Texas
| | - Jim M Koeller
- College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas
| | - Kenneth A Lawson
- College of Pharmacy, The University of Texas at Austin, Austin, Texas
| | - Mary Jo V Pugh
- South Texas Veterans Health Care System, San Antonio, Texas.,Department of Epidemiology and Biostatistics, UT Health San Antonio, San Antonio, Texas
| | - Sarah A Rumbellow
- College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas
| | - Jacqueline R Argamany
- College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, Texas.,South Texas Veterans Health Care System, San Antonio, Texas
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28
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DeWaters AL, Chansard M, Anzueto A, Pugh MJ, Mortensen EM. The Association Between Major Depressive Disorder and Outcomes in Older Veterans Hospitalized With Pneumonia. Am J Med Sci 2018; 355:21-26. [PMID: 29289257 PMCID: PMC5751938 DOI: 10.1016/j.amjms.2017.08.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 06/29/2017] [Accepted: 08/21/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Major depressive disorder ("depression") has been identified as an independent risk factor for mortality for many comorbid conditions, including heart failure, cancer and stroke. Major depressive disorder has also been linked to immune suppression by generating a chronic inflammatory state. However, the association between major depression and pneumonia has not been examined. The aim of this study was to examine the association between depression and outcomes, including mortality and intensive care unit admission, in Veterans hospitalized with pneumonia. MATERIALS AND METHODS We conducted a retrospective national study using administrative data of patients hospitalized at any Veterans Administration acute care hospital. We included patients ≥65 years old hospitalized with pneumonia from 2002-2012. Depressed patients were further analyzed based on whether they were receiving medications to treat depression. We used generalized linear mixed effect models to examine the association of depression with the outcomes of interest after controlling for potential confounders. RESULTS Patients with depression had a significantly higher 90-day mortality (odds ratio 1.12, 95% confidence interval 1.07-1.17) compared to patients without depression. Patients with untreated depression had a significantly higher 30-day (1.11, 1.04-1.20) and 90-day (1.20, 1.13-1.28) mortality, as well as significantly higher intensive care unit admission rates (1.12, 1.03-1.21), compared to patients with treated depression. CONCLUSION For older veterans hospitalized with pneumonia, a concurrent diagnosis of major depressive disorder, and especially untreated depression, was associated with higher mortality. This highlights that untreated major depressive disorder is an independent risk factor for mortality for patients with pneumonia.
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Affiliation(s)
- Ami L DeWaters
- VA North Texas Health Care System, Dallas, Texas; University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthieu Chansard
- VA North Texas Health Care System, Dallas, Texas; University of Texas Southwestern Medical Center, Dallas, Texas
| | - Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, Texas; University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Mary Jo Pugh
- South Texas Veterans Health Care System, San Antonio, Texas; University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Eric M Mortensen
- VA North Texas Health Care System, Dallas, Texas; University of Texas Southwestern Medical Center, Dallas, Texas.
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29
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Metersky ML, Eldridge N, Wang Y, Mortensen EM, Meddings J. National trends in the frequency of bladder catheterization and physician-diagnosed catheter-associated urinary tract infections: Results from the Medicare Patient Safety Monitoring System. Am J Infect Control 2017. [PMID: 28625702 DOI: 10.1016/j.ajic.2017.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND It is unclear if bladder catheterization and catheter-associated urinary tract infection (CAUTI) rates have changed since the implementation of public reporting in 2011. METHODS We analyzed data from the Medicare Patient Safety Monitoring System, a national, chart abstraction-based surveillance system, for hospitalized adults with a principal discharge diagnosis of heart failure (HF), acute myocardial infarction (AMI), or pneumonia and patients who had undergone certain major surgeries. We assessed bladder catheterization frequency (percentage of patients catheterized) and risk-adjusted CAUTI frequency (percentage of catheterized patients developing CAUTI) from 2009-2014. RESULTS Bladder catheterization frequency declined significantly (6.6% for AMI patients, 8.0% for HF patients, and 5.7% for surgical patients). For pneumonia patients, there was a nonsignificant increase of 1.1%. The risk-adjusted CAUTI rate among AMI patients decreased by 9.7% each year relative to the year before. For surgical patients, the decrease was 9.1% per year. There was no significant decline among HF or pneumonia patients. The overall burden of CAUTI among surgical patients was higher than for the other conditions because surgical patients were more likely to be catheterized. CONCLUSIONS There were statistically significant declines in observed bladder catheterization frequency and adjusted CAUTI frequency in some patient populations between 2009 and 2014.
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Metersky ML, Priya A, Mortensen EM, Lindenauer PK. Association Between the Order of Macrolide and Cephalosporin Treatment and Outcomes of Pneumonia. Open Forum Infect Dis 2017; 4:ofx141. [PMID: 28948176 PMCID: PMC5597857 DOI: 10.1093/ofid/ofx141] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/13/2017] [Indexed: 01/11/2023] Open
Abstract
Background Many patients hospitalized with pneumonia are treated with combination macrolide/cephalosporin therapy. Macrolides have immunomodulatory effects and do not directly cause bacterial lysis. These effects suggest the possibility that initial treatment with a macrolide before a cephalosporin could improve patient outcomes by preventing the inflammatory response to rapid bacterial lysis that can be caused by cephalosporin treatment. This study explores whether initial treatment for pneumonia with a macrolide before a cephalosporin is associated with better patient outcomes than treatment with a cephalosporin before a macrolide. Methods This is a retrospective cohort study using a clinically rich database derived from electronic health records of 71 hospitals. We compared outcomes for pneumonia patients who received intravenous treatment with a macrolide at least 1 hour before a cephalosporin, versus patients who received a cephalosporin at least 1 hour before a macrolide. Propensity matching was performed for 527 patients in each group. Results Among the propensity-matched cohorts, for the macrolide first group, in-hospital mortality was 4.2% vs 5.5% for the cephalosporin first group (P = .31), combined in-hospital mortality/hospice discharge was 6.3% vs 9.3% (P = .06), median hospital length of stay was 101.5 hours vs 109.5 hours (P = .09), and 30-day readmission was 12.9% vs 10.6% (P = .27). Conclusions Treatment of pneumonia with a macrolide before a cephalosporin was not associated with significantly improved outcomes when compared with treatment with a cephalosporin first; however, the lower rate of mortality/discharge to hospice and the large confidence intervals allow for the possibility of a clinically significant benefit.
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Affiliation(s)
- Mark L Metersky
- Division of Pulmonary, Critical Care Medicine, and Sleep Medicine and
| | - Aruna Priya
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical, School-Baystate, Springfield
| | - Eric M Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical, School-Baystate, Springfield
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Affiliation(s)
- Una E Makris
- Medical Service, Veterans Affairs (VA) North Texas Health Care System, Dallas2Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas3Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Carlos A Alvarez
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Dallas
| | - Wei Wei
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Dallas
| | - Eric M Mortensen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas3Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas5Department of Medicine, University of Connecticut Health Center, Farmington
| | - Ishak A Mansi
- Medical Service, Veterans Affairs (VA) North Texas Health Care System, Dallas2Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas3Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
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Hall RG, Yoo ED, Faust AC, Smith T, Goodman EL, Mortensen EM, Richardson S, Alvarez CA. Impact of total body weight on 30-day mortality in patients with gram-negative bacteremia. Expert Rev Anti Infect Ther 2017; 15:797-803. [PMID: 28481638 DOI: 10.1080/14787210.2017.1328277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 10/19/2022]
Abstract
BACKGROUND The impact of total body weight (TBW) on 30-day mortality associated with gram-negative bacteremia has not been previously evaluated. METHODS The cohort included 323 patients >/ = 18 years old with gram-negative bacteremia (1/1/2008-8/31/2011) who received >/ = 48 hours of antibiotics. We compared 30-day mortality of TBW <70 kg vs. >/ = 70 kg with a multivariable stepwise logistic regression adjusting for age >/ = 70 years, cancer diagnosis, and Pitt bacteremia score of >/ = 4. RESULTS The cohort was 57% TBW >/ = 70 kg and 43% TBW <70 kg. TBW >/ = 70 kg patients had lower 30-day mortality (11.0% vs. 16.3%), which was significant in the multivariable analysis (OR 0.45, 95% CI 0.21-0.97). Cancer and Pitt bacteremia score >/ = 4 were also independently associated with 30-day mortality. TBW was no longer significant when TBW <50 kg patients were excluded. CONCLUSION TBW >/ = 70 kg was associated with an improved 30-day mortality; however, the high mortality rates for patients with a TBW < 50 kg is responsible for this association.
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Affiliation(s)
- Ronald G Hall
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas TX , USA.,b Department of Medical Service for RGH, EMM; Department of Pharmacy Service for CAA , VA North Texas Health Care System , Dallas TX , USA.,c Department of Internal Medicine for RGH; Department of General Internal Medicine for EMM, CAA , University of Texas Southwestern Medical Center , Dallas TX , USA.,d Dose Optimization and Outcomes Research (DOOR) Program , Dallas TX , USA
| | - Eunice D Yoo
- e Department of Pharmacy , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Andrew C Faust
- f Department of Pharmacy for AF, TS; Department of Internal Medicine for ELG , Texas Health Presbyterian Dallas , USA
| | - Terri Smith
- f Department of Pharmacy for AF, TS; Department of Internal Medicine for ELG , Texas Health Presbyterian Dallas , USA
| | - Edward L Goodman
- f Department of Pharmacy for AF, TS; Department of Internal Medicine for ELG , Texas Health Presbyterian Dallas , USA
| | - Eric M Mortensen
- b Department of Medical Service for RGH, EMM; Department of Pharmacy Service for CAA , VA North Texas Health Care System , Dallas TX , USA.,c Department of Internal Medicine for RGH; Department of General Internal Medicine for EMM, CAA , University of Texas Southwestern Medical Center , Dallas TX , USA
| | - Steven Richardson
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas TX , USA
| | - Carlos A Alvarez
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas TX , USA.,b Department of Medical Service for RGH, EMM; Department of Pharmacy Service for CAA , VA North Texas Health Care System , Dallas TX , USA.,c Department of Internal Medicine for RGH; Department of General Internal Medicine for EMM, CAA , University of Texas Southwestern Medical Center , Dallas TX , USA
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Pearlman M, Covin Y, Schmidt R, Mortensen EM, Mansi IA. Statins and Lower Gastrointestinal Conditions: A Retrospective Cohort Study. J Clin Pharmacol 2017; 57:1053-1063. [PMID: 28398604 DOI: 10.1002/jcph.895] [Citation(s) in RCA: 5] [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] [Received: 11/08/2016] [Accepted: 02/23/2017] [Indexed: 11/09/2022]
Abstract
Several studies have reported constipation, abdominal pain, or diarrhea as common adverse events for statins. Statins are among the most commonly prescribed medications, and the impact on the prevalence of these conditions was rarely studied as main outcomes. The aim of this study is to determine if statin therapy is associated with constipation, abdominal pain, diarrhea, or colitis. This was a retrospective cohort study using a regional military health care data from October 1, 2003, to March 1, 2012. A propensity score-matched cohort of statin users and nonusers was created based on 82 variables. The primary analysis evaluated the odds ratios of the following diagnoses: constipation, ≥3 encounters for constipation; abdominal pain, ≥3 encounters for abdominal pain; diarrhea, ≥3 encounters for diarrhea; colitis, ≥3 encounters for colitis; and endoscopy of the lower gastrointestinal tract, ≥3 endoscopies of the lower gastrointestinal tract. After propensity score matching of 6342 statin users and 6342 nonusers, there was no statistically significant difference in constipation (OR, 0.96; 95%CI, 0.87-1.05; P = .33), abdominal pain (OR, 0.95; 95%CI, 0.88-1.02; P = .15), or colitis (OR, 1.02; 95%CI, 0.91-1.14; P = .73). However, there was an association between statin therapy and endoscopy of the lower gastrointestinal tract (OR, 1.14; 95%CI, 1.04-1.26; P = .002) and decreased odds of diarrhea (OR, 0.88; 95%CI, 0.80-0.97; P = .01). In this retrospective cohort study, an association between statin therapy and increased likelihood of being diagnosed with lower gastrointestinal conditions could not be demonstrated, contrary to some statins package inserts.
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Affiliation(s)
- Michelle Pearlman
- Division of Gastroenterology at University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yvonne Covin
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Schmidt
- Department of Gastroenterology, VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Eric M Mortensen
- Medicine Services, VA North Texas Health Care System and Departments of Medicine and Clinical Sciences at University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ishak A Mansi
- Medicine Services, VA North Texas Health Care System and Departments of Medicine and Clinical Sciences at University of Texas Southwestern Medical Center, Dallas, TX, USA
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Abstract
BACKGROUND Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the electronic health record (EHR) may improve prediction. OBJECTIVE To develop pneumonia-specific readmission risk-prediction models using EHR data from the first day and from the entire hospital stay ("full stay"). DESIGN Observational cohort study using stepwise-backward selection and cross-validation. SUBJECTS Consecutive pneumonia hospitalizations from 6 diverse hospitals in north Texas from 2009-2010. MEASURES All-cause nonelective 30-day readmissions, ascertained from 75 regional hospitals. RESULTS Of 1463 patients, 13.6% were readmitted. The first-day pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index; the full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay pneumonia-specific model outperformed the first-day model (C statistic 0.731 vs 0.695; P = 0.02; net reclassification index = 0.08). Compared to a validated multi-condition readmission model, the Centers for Medicare and Medicaid Services pneumonia model, and 2 commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C statistic range 0.604-0.681; P < 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18). CONCLUSIONS EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day pneumonia-specific model, the Centers for Medicare and Medicaid Services pneumonia model, and 2 commonly used pneumonia severity of illness scores. Journal of Hospital Medicine 2017;12:209-216.
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Affiliation(s)
- Anil N. Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- Address for correspondence and reprint requests: Anil N. Makam, MD, MAS; 5323 Harry Hines Blvd., Dallas, TX, 75390-9169; Telephone: 214-648-3272; Fax: 214-648-3232;
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Clark
- Office of Research Administration, Parkland Health and Hospital System, Dallas, Texas
| | - Song Zhang
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bin Xie
- Parkland Center for Clinical Innovation, Dallas, Texas
| | - Mark Weinreich
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric M. Mortensen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- VA North Texas Health Care System, Dallas, Texas
| | - Ethan A. Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
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Frei CR, Rehani S, Lee GC, Boyd NK, Attia E, Pechal A, Britt RS, Mortensen EM. Application of a Risk Score to Identify Older Adults with Community-Onset Pneumonia Most Likely to Benefit From Empiric Pseudomonas Therapy. Pharmacotherapy 2017; 37:195-203. [PMID: 28035692 DOI: 10.1002/phar.1891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE To assess the impact of empiric Pseudomonas pharmacotherapy on 30-day mortality in hospitalized patients with community-onset pneumonia stratified according to their risk (low, medium, or high) of drug-resistant pathogens. DESIGN Retrospective cohort study. DATA SOURCE Veterans Health Administration database. PATIENTS A total of 50,119 patients who were at least 65 years of age, hospitalized with pneumonia, and received antibiotics within 48 hours of admission between fiscal years 2002 and 2007. Patients were stratified into empiric Pseudomonas therapy (31,027 patients) and no Pseudomonas therapy (19,092 patients) groups based on antibiotics received during their first 48 hours of admission. MEASUREMENTS AND MAIN RESULTS A clinical prediction scoring system developed in 2014 that stratifies patients with community-onset pneumonia according to their risk of drug-resistant pathogens was used to identify patients who were likely to benefit from empiric Pseudomonas therapy as well as those in whom antipseudomonal therapy could be spared; patients were classified into low-risk (68%), medium-risk (21%), and high-risk (11%) groups. Of the 50,119 patients, 62% received Pseudomonas therapy. All-cause 30-day mortality was the primary outcome. Empiric Pseudomonas therapy (adjusted odds ratio 0.72, 95% confidence interval 0.62-0.84) was associated with lower 30-day mortality in the high-risk group but not the low- or medium-risk groups. CONCLUSION Application of a risk score for patients with drug-resistant pathogens can identify patients likely to benefit from empiric Pseudomonas therapy. Widespread use of this score could reduce overuse of anti-Pseudomonas antibiotics in low- to medium-risk patients and improve survival in high-risk patients.
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Affiliation(s)
- Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,South Texas Veterans Health Care System, San Antonio, Texas
| | - Sylvie Rehani
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Grace C Lee
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Natalie K Boyd
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Erene Attia
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Ashley Pechal
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Rachel S Britt
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Eric M Mortensen
- VA North Texas Health Care System, Dallas, Texas.,The University of Texas Southwestern Medical Center, Dallas, Texas
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Mansi IA, English JL, Morris MJ, Zhang S, Mortensen EM, Halm EA. Statins for primary prevention in physically active individuals: Do the risks outweigh the benefits? J Sci Med Sport 2017; 20:627-632. [PMID: 28185810 DOI: 10.1016/j.jsams.2016.12.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 09/21/2016] [Revised: 11/16/2016] [Accepted: 12/01/2016] [Indexed: 01/02/2023]
Abstract
OBJECTIVES There are little data on the potential benefits and adverse events of statins among physically fit individuals. Our objective was to examine the associations of statin use with beneficial cardiovascular outcomes and adverse events in active duty military (a surrogate for high level of physical fitness). DESIGN This is a retrospective propensity score-matched cohort study of healthy active duty military (fiscal years [FY] 2002-2011). METHODS Statin-users received statins during FY 2005 as their only prescription medication. FY 2002-2004 was used to describe baseline characteristics; and FY 2006-2011were used to capture outcomes. Study outcomes included major acute cardiovascular events (MACE), diabetes mellitus and its complications, kidney diseases, musculoskeletal diseases, obesity, and malignancy. RESULTS We propensity score matched 837 statin-users to 2488 nonusers. During follow-up, 1.6% statin-users and 1.5% nonusers were diagnosed with MACE (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.55-1.98), 12.5% of statin-users and 5.8% of nonusers were diagnosed with diabetes (OR 2.34, 95% CI 1.79-3.04), and 1.7% statin- users and 0.7% nonusers were diagnosed with diabetes with complication (OR 2.47, 95% CI 1.21-5.04). There were no differences in rates of other adverse events. CONCLUSIONS Among healthy physically active individuals, statin use was associated with doubled the odds of diabetes and diabetic complications without countervailing cardiovascular benefits.
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Affiliation(s)
- Ishak A Mansi
- Department of Medicine, VA North Texas Health Care System, United States; Departments of Internal Medicine, University of Texas Southwestern Medical Center, United States; Departments of Clinical Sciences, University of Texas Southwestern Medical Center, United States.
| | - Jenny L English
- Patient Administration Systems & Biostatistics Activity (PASBA), MEDCOM Head Quarter, JBSA Fort Sam, United States
| | - Michael J Morris
- Pulmonary/Critical Care Service, Department of Medicine, San Antonio Military Medical Center, JBSA Fort Sam, United States
| | - Song Zhang
- Departments of Clinical Sciences, University of Texas Southwestern Medical Center, United States
| | - Eric M Mortensen
- Department of Medicine, VA North Texas Health Care System, United States; Departments of Internal Medicine, University of Texas Southwestern Medical Center, United States; Departments of Clinical Sciences, University of Texas Southwestern Medical Center, United States
| | - Ethan A Halm
- Departments of Internal Medicine, University of Texas Southwestern Medical Center, United States; Departments of Clinical Sciences, University of Texas Southwestern Medical Center, United States
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Abstract
Objectives Prior studies examining the effects of statins on arterial aneurysm development and progression yielded conflicting results due to their smaller size and presence of residual confounders. The objective of this study is to examine the association of statins with risk of being diagnosed with aortic, peripheral, and visceral artery aneurysm. Methods This was a retrospective cohort study of Tricare enrollees (from 1 October 2003 to 31 March 2012). Main outcomes were diagnosis of aortic, peripheral, or visceral artery aneurysm and undergoing aortic aneurysm repair procedure during follow-up period. Using 115 baseline characteristics, we generated a propensity score to match statin users and nonusers and examine the odds of outcomes (primary analysis). Secondary analysis examined outcomes at various subcohorts. Results Out of 10,910 statin users and 49,545 nonusers, we propensity score-matched 6728 pairs of statin users and nonusers. Statin users and nonusers had similar odds of being diagnosed with aortic, peripheral, and visceral artery aneurysms (odds ratio [OR]: 1.06, 95% confidence interval [95% CI]: 0.85–1.33) and of undergoing aortic aneurysm repair procedures (OR: 0.54, 95% CI: 0.22–1.35). Secondary analysis showed a tendency toward fewer aortic aneurysm procedures among statin users that did not reach statistical significance. However, high-intensity statin users in comparison to non-intensive statin users had higher adjusted odds of aortic, peripheral, and visceral artery aneurysms (OR: 1.76, 95% CI: 1.37–2.25, p < .0001). Conclusions This study does not support a clinically significant benefit or harm from statins regarding development of arterial aneurysm. However, secondary analyses may support the hypothesis proposed by previous research proposing a bidirectional role for statins.
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Affiliation(s)
- Ishak A Mansi
- Department of Medicine, VA North Texas Health Care System, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, San Antonio, TX, USA
- Department of Medicine, School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Eric M Mortensen
- Department of Medicine, VA North Texas Health Care System, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Pugh MJ, Finley EP, Wang CP, Copeland LA, Jaramillo CA, Swan AA, Elnitsky CA, Leykum LK, Mortensen EM, Eapen BA, Noel PH, Pugh JA. A retrospective cohort study of comorbidity trajectories associated with traumatic brain injury in veterans of the Iraq and Afghanistan wars. Brain Inj 2016; 30:1481-1490. [DOI: 10.1080/02699052.2016.1219055] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mansi IA, Frei CR, Halm EA, Mortensen EM. Association of statins with diabetes mellitus and diabetic complications: role of confounders during follow-up. J Investig Med 2016; 65:32-42. [PMID: 27574296 DOI: 10.1136/jim-2016-000218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 12/15/2022]
Abstract
Studies have associated statin use with increased risk of diabetes and diabetic complications. These studies often ensure comparability of statin users and non-users at baseline; however, most studies neglect to consider confounders that occur during follow-up. Failure to consider these confounders, such as new medications or procedures, may result in identification of a spurious association between statins and outcomes. The objective of this study was to examine the association of statins with diabetes mellitus and diabetic complications; and to examine potential confounders during the follow-up period that might affect this relationship. We conducted a retrospective cohort study using Tricare data (from October 1, 2003 to March 31, 2012). We propensity score-matched statin users and non-users on 115 baseline characteristics before starting statins; these characteristics would be potentially associated with the use of statins or the outcomes of interest. Outcomes included the risk of diabetes mellitus and diabetic complications. Out of 60,455 patients (10,910 statin users and 49,545 non-users), we propensity score-matched 6728 statin users to 6728 non-users. Statin users had higher ORs for diabetes (OR 1.34, 95% CI 1.24 to 1.44) and diabetes with complications (OR 1.28, 95% CI 1.16 to 1.42). Adjustment for potential confounders that occurred during the follow-up period did not explain or diminish the association between statins and adverse outcomes. Statin users in comparison to similar non-users were more commonly diagnosed with diabetes and diabetic complications, even after adjustment for potential confounders that occurred during the follow-up period.
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Affiliation(s)
- Ishak A Mansi
- Medical Service, VA North Texas Health Care System, Dallas, Texas, USA.,Departments of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Departments of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, San Antonio, Texas, USA.,School of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Ethan A Halm
- Departments of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Departments of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eric M Mortensen
- Medical Service, VA North Texas Health Care System, Dallas, Texas, USA.,Departments of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Departments of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Attridge RT, Frei CR, Pugh MJV, Lawson KA, Ryan L, Anzueto A, Metersky ML, Restrepo MI, Mortensen EM. Health care-associated pneumonia in the intensive care unit: Guideline-concordant antibiotics and outcomes. J Crit Care 2016; 36:265-271. [PMID: 27595461 DOI: 10.1016/j.jcrc.2016.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/23/2016] [Accepted: 08/04/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Recent data have not demonstrated improved outcomes when guideline-concordant (GC) antibiotics are given to patients with health care-associated pneumonia (HCAP). This study was designed to evaluate the relationship between health outcomes and GC therapy in patients admitted to an intensive care unit (ICU) with HCAP. MATERIALS AND METHODS We performed a population-based cohort study of patients admitted to greater than 150 hospitals in the US Veterans Health Administration system to compare baseline characteristics, bacterial pathogens, and health outcomes in ICU patients with HCAP receiving GC-HCAP therapy, GC community-acquired pneumonia (GC-CAP) therapy, or non-GC therapy. The primary outcome was 30-day patient mortality. Risk factors for the primary outcome were assessed in a multivariable logistic regression model. RESULTS A total of 3593 patients met inclusion criteria and received GC-HCAP therapy (26%), GC-CAP therapy (23%), or non-GC therapy (51%). Patients receiving GC-HCAP had higher 30-day patient mortality compared to GC-CAP patients (34% vs 22%; P< .0001). After controlling for confounders, risk factors for 30-day patient mortality were vasopressor use (odds ratio, 1.67; 95% confidence interval, 1.30-2.13), recent hospital admission (1.53; 1.15-2.02), and receipt of GC-HCAP therapy (1.51; 1.20-1.90). CONCLUSIONS Our data do not demonstrate improved outcomes among ICU patients with HCAP who received GC-HCAP therapy.
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Affiliation(s)
- Russell T Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX 78209; Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229.
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712; Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Mary Jo V Pugh
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Kenneth A Lawson
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712.
| | - Laurajo Ryan
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712; Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Antonio Anzueto
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Mark L Metersky
- University of Connecticut School of Medicine, Farmington, CT 06030.
| | - Marcos I Restrepo
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Eric M Mortensen
- Section of General Internal Medicine, VA North Texas Health Care System, Dallas, TX 75216; Division of General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390.
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Mansi IA, English J, Zhang S, Mortensen EM, Halm EA. Long-Term Outcomes of Short-Term Statin Use in Healthy Adults: A Retrospective Cohort Study. Drug Saf 2016; 39:543-59. [DOI: 10.1007/s40264-016-0412-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Acharya T, Huang J, Tringali S, Frei CR, Mortensen EM, Mansi IA. Statin Use and the Risk of Kidney Disease With Long-Term Follow-Up (8.4-Year Study). Am J Cardiol 2016; 117:647-655. [PMID: 26742473 DOI: 10.1016/j.amjcard.2015.11.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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: 08/25/2015] [Revised: 11/18/2015] [Accepted: 11/18/2015] [Indexed: 12/29/2022]
Abstract
Few studies have examined long-term effects of statin therapy on kidney diseases. The objective of this study was to determine the association of statin use with incidence of acute and chronic kidney diseases after prolonged follow-up. In this retrospective cohort study, we analyzed data from the San Antonio area military health care system from October 2003 through March 2012. Statin users were propensity score matched to nonusers using 82 baseline characteristics including demographics, co-morbidities, medications, and health care utilization. Study outcomes were acute kidney injury, chronic kidney disease (CKD), and nephritis/nephrosis/renal sclerosis. Of the 43,438 subjects included, we propensity score matched 6,342 statin users with 6,342 nonusers. Statin users had greater odds of acute kidney injury (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.14 to 1.48), CKD (OR 1.36, 95% CI 1.22 to 1.52), and nephritis/nephrosis/renal sclerosis (OR 1.35, 95% CI 1.05 to 1.73). In a subset of patients without co-morbidities, the association of statin use with CKD remained significant (OR 1.53, 95% CI 1.27 to 1.85). In a secondary analysis, adjusting for diseases/conditions that developed during follow-up weakened this association. In conclusion, statin use is associated with increased incidence of acute and chronic kidney disease. These findings are cautionary and suggest that long-term effects of statins in real-life patients may differ from shorter term effects in selected clinical trial populations.
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Affiliation(s)
- Tushar Acharya
- Division of Cardiology, Department of Internal Medicine, University of California, San Francisco-Fresno Medical Education Program, Fresno, California
| | - Jian Huang
- Medicine Service, VA Central California Health Care System, Fresno, California; Department of Medicine, University of California, San Francisco-Fresno Medical Education Program, Fresno, California
| | - Steven Tringali
- Department of Medicine, University of California, San Francisco-Fresno Medical Education Program, Fresno, California
| | - Christopher R Frei
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, Texas; Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center, San Antonio, Texas
| | - Eric M Mortensen
- Department of Medicine, VA North Texas Health Care System, Dallas, Texas; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ishak A Mansi
- Department of Medicine, VA North Texas Health Care System, Dallas, Texas; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.
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Martin D, Schmidt R, Mortensen EM, Mansi I. Association of Statin Therapy and Risks of Cholelithiasis, Biliary Tract Diseases, and Gallbladder Procedures: Retrospective Cohort Analysis of a US Population. Ann Pharmacother 2015; 50:161-71. [PMID: 26706861 DOI: 10.1177/1060028015622649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Gallstone disease is a leading cause of morbidity in Western countries and carries a high economic burden. Statin medications decrease hepatic cholesterol biosynthesis and may, therefore, lower the risk of cholesterol cholelithiasis by reducing the cholesterol concentration in the bile. Population-based evidence, however, is sparse. OBJECTIVE To assess the risk of gallbladder diseases among statin users compared with nonusers in an American patient cohort. METHODS We performed a retrospective cohort study of patients enrolled in the San Antonio Tricare health system using data between October 2003 and March 2012. We defined 2 groups: statin users (use for 90 days or greater) and nonusers (no prior statin). A propensity score based on 82 variables was generated to match statin users and nonusers 1:1. Outcomes included incidence of cholelithiasis, biliary tract diseases, and gallbladder procedures. RESULTS A total of 43 438 patients were identified; 13 626 (31.4%) were statin users, and 29 812 (68.6%) were nonusers. We matched 6342 pairs of statin users and nonusers based on propensity score. The odds ratios (ORs) in statin users in comparison to nonusers were similar for cholelithiasis (OR = 0.86; 95% CI = 0.73, 1.02), biliary tract disease (OR = 0.85; 95% CI = 0.67-1.08), and gall bladder procedures (OR = 0.85; 95% CI = 0.69, 1.04). CONCLUSIONS Statin use was not significantly associated with either an increased or decreased risk of cholelithiasis or gallbladder disease.
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Affiliation(s)
- Donald Martin
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Schmidt
- University of Texas Southwestern Medical Center, Dallas, TX, USA VA North Texas Health Care System, Dallas, TX, USA
| | - Eric M Mortensen
- University of Texas Southwestern Medical Center, Dallas, TX, USA VA North Texas Health Care System, Dallas, TX, USA
| | - Ishak Mansi
- University of Texas Southwestern Medical Center, Dallas, TX, USA VA North Texas Health Care System, Dallas, TX, USA
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44
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Affiliation(s)
- Eric M Mortensen
- General Internal Medicine, Dallas Veterans Administration Medical Center, Texas
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45
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Metersky ML, Frei CR, Mortensen EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology 2015; 21:157-63. [PMID: 26682638 DOI: 10.1111/resp.12651] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/01/2015] [Accepted: 07/17/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with healthcare-associated pneumonia (HCAP) are at high risk of infection with multidrug-resistant (MDR) pathogens. Factors discriminating infection with MDR Gram-negative (MDR-GN) organism from infection with methicillin-resistant Staphylococcus aureus (MRSA) are not well understood and patients are often treated for both organisms. This study was performed to determine risk factors predicting pneumonia due to Pseudomonas versus MRSA. METHODS Veterans age ≥65 hospitalized with HCAP between 2002 and 2012 were identified from the Veterans Affairs administrative databases. Patients were identified with Pseudomonas pneumonia, MRSA pneumonia or neither according to the International Classification of Diseases, 9th Revision, Clinical Modification codes. We assessed unadjusted and adjusted associations of patient characteristics and HCAP due to Pseudomonas or MRSA. RESULTS Of the 61,651 patients with HCAP, 1156 (1.9%) were diagnosed with Pseudomonas pneumonia, 641 (1.0%) with MRSA pneumonia and 59,854 (97.1%) with neither. MRSA pneumonia was positively associated with male gender, age >74, diabetes, chronic obstructive pulmonary disease (COPD), recent nursing home or hospital stay, recent exposure to fluoroquinolone or antibiotics treating Gram-positive organisms, and severe pneumonia. MRSA pneumonia was negatively associated with complicated diabetes. Pseudomonas pneumonia was positively associated with recent hospital stay, immunocompromise, COPD, hemiplegia, recent exposure to inhaled corticosteroids, β-lactam/cephalosporin/carbapenem antibiotics, antibiotics against Gram-positive organisms, 'other antibiotics' and severe pneumonia. Pseudomonas pneumonia was negatively associated with age >84, higher socioeconomic status, drug abuse and diabetes. CONCLUSIONS Patient characteristics may assist in identifying patients at risk for HCAP due to Pseudomonas or MRSA.
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Affiliation(s)
- Mark L Metersky
- The Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, USA.,Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center School of Medicine, San Antonio, USA
| | - Eric M Mortensen
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Teshome BF, Lee GC, Reveles KR, Attridge RT, Koeller J, Wang CP, Mortensen EM, Frei CR. Application of a methicillin-resistant Staphylococcus aureus risk score for community-onset pneumonia patients and outcomes with initial treatment. BMC Infect Dis 2015; 15:380. [PMID: 26385225 PMCID: PMC4575496 DOI: 10.1186/s12879-015-1119-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 09/10/2015] [Indexed: 11/12/2022] Open
Abstract
Background Community-onset (CO) methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is an evolving problem, and there is a great need for a reliable method to assess MRSA risk at hospital admission. A new MRSA prediction score classifies CO-pneumonia patients into low, medium, and high-risk groups based on objective criteria available at baseline. Our objective was to assess the effect of initial MRSA therapy on mortality in these three risk groups. Methods We conducted a retrospective cohort study using data from the Veterans Health Administration (VHA). Patients were included if they were hospitalized with pneumonia and received antibiotics within the first 48 h of admission. They were stratified into MRSA therapy and no MRSA therapy treatment arms based on antibiotics received in the first 48 h. Multivariable logistic regression was used to adjust for potential confounders. Results A total of 80,330 patients met inclusion criteria, of which 36 % received MRSA therapy and 64 % did not receive MRSA therapy. The majority of patients were classified as either low (51 %) or medium (47 %) risk, with only 2 % classified as high-risk. Multivariable logistic regression analysis demonstrated that initial MRSA therapy was associated with a lower 30-day mortality in the high-risk group (adjusted odds ratio 0.57; 95 % confidence interval 0.42–0.77). Initial MRSA therapy was not beneficial in the low or medium-risk groups. Conclusions This study demonstrated improved survival with initial MRSA therapy in high-risk CO-pneumonia patients. The MRSA risk score might help spare MRSA therapy for only those patients who are likely to benefit. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1119-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Besu F Teshome
- St. Louis College of Pharmacy, St. Louis, MO, USA. .,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA. .,Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
| | - Grace C Lee
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA. .,Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
| | - Kelly R Reveles
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA. .,Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
| | - Russell T Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA. .,South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Jim Koeller
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA. .,Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
| | - Chen-pin Wang
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio, TX, USA.
| | - Eric M Mortensen
- The VA North Texas Health Care System, Dallas, TX, USA. .,The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA. .,Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
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Reveles KR, Mortensen EM, Attridge RT, Frei CR. Comparative-effectiveness of vancomycin and linezolid as part of guideline-recommended empiric therapy for healthcare-associated pneumonia. BMC Res Notes 2015; 8:450. [PMID: 26382940 PMCID: PMC4573683 DOI: 10.1186/s13104-015-1396-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 08/31/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Linezolid has been directly compared to vancomycin in pneumonia; however, most clinical trials have not compared outcomes specifically in the healthcare-associated pneumonia (HCAP) population. The objective of this study was to compare the effectiveness of vancomycin and linezolid in a national cohort of hospitalized veterans with HCAP. METHODS This was a retrospective cohort study of Veterans Health Administration patients admitted to >150 hospitals across the United States between 2002 and 2007. Patients were included if they were at least 65 years old, had an ICD-9-CM code for pneumonia, had one or more HCAP risk factors, and received guideline-concordant antibiotic therapy with linezolid or vancomycin within 48 h of admission. Critically ill patients were excluded. Multivariable logistic regression models and propensity scores were used to examine the association between linezolid or vancomycin therapy and 30-day mortality. RESULTS A total of 1211 patients met study criteria; 946 received vancomycin and 265 received linezolid. Thirty-day mortality was higher in patients treated with vancomycin (n = 243; 25.7 %) as compared to linezolid (n = 33; 12.5 %) (adjusted OR 2.56; 95 % CI 1.67-4.04). Vancomycin use (n = 945) was also predictive of 30-day mortality compared to linezolid use (n = 264) in the propensity score analysis (adjusted OR 2.55; 95 % CI 1.66-4.02). CONCLUSION Linezolid was associated with decreased patient mortality compared to vancomycin in a national cohort of non-critically ill, hospitalized veterans with HCAP.
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Affiliation(s)
- Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, San Antonio, TX, USA. .,Pharmacotherapy Education and Research Center (PERC), School of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229-3900, USA.
| | - Eric M Mortensen
- The VA North Texas Health Care System, Dallas, TX, USA. .,School of Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines, Boulevard, Dallas, TX, USA.
| | - Russell T Attridge
- Feik School of Pharmacy, University of the Incarnate Word, 4301 Broadway, CPO #99, San Antonio, TX, USA.
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, San Antonio, TX, USA. .,Pharmacotherapy Education and Research Center (PERC), School of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229-3900, USA.
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Badillo R, Schmidt R, Mortensen EM, Frei CR, Mansi I. Statin therapy and gastrointestinal hemorrhage: a retrospective cohort study with propensity score-matching. Pharmacoepidemiol Drug Saf 2015; 24:849-57. [DOI: 10.1002/pds.3817] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/08/2015] [Accepted: 05/21/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Ricardo Badillo
- Division of Gastroenterology; Washington University in St Louis; St. Louis MO USA
- Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Robert Schmidt
- VA North Texas Health Care System and University of Texas Southwestern Medical Center; Dallas TX USA
| | - Eric M. Mortensen
- VA North Texas Health Care System and Departments of Internal Medicine and Clinical Sciences and Division of Outcomes and Health services Research, University of Texas Southwestern Medical Center; Dallas TX USA
| | - Christopher R. Frei
- College of Pharmacy; The University of Texas at Austin; Austin TX USA
- Pharmacotherapy Education and Research Center, School of Medicine; University of Texas Health Science Center; San Antonio TX USA
| | - Ishak Mansi
- VA North Texas Health Care System and Departments of Internal Medicine and Clinical Sciences and Division of Outcomes and Health services Research, University of Texas Southwestern Medical Center; Dallas TX USA
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Copeland LA, Zeber JE, Sako EY, Mortensen EM, Pugh MJ, Wang CP, Restrepo MI, Flynn J, MacCarthy AA, Lawrence VA. Serious mental illnesses associated with receipt of surgery in retrospective analysis of patients in the Veterans Health Administration. BMC Surg 2015; 15:74. [PMID: 26084521 PMCID: PMC4472400 DOI: 10.1186/s12893-015-0064-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 06/11/2015] [Indexed: 11/10/2022] Open
Abstract
Background The STOPP study (Surgical Treatment Outcomes for Patients with Psychiatric Disorders) analyzed variation in rates and types of major surgery by serious mental illness status among patients treated in the Veterans Health Administration (VA). VA patients are veterans of United States military service who qualify for federal care by reason of disability, special service experiences, or poverty. Methods STOPP conducted a secondary data analysis of medical record extracts for seven million VA patients treated Oct 2005-Sep 2009. The retrospective study aggregated inpatient surgery events, comorbid diagnoses, demographics, and postoperative 30-day mortality. Results Serious mental illness -- schizophrenia, bipolar disorder, posttraumatic stress disorder, or major depressive disorder, was identified in 12 % of VA patients. Over the 4-year study period, 321,131 patients (4.5 %) underwent surgery with same-day preoperative or immediate post-operative admission including14 % with serious mental illness. Surgery patients were older (64 vs. 61 years) and more commonly African-American, unmarried, impoverished, highly disabled (24 % vs 12 % were Priority 1), obese, with psychotic disorder (4.3 % vs 2.9 %). Among surgery patients, 3.7 % died within 30 days postop. After covariate adjustment, patients with pre-existing serious mental illness were relatively less likely to receive surgery (adjusted odds ratios 0.4-0.7). Conclusions VA patients undergoing major surgery appeared, in models controlling for comorbidity and demographics, to disproportionately exclude those with serious mental illness. While VA preferentially treats the most economically and medically disadvantaged veterans, the surgery subpopulation may be especially ill, potentially warranting increased postoperative surveillance.
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Affiliation(s)
- Laurel A Copeland
- Veterans Affairs: Central Texas Veterans Health Care System, Center for Applied Health Research, 2102 Birdcreek Drive, Temple, TX, 76502, USA. .,Baylor Scott & White Health: Center for Applied Health Research, 2102 Birdcreek Drive, Temple, TX, 76502, USA. .,Texas A&M Health Science Center, College of Medicine, Bryan, TX, USA. .,UT Health Science Center San Antonio, San Antonio, TX, USA.
| | - John E Zeber
- Veterans Affairs: Central Texas Veterans Health Care System, Center for Applied Health Research, 2102 Birdcreek Drive, Temple, TX, 76502, USA.,Baylor Scott & White Health: Center for Applied Health Research, 2102 Birdcreek Drive, Temple, TX, 76502, USA.,Texas A&M Health Science Center, College of Medicine, Bryan, TX, USA.,UT Health Science Center San Antonio, San Antonio, TX, USA
| | - Edward Y Sako
- UT Health Science Center San Antonio, San Antonio, TX, USA
| | - Eric M Mortensen
- Veterans Affairs: North Texas Veterans Health Care System, 4500 S. Lancaster Rd, Dallas, TX, 75216, USA.,UT Southwestern Medical Center, Dallas, TX, USA
| | - Mary Jo Pugh
- UT Health Science Center San Antonio, San Antonio, TX, USA.,Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | - Chen-Pin Wang
- UT Health Science Center San Antonio, San Antonio, TX, USA.,Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | - Marcos I Restrepo
- UT Health Science Center San Antonio, San Antonio, TX, USA.,Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | - Julianne Flynn
- Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
| | - Andrea A MacCarthy
- Veterans Affairs: South Texas Veterans Health Care System, 7400 Merton Minter (11c6), San Antonio, TX, 78229, USA
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Affiliation(s)
- Eric M Mortensen
- General Internal Medicine (111E), Dallas VA Medical Center, 4500 South Lancaster, Dallas, Texas, 75216, USA,
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