Publications by authors named "Sherrie Khadanga"

15 Publications

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The Association of Patient Educational Attainment With Cardiac Rehabilitation Adherence and Health Outcomes.

J Cardiopulm Rehabil Prev 2021 Nov 24. Epub 2021 Nov 24.

Larner College of Medicine at the University of Vermont, Burlington (Drs Gaalema, O'Neill, and Bolívar and Ms Denkmann); Department of Medicine, Division of Cardiology, University of Vermont Medical Center, Burlington (Mr Savage and Drs Khadanga and Ades); and Department of Biostatistics, University of Vermont, Burlington (Dr Priest).

Purpose: Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR.

Methods: This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate.

Results: Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables.

Conclusions: Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.
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http://dx.doi.org/10.1097/HCR.0000000000000646DOI Listing
November 2021

Benchmarking Depressive Symptoms in Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2021 Nov 24. Epub 2021 Nov 24.

Vermont Center on Behavior and Health, Burlington (Mr Middleton and Drs Ades and Gaalema); Departments of Psychiatry (Dr Gaalema) and Psychology (Mr Middleton and Dr Gaalema), University of Vermont, Burlington; and Division of Cardiology, University of Vermont College of Medicine, Burlington (Messrs Savage and Rengo and Drs Khadanga and Ades).

Purpose: Depression affects cardiac health and is important to track within cardiac rehabilitation (CR). Using two depression screeners within one sample, we calculated prevalence of baseline depressive symptomology, improvements during CR, and predictors of both.

Methods: Data were drawn from the University of Vermont Medical Center CR program prospectively collected database. A total of 1781 patients who attended between January 2011 and July 2019 were included. Two depression screeners (Geriatric Depression Scale-Short Form [GDS-SF] and Patient Health Questionnaire-9 [PHQ-9]) were compared on proportion of the sample categorized with ≥ mild or moderate levels of depressive symptoms (PHQ-9 ≥5, ≥10; GDS-SF ≥6, ≥10). Changes in depressive symptoms by screener were examined within patients who had completed ≥9 sessions of CR. Patient characteristics associated with depressive symptoms at entry, and changes in symptoms were identified.

Results: Within those who completed ≥9 sessions of CR with exit scores on both screeners (n = 1201), entrance prevalence of ≥ mild and ≥ moderate depressive symptoms differed by screener (32% and 9% PHQ-9; 12% and 3% GDS-SF; both P < .001). Patients who were younger, female, with lower cardiorespiratory fitness (CRF) scores were more likely to have ≥ mild depressive symptoms at entry. Most patients with ≥ mild symptoms decreased severity by ≥1 category by exit (PHQ-9 = 73%; GDS-SF = 77%). Nonsurgical diagnosis and lower CRF were associated with less improvement in symptoms on the PHQ-9 (both P < .05).

Conclusion: Our results provide initial benchmarks of depressive symptoms in CR. They identify younger patients, women, patients with lower CRF, and those with nonsurgical diagnosis as higher risk groups for having depressive symptoms or lack of improvement in symptoms.
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http://dx.doi.org/10.1097/HCR.0000000000000657DOI Listing
November 2021

Optimizing Training Response for Women in Cardiac Rehabilitation: A Randomized Clinical Trial.

JAMA Cardiol 2021 Nov 24. Epub 2021 Nov 24.

Division of Cardiology, Department of Medicine, University of Vermont, Burlington.

Importance: Despite lower baseline fitness levels, women in cardiac rehabilitation (CR) do not typically improve peak aerobic exercise capacity (defined as peak oxygen uptake [peak Vo2]) compared with men in CR.

Objective: To evaluate the effect of high-intensity interval training (HIIT) and intensive lower extremity resistance training (RT) compared with standard moderate intensity continuous training (MCT) on peak Vo2 among women in CR.

Design, Setting, And Participants: This randomized clinical trial conducted from July 2017 to February 2020 included women from a community-based cardiac rehabilitation program affiliated with a university hospital in Vermont. A total of 56 women (mean [SD] age, 65 [11] years; range 43-98 years) participating in CR enrolled in the study.

Interventions: MCT (70% to 85% of peak heart rate [HR]) with moderate intensive RT or HIIT (90% to 95% of peak HR) along with higher-intensity lower extremity RT 3 times per week over 12 weeks.

Main Outcomes And Measures: The primary outcome was the between-group difference in change in peak Vo2 (L/min) from baseline to 12 weeks.

Results: Peak Vo2 increased to a greater degree in the HIIT group (+23%) than in the control group (+7%) (mean [SD] increase, 0.3 [0.2] L/min vs 0.1 [0.2] L/min; P = .03). Similarly, the change in leg strength was greater in the HIIT-RT group compared with the control group (mean [SD] increase, 15.3 [0.3] kg vs 6.4 [1.1] kg; P = .004).

Conclusions And Relevance: An exercise protocol combining HIIT and intensive lower extremity RT enhanced exercise training response for women in CR compared with standard CR exercise training. Women randomized to HIIT experienced significantly greater improvements in both peak Vo2 and leg strength during CR.

Trial Registration: ClinicalTrials.gov Identifier: NCT03438968.
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http://dx.doi.org/10.1001/jamacardio.2021.4822DOI Listing
November 2021

Underutilization of Cardiac Rehabilitation in Women: BARRIERS AND SOLUTIONS.

J Cardiopulm Rehabil Prev 2021 07;41(4):207-213

Department of Medicine, Division of Cardiology, University of Vermont, Burlington (Drs Khadanga and Ades and Mr Savage); Departments of Psychiatry and Psychology, University of Vermont, Burlington (Dr Gaalema); and Vermont Center on Behavior and Health, University of Vermont, Burlington (Drs Gaalema and Ades).

Purpose: Despite the known benefits of cardiac rehabilitation (CR), it remains underutilized particularly among women. The aim of this review was to provide an overview regarding women in CR, addressing barriers that may affect enrollment and attendance as well as to discuss the training response and methods to optimize exercise-related benefits of CR.

Review Methods: The review examines original studies and meta-analyses regarding women in CR.

Summary: Women are less likely to engage in CR compared with men, and this may be attributed to lack of referral or psychosocial barriers on the part of the patient. Furthermore, despite having lower levels of fitness, women do not improve their fitness as much as men in CR. This review summarizes the current literature and provides recommendations for providers regarding participation and adherence as well as optimal methods for exercise training for women in CR.
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http://dx.doi.org/10.1097/HCR.0000000000000629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243714PMC
July 2021

Predictors of Cardiac Rehabilitation Participation: OPPORTUNITIES TO INCREASE ENROLLMENT.

J Cardiopulm Rehabil Prev 2021 09;41(5):322-327

Division of Cardiology, Department of Medicine (Drs Khadanga and Ades and Mr Savage), Vermont Center on Behavior and Health (Drs Khadanga, Gaalema, and Ades and Mr Savage), and Departments of Psychiatry and Psychology (Dr Gaalema), University of Vermont, Burlington.

Purpose: Participation in cardiac rehabilitation (CR) is low despite proven benefits. The aim of this study was to assess medical, psychosocial, and behavioral predictors of participation in a phase 2 CR.

Methods: This was a prospective observational study. Participants hospitalized for an acute cardiac event and eligible for CR completed in-hospital assessments, and the primary outcome was CR participation over a 4-mo follow-up. Measures included age, sex, educational attainment, smoking status, medical diagnosis, ejection fraction, and electronic referral to CR. Data included General Anxiety Disorder, Patient Health Questionnaire, Medical Outcomes Study Short Form-36, Behavioral Rating Inventory of Executive Function, and Duke Social Support Index. Logistic regression and Classification and Regression Tree analysis were performed.

Results: Of 378 hospitalized patients approached, 294 (31% females) enrolled in the study and 175 participated in CR. The presence of electronic referral, surgical diagnosis, non/former smoker, and strength of physician recommendation (all Ps < .02) were independent predictors for CR participation. No differences were seen in participation by measures of anxiety, depression, or executive function. Males with a profile of electronic referral to CR, high school or higher education, ejection fraction >50%, and strong physician recommendation were the most likely cohort to participate in CR (89%). Patients not referred to CR were the least likely to attend (20%).

Conclusions: Lack of CR referral, lower educational attainment, nonsurgical diagnosis, current smoking, and reduced ejection fraction can predict patients at a highest risk of CR nonparticipation. Specific interventions such as electronic referral and a strong in-person recommendation from a medical provider may enhance CR participation rates.
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http://dx.doi.org/10.1097/HCR.0000000000000573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310538PMC
September 2021

Congenital left ventricular wall defects presenting with ventricular arrhythmias: A case series.

HeartRhythm Case Rep 2020 Oct 3;6(10):715-719. Epub 2020 Jul 3.

Division of Cardiovascular Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont.

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http://dx.doi.org/10.1016/j.hrcr.2020.06.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573374PMC
October 2020

Current smoking as a marker of a high-risk behavioral profile after myocardial infarction.

Prev Med 2020 11 8;140:106245. Epub 2020 Sep 8.

Vermont Center on Behavior and Health, United States; University of Vermont, Burlington, VT, United States; University of Vermont Medical Center, Burlington, VT, United States.

Continued smoking following myocardial infarction (MI) is strongly associated with increased morbidity and mortality. Patients who continue to smoke may also engage in other behaviors that exacerbate risk. This study sought to characterize the risk profile of a national sample of individuals with previous MI who currently smoke. Data were taken from the 2017 Behavioral Risk Factor Surveillance Survey (United States), with 4.2% of the sample reporting a past MI (N = 26,004). Participants were classified by smoking status (current/former/never) and compared on medical comorbidities and the clustering of modifiable behaviors relevant for secondary prevention (smoking, poor nutrition, problematic alcohol use, physical inactivity, medication adherence). Current smokers were more likely to report other comorbidities including stroke, chronic obstructive pulmonary disease, physical limitations, and poor mental health. Smokers were also less likely to report taking blood pressure and cholesterol medications, and less likely to attend cardiac rehabilitation (examined in a subset of the sample, N = 2181). Current smoking remained an independent predictor of other health-related behaviors even when controlling for age, sex, race, educational attainment, and other comorbidities. In the modifiable risk-factor behavior cluster analysis, the most common pattern among current smokers was having two risk factors, smoking plus one additional risk factor, whereas the most common pattern was zero risk factors among never or former-smokers. Physical inactivity was the most common additional risk factor across smoking statuses. Current smoking is associated with multiple comorbidities and should be considered a marker for a high-risk behavioral profile among patients with a history of MI.
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http://dx.doi.org/10.1016/j.ypmed.2020.106245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680426PMC
November 2020

Response to Exercise Training During Cardiac Rehabilitation Differs by Sex.

J Cardiopulm Rehabil Prev 2020 09;40(5):319-324

Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, Burlington (Messrs Rengo and Savage and Drs Khadanga and Ades); and University of Vermont College of Medicine, Burlington (Drs Khadanga and Ades).

Purpose: Directly measured peak aerobic capacity or oxygen uptake is a powerful predictor of prognosis in individuals with cardiovascular disease. Women enter phase 2 cardiac rehabilitation (CR) with lower and their response to training, compared with men, is equivocal. We analyzed at entry and exit in patients participating in CR and improvements by diagnosis to assess training response. We also identified sex differences that may influence change in .

Methods: The cohort included consecutive patients enrolled in CR between January 1996 and December 2015 who performed entry exercise tolerance tests. Data collected included demographics, index diagnosis, , and exercise training response.

Results: The cohort consisted of 3925 patients (24% female). There was a significant interaction between baseline and diagnosis (P < .001), with percutaneous coronary intervention and myocardial infarction greater than other diagnoses. Surgical patients demonstrated greater improvement in than nonsurgical diagnoses (n = 1789; P < .001). Women had lower than men for all diagnoses (P < .02) and demonstrated less improvement (13 vs 17%, P < .001). Percent improvement using estimated metabolic equivalents of task (METs) were similar for women and men (33 vs 31%, P = NS). Despite overall increases in , 18% of patients (24% women, 16% men) failed to demonstrate any improvement (exit ≤ entry ).

Conclusions: While there were no differences in training effect estimated by METs, directly measured showed a significantly lower training response for women despite adjusting for covariates. In addition, 18% of patients did not see any improvement in . Alternatives to traditional CR exercise programming need to be considered.
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http://dx.doi.org/10.1097/HCR.0000000000000536DOI Listing
September 2020

Resistance Training for Older Adults in Cardiac Rehabilitation.

Clin Geriatr Med 2019 11 3;35(4):459-468. Epub 2019 Jul 3.

Department of Medicine, Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, 62 Tilley Drive, South Burlington, VT 05403, USA.

Cardiac rehabilitation plays a key role in the care of older patients after a coronary event. Hospitalizations are prevented and quality of life, exercise capacity, and physical function are improved. Almost 50% of cardiac rehabilitation participants are older adults (>65 years), many of whom are frail or deconditioned. Resistance training, as a component of cardiac rehabilitation, improves muscle strength, endurance, and physical function. The purpose of this review is to describe the effects of resistance training in cardiac rehabilitation for older adults with a particular focus on physical function.
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http://dx.doi.org/10.1016/j.cger.2019.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237336PMC
November 2019

Cardiac shock wave therapy for refractory angina: angiogenesis, placebo effects, and randomized trial designs.

Authors:
Sherrie Khadanga

Coron Artery Dis 2018 11;29(7):587-588

Division of Cardiology, University of Vermont Medical Center, Burlington, Vermont, USA.

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http://dx.doi.org/10.1097/MCA.0000000000000655DOI Listing
November 2018

What do we tell patients with coronary artery disease about marijuana use?

Coron Artery Dis 2018 01;29(1):1-3

Department of Medicine, Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, Burlington, Vermont, USA.

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http://dx.doi.org/10.1097/MCA.0000000000000567DOI Listing
January 2018

Insulin Resistance and Diabetes Mellitus in Contemporary Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2016 Sep-Oct;36(5):331-8

Department of Medicine, Division of Cardiology, University of Vermont Medical Center, Burlington.

Purpose: The goal of this study was to determine the prevalence of insulin resistance (IR) and type 2 diabetes mellitus (T2DM) in contemporary cardiac rehabilitation (CR) and to compare clinical responses in CR between these subsets of patients with coronary heart disease (CHD).

Methods: The study cohort included 818 patients enrolled in CR and separated into 3 groups: (1) individuals with normal hemoglobin A1c (HbA1c) (NoIR: HbA1c < 5.7%); (2) individuals with IR (IR: HbA1c ≥ 5.7 to <6.5%); (3) and individuals with T2DM (HbA1c ≥ 6.5%).

Results: The combined prevalence of IR (44%) and T2DM (23%) was 67%, which paralleled the prevalence of metabolic syndrome (MetSyn), present in 65% of patients. Women had a higher prevalence of IR and MetSyn than men (73% vs 64%, 72% vs. 63%, respectively) and a greater percentage with an elevated waist circumference (71% vs 60%) (all P < .05). All 3 groups experienced decreases in body weight (NoIR = -2.3 ± 4.0, IR = -1.7 ± 4.0, T2DM = -1.0 ± 4.2 kg) and increases in maximal metabolic equivalents (METs) at exercise testing (NoIR = +2.2 ± 2.5 vs IR = +2.1 ± 2.8 vs T2DM = +1.3 ± 2.3) (all P < .05). Individuals with NoIR achieved greater improvements in weight, body mass index, and METs than patients with T2DM (all P < .05). Selected individuals who participated in a 4-session behavioral weight-loss program lost more than twice the weight as nonparticipants.

Conclusions: The combined prevalence of IR and T2DM in patients with CHD enrolled in CR was remarkably high (67%). To reverse the deleterious consequences of IR and T2DM, targeted interventions involving exercise and weight loss need to be a central focus of CR programming.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5048191PMC
http://dx.doi.org/10.1097/HCR.0000000000000187DOI Listing
December 2017

Partnership Status and Socioeconomic Factors in Relation to Health Behavior Changes after a Diagnosis of Ductal Carcinoma In Situ.

Cancer Epidemiol Biomarkers Prev 2016 Jan 6;25(1):76-82. Epub 2015 Nov 6.

Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, Wisconsin.

Background: Change in health behaviors can occur among women newly diagnosed with ductal carcinoma in situ (DCIS). We sought to understand whether partnership status and socioeconomic status (SES) affected behavioral changes in body weight, physical activity, alcohol consumption, and smoking.

Methods: The Wisconsin In Situ Cohort (WISC) study comprises 1,382 women diagnosed with DCIS with information on demographics, SES factors, and pre- and post-DCIS diagnosis health-related behaviors. Logistic regression models were used to determine the association between partnership status, education, and income with change in behavior variables.

Results: Higher educational attainment was associated with lower likelihood of stopping physical activity [OR, 0.45; 95% confidence interval (CI), 0.32-0.63; college vs. high school degree], or starting to drink alcohol (OR, 0.34; 95% CI, 0.15-0.80). Results suggested that higher family income was associated with lower likelihood of gaining >5% body mass index (P = 0.07) or stopping physical activity (P = 0.09). Living with a partner was not strongly associated with behavior changes.

Conclusion: Higher educational attainment and higher income, but not living with a partner, were associated with positive health behaviors after a DCIS diagnosis.

Impact: The associations between higher educational attainment and, to a lesser extent, higher income with positive health behaviors underscore the importance of considering SES when identifying those at risk for negative behavioral change after DCIS diagnosis.
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http://dx.doi.org/10.1158/1055-9965.EPI-15-0726DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4713311PMC
January 2016

Hemophagocytic Lymphohistiocytosis (HLH) Associated with T-Cell Lymphomas: Broadening our Differential for Fever of Unknown Origin.

N Am J Med Sci 2014 Sep;6(9):484-6

Division of Hematology/Oncology, University of Vermont, Vermont, USA.

Context: Hemophagocytic lymphohistiocytosis (HLH), due to the excessive activity of histiocytes and lymphocytes, is a rare but aggressive disease that typically occurs in infancy but can be seen in all ages. If left untreated, patients with HLH may live for only a few months and die from multi-organ failure.

Case Report: We present two cases of HLH diagnosis. Fever, spleen, and hepatic abnormalities were noted in both cases.

Conclusion: Early diagnosis is the key and these two cases of similar etiology highlight how fever of unknown origin should force us to broaden our differential.
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http://dx.doi.org/10.4103/1947-2714.141656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193158PMC
September 2014

Incidence of Vitamin D Insufficiency in Coastal South-Eastern US Patient Population With Cardiovascular Disease.

J Clin Med Res 2014 Dec 9;6(6):469-75. Epub 2014 Sep 9.

Division of Cardiology, University of South Alabama, Mobile, AL, USA.

Background: Vitamin D insufficiency is increasingly gaining prominence as an associated cardiovascular disease (CVD) risk factor, often thought to be an issue in colder climates and higher altitudes. The intent of this study was to ascertain vitamin D levels in the southern Alabama gulf-coast region that has a high number of sunny days along with an annual average elevated UV ray index.

Methods: An observational retrospective study of 204 patients with established CVD treated at the University of South Alabama's Heart Center from January 2007 through January 2013 was undertaken. One-way ANOVA analyses were performed to determine any significant difference in the mean 25-hydroxyvitamin D (25(OH)D) serum based on gender and also based on race/ethnicity. Further, odds ratio (OR) was computed to ascertain if there was a relationship between vitamin D insufficiency and elevated body mass index (BMI).

Results: Out of 204 patients, 53.4% (n = 109) were found to have vitamin D insufficiency (25(OH)D = 20.1 ng/mL), while 46.6% (n = 95) were within the normal range (25(OH)D = 37.8 ng/mL). The mean 25(OH)D of the entire group was 28.3, indicating a general trend of vitamin D insufficiency for patients treated at the cardiology clinics.

Conclusion: This study established the prevalence of vitamin D insufficiency in the hot and high UV ray index climate of the coastal south-eastern United States. Also, it revealed the relationship of increased BMI with low 25(OH)D serum level. More extensive studies should be conducted in similar climates to further assess vitamin D insufficiency.
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http://dx.doi.org/10.14740/jocmr1953wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4169090PMC
December 2014
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