1
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Preiss A, Bhatia A, Aragon LV, Baratta JM, Baskaran M, Blancero F, Brannock MD, Chew RF, Díaz I, Fitzgerald M, Kelly EP, Zhou A, Carton TW, Chute CG, Haendel M, Moffitt R, Pfaff E. EFFECT OF PAXLOVID TREATMENT DURING ACUTE COVID-19 ON LONG COVID ONSET: AN EHR-BASED TARGET TRIAL EMULATION FROM THE N3C AND RECOVER CONSORTIA. medRxiv 2024:2024.01.20.24301525. [PMID: 38343863 PMCID: PMC10854326 DOI: 10.1101/2024.01.20.24301525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Preventing and treating post-acute sequelae of SARS-CoV-2 infection (PASC), commonly known as Long COVID, has become a public health priority. In this study, we examined whether treatment with Paxlovid in the acute phase of COVID-19 helps prevent the onset of PASC. We used electronic health records from the National Covid Cohort Collaborative (N3C) to define a cohort of 426,352 patients who had COVID-19 since April 1, 2022, and were eligible for Paxlovid treatment due to risk for progression to severe COVID-19. We used the target trial emulation (TTE) framework to estimate the effect of Paxlovid treatment on PASC incidence. We estimated overall PASC incidence using a computable phenotype. We also measured the onset of novel cognitive, fatigue, and respiratory symptoms in the post-acute period. Paxlovid treatment did not have a significant effect on overall PASC incidence (relative risk [RR] = 0.98, 95% confidence interval [CI] 0.95-1.01). However, it had a protective effect on cognitive (RR = 0.90, 95% CI 0.84-0.96) and fatigue (RR = 0.95, 95% CI 0.91-0.98) symptom clusters, which suggests that the etiology of these symptoms may be more closely related to viral load than that of respiratory symptoms.
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Affiliation(s)
| | - Abhishek Bhatia
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - John M. Baratta
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Monika Baskaran
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | - Iván Díaz
- New York University Grossman School of Medicine, New York, NY, USA
| | | | | | - Andrea Zhou
- University of Virginia, Charlottesville, VA, USA
| | - Thomas W. Carton
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Christopher G. Chute
- Johns Hopkins University School of Medicine, Public Health, and Nursing, Baltimore, MD, USA
| | - Melissa Haendel
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Emily Pfaff
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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2
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Vettorazzi M, Díaz I, Angelina E, Salido S, Gutierrez L, Alvarez SE, Cobo J, Enriz RD. Second generation of pyrimidin-quinolone hybrids obtained from virtual screening acting as sphingosine kinase 1 inhibitors and potential anticancer agents. Bioorg Chem 2024; 144:107112. [PMID: 38237390 DOI: 10.1016/j.bioorg.2024.107112] [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: 10/27/2023] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 02/17/2024]
Abstract
We report here the virtual screening design, synthesis and activity of eight new inhibitors of SphK1. For this study we used a pre-trained Graph Convolutional Network (GCN) combined with docking calculations. This exploratory analysis proposed nine compounds from which eight displayed significant inhibitory effect against sphingosine kinase 1 (SphK1) demonstrating a high level of efficacy for this approach. Four of these compounds also displayed anticancer activity against different tumor cell lines, and three of them (5), (6) and (7) have shown a wide inhibitory action against many of the cancer cell line tested, with GI50 below 5 µM, being (5) the most promising with TGI below 10 µM for the half of cell lines. Our results suggest that the three most promising compounds reported here are the pyrimidine-quinolone hybrids (1) and (6) linked by p-aminophenylsulfanyl and o-aminophenol fragments respectively, and (8) without such aryl linker. We also performed an exhaustive study about the molecular interactions that stabilize the different ligands at the binding site of SphK1. This molecular modeling analysis was carried out by using combined techniques: docking calculations, MD simulations and QTAIM analysis. In this study we also included PF543, as reference compound, in order to better understand the molecular behavior of these ligands at the binding site of SphK1.These results provide useful information for the design of new inhibitors of SphK1 possessing these structural scaffolds.
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Affiliation(s)
- Marcela Vettorazzi
- Universidad Nacional de San Luis, Facultad de Química, Bioquímica y Farmacia, Ejercito de los Andes 950, (5700) San Luis, Argentina; Instituto Multidisciplinario de Investigaciones Biológicas (IMIBIO-SL), Ejercito de los Andes 950, (5700) San Luis, Argentina
| | - Iván Díaz
- Universidad de Jaén, Departamento de Química Inorgánica y Orgánica, Campus Las Lagunillas s/n, 23071 Jaén, Spain
| | - Emilio Angelina
- Universidad Nacional del Nordeste, Facultad de Ciencias Exactas y Naturales y Agrimensura, Departamento de Química, Área de Química Física, Laboratorio de Estructura Molecular y Propiedades, Avda. Libertad 5460, 3400 Corrientes, Argentina
| | - Sofía Salido
- Universidad de Jaén, Departamento de Química Inorgánica y Orgánica, Campus Las Lagunillas s/n, 23071 Jaén, Spain
| | - Lucas Gutierrez
- Universidad Nacional de San Luis, Facultad de Química, Bioquímica y Farmacia, Ejercito de los Andes 950, (5700) San Luis, Argentina; Instituto Multidisciplinario de Investigaciones Biológicas (IMIBIO-SL), Ejercito de los Andes 950, (5700) San Luis, Argentina
| | - Sergio E Alvarez
- Universidad Nacional de San Luis, Facultad de Química, Bioquímica y Farmacia, Ejercito de los Andes 950, (5700) San Luis, Argentina; Instituto Multidisciplinario de Investigaciones Biológicas (IMIBIO-SL), Ejercito de los Andes 950, (5700) San Luis, Argentina
| | - Justo Cobo
- Universidad de Jaén, Departamento de Química Inorgánica y Orgánica, Campus Las Lagunillas s/n, 23071 Jaén, Spain.
| | - Ricardo D Enriz
- Universidad Nacional de San Luis, Facultad de Química, Bioquímica y Farmacia, Ejercito de los Andes 950, (5700) San Luis, Argentina; Instituto Multidisciplinario de Investigaciones Biológicas (IMIBIO-SL), Ejercito de los Andes 950, (5700) San Luis, Argentina.
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3
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Rudolph KE, Williams N, Díaz I. Using instrumental variables to address unmeasured confounding in causal mediation analysis. Biometrics 2024; 80:ujad037. [PMID: 38412300 PMCID: PMC11057970 DOI: 10.1093/biomtc/ujad037] [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: 05/26/2023] [Revised: 10/24/2023] [Accepted: 12/21/2023] [Indexed: 02/29/2024]
Abstract
Mediation analysis is a strategy for understanding the mechanisms by which interventions affect later outcomes. However, unobserved confounding concerns may be compounded in mediation analyses, as there may be unobserved exposure-outcome, exposure-mediator, and mediator-outcome confounders. Instrumental variables (IVs) are a popular identification strategy in the presence of unobserved confounding. However, in contrast to the rich literature on the use of IV methods to identify and estimate a total effect of a non-randomized exposure, there has been almost no research into using IV as an identification strategy to identify mediational indirect effects. In response, we define and nonparametrically identify novel estimands-double complier interventional direct and indirect effects-when 2, possibly related, IVs are available, one for the exposure and another for the mediator. We propose nonparametric, robust, efficient estimators for these effects and apply them to a housing voucher experiment.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York 10032, USA
| | - Nicholas Williams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York 10032, USA
| | - Iván Díaz
- Division of Biostatistics, New York University Grossman School of Medicine, New York, New York 10016, USA
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4
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Díaz I, Hoffman KL, Hejazi NS. Causal survival analysis under competing risks using longitudinal modified treatment policies. Lifetime Data Anal 2024; 30:213-236. [PMID: 37620504 DOI: 10.1007/s10985-023-09606-7] [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] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/17/2023] [Indexed: 08/26/2023]
Abstract
Longitudinal modified treatment policies (LMTP) have been recently developed as a novel method to define and estimate causal parameters that depend on the natural value of treatment. LMTPs represent an important advancement in causal inference for longitudinal studies as they allow the non-parametric definition and estimation of the joint effect of multiple categorical, ordinal, or continuous treatments measured at several time points. We extend the LMTP methodology to problems in which the outcome is a time-to-event variable subject to a competing event that precludes observation of the event of interest. We present identification results and non-parametric locally efficient estimators that use flexible data-adaptive regression techniques to alleviate model misspecification bias, while retaining important asymptotic properties such as [Formula: see text]-consistency. We present an application to the estimation of the effect of the time-to-intubation on acute kidney injury amongst COVID-19 hospitalized patients, where death by other causes is taken to be the competing event.
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Affiliation(s)
- Iván Díaz
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY, 10016, USA.
| | - Katherine L Hoffman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | - Nima S Hejazi
- Department of Biostatistics, T.H. Chan School of Public Health, Harvard University, Boston, MA, 02115, USA
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5
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Díaz I, Lee H, Kıcıman E, Schenck EJ, Akacha M, Follman D, Ghosh D. Sensitivity analysis for causality in observational studies for regulatory science. J Clin Transl Sci 2023; 7:e267. [PMID: 38380390 PMCID: PMC10877517 DOI: 10.1017/cts.2023.688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/30/2023] [Accepted: 11/16/2023] [Indexed: 02/22/2024] Open
Abstract
Objective The United States Congress passed the 21st Century Cures Act mandating the development of Food and Drug Administration guidance on regulatory use of real-world evidence. The Forum on the Integration of Observational and Randomized Data conducted a meeting with various stakeholder groups to build consensus around best practices for the use of real-world data (RWD) to support regulatory science. Our companion paper describes in detail the context and discussion of the meeting, which includes a recommendation to use a causal roadmap for study designs using RWD. This article discusses one step of the roadmap: the specification of a sensitivity analysis for testing robustness to violations of causal model assumptions. Methods We present an example of a sensitivity analysis from a RWD study on the effectiveness of Nifurtimox in treating Chagas disease, and an overview of various methods, emphasizing practical considerations on their use for regulatory purposes. Results Sensitivity analyses must be accompanied by careful design of other aspects of the causal roadmap. Their prespecification is crucial to avoid wrong conclusions due to researcher degrees of freedom. Sensitivity analysis methods require auxiliary information to produce meaningful conclusions; it is important that they have at least two properties: the validity of the conclusions does not rely on unverifiable assumptions, and the auxiliary information required by the method is learnable from the corpus of current scientific knowledge. Conclusions Prespecified and assumption-lean sensitivity analyses are a crucial tool that can strengthen the validity and trustworthiness of effectiveness conclusions for regulatory science.
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Affiliation(s)
- Iván Díaz
- Division of Biostatistics, Department of Population Health,
New York University Grossman School of Medicine, New
York, NY, USA
| | - Hana Lee
- Office of Biostatistics, Office of Translational Sciences, Center for Drug
Evaluation and Research, U.S. Food and Drug Administration, Silver
Spring, MD, USA
| | | | | | | | - Dean Follman
- Biostatistics Research Branch, National Institute of Allergy and Infectious
Disease, Silver Spring, MD,
USA
| | - Debashis Ghosh
- Department of Biostatistics and Informatics, Colorado School
of Public Health, University of Colorado Anschutz Medical Campus,
Colorado, USA
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6
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Rudolph KE, Williams N, Díaz I. Efficient and flexible estimation of natural direct and indirect effects under intermediate confounding and monotonicity constraints. Biometrics 2023; 79:3126-3139. [PMID: 36905172 PMCID: PMC11037503 DOI: 10.1111/biom.13850] [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: 05/12/2022] [Accepted: 02/16/2023] [Indexed: 03/12/2023]
Abstract
Natural direct and indirect effects are mediational estimands that decompose the average treatment effect and describe how outcomes would be affected by contrasting levels of a treatment through changes induced in mediator values (in the case of the indirect effect) or not through induced changes in the mediator values (in the case of the direct effect). Natural direct and indirect effects are not generally point-identified in the presence of a treatment-induced confounder; however, they may be identified if one is willing to assume monotonicity between the treatment and the treatment-induced confounder. We argue that this assumption may be reasonable in the relatively common encouragement-design trial setting, where the intervention is randomized treatment assignment and the treatment-induced confounder is whether or not treatment was actually taken/adhered to. We develop efficiency theory for the natural direct and indirect effects under this monotonicity assumption, and use it to propose a nonparametric, multiply robust estimator. We demonstrate the finite sample properties of this estimator using a simulation study, and apply it to data from the Moving to Opportunity Study to estimate the natural direct and indirect effects of being randomly assigned to receive a Section 8 housing voucher-the most common form of federal housing assistance-on risk developing any mood or externalizing disorder among adolescent boys, possibly operating through various school and community characteristics.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Nicholas Williams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
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7
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Dang LE, Gruber S, Lee H, Dahabreh IJ, Stuart EA, Williamson BD, Wyss R, Díaz I, Ghosh D, Kıcıman E, Alemayehu D, Hoffman KL, Vossen CY, Huml RA, Ravn H, Kvist K, Pratley R, Shih MC, Pennello G, Martin D, Waddy SP, Barr CE, Akacha M, Buse JB, van der Laan M, Petersen M. A causal roadmap for generating high-quality real-world evidence. J Clin Transl Sci 2023; 7:e212. [PMID: 37900353 PMCID: PMC10603361 DOI: 10.1017/cts.2023.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/01/2023] [Accepted: 09/17/2023] [Indexed: 10/31/2023] Open
Abstract
Increasing emphasis on the use of real-world evidence (RWE) to support clinical policy and regulatory decision-making has led to a proliferation of guidance, advice, and frameworks from regulatory agencies, academia, professional societies, and industry. A broad spectrum of studies use real-world data (RWD) to produce RWE, ranging from randomized trials with outcomes assessed using RWD to fully observational studies. Yet, many proposals for generating RWE lack sufficient detail, and many analyses of RWD suffer from implausible assumptions, other methodological flaws, or inappropriate interpretations. The Causal Roadmap is an explicit, itemized, iterative process that guides investigators to prespecify study design and analysis plans; it addresses a wide range of guidance within a single framework. By supporting the transparent evaluation of causal assumptions and facilitating objective comparisons of design and analysis choices based on prespecified criteria, the Roadmap can help investigators to evaluate the quality of evidence that a given study is likely to produce, specify a study to generate high-quality RWE, and communicate effectively with regulatory agencies and other stakeholders. This paper aims to disseminate and extend the Causal Roadmap framework for use by clinical and translational researchers; three companion papers demonstrate applications of the Causal Roadmap for specific use cases.
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Affiliation(s)
- Lauren E. Dang
- Department of Biostatistics, University of California, Berkeley, CA, USA
| | | | - Hana Lee
- Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Issa J. Dahabreh
- CAUSALab, Department of Epidemiology and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brian D. Williamson
- Biostatistics Division, Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Richard Wyss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Debashis Ghosh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Katherine L. Hoffman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Carla Y. Vossen
- Syneos Health Clinical Solutions, Amsterdam, The Netherlands
| | | | | | | | - Richard Pratley
- AdventHealth Translational Research Institute, Orlando, FL, USA
| | - Mei-Chiung Shih
- Cooperative Studies Program Coordinating Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Gene Pennello
- Division of Imaging Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - David Martin
- Global Real World Evidence Group, Moderna, Cambridge, MA, USA
| | - Salina P. Waddy
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Charles E. Barr
- Graticule Inc., Newton, MA, USA
- Adaptic Health Inc., Palo Alto, CA, USA
| | | | - John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark van der Laan
- Department of Biostatistics, University of California, Berkeley, CA, USA
| | - Maya Petersen
- Department of Biostatistics, University of California, Berkeley, CA, USA
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8
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Hejazi NS, Rudolph KE, Van Der Laan MJ, Díaz I. Nonparametric causal mediation analysis for stochastic interventional (in)direct effects. Biostatistics 2023; 24:686-707. [PMID: 35102366 PMCID: PMC10345989 DOI: 10.1093/biostatistics/kxac002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 06/14/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 07/20/2023] Open
Abstract
Causal mediation analysis has historically been limited in two important ways: (i) a focus has traditionally been placed on binary exposures and static interventions and (ii) direct and indirect effect decompositions have been pursued that are only identifiable in the absence of intermediate confounders affected by exposure. We present a theoretical study of an (in)direct effect decomposition of the population intervention effect, defined by stochastic interventions jointly applied to the exposure and mediators. In contrast to existing proposals, our causal effects can be evaluated regardless of whether an exposure is categorical or continuous and remain well-defined even in the presence of intermediate confounders affected by exposure. Our (in)direct effects are identifiable without a restrictive assumption on cross-world counterfactual independencies, allowing for substantive conclusions drawn from them to be validated in randomized controlled trials. Beyond the novel effects introduced, we provide a careful study of nonparametric efficiency theory relevant for the construction of flexible, multiply robust estimators of our (in)direct effects, while avoiding undue restrictions induced by assuming parametric models of nuisance parameter functionals. To complement our nonparametric estimation strategy, we introduce inferential techniques for constructing confidence intervals and hypothesis tests, and discuss open-source software, the $\texttt{medshift}$$\texttt{R}$ package, implementing the proposed methodology. Application of our (in)direct effects and their nonparametric estimators is illustrated using data from a comparative effectiveness trial examining the direct and indirect effects of pharmacological therapeutics on relapse to opioid use disorder.
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Affiliation(s)
| | - Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W. 168th Street, New York, NY 10032, USA
| | - Mark J Van Der Laan
- Division of Biostatistics, School of Public Health, and Department of Statistics, University of California, Berkeley, 2121 Berkeley Way, Berkeley, CA 94720, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, 402 E. 67th Street, New York, NY 10065, USA
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9
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Rudolph KE, Williams NT, Díaz I, Luo SX, Rotrosen J, Nunes EV. Optimally Choosing Medication Type for Patients With Opioid Use Disorder. Am J Epidemiol 2023; 192:748-756. [PMID: 36549900 PMCID: PMC10423632 DOI: 10.1093/aje/kwac217] [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: 03/07/2022] [Revised: 09/16/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Patients with opioid use disorder (OUD) tend to get assigned to one of 3 medications based on the treatment program to which the patient presents (e.g., opioid treatment programs tend to treat patients with methadone, while office-based practices tend to prescribe buprenorphine). It is possible that optimally matching patients with treatment type would reduce the risk of return to regular opioid use (RROU). We analyzed data from 3 comparative effectiveness trials from the US National Institute on Drug Abuse Clinical Trials Network (CTN0027, 2006-2010; CTN0030, 2006-2009; and CTN0051 2014-2017), in which patients with OUD (n = 1,459) were assigned to treatment with either injection extended-release naltrexone (XR-NTX), sublingual buprenorphine-naloxone (BUP-NX), or oral methadone. We learned an individualized rule by which to assign medication type such that risk of RROU during 12 weeks of treatment would be minimized, and then estimated the amount by which RROU risk could be reduced if the rule were applied. Applying our estimated treatment rule would reduce risk of RROU compared with treating everyone with methadone (relative risk (RR) = 0.79, 95% confidence interval (CI): 0.60, 0.97) or treating everyone with XR-NTX (RR = 0.71, 95% CI: 0.47, 0.96). Applying the estimated treatment rule would have resulted in a similar risk of RROU to that of with treating everyone with BUP-NX (RR = 0.92, 95% CI: 0.73, 1.11).
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Affiliation(s)
- Kara E Rudolph
- Correspondence to Dr. Kara Rudolph, 722 W. 168th Street, Room 522, New York, NY 10032 (e-mail: )
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10
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Ackerman KS, Hoffman KL, Díaz I, Simmons W, Ballman KV, Kodiyanplakkal RP, Schenck EJ. Effect of Sepsis on Death as Modified by Solid Organ Transplantation. Open Forum Infect Dis 2023; 10:ofad148. [PMID: 37056981 PMCID: PMC10086309 DOI: 10.1093/ofid/ofad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/15/2023] [Indexed: 03/20/2023] Open
Abstract
Abstract
Background
Patients with solid organ transplants (SOT) have an increased risk for sepsis compared to the general population. Paradoxically, studies suggest that SOT patients with sepsis may experience better outcomes compared to those without a SOT. However, these analyses used previous definitions of sepsis. It remains unknown whether the more recent definitions of sepsis and modern analytic approaches demonstrate a similar relationship.
Methods
Using the Weill Cornell-Critical Care Database for Advanced Research (WC-CEDAR) we analyzed granular physiologic, microbiologic, comorbidity, and therapeutic data in patients with and without SOT admitted to intensive care units (ICU’s). We used a survival analysis with a targeted minimum loss-based estimation, adjusting for within group (SOT and non-SOT) potential confounders to ascertain whether the effect of sepsis, defined by sepsis-3, on 28-day mortality was modified by SOT status. We performed additional analyses on restricted populations.
Results
We analyzed 28,431 patients: 439 with SOT and sepsis, 281 with SOT without sepsis, 6793 with sepsis and without SOT, and 20918 with neither. The most common SOT types were kidney (475) and liver (163). Despite a higher severity of illness in both sepsis groups, the adjusted sepsis-attributable effect on 28-day mortality for non-SOT patients was 4.1% (3.8, 4.5) and -14.4% (-16.8, -12) for SOT patients. The adjusted SOT effect modification was -18.5% (-21.2, -15.9). The adjusted sepsis-attributable effect for immunocompromised controls was -3.5% (-4.5, -2.6).
Conclusions
Across a large database of patients admitted to ICU’s, the sepsis associated 28-day mortality effect was significantly lower in SOT patients compared to controls.
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Affiliation(s)
- Kevin S Ackerman
- Department of Medicine, Hospital of the University of Pennsylvania , Philadelphia, PA , USA
| | - Katherine L Hoffman
- Department of Population Health Sciences, Division of Biostatistics, Weill Cornell Medicine , New York, NY , USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine , New York, NY , USA
| | - Will Simmons
- Department of Population Health Sciences, Division of Biostatistics, Weill Cornell Medicine , New York, NY , USA
| | - Karla V Ballman
- Department of Population Health Sciences, Division of Biostatistics, Weill Cornell Medicine , New York, NY , USA
| | - Rosy P Kodiyanplakkal
- Division of Infectious Diseases, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine , New York, NY , USA
- NewYork-Presbyterian Hospital, Weill Cornell Medicine , New York, NY , USA
| | - Edward J Schenck
- NewYork-Presbyterian Hospital, Weill Cornell Medicine , New York, NY , USA
- Division of Pulmonary & Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine , New York, NY , USA
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11
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Kamel H, Liberman AL, Merkler AE, Parikh NS, Mir SA, Segal AZ, Zhang C, Díaz I, Navi BB. Validation of the International Classification of Diseases, Tenth Revision Code for the National Institutes of Health Stroke Scale Score. Circ Cardiovasc Qual Outcomes 2023; 16:e009215. [PMID: 36862375 PMCID: PMC10237010 DOI: 10.1161/circoutcomes.122.009215] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/24/2022] [Indexed: 03/03/2023]
Abstract
BACKGROUND Administrative data can be useful for stroke research but have historically lacked data on stroke severity. Hospitals increasingly report the National Institutes of Health Stroke Scale (NIHSS) score using an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code, but this code's validity remains unclear. METHODS We examined the concordance of ICD-10 NIHSS scores versus NIHSS scores recorded in CAESAR (Cornell Acute Stroke Academic Registry). We included all patients with acute ischemic stroke from October 1, 2015, when US hospitals transitioned to ICD-10, through 2018, the latest year in our registry. The NIHSS score (range, 0-42) recorded in our registry served as the reference gold standard. ICD-10 NIHSS scores were derived from hospital discharge diagnosis code R29.7xx, with the latter 2 digits representing the NIHSS score. Multiple logistic regression was used to explore factors associated with availability of ICD-10 NIHSS scores. We used ANOVA to examine the proportion of variation (R2) in the true (registry) NIHSS score that was explained by the ICD-10 NIHSS score. RESULTS Among 1357 patients, 395 (29.1%) had an ICD-10 NIHSS score recorded. This proportion increased from 0% in 2015 to 46.5% in 2018. In a logistic regression model, only higher registry NIHSS score (odds ratio per point, 1.05 [95% CI, 1.03-1.07]) and cardioembolic stroke (odds ratio, 1.4 [95% CI, 1.0-2.0]) were associated with availability of the ICD-10 NIHSS score. In an ANOVA model, the ICD-10 NIHSS score explained almost all the variation in the registry NIHSS score (R2=0.88). Fewer than 10% of patients had a large discordance (≥4 points) between their ICD-10 and registry NIHSS scores. CONCLUSIONS When present, ICD-10 codes representing NIHSS scores had excellent agreement with NIHSS scores recorded in our stroke registry. However, ICD-10 NIHSS scores were often missing, especially in less severe strokes, limiting the reliability of these codes for risk adjustment.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Neal S. Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Saad A. Mir
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Alan Z. Segal
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Iván Díaz
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
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12
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Goyal P, Schenck E, Wu Y, Zhang Y, Visaria A, Orlander D, Xi W, Díaz I, Morozyuk D, Weiner M, Kaushal R, Banerjee S. Influence of social deprivation index on in-hospital outcomes of COVID-19. Sci Rep 2023; 13:1746. [PMID: 36720999 PMCID: PMC9887560 DOI: 10.1038/s41598-023-28362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 01/17/2023] [Indexed: 02/01/2023] Open
Abstract
While it is known that social deprivation index (SDI) plays an important role on risk for acquiring Coronavirus Disease 2019 (COVID-19), the impact of SDI on in-hospital outcomes such as intubation and mortality are less well-characterized. We analyzed electronic health record data of adults hospitalized with confirmed COVID-19 between March 1, 2020 and February 8, 2021 from the INSIGHT Clinical Research Network (CRN). To compute the SDI (exposure variable), we linked clinical data using patient's residential zip-code with social data at zip-code tabulation area. SDI is a composite of seven socioeconomic characteristics determinants at the zip-code level. For this analysis, we categorized SDI into quintiles. The two outcomes of interest were in-hospital intubation and mortality. For each outcome, we examined logistic regression and random forests to determine incremental value of SDI in predicting outcomes. We studied 30,016 included COVID-19 patients. In a logistic regression model for intubation, a model including demographics, comorbidity, and vitals had an Area under the receiver operating characteristic curve (AUROC) = 0.73 (95% CI 0.70-0.75); the addition of SDI did not improve prediction [AUROC = 0.73 (95% CI 0.71-0.75)]. In a logistic regression model for in-hospital mortality, demographics, comorbidity, and vitals had an AUROC = 0.80 (95% CI 0.79-0.82); the addition of SDI in Model 2 did not improve prediction [AUROC = 0.81 (95% CI 0.79-0.82)]. Random forests revealed similar findings. SDI did not provide incremental improvement in predicting in-hospital intubation or mortality. SDI plays an important role on who acquires COVID-19 and its severity; but once hospitalized, SDI appears less important.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medical College, 1320 York Avenue, New York, NY, 10021, USA.,NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA
| | - Edward Schenck
- Department of Medicine, Weill Cornell Medical College, 1320 York Avenue, New York, NY, 10021, USA.,NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA
| | - Yiyuan Wu
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Yongkang Zhang
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Aayush Visaria
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ, USA
| | - Duncan Orlander
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Wenna Xi
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Iván Díaz
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Dmitry Morozyuk
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Mark Weiner
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA
| | - Rainu Kaushal
- Department of Medicine, Weill Cornell Medical College, 1320 York Avenue, New York, NY, 10021, USA.,NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY, 10065, USA.,Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Samprit Banerjee
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61St Street, New York, NY, 10065, USA. .,, New York, USA.
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13
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Rudolph KE, Díaz I. When the Ends do not Justify the Means: Learning Who is Predicted to Have Harmful Indirect Effects. J R Stat Soc Ser A Stat Soc 2022; 185:S573-S589. [PMID: 37397280 PMCID: PMC10312488 DOI: 10.1111/rssa.12951] [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] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
There is a growing literature on finding rules by which to assign treatment based on an individual's characteristics such that a desired outcome under the intervention is maximized. A related goal entails identifying a subpopulation of individuals predicted to have a harmful indirect effect (the effect of treatment on an outcome through mediators), perhaps even in the presence of a predicted beneficial total treatment effect. In some cases, the implications of a likely harmful indirect effect may outweigh an anticipated beneficial total treatment effect, and would motivate further discussion of whether to treat identified individuals. We build on the mediation and optimal treatment rule literatures to propose a method of identifying a subgroup for which the treatment effect through the mediator is expected to be harmful. Our approach is nonparametric, incorporates post-treatment confounders of the mediator-outcome relationship, and does not make restrictions on the distribution of baseline covariates, mediating variables, or outcomes. We apply the proposed approach to identify a subgroup of boys in the MTO housing voucher experiment who are predicted to have a harmful indirect effect of housing voucher receipt on subsequent psychiatric disorder incidence through aspects of their school and neighborhood environments.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine
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14
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Ardila DM, Rodríguez DF, Palma A, Díaz I, Cobo J, Glidewell C. Synthesis, and spectroscopic and structural characterization of three new styrylquinoline–benzimidazole hybrids. Acta Crystallogr C 2022; 78:671-680. [DOI: 10.1107/s2053229622010063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Three new 4-styrylquinoline–benzimidazole hybrids have been synthesized using a reaction sequence in which 2-methylquinoline precursors first undergo selective oxidation by selenium dioxide to form the corresponding 2-formylquinoline intermediates, followed by oxidative cyclocondensation reactions with benzene-1,2-diamine to yield the hybrid products. The formyl intermediates and the hybrid products have all been fully characterized using a combination of IR, 1H and 13C NMR spectroscopy, and high-resolution mass spectrometry, and the structures of the three hybrid products have been determined using single-crystal X-ray diffraction. Ethyl (E)-2-(1H-benzo[d]imidazol-2-yl)-4-(4-chlorostyryl)quinoline-3-carboxylate, C27H20ClN3O2, (IIIa), and ethyl (E)-2-(1H-benzo[d]imidazol-2-yl)-4-(2-methoxystyryl)quinoline-3-carboxylate, C28H23N3O3, (IIIb), both crystallize in the solvent-free form with Z′ = 1, but ethyl (E)-2-(1H-benzo[d]imidazol-2-yl)-4-(4-methylstyryl)quinoline-3-carboxylate, C28H23N3O2, (IIIc), crystallizes as a partial hexane solvate with Z′ = 3, and the ester group in one of the independent molecules is disordered over two sets of atomic sites having occupancies of 0.765 (7) and 0.235 (7). The molecules of (IIIc) enclose continuous channels which are occupied by disordered solvent molecules having partial occupancy. In all of the molecules of (IIIa)–(IIIc), the styrylquinoline fragment is markedly nonplanar. Different combinations of N—H...O and C—H...π hydrogen bonds generate supramolecular assemblies which are two-dimensional in (IIIb) and (IIIc), but three-dimensional in (IIIa). Comparisons are made with the structures of some related compounds.
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15
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Ogburn EL, Sofrygin O, Díaz I, van der Laan MJ. Causal Inference for Social Network Data. J Am Stat Assoc 2022. [DOI: 10.1080/01621459.2022.2131557] [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: 10/17/2022]
Affiliation(s)
- Elizabeth L. Ogburn
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Oleg Sofrygin
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
| | - Iván Díaz
- Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - Mark J. van der Laan
- Department of Biostatistics, University of California Berkeley, 2121 Berkeley Way, Berkeley, CA, 94720, USA
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16
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Hoffman KL, Schenck EJ, Satlin MJ, Whalen W, Pan D, Williams N, Díaz I. Comparison of a Target Trial Emulation Framework vs Cox Regression to Estimate the Association of Corticosteroids With COVID-19 Mortality. JAMA Netw Open 2022; 5:e2234425. [PMID: 36190729 PMCID: PMC9530966 DOI: 10.1001/jamanetworkopen.2022.34425] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Communication and adoption of modern study design and analytical techniques is of high importance for the improvement of clinical research from observational data. OBJECTIVE To compare a modern method for statistical inference, including a target trial emulation framework and doubly robust estimation, with approaches common in the clinical literature, such as Cox proportional hazards models. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used longitudinal electronic health record data for outcomes at 28-days from time of hospitalization within a multicenter New York, New York, hospital system. Participants included adult patients hospitalized between March 1 and May 15, 2020, with COVID-19 and not receiving corticosteroids for chronic use. Data were analyzed from October 2021 to March 2022. EXPOSURES Corticosteroid exposure was defined as more than 0.5 mg/kg methylprednisolone equivalent in a 24-hour period. For target trial emulation, exposures were corticosteroids for 6 days if and when a patient met criteria for severe hypoxia vs no corticosteroids. For approaches common in clinical literature, treatment definitions used for variables in Cox regression models varied by study design (no time frame, 1 day, and 5 days from time of severe hypoxia). MAIN OUTCOMES AND MEASURES The main outcome was 28-day mortality from time of hospitalization. The association of corticosteroids with mortality for patients with moderate to severe COVID-19 was assessed using the World Health Organization (WHO) meta-analysis of corticosteroid randomized clinical trials as a benchmark. RESULTS A total of 3298 patients (median [IQR] age, 65 [53-77] years; 1970 [60%] men) were assessed, including 423 patients who received corticosteroids at any point during hospitalization and 699 patients who died within 28 days of hospitalization. Target trial emulation analysis found corticosteroids were associated with a reduced 28-day mortality rate, from 32.2%; (95% CI, 30.9%-33.5%) to 25.7% (95% CI, 24.5%-26.9%). This estimate is qualitatively identical to the WHO meta-analysis odds ratio of 0.66 (95% CI, 0.53-0.82). Hazard ratios using methods comparable with current corticosteroid research range in size and direction, from 0.50 (95% CI, 0.41-0.62) to 1.08 (95% CI, 0.80-1.47). CONCLUSIONS AND RELEVANCE These findings suggest that clinical research based on observational data can be used to estimate findings similar to those from randomized clinical trials; however, the correctness of these estimates requires designing the study and analyzing the data based on principles that are different from the current standard in clinical research.
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Affiliation(s)
- Katherine L. Hoffman
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Edward J. Schenck
- Division of Pulmonary and Critical Care, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Michael J. Satlin
- Division of Infectious Disease, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - William Whalen
- Division of Pulmonary and Critical Care, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Di Pan
- Division of Pulmonary and Critical Care, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Nicholas Williams
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, New York
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
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17
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Rudolph KE, Williams NT, Goodwin ATS, Shulman M, Fishman M, Díaz I, Luo S, Rotrosen J, Nunes EV. Buprenorphine & methadone dosing strategies to reduce risk of relapse in the treatment of opioid use disorder. Drug Alcohol Depend 2022; 239:109609. [PMID: 36075154 PMCID: PMC9741946 DOI: 10.1016/j.drugalcdep.2022.109609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although there is consensus that having a "high-enough" dose of buprenorphine (BUP-NX) or methadone is important for reducing relapse to opioid use, there is debate about what this dose is and how it should be attained. We estimated the extent to which different dosing strategies would affect risk of relapse over 12 weeks of treatment, separately for BUP-NX and methadone. METHODS This was a secondary analysis of three comparative effectiveness trials. We examined four dosing strategies: 1) increasing dose in response to participant-specific opioid use, 2) increasing dose weekly until some minimum dose (16 mg BUP, 100 mg methadone) was reached, 3) increasing dose weekly until some minimum and increasing dose in response to opioid use thereafter (referred to as the "hybrid strategy"), and 4) keeping dose constant after the first 2 weeks of treatment. We used a longitudinal sequentially doubly robust estimator to estimate contrasts between dosing strategies on risk of relapse. RESULTS For BUP-NX, increasing dose following the hybrid strategy resulted in the lowest risk of relapse. For methadone, holding dose constant resulted in greatest risk of relapse; the other three strategies performed similarly. For example, the hybrid strategy reduced week 12 relapse risk by 13 % (RR: 0.87, 95 %CI: 0.83-0.95) and by 20 % (RR: 0.80, 95 %CI: 0.71-0.90) for BUP-NX and methadone respectively, as compared to holding dose constant. CONCLUSIONS Doses should be targeted toward minimum thresholds and, in the case of BUP-NX, raised when patients continue to use opioids.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Nicholas T Williams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Alicia T Singham Goodwin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, and Maryland Treatment Centers, Baltimore, MD, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Sean Luo
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Edward V Nunes
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
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18
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Williams N, Rosenblum M, Díaz I. Optimising precision and power by machine learning in randomised trials with ordinal and time-to-event outcomes with an application to COVID-19. J R Stat Soc Ser A Stat Soc 2022; 185:RSSA12915. [PMID: 36246572 PMCID: PMC9539267 DOI: 10.1111/rssa.12915] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 05/23/2022] [Accepted: 07/05/2022] [Indexed: 05/23/2023]
Abstract
The rapid finding of effective therapeutics requires efficient use of available resources in clinical trials. Covariate adjustment can yield statistical estimates with improved precision, resulting in a reduction in the number of participants required to draw futility or efficacy conclusions. We focus on time-to-event and ordinal outcomes. When more than a few baseline covariates are available, a key question for covariate adjustment in randomised studies is how to fit a model relating the outcome and the baseline covariates to maximise precision. We present a novel theoretical result establishing conditions for asymptotic normality of a variety of covariate-adjusted estimators that rely on machine learning (e.g.,ℓ 1 -regularisation, Random Forests, XGBoost, and Multivariate Adaptive Regression Splines [MARS]), under the assumption that outcome data are missing completely at random. We further present a consistent estimator of the asymptotic variance. Importantly, the conditions do not require the machine learning methods to converge to the true outcome distribution conditional on baseline variables, as long as they converge to some (possibly incorrect) limit. We conducted a simulation study to evaluate the performance of the aforementioned prediction methods in COVID-19 trials. Our simulation is based on resampling longitudinal data from over 1500 patients hospitalised with COVID-19 at Weill Cornell Medicine New York Presbyterian Hospital. We found that usingℓ 1 -regularisation led to estimators and corresponding hypothesis tests that control type 1 error and are more precise than an unadjusted estimator across all sample sizes tested. We also show that when covariates are not prognostic of the outcome,ℓ 1 -regularisation remains as precise as the unadjusted estimator, even at small sample sizes (n = 100 ). We give an R package adjrct that performs model-robust covariate adjustment for ordinal and time-to-event outcomes.
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Affiliation(s)
- Nicholas Williams
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew York CityNew YorkUSA
| | - Michael Rosenblum
- Department of BiostatisticsJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Iván Díaz
- Division of Biostatistics, Department of Population HealthNew York University Grossman School of MedicineNew York CityNew YorkUSA
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Rudolph KE, Gimbrone C, Matthay EC, Díaz I, Davis CS, Keyes K, Cerdá M. When Effects Cannot be Estimated: Redefining Estimands to Understand the Effects of Naloxone Access Laws. Epidemiology 2022; 33:689-698. [PMID: 35944151 PMCID: PMC9373236 DOI: 10.1097/ede.0000000000001502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Violations of the positivity assumption (also called the common support condition) challenge health policy research and can result in significant bias, large variance, and invalid inference. We define positivity in the single- and multiple-timepoint (i.e., longitudinal) health policy evaluation setting, and discuss real-world threats to positivity. We show empirical evidence of the practical positivity violations that can result when attempting to estimate the effects of health policies (in this case, Naloxone Access Laws). In such scenarios, an alternative is to estimate the effect of a shift in law enactment (e.g., the effect if enactment had been delayed by some number of years). Such an effect corresponds to what is called a modified treatment policy, and dramatically weakens the required positivity assumption, thereby offering a means to estimate policy effects even in scenarios with serious positivity problems. We apply the approach to define and estimate the longitudinal effects of Naloxone Access Laws on opioid overdose rates.
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Affiliation(s)
- Kara E. Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Catherine Gimbrone
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Ellicott C. Matthay
- Center for Health and Community, School of Medicine, University of California, San Francisco
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | | | - Katherine Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, School of Medicine, New York University, New York, New York
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20
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Hoffman KL, Schenck EJ, Satlin MJ, Whalen W, Pan D, Williams N, Díaz I. Comparison of a Target Trial Emulation Framework to Cox Regression to Estimate the Effect of Corticosteroids on COVID-19 Mortality. medRxiv 2022:2022.05.27.22275037. [PMID: 35702149 PMCID: PMC9196111 DOI: 10.1101/2022.05.27.22275037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Communication and adoption of modern study design and analytical techniques is of high importance for the improvement of clinical research from observational data. Objective To compare (1) a modern method for causal inference including a target trial emulation framework and doubly robust estimation to (2) approaches common in the clinical literature such as Cox proportional hazards models. To do this, we estimate the effect of corticosteroids on mortality for moderate-to-severe coronavirus disease 2019 (COVID-19) patients. We use the World Health Organization's (WHO) meta-analysis of corticosteroid randomized controlled trials (RCTs) as a benchmark. Design Retrospective cohort study using longitudinal electronic health record data for 28 days from time of hospitalization. Settings Multi-center New York City hospital system. Participants Adult patients hospitalized between March 1-May 15, 2020 with COVID-19 and not on corticosteroids for chronic use. Intervention Corticosteroid exposure defined as >0.5mg/kg methylprednisolone equivalent in a 24-hour period. For target trial emulation, interventions are (1) corticosteroids for six days if and when patient meets criteria for severe hypoxia and (2) no corticosteroids. For approaches common in clinical literature, treatment definitions used for variables in Cox regression models vary by study design (no time frame, one-, and five-days from time of severe hypoxia). Main outcome 28-day mortality from time of hospitalization. Results 3,298 patients (median age 65 (IQR 53-77), 60% male). 423 receive corticosteroids at any point during hospitalization, 699 die within 28 days of hospitalization. Target trial emulation estimates corticosteroids to reduce 28-day mortality from 32.2% (95% CI 30.9-33.5) to 25.7% (24.5-26.9). This estimate is qualitatively identical to the WHO's RCT meta-analysis odds ratio of 0.66 (0.53-0.82)). Hazard ratios using methods comparable to current corticosteroid research range in size and direction from 0.50 (0.41-0.62) to 1.08 (0.80-1.47). Conclusion and Relevance Clinical research based on observational data can unveil true causal relationships; however, the correctness of these effect estimates requires designing the study and analyzing the data based on principles which are different from the current standard in clinical research.
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Affiliation(s)
- Katherine L Hoffman
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Edward J Schenck
- Division of Pulmonary and Critical Care, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Michael J Satlin
- Division of Infectious Disease, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - William Whalen
- Division of Pulmonary and Critical Care, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Di Pan
- Division of Pulmonary and Critical Care, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Nicholas Williams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
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21
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Díaz I, Salido S, Nogueras M, Cobo J. Design and Synthesis of New Pyrimidine-Quinolone Hybrids as Novel hLDHA Inhibitors. Pharmaceuticals (Basel) 2022; 15:ph15070792. [PMID: 35890090 PMCID: PMC9322123 DOI: 10.3390/ph15070792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/17/2022] [Accepted: 06/18/2022] [Indexed: 02/05/2023] Open
Abstract
A battery of novel pyrimidine-quinolone hybrids was designed by docking scaffold replacement as lactate dehydrogenase A (hLDHA) inhibitors. Structures with different linkers between the pyrimidine and quinolone scaffolds (10-21 and 24−31) were studied in silico, and those with the 2-aminophenylsulfide (U-shaped) and 4-aminophenylsulfide linkers (24−31) were finally selected. These new pyrimidine-quinolone hybrids (24−31)(a−c) were easily synthesized in good to excellent yields by a green catalyst-free microwave-assisted aromatic nucleophilic substitution reaction between 3-(((2/4-aminophenyl)thio)methyl)quinolin-2(1H)-ones 22/23(a−c) and 4-aryl-2-chloropyrimidines (1−4). The inhibitory activity against hLDHA of the synthesized hybrids was evaluated, resulting IC50 values of the U-shaped hybrids 24−27(a−c) much better than the ones of the 1,4-linked hybrids 28−31(a−c). From these results, a preliminary structure−activity relationship (SAR) was established, which enabled the design of novel 1,3-linked pyrimidine-quinolone hybrids (33−36)(a−c). Compounds 35(a−c), the most promising ones, were synthesized and evaluated, fitting the experimental results with the predictions from docking analysis. In this way, we obtained novel pyrimidine-quinolone hybrids (25a, 25b, and 35a) with good IC50 values (<20 μM) and developed a preliminary SAR.
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22
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Alcántara I, Somma A, Chalar G, Fabre A, Segura A, Achkar M, Arocena R, Aubriot L, Baladán C, Barrios M, Bonilla S, Burwood M, Calliari DL, Calvo C, Capurro L, Carballo C, Céspedes-Payret C, Conde D, Corrales N, Cremella B, Crisci C, Cuevas J, De Giacomi S, De León L, Delbene L, Díaz I, Fleitas V, González-Bergonzoni I, González-Madina L, González-Piana M, Goyenola G, Gutiérrez O, Haakonsson S, Iglesias C, Kruk C, Lacerot G, Langone J, Lepillanca F, Lucas C, Martigani F, Martínez de la Escalera G, Meerhoff M, Nogueira L, Olano H, Pacheco JP, Panario D, Piccini C, Quintans F, Teixeira de Mello F, Terradas L, Tesitore G, Vidal L, García-Rodríguez F. A reply to "Relevant factors in the eutrophication of the Uruguay River and the Río Negro". Sci Total Environ 2022; 818:151854. [PMID: 34826482 DOI: 10.1016/j.scitotenv.2021.151854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/02/2021] [Accepted: 11/17/2021] [Indexed: 06/13/2023]
Abstract
A recent paper by Beretta-Blanco and Carrasco-Letelier (2021) claims that agricultural eutrophication is not one of the main causes for cyanobacterial blooms in rivers and artificial reservoirs. By combining rivers of markedly different hydrological characteristics e.g., presence/absence and number of dams, river discharge and geological setting, the study speculates about the role of nutrients for modulating phytoplankton chlorophyll-a. Here, we identified serious flaws, from erratic and inaccurate data manipulation. The study did not define how erroneous original dataset values were treated, how the variables below the detection/quantification limit were numerically introduced, lack of mandatory variables for river studies such as flow and rainfall, arbitrary removal of pH > 7.5 values (which were not outliers), and finally how extreme values of other environmental variables were included. In addition, we identified conceptual and procedural mistakes such as biased construction/evaluation of model prediction capability. The study trained the model using pooled data from a short restricted lotic section of the (large) Uruguay River and from both lotic and reservoir domains of the Negro River, but then tested predictability within the (small) Cuareim River. Besides these methodological considerations, the article shows misinterpretations of the statistical correlation of cause and effect neglecting basic limnological knowledge of the ecology of harmful algal blooms (HABs) and international research on land use effects on freshwater quality. The argument that pH is a predictor variable for HABs neglects overwhelming basic paradigms of carbon fluxes and change in pH because of primary productivity. As a result, the article introduces the notion that HABs formation are not related to agricultural land use and water residence time and generate a great risk for the management of surface waterbodies. This reply also emphasizes the need for good practices of open data management, especially for public databases in view of external reproducibility.
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Affiliation(s)
- I Alcántara
- Ud. Bioestadística, Departamento de Salud Pública, Facultad de Veterinaria, Universidad de la República, Montevideo, Uruguay
| | - A Somma
- Polo de Ecología Fluvial, CENUR Litoral Norte sede Paysandú, Universidad de la República, Paysandú, Uruguay; Unidad Usinas de Montevideo, Área Tratamiento - Obras Sanitarias del Estado, Aguas Corrientes, Canelones, Uruguay
| | - G Chalar
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - A Fabre
- ITR Suroeste, Universidad Tecnológica, La Paz, Colonia, Uruguay
| | - A Segura
- Modelización y Análisis de Recursos Naturales, Centro Universitario Regional del Este, Universidad de la República, Rocha, Uruguay
| | - M Achkar
- LDSGAT, IECA, Facultad de Ciencias, Universidad de la República, Montevideo, Uruguay
| | - R Arocena
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - L Aubriot
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - C Baladán
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - M Barrios
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - S Bonilla
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - M Burwood
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - D L Calliari
- Sección Oceanografía y Ecología Marina, IECA, Facultad de Ciencias, Universidad de la República, Montevideo, Uruguay
| | - C Calvo
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - L Capurro
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - C Carballo
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - C Céspedes-Payret
- UNCIEP, IECA, Facultad de Ciencias, Universidad de la República, Montevideo, Uruguay
| | - D Conde
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - N Corrales
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - B Cremella
- Laboratory of Environmental Analysis, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - C Crisci
- Modelización y Análisis de Recursos Naturales, Centro Universitario Regional del Este, Universidad de la República, Rocha, Uruguay
| | - J Cuevas
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - S De Giacomi
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - L De León
- Ministerio de Ambiente - Dirección Nacional de Calidad y Evaluación Ambiental, Uruguay
| | - L Delbene
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - I Díaz
- LDSGAT, IECA, Facultad de Ciencias, Universidad de la República, Montevideo, Uruguay
| | - V Fleitas
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - I González-Bergonzoni
- Polo de Ecología Fluvial, CENUR Litoral Norte sede Paysandú, Universidad de la República, Paysandú, Uruguay
| | - L González-Madina
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay; Unidad Usinas de Montevideo, Área Tratamiento - Obras Sanitarias del Estado, Aguas Corrientes, Canelones, Uruguay
| | - M González-Piana
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - G Goyenola
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - O Gutiérrez
- UNCIEP, IECA, Facultad de Ciencias, Universidad de la República, Montevideo, Uruguay
| | - S Haakonsson
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - C Iglesias
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - C Kruk
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay; Modelización y Análisis de Recursos Naturales, Centro Universitario Regional del Este, Universidad de la República, Rocha, Uruguay
| | - G Lacerot
- Ecología Funcional de Sistemas Acuáticos, Centro Universitario Regional del Este, Universidad de la República, Uruguay
| | - J Langone
- Unidad Usinas de Montevideo, Área Tratamiento - Obras Sanitarias del Estado, Aguas Corrientes, Canelones, Uruguay
| | - F Lepillanca
- Departamento de Microbiología, Instituto de Investigaciones Biológicas Clemente Estable, Ministerio de Educación y Cultura, Montevideo, Uruguay
| | - C Lucas
- Polo de Ecología Fluvial, CENUR Litoral Norte sede Paysandú, Universidad de la República, Paysandú, Uruguay
| | - F Martigani
- Área Hidrobiología, Gerencia de Gestión de Laboratorios, OSE, Montevideo, Uruguay
| | - G Martínez de la Escalera
- Departamento de Microbiología, Instituto de Investigaciones Biológicas Clemente Estable, Ministerio de Educación y Cultura, Montevideo, Uruguay
| | - M Meerhoff
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay; Department of Biosciences, Aarhus University, Silkeborg, Denmark
| | - L Nogueira
- Unidad Usinas de Montevideo, Área Tratamiento - Obras Sanitarias del Estado, Aguas Corrientes, Canelones, Uruguay
| | - H Olano
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - J P Pacheco
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - D Panario
- UNCIEP, IECA, Facultad de Ciencias, Universidad de la República, Montevideo, Uruguay
| | - C Piccini
- Departamento de Microbiología, Instituto de Investigaciones Biológicas Clemente Estable, Ministerio de Educación y Cultura, Montevideo, Uruguay
| | - F Quintans
- Sección Limnología, IECA, Facultad de Ciencias, Universidad de la Republica, Montevideo, Uruguay
| | - F Teixeira de Mello
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - L Terradas
- UNCIEP, IECA, Facultad de Ciencias, Universidad de la República, Montevideo, Uruguay
| | - G Tesitore
- Departamento de Ecología y Gestión Ambiental, Centro Universitario Regional del Este, Universidad de la República, Maldonado, Uruguay
| | - L Vidal
- Área Hidrobiología, Gerencia de Gestión de Laboratorios, OSE, Montevideo, Uruguay
| | - F García-Rodríguez
- Departamento de Geociencias, Centro Universitario Regional del Este, Universidad de la República, Rocha, Uruguay; Instituto de Oceanografia, Universidade Federal do Rio Grande (FURG), Rio Grande, Brazil.
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Masterson Creber RM, Daniels B, Munjal K, Reading Turchioe M, Shafran Topaz L, Goytia C, Díaz I, Goyal P, Weiner M, Yu J, Khullar D, Slotwiner D, Ramasubbu K, Kaushal R. Using Mobile Integrated Health and telehealth to support transitions of care among patients with heart failure (MIGHTy-Heart): protocol for a pragmatic randomised controlled trial. BMJ Open 2022; 12:e054956. [PMID: 35273051 PMCID: PMC8915277 DOI: 10.1136/bmjopen-2021-054956] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/16/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Nearly one-quarter of patients discharged from the hospital with heart failure (HF) are readmitted within 30 days, placing a significant burden on patients, families and health systems. The objective of the 'Using Mobile Integrated Health and Telehealth to support transitions of care among patients with Heart failure' (MIGHTy-Heart) study is to compare the effectiveness of two postdischarge interventions on healthcare utilisation, patient-reported outcomes and healthcare quality among patients with HF. METHODS AND ANALYSIS The MIGHTy-Heart study is a pragmatic comparative effectiveness trial comparing two interventions demonstrated to improve the hospital to home transition for patients with HF: mobile integrated health (MIH) and transitions of care coordinators (TOCC). The MIH intervention bundles home visits from a community paramedic (CP) with telehealth video visits by emergency medicine physicians to support the management of acute symptoms and postdischarge care coordination. The TOCC intervention consists of follow-up phone calls from a registered nurse within 48-72 hours of discharge to assess a patient's clinical status, identify unmet clinical and social needs and reinforce patient education (eg, medication adherence and lifestyle changes). MIGHTy-Heart is enrolling and randomising (1:1) 2100 patients with HF who are discharged to home following a hospitalisation in two New York City (NY, USA) academic health systems. The coprimary study outcomes are all-cause 30-day hospital readmissions and quality of life measured with the Kansas City Cardiomyopathy Questionnaire 30 days after hospital discharge. The secondary endpoints are days at home, preventable emergency department visits, unplanned hospital admissions and patient-reported symptoms. Data sources for the study outcomes include patient surveys, electronic health records and claims submitted to Medicare and Medicaid. ETHICS AND DISSEMINATION All participants provide written or verbal informed consent prior to randomisation in English, Spanish, French, Mandarin or Russian. Study findings are being disseminated to scientific audiences through peer-reviewed publications and presentations at national and international conferences. This study has been approved by: Biomedical Research Alliance of New York (BRANY #20-08-329-380), Weill Cornell Medicine Institutional Review Board (20-08022605) and Mt. Sinai Institutional Review Board (20-01901). TRIAL REGISTRATION NUMBER Clinicaltrials.gov, NCT04662541.
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Affiliation(s)
| | - Brock Daniels
- Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Kevin Munjal
- Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Leah Shafran Topaz
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Crispin Goytia
- Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Iván Díaz
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Parag Goyal
- Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Mark Weiner
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Jiani Yu
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Dhruv Khullar
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - David Slotwiner
- Medicine, Weill Cornell Medical College, New York, New York, USA
- Medicine, NewYork-Presbyterian Queens, Flushing, New York, USA
| | - Kumudha Ramasubbu
- Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Rainu Kaushal
- Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
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24
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Arredondo C, Cefaliello C, Dyrda A, Jury N, Martinez P, Díaz I, Amaro A, Tran H, Morales D, Pertusa M, Stoica L, Fritz E, Corvalán D, Abarzúa S, Méndez-Ruette M, Fernández P, Rojas F, Kumar MS, Aguilar R, Almeida S, Weiss A, Bustos FJ, González-Nilo F, Otero C, Tevy MF, Bosco DA, Sáez JC, Kähne T, Gao FB, Berry JD, Nicholson K, Sena-Esteves M, Madrid R, Varela D, Montecino M, Brown RH, van Zundert B. Excessive release of inorganic phosphate by ALS/FTD astrocytes causes non-cell-autonomous toxicity to motoneurons. Neuron 2022; 110:1656-1670.e12. [PMID: 35276083 DOI: 10.1016/j.neuron.2022.02.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [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: 08/24/2020] [Revised: 10/01/2021] [Accepted: 02/15/2022] [Indexed: 12/13/2022]
Abstract
Non-cell-autonomous mechanisms contribute to neurodegenerative diseases such as amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD), in which astrocytes release unidentified factors that are toxic to motoneurons (MNs). We report here that mouse and patient iPSC-derived astrocytes with diverse ALS/FTD-linked mutations (SOD1, TARDBP, and C9ORF72) display elevated levels of intracellular inorganic polyphosphate (polyP), a ubiquitous, negatively charged biopolymer. PolyP levels are also increased in astrocyte-conditioned media (ACM) from ALS/FTD astrocytes. ACM-mediated MN death is prevented by degrading or neutralizing polyP in ALS/FTD astrocytes or ACM. Studies further reveal that postmortem familial and sporadic ALS spinal cord sections display enriched polyP staining signals and that ALS cerebrospinal fluid (CSF) exhibits increased polyP concentrations. Our in vitro results establish excessive astrocyte-derived polyP as a critical factor in non-cell-autonomous MN degeneration and a potential therapeutic target for ALS/FTD. The CSF data indicate that polyP might serve as a new biomarker for ALS/FTD.
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Affiliation(s)
- Cristian Arredondo
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Carolina Cefaliello
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Agnieszka Dyrda
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Nur Jury
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Pablo Martinez
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Iván Díaz
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Armando Amaro
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Helene Tran
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Danna Morales
- Program of Physiology and Biophysics, Institute of Biomedical Sciences, Faculty of Medicine, Universidad de Chile, Santiago 8380453, Chile; Millennium Nucleus of Ion Channels-Associated Diseases (MiNICAD), Santiago 9160000, Chile
| | - Maria Pertusa
- Millennium Nucleus of Ion Channels-Associated Diseases (MiNICAD), Santiago 9160000, Chile; Millennium Nucleus for the Study of Pain (MiNuSPain), Santiago 9160000, Chile; Department of Biology, Faculty of Chemistry and Biology, Universidad de Santiago de Chile, Santiago 9160000, Chile
| | - Lorelei Stoica
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Elsa Fritz
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Daniela Corvalán
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Sebastián Abarzúa
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile; FONDAP Center for Genome Regulation, Santiago 8370146, Chile
| | - Maxs Méndez-Ruette
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Paola Fernández
- Instituto de Neurociencias, Centro Interdisciplinario de Neurociencias de Valparaíso, Universidad de Valparaíso, Valparaíso 2340000, Chile
| | - Fabiola Rojas
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Meenakshi Sundaram Kumar
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Rodrigo Aguilar
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile
| | - Sandra Almeida
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Alexandra Weiss
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Fernando J Bustos
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile
| | - Fernando González-Nilo
- Instituto de Neurociencias, Centro Interdisciplinario de Neurociencias de Valparaíso, Universidad de Valparaíso, Valparaíso 2340000, Chile; Center for Bioinformatics and Integrative Biology (CBIB), Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile
| | - Carolina Otero
- School of Chemistry and Pharmacy, Faculty of Medicine, Universidad Andres Bello, Santiago 8320000, Chile
| | - Maria Florencia Tevy
- Cell Biology Laboratory, INTA, University of Chile and GEDIS Biotech, Santiago 7810000, Chile
| | - Daryl A Bosco
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Juan C Sáez
- Instituto de Neurociencias, Centro Interdisciplinario de Neurociencias de Valparaíso, Universidad de Valparaíso, Valparaíso 2340000, Chile
| | - Thilo Kähne
- Institute of Experimental Internal Medicine, Medical School, Otto von Guericke University Magdeburg, Magdeburg 39120, Germany
| | - Fen-Biao Gao
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - James D Berry
- Massachusetts General Hospital Neurological Clinical Research Institute and Harvard Medical School, Boston, MA 02114, USA
| | - Katharine Nicholson
- Massachusetts General Hospital Neurological Clinical Research Institute and Harvard Medical School, Boston, MA 02114, USA
| | - Miguel Sena-Esteves
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Rodolfo Madrid
- Millennium Nucleus of Ion Channels-Associated Diseases (MiNICAD), Santiago 9160000, Chile; Millennium Nucleus for the Study of Pain (MiNuSPain), Santiago 9160000, Chile; Department of Biology, Faculty of Chemistry and Biology, Universidad de Santiago de Chile, Santiago 9160000, Chile
| | - Diego Varela
- Program of Physiology and Biophysics, Institute of Biomedical Sciences, Faculty of Medicine, Universidad de Chile, Santiago 8380453, Chile; Millennium Nucleus of Ion Channels-Associated Diseases (MiNICAD), Santiago 9160000, Chile
| | - Martin Montecino
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; FONDAP Center for Genome Regulation, Santiago 8370146, Chile
| | - Robert H Brown
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Brigitte van Zundert
- Institute of Biomedical Sciences (ICB), Faculty of Medicine & Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370186, Chile; CARE Biomedical Research Center, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile; Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA.
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25
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Rudolph KE, Shulman M, Fishman M, Díaz I, Rotrosen J, Nunes EV. Association between dynamic dose increases of buprenorphine for treatment of opioid use disorder and risk of relapse. Addiction 2022; 117:637-645. [PMID: 34338389 PMCID: PMC9717480 DOI: 10.1111/add.15654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Dynamic, adaptive pharmacologic treatment for opioid use disorder (OUD) has been previously recommended over static dosing to prevent relapse, and is aligned with personalized medicine. However, there has been no quantitative evidence demonstrating its advantage. Our objective was to estimate the extent to which a hypothetical intervention that increased buprenorphine dose in response to opioid use would affect risk of relapse over 24 weeks of follow-up. DESIGN A secondary analysis of the buprenorphine arm of an open-label randomized controlled 24-week comparative effectiveness trial, 2014-17. SETTING Eight community addiction treatment programs in the United States. PARTICIPANTS English-speaking adults with DSM-5 OUD, recruited during inpatient admission (n = 270). Participants were mainly white (65%) and male (72%). INTERVENTION(S) Participants were treated with daily sublingual buprenorphine-naloxone (BUP-NX), with dose based on clinical indication, determined by the provider. We examined a hypothetical intervention of increasing dose in response to opioid use. MEASUREMENTS Outcome was relapse to regular opioid use during the 24 weeks of outpatient treatment, assessed in a survival framework. We estimated the relapse-free survival curves of participants under a hypothetical (i.e. counterfactual) intervention in which their BUP-NX dosage would be increased following their own subject-specific opioid use during the first 12 weeks of treatment versus a hypothetical intervention in which dose would remain constant. FINDINGS We estimated that increasing BUP-NX dose in response to recent opioid use would lower risk of relapse by 19.17 percentage points [95% confidence interval (CI) = -32.17, -6.18) (additive risk)] and 32% (0.68, 95% CI = 0.49, 0.86) (relative risk). The number-needed-to-treat with this intervention to prevent a single relapse is 6. CONCLUSIONS In people with opioid use disorder, a hypothetical intervention that increases sublingual buprenorphine-naloxone dose in response to opioid use during the first 12 weeks of treatment appears to reduce risk of relapse over 24 weeks, compared with holding the dose constant after week 2.
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Affiliation(s)
- Kara E. Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Marc Fishman
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Maryland Treatment Centers, Baltimore, MD, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, School of Medicine, New York University, New York, NY, USA
| | - Edward V. Nunes
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
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Bruce SS, Navi BB, Zhang C, Kim J, Devereux RB, Schenck EJ, Sedrakyan A, Díaz I, Kamel H. Transesophageal echocardiography and risk of respiratory failure in patients who had ischemic stroke or transient ischemic attack: an IDEAL phase 4 study. BMJ Surg Interv Health Technol 2022; 4:e000116. [PMID: 35187480 PMCID: PMC8823208 DOI: 10.1136/bmjsit-2021-000116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/24/2022] [Indexed: 11/17/2022] Open
Abstract
Objective Transesophageal echocardiography (TEE) is sometimes used to search for cardioembolic sources after ischemic stroke or transient ischemic attack (TIA). TEE visualizes some sources better than transthoracic echocardiography, but TEE is invasive and may cause aspiration. Few data exist on the risk of respiratory complications after TEE in patients who had stroke or TIA. Our objective was to determine whether TEE was associated with increased risk of respiratory failure in patients who had ischemic stroke or TIA. Design This is a retrospective cohort study using administrative data from inpatient and outpatient insurance claims collected by the US federal government’s Centers for Medicare and Medicaid Services. Setting Hospitals and outpatient clinics throughout the USA. Participants 99 081 patients ≥65 years old hospitalized for out-of-hospital ischemic stroke or TIA, defined by validated International Classification of Disease-9/10 diagnosis codes and present-on-admission codes, using claims data from 2008 to 2018 in a random 5% sample of Medicare beneficiaries. Main outcome measures Acute respiratory failure, defined as endotracheal intubation and/or mechanical ventilation, starting on the first day after admission through 28 days afterward. Results Of 99 081 patients included in this analysis, 73 733 (74.4%) had an ischemic stroke and 25 348 (25.6%) a TIA. TEE was performed in 4677 (4.7%) patients and intubation and/or mechanical ventilation in 1403 (1.4%) patients. The 28-day cumulative risk of respiratory failure after TEE (1.4%; 95% CI 0.8% to 2.7%) was similar to that seen in those without TEE (1.4%; 95% CI 1.4% to 1.5%) (p=0.84). After adjustment for age, sex, race, Charlson comorbidities, diagnosis of stroke versus TIA, intravenous thrombolysis, and mechanical thrombectomy, TEE was not associated with an increased risk of respiratory failure (HR, 0.9; 95% CI 0.6 to 1.2). Conclusions In a cohort of older patients who had ischemic stroke or TIA, TEE was not associated with an increased risk of subsequent respiratory failure.
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Affiliation(s)
- Samuel S Bruce
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jiwon Kim
- Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | | | - Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Iván Díaz
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
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Benkeser D, Díaz I, Luedtke A, Segal J, Scharfstein D, Rosenblum M. Improving precision and power in randomized trials for COVID-19 treatments using covariate adjustment, for binary, ordinal, and time-to-event outcomes. Biometrics 2021; 77:1467-1481. [PMID: 32978962 PMCID: PMC7537316 DOI: 10.1111/biom.13377] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/01/2020] [Accepted: 09/15/2020] [Indexed: 12/31/2022]
Abstract
Time is of the essence in evaluating potential drugs and biologics for the treatment and prevention of COVID-19. There are currently 876 randomized clinical trials (phase 2 and 3) of treatments for COVID-19 registered on clinicaltrials.gov. Covariate adjustment is a statistical analysis method with potential to improve precision and reduce the required sample size for a substantial number of these trials. Though covariate adjustment is recommended by the U.S. Food and Drug Administration and the European Medicines Agency, it is underutilized, especially for the types of outcomes (binary, ordinal, and time-to-event) that are common in COVID-19 trials. To demonstrate the potential value added by covariate adjustment in this context, we simulated two-arm, randomized trials comparing a hypothetical COVID-19 treatment versus standard of care, where the primary outcome is binary, ordinal, or time-to-event. Our simulated distributions are derived from two sources: longitudinal data on over 500 patients hospitalized at Weill Cornell Medicine New York Presbyterian Hospital and a Centers for Disease Control and Prevention preliminary description of 2449 cases. In simulated trials with sample sizes ranging from 100 to 1000 participants, we found substantial precision gains from using covariate adjustment-equivalent to 4-18% reductions in the required sample size to achieve a desired power. This was the case for a variety of estimands (targets of inference). From these simulations, we conclude that covariate adjustment is a low-risk, high-reward approach to streamlining COVID-19 treatment trials. We provide an R package and practical recommendations for implementation.
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Affiliation(s)
- David Benkeser
- Department of Biostatistics and BioinformaticsEmory UniversityAtlantaGeorgiaUSA
| | - Iván Díaz
- Division of BiostatisticsDepartment of Population Health SciencesWeill Cornell MedicineNew YorkNew YorkUSA
| | - Alex Luedtke
- Department of StatisticsUniversity of WashingtonSeattleWashingtonUSA
- Vaccine and Infectious Disease DivisionFred Hutchinson Cancer Research Center, University of WashingtonSeattleWashingtonUSA
| | - Jodi Segal
- Department of MedicineSchool of MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Daniel Scharfstein
- Division of BiostatisticsDepartment of Population Health SciencesUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Michael Rosenblum
- Department of BiostatisticsJohns Hopkins Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
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Rudolph KE, Díaz I, Luo SX, Rotrosen J, Nunes EV. Optimizing opioid use disorder treatment with naltrexone or buprenorphine. Drug Alcohol Depend 2021; 228:109031. [PMID: 34534863 PMCID: PMC8595679 DOI: 10.1016/j.drugalcdep.2021.109031] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Relapse rates during opioid use disorder (OUD) treatment remain unacceptably high. It is possible that optimally matching patients with medication type would reduce risk of relapse. Our objective was to learn a rule by which to assign type of medication for OUD to reduce risk of relapse, and to estimate the extent to which risk of relapse would be reduced if such a rule were used. METHODS This was a secondary analysis of an open-label randomized controlled, 24-week comparative effectiveness trial of injection extended-release naltrexone (XR-NTX), delivered approximately every 28 days, or daily sublingual buprenorphine-naloxone (BUP-NX) for treating OUD, 2014-2017 (N = 570). Outcome was a binary indicator of relapse to regular opioid use during the 24 weeks of outpatient treatment. RESULTS We found that applying an estimated individualized treatment rule-i.e., a rule that assigns patients with OUD to either XR-NTX or BUP-NX based on their individual characteristics in such a way that risk of relapse is minimized-would reduce risk of relapse by 24 weeks by 12% compared to randomly assigned treatment. CONCLUSIONS The number-needed-to-treat with the estimated treatment rule to prevent a single relapse is 14. A simpler, alternative estimated rule in which homeless participants would be treated with XR-NTX and stably housed participants would be treated with BUP-NX performed similarly. These results provide an estimate of the amount by which a relatively simple change in clinical practice could be expected to improve prevention of OUD relapse.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States.
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States
| | - Sean X Luo
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, United States
| | - John Rotrosen
- Department of Psychiatry, School of Medicine, New York University, New York, NY, United States
| | - Edward V Nunes
- Department of Psychiatry, School of Medicine, Columbia University, and New York State Psychiatric Institute, New York, NY, United States
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29
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Affiliation(s)
- Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York
| | - Nicholas Williams
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York
| | - Katherine L. Hoffman
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York
| | - Edward J. Schenck
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York
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30
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Rudolph KE, Díaz I, Hejazi NS, van der Laan MJ, Luo SX, Shulman M, Campbell A, Rotrosen J, Nunes EV. Explaining differential effects of medication for opioid use disorder using a novel approach incorporating mediating variables. Addiction 2021; 116:2094-2103. [PMID: 33340181 DOI: 10.1111/add.15377] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/28/2020] [Accepted: 12/09/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS A recent study found that homeless individuals with opioid use disorder (OUD) had a lower risk of relapse on extended-release naltrexone (XR-NTX) versus buprenorphine-naloxone (BUP-NX), whereas non-homeless individuals had a lower risk of relapse on BUP-NX. This secondary study examined differences in mediation pathways to medication effect between homeless and non-homeless participants. DESIGN Secondary analysis of an open-label randomized controlled, 24-week comparative effectiveness trial, 2014-17. SETTING Eight community addiction treatment programs in the United States. PARTICIPANTS English-speaking adults with DSM-5 OUD, recruited during inpatient admission (n = 570). INTERVENTION(S) Randomization to monthly injection of XR-NTX or daily sublingual BUP-NX. MEASUREMENTS(S) Mediation analysis estimated the direct effect of XR-NTX versus BUP-NX on relapse and indirect effect through mediators of medication adherence, use of illicit opioids, depressive symptoms and pain, separately by homeless status. FINDINGS For the homeless subgroup, the protective indirect path contributed a 3.4 percentage point reduced risk of relapse [95% confidence interval (CI) = -12.0, 5.3] comparing XR-NTX to BUP-NX (explaining 21% of the total effect). For the non-homeless subgroup, the indirect path contributed a 9.4 percentage point increased risk of relapse (95% CI = 3.1, 15.7) comparing XR-NTX to BUP-NX (explaining 57% of the total effect). CONCLUSIONS A novel approach to mediation analysis shows that much of the difference in medication effectiveness (extended-release naltrexone versus buprenorphine-naloxone) on opioid relapse among non-homeless adults with opioid use disorder appears to be explained by mediators of adherence, illicit opioid use, depressive symptoms and pain.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Nima S Hejazi
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Sean X Luo
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Matisyahu Shulman
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Aimee Campbell
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - John Rotrosen
- Department of Psychiatry, School of Medicine, New York University, New York, NY, USA
| | - Edward V Nunes
- Department of Psychiatry, School of Medicine, Columbia University and New York State Psychiatric Institute, New York, NY, USA
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31
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Díaz I, Colmenárez-Raga AC, Pérez-González D, Carmona VG, Plaza Lopez I, Merchán MA. Effects of Multisession Anodal Electrical Stimulation of the Auditory Cortex on Temporary Noise-Induced Hearing Loss in the Rat. Front Neurosci 2021; 15:642047. [PMID: 34393701 PMCID: PMC8358804 DOI: 10.3389/fnins.2021.642047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
The protective effect of the efferent system against acoustic trauma (AT) has been shown by several experimental approaches, including damage to one ear, sectioning of the olivocochlear bundle (OCB) in the floor of the IV ventricle, and knock-in mice overexpressing outer hair cell (OHC) cholinergic receptors, among others. Such effects have been related to changes in the regulation of the cholinergic efferent system and in cochlear amplification, which ultimately reverse upon protective hearing suppression. In addition to well-known circuits of the brainstem, the descending corticofugal pathway also regulates efferent neurons of the olivary complex. In this study, we applied our recently developed experimental paradigm of multiple sessions of electrical stimulation (ES) to activate the efferent system in combination with noise overstimulation. ABR thresholds increased 1 and 2 days after AT (8-16 kHz bandpass noise at 107 dB for 90 min) recovering at AT + 14 days. However, after multiple sessions of epidural anodal stimulation, no changes in thresholds were observed following AT. Although an inflammatory response was also observed 1 day after AT in both groups, the counts of reactive macrophages in both experimental conditions suggest decreased inflammation in the epidural stimulation group. Quantitative immunocytochemistry for choline acetyltransferase (ChAT) showed a significant decrease in the size and optical density of the efferent terminals 1 day after AT and a rebound at 14 days, suggesting depletion of the terminals followed by a long-term compensatory response. Such a synthesis recovery was significantly higher upon cortical stimulation. No significant correlation was found between ChAT optical density and size of the buttons in sham controls (SC) and ES/AT + 1day animals; however, significant negative correlations were shown in all other experimental conditions. Therefore, our comparative analysis suggests that cochleotopic cholinergic neurotransmission is also better preserved after multisession epidural stimulation.
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Affiliation(s)
- Iván Díaz
- Instituto de Neurociencias de Castilla y León (INCYL), Universidad de Salamanca, Salamanca, Spain
| | | | - David Pérez-González
- Instituto de Neurociencias de Castilla y León (INCYL), Universidad de Salamanca, Salamanca, Spain
| | - Venezia G Carmona
- Instituto de Neurociencias de Castilla y León (INCYL), Universidad de Salamanca, Salamanca, Spain
| | - Ignacio Plaza Lopez
- Instituto de Neurociencias de Castilla y León (INCYL), Universidad de Salamanca, Salamanca, Spain
| | - Miguel A Merchán
- Instituto de Neurociencias de Castilla y León (INCYL), Universidad de Salamanca, Salamanca, Spain
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32
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Benkeser D, Díaz I, Luedtke A, Segal J, Scharfstein D, Rosenblum M. Rejoinder: Improving precision and power in randomized trials for COVID-19 treatments using covariate adjustment, for binary, ordinal, and time-to-event outcomes. Biometrics 2021; 77:1492-1494. [PMID: 34050931 PMCID: PMC8239503 DOI: 10.1111/biom.13495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Indexed: 12/01/2022]
Affiliation(s)
- David Benkeser
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Jodi Segal
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael Rosenblum
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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33
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Kamel H, Parikh NS, Chatterjee A, Kim LK, Saver JL, Schwamm LH, Zachrison KS, Nogueira RG, Adeoye O, Díaz I, Ryan AM, Pandya A, Navi BB. Access to Mechanical Thrombectomy for Ischemic Stroke in the United States. Stroke 2021; 52:2554-2561. [PMID: 33980045 DOI: 10.1161/strokeaha.120.033485] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Abhinaba Chatterjee
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Luke K Kim
- Division of Cardiology (L.K.K.), Weill Cornell Medicine, New York, NY
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Lee H Schwamm
- Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston
| | - Kori S Zachrison
- Department of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Atlanta, GA (R.G.N.)
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, OH (O.A.)
| | - Iván Díaz
- Division of Biostatistics and Epidemiology (I.D.), Weill Cornell Medicine, New York, NY
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (A.M.R.)
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (A.P.)
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
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Abstract
BACKGROUND Interventions can have harmful effects among subgroups they intend to help. The Moving To Opportunity experiment, in which families were randomized to receive a Section 8 housing voucher, was one example. Voucher receipt generally resulted in better long-term mental health and lower substance use and risk behavior outcomes among adolescent girls, but resulted in worse outcomes among adolescent boys. Reasons for this discrepancy and the unintended harmful health effects for boys are unclear. We used mediation analysis to estimate processes through which voucher receipt was hypothesized to affect adolescent mental health and substance use. METHODS We used longitudinal data (10-15 years) on boys enrolled in Moving To Opportunity. We estimated interventional (also known as stochastic) indirect effects of voucher receipt on mental health and substance use outcomes through mediators capturing aspects of the school environment, neighborhood poverty, and instability of the social environment. We also estimated interventional direct effects not operating through these mediators. We used a robust, efficient, nonparametric substitution estimator in the targeted minimum loss-based framework. RESULTS Housing voucher receipt increased long-term risk of any diagnostic statistical manual disorder, any mood disorder, any externalizing disorder, and cigarette smoking among boys. The majority (between 69% and 90%) of the total negative long-term effects could be explained by indirect effects through the mediators considered. CONCLUSIONS This evidence suggests that, even though the intervention had the desired effects on neighborhood poverty and the school environment, these "positives" ultimately negatively impacted the long-term mental health and behaviors of boys.
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Affiliation(s)
- Kara E. Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Catherine Gimbrone
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
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35
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Argüello H, Rodríguez-Gómez IM, Sánchez-Carvajal JM, Pallares FJ, Díaz I, Cabrera-Rubio R, Crispie F, Cotter PD, Mateu E, Martín-Valls G, Carrasco L, Gómez-Laguna J. Porcine reproductive and respiratory syndrome virus impacts on gut microbiome in a strain virulence-dependent fashion. Microb Biotechnol 2021; 15:1007-1016. [PMID: 33656781 PMCID: PMC8913879 DOI: 10.1111/1751-7915.13757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 12/23/2020] [Accepted: 01/05/2021] [Indexed: 12/24/2022] Open
Abstract
Porcine reproductive and respiratory syndrome (PRRS) is a viral disease defined by reproductive problems, respiratory distress and a negative impact on growth rate and general condition. Virulent PRRS virus (PRRSV) strains have emerged in the last years with evident knowledge gaps in their impact on the host immune response. Thus, the present study examines the impact of acute PRRS virus (PRRSV) infection, with two strains of different virulence, on selected immune parameters and on the gut microbiota composition of infected pigs using 16S rRNA compositional sequencing. Pigs were infected with a low virulent (PRRS_3249) or a virulent (Lena) PRRSV‐1 strain and euthanized at 1, 3, 6, 8 or 13 days post‐inoculation (dpi). Faeces were collected from each animal at the necropsy time‐point. Alpha and beta diversity analyses demonstrated that infection, particularly with the Lena strain, impacted the microbiome composition from 6 dpi onwards. Taxonomic differences revealed that infected pigs had higher abundance of Treponema and Methanobrevibacter (FDR < 0.05). Differences were more considerable for Lena‐ than for PRRS_3249‐infected pigs, showing the impact of strain virulence in the intestinal changes. Lena‐infected pigs had reduced abundancies of anaerobic commensals such as Roseburia, Anaerostipes, Butyricicoccus and Prevotella (P < 0.05). The depletion of these desirable commensals was significantly correlated to infection severity measured by viraemia, clinical signs, lung lesions and immune parameters (IL‐6, IFN‐γ and Hp serum levels). Altogether, the results from this study demonstrate the indirect impact of PRRSV infection on gut microbiome composition in a strain virulence‐dependent fashion and its association with selected immune markers.
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Affiliation(s)
- Héctor Argüello
- Infectious Diseases and Epidemiology Unit, Department of Animal Health, Faculty of Veterinary Medicine, University of León, León, Spain
| | - Irene Magdalena Rodríguez-Gómez
- Department of Anatomy and Comparative Pathology and Toxicology, Faculty of Veterinary Medicine, University of Córdoba, International Excellence Agrifood Campus 'ceiA3', Córdoba, Spain
| | - Jose María Sánchez-Carvajal
- Department of Anatomy and Comparative Pathology and Toxicology, Faculty of Veterinary Medicine, University of Córdoba, International Excellence Agrifood Campus 'ceiA3', Córdoba, Spain
| | - Francisco José Pallares
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Murcia, Mare Nostrum Excellence Campus, Murcia, Spain
| | - Iván Díaz
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Bellaterra, Spain
| | - Raúl Cabrera-Rubio
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland.,APC Microbiome Ireland, Cork, Ireland
| | - Fiona Crispie
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland.,APC Microbiome Ireland, Cork, Ireland
| | - Paul D Cotter
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland.,APC Microbiome Ireland, Cork, Ireland.,Vistamilk, Fermoy, Co. Cork, Ireland
| | - Enric Mateu
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Bellaterra, Spain.,Department of Animal Health and Anatomy, Faculty of Veterinary Medicine, Autonomous University of Barcelona, Bellaterra, Spain
| | - Gerard Martín-Valls
- Department of Animal Health and Anatomy, Faculty of Veterinary Medicine, Autonomous University of Barcelona, Bellaterra, Spain
| | - Librado Carrasco
- Department of Anatomy and Comparative Pathology and Toxicology, Faculty of Veterinary Medicine, University of Córdoba, International Excellence Agrifood Campus 'ceiA3', Córdoba, Spain
| | - Jaime Gómez-Laguna
- Department of Anatomy and Comparative Pathology and Toxicology, Faculty of Veterinary Medicine, University of Córdoba, International Excellence Agrifood Campus 'ceiA3', Córdoba, Spain
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Díaz I, Pujols J, Cano E, Cuadrado R, Navarro N, Mateu E, Martín M. Assessment of three commercial ELISAs for the detection of antibodies against Porcine epidemic diarrhea virus at different stages of the immune response. Vet Immunol Immunopathol 2021; 234:110206. [PMID: 33601087 DOI: 10.1016/j.vetimm.2021.110206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/20/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
Three commercial ELISAs -two based on spike (E1 and E3) and one on nucleocapsid protein (E2)-were used to analyze the development and persistence of antibodies against Porcine epidemic diarrhea virus (PEDV). Seventy-five four-week-old PEDV-negative piglets were inoculated orally with a European G1b PEDV (INOC) and fourteen were kept as controls (CTRL). After the inoculation, E3 detected positive animals as soon as 7 days post inoculation (dpi), while the earliest detection with E1 and E2 was at 14 dpi. All samples were positive at 21 and 28 dpi using E1 and E3, respectively, while E2 failed to detect 23.3 % of the inoculated pigs at any time point. The percentages of positive samples were different through the study: E1 and E3 > E2 from 14 to 56 dpi; and E3 > E1 > E2 from 56 to 154 dpi (P < 0.05). Five months after the inoculation, E3 still detected 92.0 % (IC95 % = 85.1-98.8 %) of pigs as positive, while E1 and E2 detected only 27.0 % (IC95 % = 16.0-37.9 %) and 0%, respectively. The sensitivity for E2 never exceeded 0.62. Specificity was 1 for all ELISAs. These different outcomes could be related to the ELISA strategies (indirect versus competition), the antigens used, the cut-off, or to other intrinsic factors of each test. The observed differences could be of importance when assessing whether older animals, such as fatteners or gilts, had previously been in contact with PEDV.
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Affiliation(s)
- I Díaz
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain; OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain.
| | - J Pujols
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain; OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain
| | - E Cano
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain; OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain
| | - R Cuadrado
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain; OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain
| | - N Navarro
- IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Campus de la Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain; OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain
| | - E Mateu
- OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain; Departament de Sanitat i Anatomia Animals, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra, Spain; Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), UAB, Campus de la Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - M Martín
- OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), 08193 Bellaterra, Spain; Departament de Sanitat i Anatomia Animals, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra, Spain; Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), UAB, Campus de la Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
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Rudolph KE, Díaz I. Efficiently transporting causal direct and indirect effects to new populations under intermediate confounding and with multiple mediators. Biostatistics 2021; 23:789-806. [PMID: 33528006 DOI: 10.1093/biostatistics/kxaa057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/16/2020] [Accepted: 11/28/2020] [Indexed: 11/12/2022] Open
Abstract
The same intervention can produce different effects in different sites. Existing transport mediation estimators can estimate the extent to which such differences can be explained by differences in compositional factors and the mechanisms by which mediating or intermediate variables are produced; however, they are limited to consider a single, binary mediator. We propose novel nonparametric estimators of transported interventional (in)direct effects that consider multiple, high-dimensional mediators and a single, binary intermediate variable. They are multiply robust, efficient, asymptotically normal, and can incorporate data-adaptive estimation of nuisance parameters. They can be applied to understand differences in treatment effects across sites and/or to predict treatment effects in a target site based on outcome data in source sites.
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Affiliation(s)
- Kara E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University; and Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Iván Díaz
- Department of Epidemiology, Mailman School of Public Health, Columbia University; and Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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Díaz I. Machine learning in the estimation of causal effects: targeted minimum loss-based estimation and double/debiased machine learning. Biostatistics 2020; 21:353-358. [PMID: 31742333 DOI: 10.1093/biostatistics/kxz042] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 11/14/2022] Open
Abstract
In recent decades, the fields of statistical and machine learning have seen a revolution in the development of data-adaptive regression methods that have optimal performance under flexible, sometimes minimal, assumptions on the true regression functions. These developments have impacted all areas of applied and theoretical statistics and have allowed data analysts to avoid the biases incurred under the pervasive practice of parametric model misspecification. In this commentary, I discuss issues around the use of data-adaptive regression in estimation of causal inference parameters. To ground ideas, I focus on two estimation approaches with roots in semi-parametric estimation theory: targeted minimum loss-based estimation (TMLE; van der Laan and Rubin, 2006) and double/debiased machine learning (DML; Chernozhukov and others, 2018). This commentary is not comprehensive, the literature on these topics is rich, and there are many subtleties and developments which I do not address. These two frameworks represent only a small fraction of an increasingly large number of methods for causal inference using machine learning. To my knowledge, they are the only methods grounded in statistical semi-parametric theory that also allow unrestricted use of data-adaptive regression techniques.
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Affiliation(s)
- Iván Díaz
- Division of Biostatistics, Weill Cornell Medicine, 402 East 67th Street, New York, NY 10065, USA
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Abstract
Summary
Interventional effects for mediation analysis were proposed as a solution to the lack of identifiability of natural (in)direct effects in the presence of a mediator-outcome confounder affected by exposure. We present a theoretical and computational study of the properties of the interventional (in)direct effect estimands based on the efficient influence function in the nonparametric statistical model. We use the efficient influence function to develop two asymptotically optimal nonparametric estimators that leverage data-adaptive regression for the estimation of nuisance parameters: a one-step estimator and a targeted minimum loss estimator. We further present results establishing the conditions under which these estimators are consistent, multiply robust, $n^{1/2}$-consistent and efficient. We illustrate the finite-sample performance of the estimators and corroborate our theoretical results in a simulation study. We also demonstrate the use of the estimators in our motivating application to elucidate the mechanisms behind the unintended harmful effects that a housing intervention had on risky behaviour in adolescent girls.
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Affiliation(s)
- I Díaz
- Division of Biostatistics, Department of Healthcare Policy & Research, Weill Cornell Medicine, 425 East 61st Street, New York, New York 10065, U.S.A
| | - N S Hejazi
- Division of Epidemiology & Biostatistics, School of Public Health, University of California, Berkeley, 2121 Berkeley Way, Berkeley, California 94720, U.S.A
| | - K E Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, New York 10032, U.S.A
| | - M J van Der Laan
- Division of Epidemiology & Biostatistics, School of Public Health, University of California, Berkeley, 2121 Berkeley Way, Berkeley, California 94720, U.S.A
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Kamel H, Navi BB, Parikh NS, Merkler AE, Okin PM, Devereux RB, Weinsaft JW, Kim J, Cheung JW, Kim LK, Casadei B, Iadecola C, Sabuncu MR, Gupta A, Díaz I. Machine Learning Prediction of Stroke Mechanism in Embolic Strokes of Undetermined Source. Stroke 2020; 51:e203-e210. [PMID: 32781943 PMCID: PMC8034802 DOI: 10.1161/strokeaha.120.029305] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE One-fifth of ischemic strokes are embolic strokes of undetermined source (ESUS). Their theoretical causes can be classified as cardioembolic versus noncardioembolic. This distinction has important implications, but the categories' proportions are unknown. METHODS Using data from the Cornell Acute Stroke Academic Registry, we trained a machine-learning algorithm to distinguish cardioembolic versus non-cardioembolic strokes, then applied the algorithm to ESUS cases to determine the predicted proportion with an occult cardioembolic source. A panel of neurologists adjudicated stroke etiologies using standard criteria. We trained a machine learning classifier using data on demographics, comorbidities, vitals, laboratory results, and echocardiograms. An ensemble predictive method including L1 regularization, gradient-boosted decision tree ensemble (XGBoost), random forests, and multivariate adaptive splines was used. Random search and cross-validation were used to tune hyperparameters. Model performance was assessed using cross-validation among cases of known etiology. We applied the final algorithm to an independent set of ESUS cases to determine the predicted mechanism (cardioembolic or not). To assess our classifier's validity, we correlated the predicted probability of a cardioembolic source with the eventual post-ESUS diagnosis of atrial fibrillation. RESULTS Among 1083 strokes with known etiologies, our classifier distinguished cardioembolic versus noncardioembolic cases with excellent accuracy (area under the curve, 0.85). Applied to 580 ESUS cases, the classifier predicted that 44% (95% credibility interval, 39%-49%) resulted from cardiac embolism. Individual ESUS patients' predicted likelihood of cardiac embolism was associated with eventual atrial fibrillation detection (OR per 10% increase, 1.27 [95% CI, 1.03-1.57]; c-statistic, 0.68 [95% CI, 0.58-0.78]). ESUS patients with high predicted probability of cardiac embolism were older and had more coronary and peripheral vascular disease, lower ejection fractions, larger left atria, lower blood pressures, and higher creatinine levels. CONCLUSIONS A machine learning estimator that distinguished known cardioembolic versus noncardioembolic strokes indirectly estimated that 44% of ESUS cases were cardioembolic.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Neal S. Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Peter M. Okin
- Division of Cardiology, Weill Cornell Medical College, New York, NY
| | | | | | - Jiwon Kim
- Division of Cardiology, Weill Cornell Medical College, New York, NY
| | - Jim W. Cheung
- Division of Cardiology, Weill Cornell Medical College, New York, NY
| | - Luke K. Kim
- Division of Cardiology, Weill Cornell Medical College, New York, NY
| | - Barbara Casadei
- Division of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Mert R. Sabuncu
- School of Electrical and Computer Engineering, and Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medical College, New York, NY
| | - Iván Díaz
- Division of Biostatistics and Epidemiology, Weill Cornell Medical College, New York, NY
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Benkeser D, Díaz I, Luedtke A, Segal J, Scharfstein D, Rosenblum M. Improving Precision and Power in Randomized Trials for COVID-19 Treatments Using Covariate Adjustment, for Binary, Ordinal, and Time-to-Event Outcomes. medRxiv 2020:2020.04.19.20069922. [PMID: 32577668 PMCID: PMC7302221 DOI: 10.1101/2020.04.19.20069922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Time is of the essence in evaluating potential drugs and biologics for the treatment and prevention of COVID-19. There are currently over 400 clinical trials (phase 2 and 3) of treatments for COVID-19 registered on clinicaltrials.gov. Covariate adjustment is a statistical analysis method with potential to improve precision and reduce the required sample size for a substantial number of these trials. Though covariate adjustment is recommended by the U.S. Food and Drug Administration and the European Medicines Agency, it is underutilized, especially for the types of outcomes (binary, ordinal and time-to-event) that are common in COVID-19 trials. To demonstrate the potential value added by covariate adjustment in this context, we simulated two-arm, randomized trials comparing a hypothetical COVID-19 treatment versus standard of care, where the primary outcome is binary, ordinal, or time-to-event. Our simulated distributions are derived from two sources: longitudinal data on over 500 patients hospitalized at Weill Cornell Medicine New York Presbyterian Hospital, and a Centers for Disease Control and Prevention (CDC) preliminary description of 2449 cases. We found substantial precision gains from using covariate adjustment--equivalent to 9-21% reductions in the required sample size to achieve a desired power--for a variety of estimands (targets of inference) when the trial sample size was at least 200. We provide an R package and practical recommendations for implementing covariate adjustment. The estimators that we consider are robust to model misspecification.
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Affiliation(s)
- David Benkeser
- Department of Biostatistics and Bioinformatics, Emory University
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine
| | - Alex Luedtke
- Department of Statistics, University of Washington, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center
| | - Jodi Segal
- Department of Medicine, School of Medicine, Johns Hopkins University
| | - Daniel Scharfstein
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University
| | - Michael Rosenblum
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University
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Díaz I, Savenkov O, Kamel H. Nonparametric targeted Bayesian estimation of class proportions in unlabeled data. Biostatistics 2020; 23:274-293. [PMID: 32529244 DOI: 10.1093/biostatistics/kxaa022] [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: 10/04/2019] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 12/20/2022] Open
Abstract
We introduce a novel Bayesian estimator for the class proportion in an unlabeled dataset, based on the targeted learning framework. The procedure requires the specification of a prior (and outputs a posterior) only for the target of inference, and yields a tightly concentrated posterior. When the scientific question can be characterized by a low-dimensional parameter functional, this focus on target prior and posterior distributions perfectly aligns with Bayesian subjectivism. We prove a Bernstein-von Mises-type result for our proposed Bayesian procedure, which guarantees that the posterior distribution converges to the distribution of an efficient, asymptotically linear estimator. In particular, the posterior is Gaussian, doubly robust, and efficient in the limit, under the only assumption that certain nuisance parameters are estimated at slower-than-parametric rates. We perform numerical studies illustrating the frequentist properties of the method. We also illustrate their use in a motivating application to estimate the proportion of embolic strokes of undetermined source arising from occult cardiac sources or large-artery atherosclerotic lesions. Though we focus on the motivating example of the proportion of cases in an unlabeled dataset, the procedure is general and can be adapted to estimate any pathwise differentiable parameter in a non-parametric model.
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Affiliation(s)
- Iván Díaz
- Division of Biostatistics, Weill Cornell Medicine, New York, NY 10065, USA
| | | | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY 10065, USA
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Sánchez-Carvajal JM, Rodríguez-Gómez IM, Ruedas-Torres I, Larenas-Muñoz F, Díaz I, Revilla C, Mateu E, Domínguez J, Martín-Valls G, Barranco I, Pallarés FJ, Carrasco L, Gómez-Laguna J. Activation of pro- and anti-inflammatory responses in lung tissue injury during the acute phase of PRRSV-1 infection with the virulent strain Lena. Vet Microbiol 2020; 246:108744. [PMID: 32605751 PMCID: PMC7265841 DOI: 10.1016/j.vetmic.2020.108744] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/29/2020] [Accepted: 05/31/2020] [Indexed: 12/16/2022]
Abstract
Lena virulent strain caused an increase in sera levels of IFN-γ and IL-6. Lung viral load and PRRSV-N-protein+ cells were inversely correlated with CD163+ macrophages in the lung. CD14+ cells infiltrated interstitium to possibly replenish macrophages subsets. Lena-induced microscopic lung injury was linked to an increase of iNOS+ cells. The increase of CD200R1+ and FoxP3+ cells was associated with the course of lung injury.
Porcine reproductive and respiratory syndrome virus (PRRSV) plays a key role in porcine respiratory disease complex modulating the host immune response and favouring secondary bacterial infections. Pulmonary alveolar macrophages (PAMs) are the main cells supporting PRRSV replication, with CD163 as the essential receptor for viral infection. Although interstitial pneumonia is by far the representative lung lesion, suppurative bronchopneumonia is described for PRRSV virulent strains. This research explores the role of several immune markers potentially involved in the regulation of the inflammatory response and sensitisation of lung to secondary bacterial infections by PRRSV-1 strains of different virulence. Conventional pigs were intranasally inoculated with the virulent subtype 3 Lena strain or the low virulent subtype 1 3249 strain and euthanised at 1, 3, 6 and 8 dpi. Lena-infected pigs exhibited more severe clinical signs, macroscopic lung score and viraemia associated with an increase of IL-6 and IFN-γ in sera compared to 3249-infected pigs. Extensive areas of lung consolidation corresponding with suppurative bronchopneumonia were observed in Lena-infected pigs. Lung viral load and PRRSV-N-protein+ cells were always higher in Lena-infected animals. PRRSV-N-protein+ cells were linked to a marked drop of CD163+ macrophages. The number of CD14+ and iNOS+ cells gradually increased along PRRSV-1 infection, being more evident in Lena-infected pigs. The frequency of CD200R1+ and FoxP3+ cells peaked late in both PRRSV-1 strains, with a strong correlation between CD200R1+ cells and lung injury in Lena-infected pigs. These results highlight the role of molecules involved in the earlier and higher extent of lung lesions in piglets infected with the virulent Lena strain, pointing out the activation of routes potentially involved in the restraint of the local inflammatory response.
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Affiliation(s)
- J M Sánchez-Carvajal
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Córdoba, 14014, Córdoba, Spain.
| | - I M Rodríguez-Gómez
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Córdoba, 14014, Córdoba, Spain
| | - I Ruedas-Torres
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Córdoba, 14014, Córdoba, Spain
| | - F Larenas-Muñoz
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Córdoba, 14014, Córdoba, Spain
| | - I Díaz
- Institut de Recerca i Tecnologia Agroalimentàries - Centre de Recerca en Sanitat Animal (IRTA-CReSA), Campus de la Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - C Revilla
- Department of Biotechnology, National Institute for Agricultural and Food Research and Technology (INIA), 28040, Madrid, Spain
| | - E Mateu
- Institut de Recerca i Tecnologia Agroalimentàries - Centre de Recerca en Sanitat Animal (IRTA-CReSA), Campus de la Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; Department of Animal Health and Anatomy, Faculty of Veterinary Medicine, Autonomous University of Barcelona, 08193, Bellaterra, Spain
| | - J Domínguez
- Department of Biotechnology, National Institute for Agricultural and Food Research and Technology (INIA), 28040, Madrid, Spain
| | - G Martín-Valls
- Department of Animal Health and Anatomy, Faculty of Veterinary Medicine, Autonomous University of Barcelona, 08193, Bellaterra, Spain
| | - I Barranco
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Córdoba, 14014, Córdoba, Spain
| | - F J Pallarés
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Murcia, 30100, Murcia, Spain
| | - L Carrasco
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Córdoba, 14014, Córdoba, Spain
| | - J Gómez-Laguna
- Department of Anatomy and Comparative Pathology, Faculty of Veterinary Medicine, University of Córdoba, 14014, Córdoba, Spain
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Parikh NS, Chatterjee A, Díaz I, Merkler AE, Murthy SB, Iadecola C, Navi BB, Kamel H. Trends in Active Cigarette Smoking Among Stroke Survivors in the United States, 1999 to 2018. Stroke 2020; 51:1656-1661. [DOI: 10.1161/strokeaha.120.029084] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and Purpose—
Patients who continue to smoke after a stroke face a higher risk of recurrent stroke. While several effective drugs for smoking cessation became available over the past 2 decades, whether active smoking has decreased among stroke survivors is unknown. We, therefore, evaluated trends in active smoking among stroke survivors during this period.
Methods—
We performed trends analyses using cross-sectional data collected every 1 to 2 years from 2 US health surveys spanning 1999 to 2018. In the National Health and Nutrition Examination Survey (NHANES) and the Behavioral Risk Factor Surveillance System (BRFSS) survey, participants were asked about prior stroke and active tobacco smoking. In NHANES, serum cotinine levels were available as a secondary measure of active smoking. We used multivariable logistic regression models for survey data to assess trends in active smoking among participants with and without prior stroke.
Results—
Among 49 375 participants in NHANES during 1999 to 2016 and 3 621 741 participants in BRFSS during 2011 to 2018, the prevalence of stroke was ≈3%. The overall prevalence of active smoking among stroke survivors was 24% in NHANES and 23% in BRFSS. Among individuals without prior stroke, the odds of smoking decreased over time in both NHANES (odds ratio, 0.95 per 2 years [95% CI, 0.93–0.96]) and BRFSS (odds ratio, 0.96 per year [95% CI, 0.96–0.96]). In contrast, there was no decrease in smoking among stroke survivors in NHANES (odds ratio, 1.00 [95% CI, 0.93–1.07]) or BRFSS (odds ratio, 0.99 [95% CI, 0.98–1.004]). Results were consistent in secondary analysis using biochemical ascertainment of active smoking in NHANES and in sensitivity analyses accounting for potential demographic changes in stroke epidemiology.
Conclusions—
In contrast to the general population, the prevalence of active smoking among stroke survivors has not decreased during the past 2 decades.
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Affiliation(s)
- Neal S. Parikh
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., A.C., A.E.M., S.B.M., C.I., B.B.N., H.K.), Weill Cornell Medicine, New York, NY
| | - Abhinaba Chatterjee
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., A.C., A.E.M., S.B.M., C.I., B.B.N., H.K.), Weill Cornell Medicine, New York, NY
| | - Iván Díaz
- Department of Population Health Sciences (I.D.), Weill Cornell Medicine, New York, NY
| | - Alexander E. Merkler
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., A.C., A.E.M., S.B.M., C.I., B.B.N., H.K.), Weill Cornell Medicine, New York, NY
| | - Santosh B. Murthy
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., A.C., A.E.M., S.B.M., C.I., B.B.N., H.K.), Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., A.C., A.E.M., S.B.M., C.I., B.B.N., H.K.), Weill Cornell Medicine, New York, NY
| | - Babak B. Navi
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., A.C., A.E.M., S.B.M., C.I., B.B.N., H.K.), Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., A.C., A.E.M., S.B.M., C.I., B.B.N., H.K.), Weill Cornell Medicine, New York, NY
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45
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Affiliation(s)
- Iván Díaz
- Weill Cornell Medicine; New York USA
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Pernia M, Díaz I, Colmenárez-Raga AC, Rivadulla C, Cudeiro J, Plaza I, Merchán MA. Cross-modal reaction of auditory and visual cortices after long-term bilateral hearing deprivation in the rat. Brain Struct Funct 2020; 225:129-148. [PMID: 31781971 PMCID: PMC6957565 DOI: 10.1007/s00429-019-01991-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 11/21/2019] [Indexed: 12/26/2022]
Abstract
Visual cortex (VC) over-activation analysed by evoked responses has been demonstrated in congenital deafness and after long-term acquired hearing loss in humans. However, permanent hearing deprivation has not yet been explored in animal models. Thus, the present study aimed to examine functional and molecular changes underlying the visual and auditory cross-modal reaction. For such purpose, we analysed cortical visual evoked potentials (VEPs) and the gene expression (RT-qPCR) of a set of markers for neuronal activation (c-Fos) and activity-dependent homeostatic compensation (Arc/Arg3.1). To determine the state of excitation and inhibition, we performed RT-qPCR and quantitative immunocytochemistry for excitatory (receptor subunits GluA2/3) and inhibitory (GABAA-α1, GABAB-R2, GAD65/67 and parvalbumin-PV) markers. VC over-activation was demonstrated by a significant increase in VEPs wave N1 and by up-regulation of the activity-dependent early genes c-Fos and Arc/Arg3.1 (thus confirming, by RT-qPCR, our previously published immunocytochemical results). GluA2 gene and protein expression were significantly increased in the auditory cortex (AC), particularly in layers 2/3 pyramidal neurons, but inhibitory markers (GAD65/67 and PV-GABA interneurons) were also significantly upregulated in the AC, indicating a concurrent increase in inhibition. Therefore, after permanent hearing loss in the rat, the VC is not only over-activated but also potentially balanced by homeostatic regulation, while excitatory and inhibitory markers remain imbalanced in the AC, most likely resulting from changes in horizontal intermodal regulation.
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Affiliation(s)
- M Pernia
- Instituto de Neurociencias of Castilla y León-INCyL, Universidad de Salamanca, Salamanca, Spain
| | - I Díaz
- Instituto de Neurociencias of Castilla y León-INCyL, Universidad de Salamanca, Salamanca, Spain
| | - A C Colmenárez-Raga
- Instituto de Neurociencias of Castilla y León-INCyL, Universidad de Salamanca, Salamanca, Spain
| | - C Rivadulla
- Centro de Investigaciones Científicas Avanzadas (CICA), Facultad de Ciencias de la Salud, Universidad de A Coruña and Instituto de Investigaciones Biomédicas de A Coruña (INIBIC), A Coruña, Spain
| | - J Cudeiro
- Centro de Investigaciones Científicas Avanzadas (CICA), Facultad de Ciencias de la Salud, Universidad de A Coruña and Instituto de Investigaciones Biomédicas de A Coruña (INIBIC), A Coruña, Spain
| | - I Plaza
- Instituto de Neurociencias of Castilla y León-INCyL, Universidad de Salamanca, Salamanca, Spain
| | - M A Merchán
- Instituto de Neurociencias of Castilla y León-INCyL, Universidad de Salamanca, Salamanca, Spain.
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Díaz I, Colantuoni E, Hanley DF, Rosenblum M. Correction to: Improved precision in the analysis of randomized trials with survival outcomes, without assuming proportional hazards. Lifetime Data Anal 2020; 26:214-220. [PMID: 31485927 DOI: 10.1007/s10985-019-09484-y] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The R code used for the data analysis and simulations in our manuscript (Díaz et al. 2018) had two errors, which we have corrected.
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Affiliation(s)
- Iván Díaz
- Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA.
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael Rosenblum
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Kamel H, Navi BB, Merkler AE, Baradaran H, Díaz I, Parikh NS, Kasner SE, Gladstone DJ, Iadecola C, Gupta A. Reclassification of Ischemic Stroke Etiological Subtypes on the Basis of High-Risk Nonstenosing Carotid Plaque. Stroke 2019; 51:504-510. [PMID: 31847749 DOI: 10.1161/strokeaha.119.027970] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Carotid artery plaque with <50% luminal stenosis may be an underappreciated stroke mechanism. We assessed how many stroke causes might be reclassified after accounting for nonstenosing plaques with high-risk features. Methods- We included patients enrolled in the Cornell Acute Stroke Academic Registry from 2011 to 2015 who had anterior circulation infarction, magnetic resonance imaging of the brain, and magnetic resonance angiography of the neck. High-risk plaque was identified by intraplaque hemorrhage ascertained from routine neck magnetic resonance angiography studies using validated methods. Infarct location was determined from diffusion-weighted imaging. Intraplaque hemorrhage and infarct location were assessed separately in a blinded fashion by a neuroradiologist. We used the McNemar test for matched data to compare the prevalence of intraplaque hemorrhage ipsilateral versus contralateral to brain infarction. We reclassified stroke subtypes by including large-artery atherosclerosis as a cause if there was intraplaque hemorrhage ipsilateral to brain infarction, regardless of the degree of stenosis. Results- Among the 1721 acute ischemic stroke patients registered in the Cornell Acute Stroke Academic Registry from 2011 to 2015, 579 were eligible for this analysis. High-risk plaque was more common ipsilateral versus contralateral to brain infarction in large-artery atherosclerotic (risk ratio [RR], 3.7 [95% CI, 2.2-6.1]), cryptogenic (RR, 2.1 [95% CI, 1.4-3.1]), and cardioembolic strokes (RR, 1.7 [95% CI, 1.1-2.4]). There were nonsignificant ipsilateral-contralateral differences in high-risk plaque among lacunar strokes (RR, 1.2 [95% CI, 0.4-3.5]) and strokes of other determined cause (RR, 1.5 [95% CI, 0.7-3.3]). After accounting for ipsilateral high-risk plaque, 88 (15.2%) patients were reclassified: 38 (22.6%) cardioembolic to multiple potential etiologies, 6 (8.5%) lacunar to multiple, 3 (15.8%) other determined cause to multiple, and 41 (20.8%) cryptogenic to large-artery atherosclerosis. Conclusions- High-risk carotid plaque was more prevalent ipsilateral to brain infarction across several ischemic stroke subtypes. Accounting for such plaques may reclassify the etiologies of up to 15% of cases in our sample.
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Affiliation(s)
- Hooman Kamel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | - Babak B Navi
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | - Alexander E Merkler
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | | | - Iván Díaz
- Division of Biostatistics and Epidemiology (I.D.), Weill Cornell Medicine, New York, NY
| | - Neal S Parikh
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.)
| | - David J Gladstone
- Division of Neurology and Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, University of Toronto, ON, Canada (D.J.G.)
| | - Costantino Iadecola
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY
| | - Ajay Gupta
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., B.B.N., A.E.M., N.S.P., C.I., A.G.), Weill Cornell Medicine, New York, NY.,Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY
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Caballero F, Puig M, Leal J, Trejo O, Díaz I, Herrera S, Turbau M, Ris J, Benito S. Successful organ donation for transplantation: Targeted actions in the emergency department. Am J Transplant 2019; 19:2960-2961. [PMID: 31246336 DOI: 10.1111/ajt.15516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Francisco Caballero
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mireia Puig
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesus Leal
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Olga Trejo
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Iván Díaz
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sergio Herrera
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miquel Turbau
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep Ris
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Salvador Benito
- Department of Emergency Medicine and Transplant Coordination, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Reynolds AS, Chen ML, Merkler AE, Chatterjee A, Díaz I, Navi BB, Kamel H. Effect of A Randomized trial of Unruptured Brain Arteriovenous Malformation on Interventional Treatment Rates for Unruptured Arteriovenous Malformations. Cerebrovasc Dis 2019; 47:299-302. [PMID: 31434094 DOI: 10.1159/000502314] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/17/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In 2013, investigators from A Randomized Trial of Unruptured Brain Arteriovenous Malformations (AVM; ARUBA) reported that interventions to obliterate unruptured AVMs caused more morbidity and mortality than medical management. OBJECTIVE We sought to determine whether interventions for unruptured AVM decreased after publication of ARUBA results. METHODS We used the Nationwide Readmissions Database to assess trends in interventional AVM management in patients ≥18 years of age from 2010 through 2015. Unruptured brain AVMs were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 747.81 and excluding any patient with a diagnosis of intracranial hemorrhage. Our primary outcome was interventional AVM treatment, identified using ICD-9-CM procedure codes for surgical resection, endovascular therapy, and stereotactic radiosurgery. Join-point regression was used to assess trends in the incidence of interventional AVM management among adults from 2010 through 2015. RESULTS There was no significant U.S. population level change in unruptured brain AVM intervention rates before versus after ARUBA (p = 0.59), with the incidence of AVM intervention ranging from 8.0 to 9.2 per 10 million U.S. residents before the trial publication to 7.7-8.3 per 10 million afterwards. CONCLUSIONS In a nationally representative sample, we found no change in rates of interventional unruptured AVM management after publication of the ARUBA trial results.
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Affiliation(s)
- Alexandra S Reynolds
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, New York, USA.,Department of Neurology, Columbia College of Physicians and Surgeons, New York, New York, USA
| | - Monica L Chen
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, New York, USA
| | - Alexander E Merkler
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, New York, USA
| | - Abhinaba Chatterjee
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, New York, USA
| | - Iván Díaz
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, New York, USA.,Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Babak B Navi
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, New York, USA
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, New York, USA,
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