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Dr. Fares Qeadan
assistant professor

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0 Biostatistics
0 Substance Use Disorders
0 Opioids
0 Native American
0 covid-19

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Journal article
Published: 23 August 2021 in International Journal of Environmental Research and Public Health
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Background: Naltrexone, a medication for addiction treatment (MAT), is an FDA-approved medication recommended for the treatment of alcohol use disorder (AUD). Despite the high prevalence of AUD and efficacy of naltrexone, only a small percentage of individuals with AUD receive treatment. Objectives: To identify trends for the prescription of naltrexone in AUD admissions in substance use treatment centers across the U.S. Methods: Data from the 2000–2018 U.S. Treatment Episode Data Set: Admissions (TEDS-A) were used in temporal trend analysis of naltrexone prescription in admissions that only used alcohol. Data from the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) were also used to characterize medication use among AUD clients across different treatment service settings. Results: Treatment of AUD with naltrexone was 0.49% in 2000 and tripled from 0.53% in 2015 to 1.64% in 2018 in AUD admissions (p< 0.0001 for the Cochran–Armitage trend test). Women, middle-aged adults, and admissions for clients living in the Northeast U.S. were more likely to be prescribed naltrexone than their respective counterparts, as were admissions with prior treatment episodes and referrals through alcohol/drug use care providers, who paid for treatment primarily through private insurance, used alcohol daily in the month prior to admission, and waited 1–7 days to enter treatment. Naltrexone was more commonly prescribed by AUD admissions compared to acamprosate and disulfiram and was more frequently prescribed in residential and outpatient services as opposed to hospital inpatient services. Conclusions: Naltrexone remains underutilized for AUD, and factors that influence prescription of medication are multifaceted. This study may contribute to the creation of effective interventions aimed at reducing naltrexone disparities for AUD.

ACS Style

Fares Qeadan; Nana A. Mensah; Lily Y. Gu; Erin F. Madden; Kamilla L. Venner; Kevin English. Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities. International Journal of Environmental Research and Public Health 2021, 18, 8884 .

AMA Style

Fares Qeadan, Nana A. Mensah, Lily Y. Gu, Erin F. Madden, Kamilla L. Venner, Kevin English. Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities. International Journal of Environmental Research and Public Health. 2021; 18 (16):8884.

Chicago/Turabian Style

Fares Qeadan; Nana A. Mensah; Lily Y. Gu; Erin F. Madden; Kamilla L. Venner; Kevin English. 2021. "Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities." International Journal of Environmental Research and Public Health 18, no. 16: 8884.

Review
Published: 08 August 2021 in Sleep Medicine Reviews
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The goal of this study was to examine the effects of behavioral sleep extension interventions on sleep duration outcomes in children and adults >age 12. We conducted a systematic literature review, article extraction and meta-analysis. Our search yielded 42 studies from 14 countries. The majority of studies (n=19) enrolled adults, 10 studies enrolled college students, 13 enrolled children (high school or middle school aged). Results from the meta-analysis demonstrated behavioral sleep extension resulted in a significantly higher sleep duration as compared to control group or baseline, with pooled standardized mean difference (SMD) that was similar for both two-arm 0.80 (95% CI 0.28 to 1.31; p < 0.01; I2= 99.2%) and one-arm studies 0.75 (95% CI 0.39 to 1.11; p < 0.01; I2= 86%), and there was significant heterogeneity among both study types. Subgroup analyses revealed that studies with direct interventions on sleep duration (i.e., specified the sleep schedule) had larger effects compared to indirect methods (coaching, educational approaches) and a greater number of curriculum components was associated with smaller effects. Results of this review demonstrate that sleep extension studies are effective at extending sleep in a variety of populations but improving the description of intervention methods and use of more rigorous study designs will improve the quality and reproducibility of this area of research.

ACS Style

Kelly Glazer Baron; Jennifer Duffecy; Sirimon Reutrakul; Jessica C. Levenson; Mary M. McFarland; Seunghoon Lee; Fares Qeadan. Behavioral interventions to extend sleep duration: A systematic review and meta-analysis. Sleep Medicine Reviews 2021, 101532 .

AMA Style

Kelly Glazer Baron, Jennifer Duffecy, Sirimon Reutrakul, Jessica C. Levenson, Mary M. McFarland, Seunghoon Lee, Fares Qeadan. Behavioral interventions to extend sleep duration: A systematic review and meta-analysis. Sleep Medicine Reviews. 2021; ():101532.

Chicago/Turabian Style

Kelly Glazer Baron; Jennifer Duffecy; Sirimon Reutrakul; Jessica C. Levenson; Mary M. McFarland; Seunghoon Lee; Fares Qeadan. 2021. "Behavioral interventions to extend sleep duration: A systematic review and meta-analysis." Sleep Medicine Reviews , no. : 101532.

Research report
Published: 19 July 2021 in Addiction
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Aims To assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose. Design A retrospective cohort study using data from the Health Facts® Database. Setting Over 600 U.S. healthcare facilities. Participants Three patient groups were followed for 2 years during 2009-2017: individuals with shoulder or long bone fractures (n=252,424), chronic pain syndrome (CPS) (n=76,141), or non-traumatic low back pain (n=792,956) who received an opioid prescription. Groups were chosen based on previous work. Measurements The outcome was opioid overdose identified by International Classification of Diseases codes (ICDs) and the primary predictor was number of naloxone prescriptions identified by National Drug Codes (NDCs). Findings Opioid overdoses occurred among 0.16% of fracture patients [average follow-up time to overdose (AFU)= 240 days], 1.28% of CPS patients (AFU= 244 days), and 0.30% low back pain patients (AFU= 264 days). 58,083 bone fracture patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose [hazard ratio (HR)=1.87, 95% Confidence Interval (CI)= 1.68-2.09], and number of subsequent overdoses [incidence rate ratio (IRR)=1.89, 95% CI= 1.69-2.12]. 19,529 CPS patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR=1.69, 95% CI 1.61-1.78) and number of subsequent overdoses (IRR=1.74, 95% CI= 1.67-1.83). 110,608 low back pain patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR=1.33, 95% CI 1.27-1.40) and number of subsequent overdoses (IRR= 1.35, 95% CI= 1.29-1.41). Conclusions Receiving a naloxone prescription appears to be associated with increased risk of subsequent opioid overdose among patients with acute and chronic pain, suggesting prescribers often identify patients most in need of naloxone.

ACS Style

Fares Qeadan; Erin Fanning Madden. Associations between naloxone prescribing and opioid overdose among patients with acute and chronic pain conditions. Addiction 2021, 1 .

AMA Style

Fares Qeadan, Erin Fanning Madden. Associations between naloxone prescribing and opioid overdose among patients with acute and chronic pain conditions. Addiction. 2021; ():1.

Chicago/Turabian Style

Fares Qeadan; Erin Fanning Madden. 2021. "Associations between naloxone prescribing and opioid overdose among patients with acute and chronic pain conditions." Addiction , no. : 1.

Pdf only
Published: 18 June 2021 in Advances in Neonatal Care
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Background: The rate of infants born with neonatal abstinence syndrome (NAS) increased by more than 500% between 2004 and 2016. Although feeding problems among infants diagnosed with NAS have been documented, the risk of feeding problems among infants diagnosed with NAS has not been estimated. Purpose: This study evaluates the extent to which feeding problems among infants diagnosed with NAS differ from thise in infants without an NAS diagnosis. Methods/Search Strategy: A matched retrospective cohort study (2008-2017) of infants diagnosed with NAS in the United States was conducted using hospital admission data from the Cerner Health Facts Database. Multivariable logistic regressions controlling for confounders were used to assess whether an NAS diagnosis is associated with hospital admission due to feeding problems. Findings/Results: Infants with NAS were nearly 3 times as likely (OR = 2.81; 95% CI, 2.68-2.95) to have feeding problems compared with infants without NAS after adjusting for infant and hospital characteristics. Lower birth weight, higher infant age, Hispanic ethnicity, and hospital location in the Midwest region were also associated with higher odds of feeding problems. Infants diagnosed with NAS who had feeding problems had slightly lower odds of being offered lactation services than infants without NAS who had feeding problems. Implications for Practice: These findings suggest the need for targeted feeding interventions. Implications for Research: Future research on infants with NAS may build on these findings by assessing the role of maternal factors such as nutrition and substance use to understand how parental characteristics also influence the risk for hospitalization.

ACS Style

Nana A. Mensah; Erin F. Madden; Fares Qeadan. Risk of Feeding Problems Among Infants With Neonatal Abstinence Syndrome. Advances in Neonatal Care 2021, Publish Ah, 1 .

AMA Style

Nana A. Mensah, Erin F. Madden, Fares Qeadan. Risk of Feeding Problems Among Infants With Neonatal Abstinence Syndrome. Advances in Neonatal Care. 2021; Publish Ah ():1.

Chicago/Turabian Style

Nana A. Mensah; Erin F. Madden; Fares Qeadan. 2021. "Risk of Feeding Problems Among Infants With Neonatal Abstinence Syndrome." Advances in Neonatal Care Publish Ah, no. : 1.

Journal article
Published: 15 June 2021 in Archives of Public Health
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Background The spread of the COVID-19 pandemic throughout the world presents an unprecedented challenge to public health inequities. People who use opioids may be a vulnerable group disproportionately impacted by the current pandemic, however, the limited prior research in this area makes it unclear whether COVID-19 and opioid use outcomes may be related, and whether other environmental and socioeconomic factors might play a role in explaining COVID-19 mortality. The objective of this study is to evaluate the association between opioid-related mortality and COVID-19 mortality across U.S. counties. Methods Data from 3142 counties across the U.S. were used to model the cumulative count of deaths due to COVID-19 up to June 2, 2020. A multivariable negative-binomial regression model was employed to evaluate the adjusted COVID-19 mortality rate ratios (aMRR). Results After controlling for covariates, counties with higher rates of opioid-related mortality per 100,000 persons were found to be significantly associated with higher rates of COVID-19 mortality (aMRR: 1.0134; 95% CI [1.0054, 1.0214]; P = 0.001). Counties with higher average daily Particulate Matter (PM2.5) exposure also saw significantly higher rates of COVID-19 mortality. Analyses revealed rural counties, counties with higher percentages of non-Hispanic whites, and counties with increased average maximum temperatures are significantly associated with lower mortality rates from COVID-19. Conclusions This study indicates need for public health efforts in hard hit COVID-19 regions to also focus prevention efforts on overdose risk among people who use opioids. Future studies using individual-level data are needed to allow for detailed inferences.

ACS Style

Fares Qeadan; Nana Akofua Mensah; Benjamin Tingey; Rona Bern; Tracy Rees; Erin Fanning Madden; Christina A. Porucznik; Kevin English; Trenton Honda. The association between opioids, environmental, demographic, and socioeconomic indicators and COVID-19 mortality rates in the United States: an ecological study at the county level. Archives of Public Health 2021, 79, 1 -8.

AMA Style

Fares Qeadan, Nana Akofua Mensah, Benjamin Tingey, Rona Bern, Tracy Rees, Erin Fanning Madden, Christina A. Porucznik, Kevin English, Trenton Honda. The association between opioids, environmental, demographic, and socioeconomic indicators and COVID-19 mortality rates in the United States: an ecological study at the county level. Archives of Public Health. 2021; 79 (1):1-8.

Chicago/Turabian Style

Fares Qeadan; Nana Akofua Mensah; Benjamin Tingey; Rona Bern; Tracy Rees; Erin Fanning Madden; Christina A. Porucznik; Kevin English; Trenton Honda. 2021. "The association between opioids, environmental, demographic, and socioeconomic indicators and COVID-19 mortality rates in the United States: an ecological study at the county level." Archives of Public Health 79, no. 1: 1-8.

Research paper
Published: 04 June 2021 in EClinicalMedicine
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Background Both opioid use and COVID-19 affect respiratory and pulmonary health, potentially putting individuals with opioid use disorders (OUD) at risk for complications from COVID-19. We examine the relationship between OUD and subsequent hospitalization, length of stay, risk for invasive ventilator dependence (IVD), and COVID-19 mortality. Methods Multivariable logistic and exponential regression models using electronic health records data from the Cerner COVID-19 De-Identified Data Cohort from January through June 2020. Findings Out of 52,312 patients with COVID-19, 1.9% (n=1,013) had an OUD. COVID-19 patients with an OUD had higher odds of hospitalization (aOR=3.44, 95% CI=2.81–4.21), maximum length of stay (eβ^=1.16, 95% CI=1.09–1.22), and odds of IVD (aOR=1.26, 95% CI=1.06–1.49) than patients without an OUD, but did not differ with respect to COVID-19 mortality. However, OUD patients under age 45 exhibited greater COVID-19 mortality (aOR=3.23, 95% CI=1.59–6.56) compared to patients under age 45 without an OUD. OUD patients using opioid agonist treatment (OAT) exhibited higher odds of hospitalization (aOR=5.14, 95% CI=2.75–10.60) and higher maximum length of stay (eβ^=1.22, 95% CI=1.01–1.48) than patients without OUDs; however, risk for IVD and COVID-19 mortality did not differ. OUD patients using naltrexone had higher odds of hospitalization (aOR=32.19, 95% CI=4.29–4,119.83), higher maximum length of stay (eβ^=1.59, 95% CI=1.06–2.38), and higher odds of IVD (aOR=3.15, 95% CI=1.04–9.51) than patients without OUDs, but mortality did not differ. OUD patients who did not use treatment medication had higher odds of hospitalization (aOR=4.05, 95% CI=3.32–4.98), higher maximum length of stay (eβ^=1.14, 95% CI=1.08–1.21), and higher odds of IVD (aOR=1.25, 95% CI=1.04–1.50) and COVID-19 mortality (aOR=1.31, 95% CI=1.07–1.61) than patients without OUDs. Interpretation This study suggests people with OUD and COVID-19 often require higher levels of care, and OUD patients who are younger or not using medication treatment for OUDs are particularly vulnerable to death due to COVID-19.

ACS Style

Fares Qeadan; Benjamin Tingey; Rona Bern; Christina A. Porucznik; Kevin English; Ali I. Saeed; Erin Fanning Madden. Opioid use disorder and health service utilization among COVID-19 patients in the US: A nationwide cohort from the Cerner Real-World Data. EClinicalMedicine 2021, 37, 100938 .

AMA Style

Fares Qeadan, Benjamin Tingey, Rona Bern, Christina A. Porucznik, Kevin English, Ali I. Saeed, Erin Fanning Madden. Opioid use disorder and health service utilization among COVID-19 patients in the US: A nationwide cohort from the Cerner Real-World Data. EClinicalMedicine. 2021; 37 ():100938.

Chicago/Turabian Style

Fares Qeadan; Benjamin Tingey; Rona Bern; Christina A. Porucznik; Kevin English; Ali I. Saeed; Erin Fanning Madden. 2021. "Opioid use disorder and health service utilization among COVID-19 patients in the US: A nationwide cohort from the Cerner Real-World Data." EClinicalMedicine 37, no. : 100938.

Comparative study
Published: 22 April 2021 in Scientific Reports
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Factors contributing to racial inequities in outcomes from coronavirus disease 2019 (COVID-19) remain poorly understood. We compared by race the risk of 4 COVID-19 health outcomes––maximum length of hospital stay (LOS), invasive ventilation, hospitalization exceeding 24 h, and death––stratified by Elixhauser comorbidity index (ECI) ranking. Outcomes and ECI scores were constructed from retrospective data obtained from the Cerner COVID-19 De-Identified Data cohort. We hypothesized that racial disparities in COVID-19 outcomes would exist despite comparable ECI scores among non-Hispanic (NH) Blacks, Hispanics, American Indians/Alaska Natives (AI/ANs), and NH Whites. Compared with NH Whites, NH Blacks had longer hospital LOS, higher rates of ventilator dependence, and a higher mortality rate; AI/ANs, higher odds of hospitalization for ECI = 0 but lower for ECI ≥ 5, longer LOS for ECI = 0, a higher risk of death across all ECI categories except ECI ≥ 5, and higher odds of ventilator dependence; Hispanics, a lower risk of death across all ECI categories except ECI = 0, lower odds of hospitalization, shorter LOS for ECI ≥ 5, and higher odds of ventilator dependence for ECI = 0 but lower for ECI = 1–4. Our findings contest arguments that higher comorbidity levels explain elevated COVID-19 death rates among NH Blacks and AI/ANs compared with Hispanics and NH Whites.

ACS Style

Fares Qeadan; Elizabeth VanSant-Webb; Benjamin Tingey; Tiana N. Rogers; Ellen Brooks; Nana A. Mensah; Karen M. Winkfield; Ali I. Saeed; Kevin English; Charles R. Rogers. Racial disparities in COVID-19 outcomes exist despite comparable Elixhauser comorbidity indices between Blacks, Hispanics, Native Americans, and Whites. Scientific Reports 2021, 11, 1 -11.

AMA Style

Fares Qeadan, Elizabeth VanSant-Webb, Benjamin Tingey, Tiana N. Rogers, Ellen Brooks, Nana A. Mensah, Karen M. Winkfield, Ali I. Saeed, Kevin English, Charles R. Rogers. Racial disparities in COVID-19 outcomes exist despite comparable Elixhauser comorbidity indices between Blacks, Hispanics, Native Americans, and Whites. Scientific Reports. 2021; 11 (1):1-11.

Chicago/Turabian Style

Fares Qeadan; Elizabeth VanSant-Webb; Benjamin Tingey; Tiana N. Rogers; Ellen Brooks; Nana A. Mensah; Karen M. Winkfield; Ali I. Saeed; Kevin English; Charles R. Rogers. 2021. "Racial disparities in COVID-19 outcomes exist despite comparable Elixhauser comorbidity indices between Blacks, Hispanics, Native Americans, and Whites." Scientific Reports 11, no. 1: 1-11.

Journal article
Published: 16 April 2021 in BMC Pregnancy and Childbirth
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Background Pregnant women are potentially a high-risk population during infectious disease outbreaks such as COVID-19, because of physiologic immune suppression in pregnancy. However, data on the morbidity and mortality of COVID-19 among pregnant women, compared to nonpregnant women, are sparse and inconclusive. We sought to assess the impact of pregnancy on COVID-19 associated morbidity and mortality, with particular attention to the impact of pre-existing comorbidity. Methods We used retrospective data from January through June 2020 on female patients aged 18–44 years old utilizing the Cerner COVID-19 de-identified cohort. We used mixed-effects logistic and exponential regression models to evaluate the risk of hospitalization, maximum hospital length of stay (LOS), moderate ventilation, invasive ventilation, and death for pregnant women while adjusting for age, race/ethnicity, insurance, Elixhauser AHRQ weighted Comorbidity Index, diabetes history, medication, and accounting for clustering of results in similar zip-code regions. Results Out of 22,493 female patients with associated COVID-19, 7.2% (n = 1609) were pregnant. Crude results indicate that pregnant women, compared to non-pregnant women, had higher rates of hospitalization (60.5% vs. 17.0%, P < 0.001), higher mean maximum LOS (0.15 day vs. 0.08 day, P < 0.001) among those who stayed < 1 day, lower mean maximum LOS (2.55 days vs. 3.32 days, P < 0.001) among those who stayed ≥1 day, and higher moderate ventilation use (1.7% vs. 0.7%, P < 0.001) but showed no significant differences in rates of invasive ventilation or death. After adjusting for potentially confounding variables, pregnant women, compared to non-pregnant women, saw higher odds in hospitalization (aOR: 12.26; 95% CI (10.69, 14.06)), moderate ventilation (aOR: 2.35; 95% CI (1.48, 3.74)), higher maximum LOS among those who stayed < 1 day, and lower maximum LOS among those who stayed ≥1 day. No significant associations were found with invasive ventilation or death. For moderate ventilation, differences were seen among age and race/ethnicity groups. Conclusions Among women with COVID-19 disease, pregnancy confers substantial additional risk of morbidity, but no difference in mortality. Knowing these variabilities in the risk is essential to inform decision-makers and guide clinical recommendations for the management of COVID-19 in pregnant women.

ACS Style

Fares Qeadan; Nana A. Mensah; Benjamin Tingey; Joseph B. Stanford. The risk of clinical complications and death among pregnant women with COVID-19 in the Cerner COVID-19 cohort: a retrospective analysis. BMC Pregnancy and Childbirth 2021, 21, 1 -14.

AMA Style

Fares Qeadan, Nana A. Mensah, Benjamin Tingey, Joseph B. Stanford. The risk of clinical complications and death among pregnant women with COVID-19 in the Cerner COVID-19 cohort: a retrospective analysis. BMC Pregnancy and Childbirth. 2021; 21 (1):1-14.

Chicago/Turabian Style

Fares Qeadan; Nana A. Mensah; Benjamin Tingey; Joseph B. Stanford. 2021. "The risk of clinical complications and death among pregnant women with COVID-19 in the Cerner COVID-19 cohort: a retrospective analysis." BMC Pregnancy and Childbirth 21, no. 1: 1-14.

Journal article
Published: 18 March 2021 in Drug and Alcohol Dependence
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Despite declining overall rates of opioid misuse among college students, racial and ethnic differences in percentage and correlates of opioid misuse among student populations remains unclear. This study seeks to estimate percentages of opioid misuse among American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students and determine whether problems in social bonds affect AI/AN/NH opioid misuse. Guided by social relationship factors associated with substance use in the Social Development Model, we used 2015–2019 data from the American College Health Association-National College Health Assessment survey in multivariable logistic regression models to examine the role of social bonds with peers and family in opioid misuse (prescription and non-prescription) among AI/AN/NH college students across the U.S. The percentage of opioid misuse was highest among AI/AN/NH college students (7.12 %) relative to other race/ethnicity groups. AI/AN/NH college students who reported experiencing loneliness (aOR: 1.68; 95 % CI 1.33−2.12; P < .0001), difficult social relationships (aOR: 1.27; 95 % CI 1.04−1.55; P = 0.0196), family problems (aOR: 1.32; 95 % CI 1.07−1.63; P = 0.0097), and intimate partner violence (aOR: 1.92; 95 % CI 1.56−2.36; P < .0001) were significantly more likely to misuse opioids than students who did not report experiencing these relationship problems. Relationship problems with peers and family increase AI/AN/NH college student risk for opioid misuse, indicating opportunities for colleges to support programs addressing healthy social relationships as a means to reduce opioid misuse among AI/AN/NH students.

ACS Style

Fares Qeadan; Erin F. Madden; Rona Bern; Nasim Parsinejad; Christina A. Porucznik; Kamilla L. Venner; Kevin English. Associations between opioid misuse and social relationship factors among American Indian, Alaska Native, and Native Hawaiian college students in the U.S. Drug and Alcohol Dependence 2021, 108667 .

AMA Style

Fares Qeadan, Erin F. Madden, Rona Bern, Nasim Parsinejad, Christina A. Porucznik, Kamilla L. Venner, Kevin English. Associations between opioid misuse and social relationship factors among American Indian, Alaska Native, and Native Hawaiian college students in the U.S. Drug and Alcohol Dependence. 2021; ():108667.

Chicago/Turabian Style

Fares Qeadan; Erin F. Madden; Rona Bern; Nasim Parsinejad; Christina A. Porucznik; Kamilla L. Venner; Kevin English. 2021. "Associations between opioid misuse and social relationship factors among American Indian, Alaska Native, and Native Hawaiian college students in the U.S." Drug and Alcohol Dependence , no. : 108667.

Journal article
Published: 05 March 2021 in Viruses
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Cytokine storm syndrome in patients with COVID-19 is mediated by pro-inflammatory cytokines resulting in acute lung injury and multiorgan failure. Elevation in serum ferritin and D-dimer is observed in COVID-19 patients. To determine prognostic values of optimal serum cutoff with trajectory plots for both serum ferritin and D-dimer in COVID-19 patients with invasive ventilator dependence and in-hospital mortality. We used retrospective longitudinal data from the Cerner COVID-19 de-identified cohort. COVID-19 infected patients with valid repeated values of serum ferritin and D-dimer during hospitalization were used in mixed-effects logistic-regression models. Among 52,411 patients, 28.5% (14,958) had valid serum ferritin and 28.6% (15,005) D-dimer laboratory results. Optimal cutoffs of ferritin (714 ng/mL) and D-dimer (2.1 mg/L) revealed AUCs ≥ 0.99 for in-hospital mortality. Optimal cutoffs for ferritin (502 ng/mL) and D-dimer (2.0 mg/L) revealed AUCs ≥ 0.99 for invasive ventilator dependence. Optimal cutoffs for in-house mortality, among females, were lower in serum ferritin (433 ng/mL) and D-dimer (1.9 mg/L) compared to males (740 ng/mL and 2.5 mg/L, respectively). Optimal cutoffs for invasive ventilator dependence, among females, were lower in ferritin (270 ng/mL) and D-dimer (1.3 mg/L) compared to males (860 ng/mL and 2.3 mg/L, respectively). Optimal prognostic cutoffs for serum ferritin and D-dimer require considering the entire trajectory of laboratory values during the disease course. Females have an overall lower optimal cutoff for both serum ferritin and D-dimer. The presented research allows health professionals to predict clinical outcomes and appropriate allocation of resources during the COVID-19 pandemic, especially early recognition of COVID-19 patients needing higher levels of care.

ACS Style

Fares Qeadan; Benjamin Tingey; Lily Gu; Ashley Packard; Esther Erdei; Ali Saeed. Prognostic Values of Serum Ferritin and D-Dimer Trajectory in Patients with COVID-19. Viruses 2021, 13, 419 .

AMA Style

Fares Qeadan, Benjamin Tingey, Lily Gu, Ashley Packard, Esther Erdei, Ali Saeed. Prognostic Values of Serum Ferritin and D-Dimer Trajectory in Patients with COVID-19. Viruses. 2021; 13 (3):419.

Chicago/Turabian Style

Fares Qeadan; Benjamin Tingey; Lily Gu; Ashley Packard; Esther Erdei; Ali Saeed. 2021. "Prognostic Values of Serum Ferritin and D-Dimer Trajectory in Patients with COVID-19." Viruses 13, no. 3: 419.

Research article
Published: 22 January 2021 in PLOS Pathogens
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Intracellular pathogens have evolved to utilize normal cellular processes to complete their replicative cycles. Pathogens that interface with proliferative cell signaling pathways risk infections that can lead to cancers, but the factors that influence malignant outcomes are incompletely understood. Human papillomaviruses (HPVs) predominantly cause benign hyperplasia in stratifying epithelial tissues. However, a subset of carcinogenic or “high-risk” HPV (hr-HPV) genotypes are etiologically linked to nearly 5% of all human cancers. Progression of hr-HPV-induced lesions to malignancies is characterized by increased expression of the E6 and E7 oncogenes and the oncogenic functions of these viral proteins have been widely studied. Yet, the mechanisms that regulate hr-HPV oncogene transcription and suppress their expression in benign lesions remain poorly understood. Here, we demonstrate that EGFR/MEK/ERK signaling, influenced by epithelial contact inhibition and tissue differentiation cues, regulates hr-HPV oncogene expression. Using monolayer cells, epithelial organotypic tissue models, and neoplastic tissue biopsy materials, we show that cell-extrinsic activation of ERK overrides cellular control to promote HPV oncogene expression and the neoplastic phenotype. Our data suggest that HPVs are adapted to use the EGFR/MEK/ERK signaling pathway to regulate their productive replicative cycles. Mechanistic studies show that EGFR/MEK/ERK signaling influences AP-1 transcription factor activity and AP-1 factor knockdown reduces oncogene transcription. Furthermore, pharmacological inhibitors of EGFR, MEK, and ERK signaling quash HPV oncogene expression and the neoplastic phenotype, revealing a potential clinical strategy to suppress uncontrolled cell proliferation, reduce oncogene expression and treat HPV neoplasia.

ACS Style

Adrian J. Luna; Rosa T. Sterk; Anastacia M. Griego-Fisher; Joon-Yong Chung; Kiersten L. Berggren; Virginie Bondu; Pamela Barraza-Flores; Andrew T. Cowan; Gregory N. Gan; Emrullah Yilmaz; Hanbyoul Cho; Jae-Hoon Kim; Stephen M. Hewitt; Julie E. Bauman; Michelle A. Ozbun. MEK/ERK signaling is a critical regulator of high-risk human papillomavirus oncogene expression revealing therapeutic targets for HPV-induced tumors. PLOS Pathogens 2021, 17, e1009216 .

AMA Style

Adrian J. Luna, Rosa T. Sterk, Anastacia M. Griego-Fisher, Joon-Yong Chung, Kiersten L. Berggren, Virginie Bondu, Pamela Barraza-Flores, Andrew T. Cowan, Gregory N. Gan, Emrullah Yilmaz, Hanbyoul Cho, Jae-Hoon Kim, Stephen M. Hewitt, Julie E. Bauman, Michelle A. Ozbun. MEK/ERK signaling is a critical regulator of high-risk human papillomavirus oncogene expression revealing therapeutic targets for HPV-induced tumors. PLOS Pathogens. 2021; 17 (1):e1009216.

Chicago/Turabian Style

Adrian J. Luna; Rosa T. Sterk; Anastacia M. Griego-Fisher; Joon-Yong Chung; Kiersten L. Berggren; Virginie Bondu; Pamela Barraza-Flores; Andrew T. Cowan; Gregory N. Gan; Emrullah Yilmaz; Hanbyoul Cho; Jae-Hoon Kim; Stephen M. Hewitt; Julie E. Bauman; Michelle A. Ozbun. 2021. "MEK/ERK signaling is a critical regulator of high-risk human papillomavirus oncogene expression revealing therapeutic targets for HPV-induced tumors." PLOS Pathogens 17, no. 1: e1009216.

Preprint content
Published: 14 January 2021
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Background: Pregnant women are potentially a high-risk population during infectious disease outbreaks such as COVID-19, because of physiologic immune suppression in pregnancy. However, data on the morbidity and mortality of COVID-19 among pregnant women, compared to nonpregnant women, are sparse and inconclusive. We sought to assess the impact of pregnancy on COVID-19 associated morbidity and mortality, with particular attention to the impact of pre-existing comorbidity.Methods: We used retrospective data from January through June 2020 on female patients aged 18-44 years old utilizing the Cerner COVID-19 de-identified cohort. We used mixed-effects logistic and exponential regression models to evaluate the risk of hospitalization, maximum hospital length of stay (LOS), moderate ventilator dependence, invasive ventilator dependence, and death for pregnant women while adjusting for age, race/ethnicity, insurance, Elixhauser AHRQ weighted Comorbidity Index, diabetes history, medication, and accounting for clustering of results in similar zip-code regions. Results: Out of 22,493 female patients with identified COVID-19, 7.2% (n=1,609) were pregnant. Crude results indicate that pregnant women, compared to non-pregnant women, had higher rates of hospitalization (60.5% vs. 17.0%, PConclusions: Among women with COVID-19 disease, pregnancy confers substantial additional risk of morbidity, but no difference in mortality. Knowing these variabilities in the risk is essential to inform decision-makers and guide clinical recommendations for the management of COVID-19 in pregnant women.

ACS Style

Fares Qeadan; Nana Mensah; Benjamin Tingey; Joseph Stanford. The Risk of Clinical Complications and Death among Pregnant Women with COVID-19 . 2021, 1 .

AMA Style

Fares Qeadan, Nana Mensah, Benjamin Tingey, Joseph Stanford. The Risk of Clinical Complications and Death among Pregnant Women with COVID-19 . . 2021; ():1.

Chicago/Turabian Style

Fares Qeadan; Nana Mensah; Benjamin Tingey; Joseph Stanford. 2021. "The Risk of Clinical Complications and Death among Pregnant Women with COVID-19 ." , no. : 1.

Preprint content
Published: 31 December 2020
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Background: Cytokine profiles have traditionally been explored in serum due to its ease of accessibility and the diagnostic and assessment capabilities in a clinic setting. Utilization of additional cytokine depots, such as hilar lymph nodes, has not thoroughly been explored. In this study, we examined the cytokine profile of mediastinal and hilar lymph node fine needle aspirates to identify markers capable of differentiating high-risk smokers (>30 pack-years) from low-risk smokers (Methods: We used the cytokine profiles of 27 patients from a pro-spective convenience pilot study conducted at the University of New Mexico. Logistic regression analysis was employed.Results: A significant difference in mean cytokine values for Leptin was discovered between patients categorized as low-risk and high-risk pack year smokers (p=0.034). Additionally, mean cytokine values of Leptin did not differ between patients by cancer diagnosis (malignant vs. benign). Our analysis demonstrated Leptin as a fair marker for discriminating between high-risk smokers and low-risk smokers (AUC 0.73). Conclusions: We conclude Leptin is an optimal cytokine to discriminate between high-risk and low-risk smokers. To our knowledge, this is the first study to assess the ability of Leptin to serve as such an indicator via hilar lymph nodes.

ACS Style

Fares Qeadan; Rosstin Ahmadian; Emily Alden; Erica Pascetti; Lily Y. Gu; Ali I. Saeed. Leptin Levels in Lymph Node Aspiration Biopsy is a Predictor of Smoking Tendencies: A Pilot Study. 2020, 1 .

AMA Style

Fares Qeadan, Rosstin Ahmadian, Emily Alden, Erica Pascetti, Lily Y. Gu, Ali I. Saeed. Leptin Levels in Lymph Node Aspiration Biopsy is a Predictor of Smoking Tendencies: A Pilot Study. . 2020; ():1.

Chicago/Turabian Style

Fares Qeadan; Rosstin Ahmadian; Emily Alden; Erica Pascetti; Lily Y. Gu; Ali I. Saeed. 2020. "Leptin Levels in Lymph Node Aspiration Biopsy is a Predictor of Smoking Tendencies: A Pilot Study." , no. : 1.

Journal article
Published: 31 December 2020 in Preventive Medicine
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Prior research has shown that sexual minorities are disproportionately affected by substance use disorders and prescription opioid misuse. While most studies explore how single dimensions of sexual orientation (i.e., identity, attraction, and behavior) are associated with substance use disorders, we aimed to explore how multiple dimensions of sexual orientation interact with substance use behaviors. Specifically, we examined sexual identity-attraction discordance, the situation when one's sexual identity does not match their socially-expected sexual attractions, with prescription opioid misuse. This study assessed the association between sexual identity-attraction discordance with prescription opioid misuse utilizing data from the National Survey on Drug Use and Health from 2015 to 2017 among adults while employing propensity score weighting with multivariable logistic regression. The study included 127,430 adult participants, of whom 1.3%, 4.4%, and 10.6% self-reported prescription opioid misuse in the past month, past year, and lifetime, respectively. Those with discordant sexual identity-attractions had higher odds of prescription opioid misuse in their lifetime (aOR= 1.22, 95% CI 1.07–1.40) when compared to those with concordant sexual identity-attractions. When stratified by sex, we found sexual identity-attraction discordant females had higher odds of prescription opioid misuse in their lifetime (aOR= 1.29, 95% CI 1.13–1.49); there was no association among males. These findings further emphasize the need to consider the dynamic nature of sexual orientation in substance use research.

ACS Style

Fares Qeadan; William A. Barbeau; Lingpeng Shan; Sunday Azagba. Associations between sexual identity-attraction discordance, and prescription opioid misuse among adults. Preventive Medicine 2020, 145, 106401 .

AMA Style

Fares Qeadan, William A. Barbeau, Lingpeng Shan, Sunday Azagba. Associations between sexual identity-attraction discordance, and prescription opioid misuse among adults. Preventive Medicine. 2020; 145 ():106401.

Chicago/Turabian Style

Fares Qeadan; William A. Barbeau; Lingpeng Shan; Sunday Azagba. 2020. "Associations between sexual identity-attraction discordance, and prescription opioid misuse among adults." Preventive Medicine 145, no. : 106401.

Original investigation
Published: 01 October 2020 in Journal of the Medical Library Association
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Objective: The authors measured burnout among health sciences librarians at our institution and determined whether a serious game intervention could improve personal and workplace well-being.Methods: A modified American Medical Association Mini-Z burnout survey was administered to library faculty in 2016 and both library faculty and staff in 2017. A three-month team-based game was implemented and assessed as an intervention to improve well-being among library employees. After the game, the burnout survey was re-administered to employees in 2018.Results: Library faculty scored poorly on burnout indicators, with 38%–73% of faculty reporting emotional exhaustion and 54%–91% reporting job-related stress over the years. In 2017, 62% of library staff members reported experiencing burnout and 38% indicated they felt a great deal of stress because of their jobs. Regarding the game intervention, 70% of post-game survey respondents reported that the game encouraged them to socialize with colleagues. Qualitative coding of survey responses resulted in 4 themes describing the most enjoyable aspects of the game: sociability, motivation, game play, and fun. Employees found that the game was a useful strategy for encouraging a more social culture with fun activities.Conclusions: Similar to previous studies of librarians and health professionals, health sciences librarians at our institution experienced burnout. Although the game intervention did not significantly reduce burnout or increase job satisfaction, it improved collegiality and recognition. Therefore, a workplace well-being game can encourage team building but may not sufficiently address the root causes of health sciences librarian burnout.

ACS Style

Tallie Casucci; Amy B. Locke; Autumn Henson; Fares Qeadan. A workplace well-being game intervention for health sciences librarians to address burnout. Journal of the Medical Library Association 2020, 108, 605 -617.

AMA Style

Tallie Casucci, Amy B. Locke, Autumn Henson, Fares Qeadan. A workplace well-being game intervention for health sciences librarians to address burnout. Journal of the Medical Library Association. 2020; 108 (4):605-617.

Chicago/Turabian Style

Tallie Casucci; Amy B. Locke; Autumn Henson; Fares Qeadan. 2020. "A workplace well-being game intervention for health sciences librarians to address burnout." Journal of the Medical Library Association 108, no. 4: 605-617.

Journal article
Published: 29 August 2020 in International Journal of Environmental Research and Public Health
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With the emergence of the novel SARS-CoV-2 and the disease it causes; COVID-19, compliance with/adherence to protective measures is needed. Information is needed on which measures are, or are not, being undertaken. Data collected from the COVID Impact Survey, conducted by the non-partisan and objective research organization NORC at the University of Chicago on April, May, and June of 2020, were analyzed through weighted Quasi-Poisson regression modeling to determine the association of demographics, socioeconomics, and health conditions with protective health measures taken at the individual level in response to COVID-19. The three surveys included data from 18 regional areas including 10 states (CA, CO, FL, LA, MN, MO, MT, NY, OR, and TX) and 8 Metropolitan Statistical Areas (Atlanta, GA; Baltimore, MD; Birmingham, AL; Chicago, IL; Cleveland and Columbus, OH; Phoenix, AZ; and Pittsburgh, PA). Individuals with higher incomes, insurance, higher education levels, large household size, age 60+, females, minorities, those who have asthma, have hypertension, overweight or obese, and those who suffer from mental health issues during the pandemic were significantly more likely to report taking precautionary protective measures relative to their counterparts. Protective measures for the three subgroups with a known relationship to COVID-19 (positive for COVID-19, knowing an individual with COVID-19, and knowing someone who had died from COVID-19) were strongly associated with the protective health measures of washing hands, avoiding public places, and canceling social engagements. This study provides first baseline data on the response to the national COVID-19 pandemic at the individual level in the US. The found heterogeneity in the response to this pandemic by different variables can inform future research and interventions to reduce exposure to the novel SARS-CoV-2 virus.

ACS Style

Fares Qeadan; Nana Akofua Mensah; Benjamin Tingey; Rona Bern; Tracy Rees; Sharon Talboys; Tejinder Pal Singh; Steven Lacey; Kimberley Shoaf. What Protective Health Measures Are Americans Taking in Response to COVID-19? Results from the COVID Impact Survey. International Journal of Environmental Research and Public Health 2020, 17, 6295 .

AMA Style

Fares Qeadan, Nana Akofua Mensah, Benjamin Tingey, Rona Bern, Tracy Rees, Sharon Talboys, Tejinder Pal Singh, Steven Lacey, Kimberley Shoaf. What Protective Health Measures Are Americans Taking in Response to COVID-19? Results from the COVID Impact Survey. International Journal of Environmental Research and Public Health. 2020; 17 (17):6295.

Chicago/Turabian Style

Fares Qeadan; Nana Akofua Mensah; Benjamin Tingey; Rona Bern; Tracy Rees; Sharon Talboys; Tejinder Pal Singh; Steven Lacey; Kimberley Shoaf. 2020. "What Protective Health Measures Are Americans Taking in Response to COVID-19? Results from the COVID Impact Survey." International Journal of Environmental Research and Public Health 17, no. 17: 6295.

Journal article
Published: 16 July 2020 in American Journal of Preventive Medicine
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Introduction The relationship between e-cigarette use and cigarette smoking is the subject of ongoing debate. There is limited research on e-cigarette use and changes in the frequency of cigarette smoking. This study examines whether the frequency of e-cigarette use is associated with changes in cigarette smoking behavior among U.S. adults. Methods The study used data (n=20,558) from Waves 1 (2013–2014) and 2 (2014–2015) of the Population Assessment of Tobacco and Health, analyzed in 2019. Multivariable multinomial logistic regression assessed the association between e-cigarette use at Wave 1 and change in cigarette smoking frequency between Waves 1 and 2. Results Every day cigarette smokers who used e-cigarettes some days (OR=1.95, 95% CI=1.27, 2.98) and every day (OR=3.37, 95% CI=1.78, 6.36) in Wave 1 had significantly higher odds of switching to some days cigarette smoking in Wave 2. Every day smokers who used e-cigarettes every day in Wave 1 had higher odds of becoming former cigarette smokers in Wave 2. Likewise, e-cigarette use at baseline among former cigarette smokers was associated with higher odds of switching to some days cigarette smoking (experimental e-cigarette use: OR=5.43, 95% CI=2.13, 10.72; some days e-cigarette use: OR=4.78, 95% CI=2.13, 10.72). In addition, experimental smokers who were also some days e-cigarettes users in Wave 1 had significantly lower odds of switching to experimental former smokers. Conclusions Although e-cigarette use may reduce cigarette smoking frequency among continuing smokers, findings suggest that e-cigarette use may be associated with cigarette smoking relapse among former smokers.

ACS Style

Sunday Azagba; Fares Qeadan; Lingpeng Shan; Keely Latham; Mark Wolfson. E-Cigarette Use and Transition in Adult Smoking Frequency: A Longitudinal Study. American Journal of Preventive Medicine 2020, 59, 367 -376.

AMA Style

Sunday Azagba, Fares Qeadan, Lingpeng Shan, Keely Latham, Mark Wolfson. E-Cigarette Use and Transition in Adult Smoking Frequency: A Longitudinal Study. American Journal of Preventive Medicine. 2020; 59 (3):367-376.

Chicago/Turabian Style

Sunday Azagba; Fares Qeadan; Lingpeng Shan; Keely Latham; Mark Wolfson. 2020. "E-Cigarette Use and Transition in Adult Smoking Frequency: A Longitudinal Study." American Journal of Preventive Medicine 59, no. 3: 367-376.

Article
Published: 28 May 2020 in Metrika
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For the special case of balanced one-way random effects ANOVA, it has been established that the generalized likelihood ratio test (LRT) and Wald’s test are largely equivalent in testing the variance component. We extend these results to explore the relationships between Wald’s F test, and the LRT for a much broader class of linear mixed models; the generalized split-plot models. In particular, we explore when the two tests are equivalent and prove that when they are not equivalent, Wald’s F test is more powerful, thus making the LRT test inadmissible. We show that inadmissibility arises in realistic situations with common number of degrees of freedom. Further, we derive the statistical distribution of the LRT under both the null and alternative hypotheses \(H_0\) and \(H_1\) where \(H_0\) is the hypothesis that the between variance component is zero. Providing an exact distribution of the test statistic for the LRT in these models will help in calculating a more accurate p-value than the traditionally used p-value derived from the large sample chi-square mixture approximations.

ACS Style

Fares Qeadan; Ronald Christensen. On the equivalence between the LRT and F-test for testing variance components in a class of linear mixed models. Metrika 2020, 84, 313 -338.

AMA Style

Fares Qeadan, Ronald Christensen. On the equivalence between the LRT and F-test for testing variance components in a class of linear mixed models. Metrika. 2020; 84 (3):313-338.

Chicago/Turabian Style

Fares Qeadan; Ronald Christensen. 2020. "On the equivalence between the LRT and F-test for testing variance components in a class of linear mixed models." Metrika 84, no. 3: 313-338.

Journal article
Published: 01 May 2020 in Urology
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To determine factors and barriers associated with scholarly activity among faculty members at urology residency programs in the United States. An online survey was sent to all 134 urology residency program directors. The survey assessed program characteristics including size, location and definition of scholarly activity. It assessed available support for and barriers to resident scholarly activity, faculty participation in scholarly activity and mentorship of residents. Linear regression analysis was used. We had a 40% response rate (N = 40). Faculty attitudes toward conducting scholarly activity (P < .001) and lack of a research curriculum (P = .05) were barriers to the outcome 'participation in scholarly activity'. Faculty attitudes toward conducting scholarly activity was also a barrier to the outcomes 'mentorship of residents' (P = .004) and 'publication of at least 1 paper' (P = .004). Available statistician was positively associated with the outcomes 'publications' (P = .062) and 'presentations' (P = .032). A minimum requirement of a local presentation (P=0.04) and chairman support (P = .015) were positively associated with the outcome 'presentation at a conference.' Training residents in research matters for the resident, the institution and future generations of surgeon scientists. Higher levels of faculty scholarly activity were associated with a minimum requirement for residents to submit a manuscript for publication, strong chairman support for resident research, and the availability of a statistician. A common barrier to faculty scholarly activity, publications, and resident mentorship was faculty attitudes toward resident scholarly activity. Urology residency programs seeking to prioritize scholarly activity among faculty should consider these factors.

ACS Style

David J. Gangwish; Carolyn A. Parshall; Fares Qeadan; Martin Jurado; Renata N. Bennett; Frances M. Alba. Predictors and Barriers to Faculty Scholarly Activity in United States Urology Residency Programs. Urology 2020, 139, 37 -43.

AMA Style

David J. Gangwish, Carolyn A. Parshall, Fares Qeadan, Martin Jurado, Renata N. Bennett, Frances M. Alba. Predictors and Barriers to Faculty Scholarly Activity in United States Urology Residency Programs. Urology. 2020; 139 ():37-43.

Chicago/Turabian Style

David J. Gangwish; Carolyn A. Parshall; Fares Qeadan; Martin Jurado; Renata N. Bennett; Frances M. Alba. 2020. "Predictors and Barriers to Faculty Scholarly Activity in United States Urology Residency Programs." Urology 139, no. : 37-43.

Journal article
Published: 16 April 2020 in International Journal of Environmental Research and Public Health
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Differences in jurisdictional public health actions have played a significant role in the relative success of local communities in combating and containing the COVID-19 pandemic. We forecast the possible COVID-19 outbreak in one US state (Utah) by applying empirical data from South Korea and Italy, two countries that implemented disparate public health actions. Forecasts were created by aligning the start of the pandemic in Utah with that in South Korea and Italy, getting a short-run forecast based on actual daily rates of spread, and long-run forecast by employing a log-logistic model with four parameters. Applying the South Korea model, the epidemic peak in Utah is 169 cases/day, with epidemic resolution by the end of May. Applying the Italy model, new cases are forecast to exceed 200/day by mid-April, with the potential for 250 new cases a day at the epidemic peak, with the epidemic continuing through the end of August. We identify a 3-month variation in the likely length of the pandemic, a 1.5-fold difference in the number of daily infections at outbreak peak, and a 3-fold difference in the expected cumulative cases when applying the experience of two developed countries in handling this virus to the Utah context.

ACS Style

Fares Qeadan; Trenton Honda; Lisa H. Gren; Jennifer Dailey-Provost; L. Scott Benson; James A. Vanderslice; Christina A. Porucznik; A. Blake Waters; Steven Lacey; Kimberley Shoaf. Naive Forecast for COVID-19 in Utah Based on the South Korea and Italy Models-the Fluctuation between Two Extremes. International Journal of Environmental Research and Public Health 2020, 17, 2750 .

AMA Style

Fares Qeadan, Trenton Honda, Lisa H. Gren, Jennifer Dailey-Provost, L. Scott Benson, James A. Vanderslice, Christina A. Porucznik, A. Blake Waters, Steven Lacey, Kimberley Shoaf. Naive Forecast for COVID-19 in Utah Based on the South Korea and Italy Models-the Fluctuation between Two Extremes. International Journal of Environmental Research and Public Health. 2020; 17 (8):2750.

Chicago/Turabian Style

Fares Qeadan; Trenton Honda; Lisa H. Gren; Jennifer Dailey-Provost; L. Scott Benson; James A. Vanderslice; Christina A. Porucznik; A. Blake Waters; Steven Lacey; Kimberley Shoaf. 2020. "Naive Forecast for COVID-19 in Utah Based on the South Korea and Italy Models-the Fluctuation between Two Extremes." International Journal of Environmental Research and Public Health 17, no. 8: 2750.