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West Haven, CT, United States

Re III V.L.,University of Pennsylvania | Kallan M.J.,University of Pennsylvania | Tate J.P.,VA Connecticut Health Systems | Localio A.R.,University of Pennsylvania | And 14 more authors.
Annals of Internal Medicine | Year: 2014

Background: The incidence and determinants of hepatic decompensation have been incompletely examined among patients coinfected with HIV and hepatitis C virus (HCV) in the antiretroviral therapy (ART) era, and few studies have compared outcome rates with those of patients with chronic HCV alone. Objective: To compare the incidence of hepatic decompensation between antiretroviral- treated patients co-infected with HIV and HCV and HCV-monoinfected patients and to evaluate factors associated with decompensation among co-infected patients receiving ART. Design: Retrospective cohort study. Setting: Veterans Health Administration. Patients: 4280 co-infected patients who initiated ART and 6079 HCV-monoinfected patients receiving care between 1997 and 2010. All patients had detectable HCV RNA and were HCV treatment-naive. Measurements: Incident hepatic decompensation, determined by diagnoses of ascites, spontaneous bacterial peritonitis, or esophageal variceal hemorrhage. Results: The incidence of hepatic decompensation was greater among co-infected than monoinfected patients (7.4% vs. 4.8% at 10 years; P < 0.001). Compared with HCV-monoinfected patients, co-infected patients had a higher rate of hepatic decompensation (hazard ratio [HR] accounting for competing risks, 1.56 [95% CI, 1.31 to 1.86]). Co-infected patients who maintained HIV RNA levels less than 1000 copies/mL still had higher rates of decompensation than HCV-monoinfected patients (HR, 1.44 [CI, 1.05 to 1.99]). Baseline advanced hepatic fibrosis (FIB-4 score >3.25) (HR, 5.45 [CI, 3.79 to 7.84]), baseline hemoglobin level less than 100 g/L (HR, 2.24 [CI, 1.20 to 4.20]), diabetes mellitus (HR, 1.88 [CI, 1.38 to 2.56]), and nonblack race (HR, 2.12 [CI, 1.65 to 2.72]) were each associated with higher rates of decompensation among co-infected patients. Limitation: Observational study of predominantly male patients. Conclusion: Despite receiving ART, patients co-infected with HIV and HCV had higher rates of hepatic decompensation than HCVmonoinfected patients. Rates of decompensation were higher for co-infected patients with advanced liver fibrosis, severe anemia, diabetes, and nonblack race. Primary Funding Source: National Institutes of Health. © 2014 American College of Physicians. Source


Crothers K.,University of Washington | Huang L.,University of California at San Francisco | Goulet J.L.,Veterans Affairs Connecticut Healthcare System | Goetz M.B.,University of California at Los Angeles | And 9 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2011

Rationale: In aging HIV-infected populations comorbid diseases are important determinants of morbidity and mortality. Pulmonary diseases have not been systematically assessed in the combination antiretroviral therapy (ART) era. Objectives: To determine the incidence of pulmonary diseases in HIV-infected persons compared with HIV-uninfected persons. Methods: We analyzed data from the Veterans Aging Cohort Study Virtual Cohort, consisting of 33,420 HIV-infected veterans and 66,840 age, sex, raceandethnicity,andsite-matched HIV-uninfected veterans. Using Poisson regression, incidence rates and adjusted incidence rate ratios were calculated to determine the association of HIV with pulmonary disease. The Virtual Cohort was merged with the 1999 Veterans Large Health Survey to adjust for self-reported smoking in a nested sample (14%). Measurements and Main Results: Incident chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and pulmonary fibrosis, as well as pulmonary infections, were significantly more likely among HIV-infected patients compared with uninfected patients in adjusted analyses, although rates of asthma did not differ by HIV status. Bacterial pneumonia and chronic obstructive pulmonary disease were the two most common incident pulmonary diseases, whereas opportunistic pneumonias were less common. Absolute rates of most pulmonary diseases increased with age, although the relative differences between those with and without HIV infection were greatest in younger persons. Chronic obstructive pulmonary disease and asthma, as well as pulmonary infections, were less likely in those with lower HIV RNA levels and use of ART at baseline. Conclusions: Pulmonary diseases among HIV-infected patients receiving care within the Veterans Affairs Healthcare System in the combination ART era reflect a substantial burden of non-AIDS-defining and chronic conditions, many of which are associated with aging. Source


Tsai J.,Veterans Affairs Connecticut Healthcare System
Psychiatric services (Washington, D.C.) | Year: 2013

The Health Care for Reentry Veterans (HCRV) program provides Veterans Health Administration outreach services to veterans incarcerated in state and federal prisons. This study used HCRV data to compare risk of incarceration of veterans of Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), and New Dawn (OND) and other veterans and to identify sociodemographic and clinical characteristics of incarcerated veterans of OEF/OIF/OND. Administrative national data were analyzed for 30,968 incarcerated veterans, including 1,201 OEF/OIF/OND veterans, contacted from October 2007 to April 2011. Odds ratios were calculated comparing the risk of incarceration among OEF/OIF/OND and other veterans in the HCRV sample and in a weighted sample of nonincarcerated veterans from the 2010 National Survey of Veterans. Stepwise logistic regressions of HCRV data examined characteristics of incarcerated veterans independently associated with OEF/OIF/OND service. Regardless of ethnicity or age, OEF/OIF/OND veterans were less than half as likely as other veterans to be incarcerated and constituted only 3.9% of the incarcerated veterans. Compared with other incarcerated veterans, OEF/OIF/OND veterans were younger, were more likely to be married, were more likely to report combat exposure, expected a shorter incarceration, were 26% less likely to have a diagnosis of drug abuse or dependence, and were three times more likely to have combat-related posttraumatic stress disorder (PTSD). OEF/OIF/OND veterans appeared to be at lower risk of incarceration than veterans of other service eras, but those who were incarcerated had higher rates of PTSD. Efforts to link these veterans to mental health services upon their release are warranted. Source


Kuy S.,Yale University | Kuy S.,Medical College of Wisconsin | Sosa J.A.,Yale University | Roman S.A.,Yale University | And 3 more authors.
American Journal of Surgery | Year: 2011

Background: Gallstone disease increases with age. The aims of this study were to measure short-term outcomes from cholecystectomy in hospitalized elderly patients, assess the effect of age, and identify predictors of outcomes. Methods: This was a cross-sectional analysis, using the Health Care Utilization Project Nationwide Inpatient Sample (19992006), of elderly patients (aged 6579 and <80 years) and a comparison group (aged 5064 years) hospitalized for cholecystectomy. Linear and logistic regression models were used to evaluate age and outcome relationships. Main outcomes were in-hospital mortality, complications, discharge disposition, mean length of stay, and cost. Results: A total of 149,855 patients aged 65 to 79 years, 62,561 patients aged < 80 years, and 145,675 subjects aged 50 to 64 years were included. Elderly patients had multiple biliary diagnoses and longer times to surgery from admission and underwent more open procedures. Patients aged 65 to 79 years and those aged <80 years had higher adjusted odds of mortality (odds ratios [ORs], 2.36 and 5.91, respectively), complications (ORs, 1.57 and 2.39), nonroutine discharge (ORs, 3.02 and 10.76), longer length of stay (ORs, 1.11 and 1.31), and higher cost (ORs, 1.09 and 1.22) than younger patients. Conclusions: Elderly patients undergoing inpatient cholecystectomy have complex disease, with worse outcomes. Longer time from admission to surgery predicts poor outcome. © 2011 Elsevier Inc. All rights reserved. Source


Abdallah C.G.,Abraham Ribicoff Research Facilities | Niciu M.J.,Abraham Ribicoff Research Facilities | Fenton L.R.,Veterans Affairs Connecticut Healthcare System | Fasula M.K.,Abraham Ribicoff Research Facilities | And 6 more authors.
Psychotherapy and Psychosomatics | Year: 2014

Background: Previous studies have demonstrated that antidepressant medication and electroconvulsive therapy increase occipital cortical γ-aminobutyric acid (GABA) in major depressive disorder (MDD), but a small pilot study failed to show a similar effect of cognitive-behavioral therapy (CBT) on occipital GABA. In light of these findings we sought to determine if baseline GABA levels predict treatment response and to broaden the analysis to other metabolites and neurotransmitters in this larger study. Methods: A total of 40 MDD outpatients received baseline proton magnetic resonance spectroscopy (1H-MRS), and 30 subjects completed both pre- and post-CBT 1H-MRS; 9 CBT nonresponders completed an open-label medication phase followed by an additional/3rd 1H-MRS. The magnitude of treatment response was correlated with occipital amino acid neurotransmitter levels. Results: Baseline GABA did not predict treatment outcome. Furthermore, there was no significant effect of CBT on GABA levels. However, we found a significant group × time interaction (F1, 28 = 6.30, p = 0.02), demonstrating reduced glutamate in CBT responders, with no significant glutamate change in CBT nonresponders. Conclusions: These findings corroborate the lack of effect of successful CBT on occipital cortical GABA levels in a larger sample. A reduction in glutamate levels following treatment, on the other hand, correlated with successful CBT and antidepressant medication response. Based on this finding and other reports, decreased occipital glutamate may be an antidepressant response biomarker. Healthy control comparator and nonintervention groups may shed light on the sensitivity and specificity of these results. © 2014 S. Karger AG, Basel. Source

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