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Fleischhacker S, Colón-Ramos U, Haynes-Maslow L, Clay L. Position of the Society for Nutrition Education and Behavior: The Importance of Emergency-Related Food and Nutrition Education Before, During, and After a Disaster. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2024; 56:419-427. [PMID: 38972707 DOI: 10.1016/j.jneb.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 01/07/2024] [Accepted: 04/17/2024] [Indexed: 07/09/2024]
Abstract
It is the position of the Society for Nutrition Education and Behavior that for effective recovery from and resilience to disasters, it is essential that impacted individuals and communities have access to safe, nutritious, and culturally and contextually appropriate foods and beverages, and receive emergency-related food and nutrition education before, during, and after a disaster. Despite the increasing number, duration, and intensity of disasters worldwide, there is relatively limited guidance for research, policy, and practice about addressing the emergency-related food and nutrition needs of affected populations. Although nutrition emergencies tend to be understudied, emerging efforts are working to advance food and nutrition security during disaster response and recovery. To help elevate the importance of emergency-related food and nutrition education before, during, and after a disaster, Society for Nutrition Education and Behavior, which represents the unique professional interests of nutrition educators worldwide, summarizes the relevant literature and puts forth recommendations for all those who are engaged in this work in the following 4 key areas: (1) improving communication and outreach, (2) fostering community engagement and locally-driven preparedness, (3) building the evidence base and translating the evidence into action, and (4) training current professionals and the next generation of public health leaders. Altogether, before, during, and after a disaster, those who engage in this work, among other allies, can help elevate the importance of nutrition education and other strategies to promote healthy eating behaviors through research, policy, and practice.
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Affiliation(s)
| | | | - Lindsey Haynes-Maslow
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lauren Clay
- Department of Emergency and Disaster Health Systems, University of Maryland Baltimore County, Baltimore, MD
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Guardiola Dávila G, López-Fontanet JJ, Ramos F, Acevedo Monsanto MA. Examining Global Crises: Extracting Insights From the COVID-19 Pandemic and Natural Disasters to Develop a Robust Emergency Diabetic Retinopathy Strategy for Puerto Rico. Cureus 2023; 15:e47070. [PMID: 37846348 PMCID: PMC10577004 DOI: 10.7759/cureus.47070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 10/18/2023] Open
Abstract
In this critical analysis, we investigate the profound impact of natural disasters and pandemics on the care and adherence to treating diabetic retinopathy, a severe complication of diabetes requiring continuous monitoring and treatment to prevent vision loss. Our study also sheds light on the social and economic context of Puerto Rico, emphasizing recent emergency events that have exacerbated existing public health challenges. Through a comprehensive review of relevant literature from PubMed, Google Scholar, and the George Washington University Himmelfarb Health Sciences Library database, we identified 31 pertinent articles out of 45 evaluated, focusing on the effects of these crises on healthcare delivery, diabetic retinopathy screening, and treatment. The evidence strongly indicates that during such emergencies, barriers to healthcare escalate, leading to significant treatment delays and a reduction in diabetic retinopathy screening and diagnosis, ultimately resulting in deteriorated visual outcomes. Thus, our review underscores the urgent need for the development of effective emergency plans tailored specifically to diabetic retinopathy, particularly in Puerto Rico, where diabetes prevalence and its complications are notably higher. Such plans should not only incorporate established emergency measures but also harness emerging technological advances in the field of ophthalmology to ensure optimal preparedness for future pandemics and natural disasters.
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Affiliation(s)
| | - José J López-Fontanet
- Department of Ophthalmology, Medical Sciences Campus, University of Puerto Rico, San Juan, PRI
| | - Fabiola Ramos
- Department of Ophthalmology, Medical Sciences Campus, University of Puerto Rico, San Juan, PRI
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Kim I, Locascio JJ, Sarin R, Hart A, Ciottone GR. Time Series Analysis of Congestive Heart Failure Discharges in Florida (USA) Post Tropical Cyclones. Prehosp Disaster Med 2023; 38:207-215. [PMID: 36691696 DOI: 10.1017/s1049023x23000067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The aim of this study was to analyze congestive heart failure (CHF) discharges in Florida (USA) post tropical cyclones from 2007 through 2017. METHODS This was a retrospective longitudinal time series analysis of hospital CHF quarterly discharges across Florida using the Healthcare Cost and Utilization Project (HCUP) database. The autoregressive integrated moving average (ARIMA) model was used with correlated seasonal regressor variables such as cyclone frequency, maximum cyclone wind speed, average temperature, and reports of influenza-like illness (ILI). RESULTS A total of 3,372,993 patients were identified, with average age in each quarter ranging 72.2 to 73.9 years and overall mortality ranging 4.3% to 6.4%. The CHF discharges within each year peaked from October through December and nadired from April through June with an increasing overall time trend. Significant correlation was found between CHF discharge and the average temperature (P <.001), with approximately 331.8 less CHF discharges (SE = 91.7) per degree of increase in temperature. However, no significant correlation was found between CHF discharges and frequency of cyclones, the maximum wind speed, and reported ILI. CONCLUSIONS This study suggests that with the current methods and the HCUP dataset, there is no significant increase in overall CHF discharges in Florida as a result of recent previous cyclone occurrences.
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Affiliation(s)
- Inkyu Kim
- Harvard Medical School, Boston, MassachusettsUSA; currently: Harvard-Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts USA
| | | | - Ritu Sarin
- Beth Israel Deaconess Medical Center, Disaster Medicine Fellowship, Boston, MassachusettsUSA
| | - Alexander Hart
- Beth Israel Deaconess Medical Center, Disaster Medicine Fellowship, Boston, MassachusettsUSA
| | - Gregory R Ciottone
- Beth Israel Deaconess Medical Center, Disaster Medicine Fellowship, Boston, MassachusettsUSA
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Clyne B, Hynes L, Kirwan C, McGeehan M, Byrne P, Killilea M, Smith SM, Ryan M, Collins C, O'Neill M, Wallace E, Murphy AW, Kelly ME. Perspectives on the production, and use, of rapid evidence in decision making during the COVID-19 pandemic: a qualitative study. BMJ Evid Based Med 2023; 28:48-57. [PMID: 35772940 PMCID: PMC9887371 DOI: 10.1136/bmjebm-2021-111905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To describe perceptions of providing, and using rapid evidence, to support decision making by two national bodies (one public health policy and one front-line clinical practice) during the COVID-19 pandemic. DESIGN Descriptive qualitative study (March-August 2020): 25 semistructured interviews were conducted, transcribed verbatim and thematically analysed. SETTING Data were obtained as part of an evaluation of two Irish national projects; the Irish COVID-19 Evidence for General Practitioners project (General Practice (GP) project) which provided relevant evidence to address clinical questions posed by GPs; and the COVID-19 Evidence Synthesis Team (Health Policy project) which produced rapid evidence products at the request of the National Public Health Emergency Team. PARTICIPANTS Purposive sample of 14 evidence providers (EPs: generated and disseminated rapid evidence) and 11 service ssers (SUs: GPs and policy-makers, who used the evidence). MAIN OUTCOME MEASURES Participant perceptions. RESULTS The Policy Project comprised 27 EPs, producing 30 reports across 1432 person-work-days. The GP project comprised 10 members from 3 organisations, meeting 49 times and posting evidence-based answers to 126 questions. Four unique themes were generated. 'The Work' highlighted that a structured but flexible organisational approach to producing evidence was essential. Ensuring quality of evidence products was challenging, particularly in the context of absent or poor-quality evidence. 'The Use' highlighted that rapid evidence products were considered invaluable to decision making. Trust and credibility of EPs were key, however, communication difficulties were highlighted by SUs (eg, website functionality). 'The Team' emphasised that a highly skilled team, working collaboratively, is essential to meeting the substantial workload demands and tight turnaround time. 'The Future' highlighted that investing in resources, planning and embedding evidence synthesis support, is crucial to national emergency preparedness. CONCLUSIONS Rapid evidence products were considered invaluable to decision making. The credibility of EPs, a close relationship with SUs and having a highly skilled and adaptable team to meet the workload demands were identified as key strengths that optimised the utilisation of rapid evidence. ETHICS APPROVAL Ethical approval was obtained from the National Research Ethics Committee for COVID-19-related Research, Ireland.
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Affiliation(s)
- Barbara Clyne
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Lisa Hynes
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Colette Kirwan
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Máire McGeehan
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Paula Byrne
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Martha Killilea
- PPI Ignite Network @ NUI Galway, National University of Ireland Galway, Galway, Ireland
- HRB Primary Care Clinical Trials Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Susan M Smith
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Máirín Ryan
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
- Department of Pharmacology & Therapeutics, St James's Hospital, Trinity College Dublin Faculty of Health Sciences, Dublin, Ireland
| | | | - Michelle O'Neill
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Andrew W Murphy
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
- HRB Primary Care Clinical Trials Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Maureen E Kelly
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
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A systematic review of effective strategies for chronic disease management in humanitarian settings; opportunities and challenges. Prev Med 2022; 161:107154. [PMID: 35817161 DOI: 10.1016/j.ypmed.2022.107154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 11/22/2022]
Abstract
Large number of people with non-communicable diseases (NCDs) face barriers to adequate healthcare in humanitarian settings. We conducted a systematic literature review in MEDLINE/PubMed, Web of Science, EMBASE/DARE, Cochrane, and grey literature from 1990 to 2021 to evaluate effective strategies in addressing NCDs (diabetes, cardiovascular diseases, COPD, cancer) in humanitarian settings. From 2793 articles, 2652 were eliminated through title/abstract screening; 141 articles were reviewed in full; 93 were eliminated for not meeting full criteria. Remaining 48 articles were reviewed qualitatively to assess populations, settings, interventions, outcome, and efficacy and effectiveness; 38 studies addressed treatments, 9 prevention, and 7 epidemiology. Prevention studies broadly addressed capacity-building. Treatment and epidemiology studies largely addressed hypertension and diabetes. Interventions included web-based/mobile health strategies, pharmacy-level interventions, portable imaging, and capacity building including physical clinics, staff training, forging collaborations, guideline development, point-of-care labs, health promotion activities, EMR, and monitoring interventions. Collaboration between academia and implementing agencies was limited. Models of care were largely not well-described and varied between studies due to contextual constraints. Barriers to interventions included financial, logistical, organizational, sociocultural, and security. Cancer care is significantly understudied. Simplified care models adapted to contexts and program evaluations of implemented strategies could address gaps in applied research. Inherent challenges in humanitarian settings pose unavoidable perils to evidence generation which requires a shift in research mindset to match aspirations with practicality, research collaborations at the inception of projects, reworking of desired conventional level of research evidence considering resource-intense constraints (HR, time, cost), and adapted research tools, methods, and procedures.
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[What have we missed because of COVID-19? Missed diagnoses and delayed follow-ups. SESPAS Report 2022]. GACETA SANITARIA 2022; 36 Suppl 1:S36-S43. [PMID: 35781146 PMCID: PMC9244613 DOI: 10.1016/j.gaceta.2022.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022]
Abstract
La pandemia de COVID-19 y la emergencia de salud pública asociada han afectado a los/las pacientes y a los servicios de salud en lo que respecta a las patologías no relacionadas con la COVID-19. Diversos estudios han evidenciado su desvinculación con los servicios sanitarios, con disminución de las consultas a los servicios de urgencias, de los ingresos hospitalarios de patologías no COVID-19, así como de la incidencia semanal notificada de enfermedades agudas y nuevos diagnósticos en atención primaria. Paralelamente, la pandemia ha tenido efectos directos e indirectos en las personas con enfermedades crónicas; las dificultades de acceso a los servicios sanitarios, la interrupción de la atención, la saturación del propio sistema y su reorientación hacia formatos no presenciales ha reducido la capacidad de prevenir o controlar las enfermedades crónicas, impactando además en los diferentes ámbitos de la vida de las personas, creando nuevas dificultades sociales y económicas, o agravando las preexistentes antes de la pandemia. Todas estas circunstancias se han ido modificando con cada una de las olas epidémicas. Se presenta una revisión de los estudios más relevantes que han ido analizando este problema y se incorporan como estudio de caso los resultados de un estudio observacional retrospectivo realizado en atención primaria en Madrid, que da cobertura sanitaria a una población de más de 6 millones de personas, y cuyo objetivo ha sido analizar la pérdida de nuevos diagnósticos en las patologías más prevalentes, como los problemas comunes de salud mental, enfermedades cardiovasculares y cerebrovasculares, diabetes tipo 2, enfermedad pulmonar obstructiva crónica y tumores de mama y de colon, en la primera y la segunda olas. Se calcularon las tasas de incidencia anual con su intervalo de confianza para cada patología y se comparó la frecuencia mensual de los nuevos códigos registrados entre el 1 de enero y el 31 de diciembre de 2020 con la media mensual de los recuentos observados para los mismos meses en 2016-2019. La tasa de incidencia anual para todos los procesos estudiados disminuyó en 2020, excepto para los trastornos de ansiedad. En relación con la recuperación de los diagnósticos perdidos, la insuficiencia cardiaca es el único diagnóstico que presenta una recuperación por encima de la media después de la primera ola. Para volver a los niveles prepandémicos de diagnóstico y seguimiento de la patología no COVID-19, el sistema sanitario debe reorganizarse y contemplar acciones específicas para los grupos de mayor riesgo.
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Posttraumatic Stress Symptoms, Physical Illness, and Social Adjustment Among Disaster Victims. Disaster Med Public Health Prep 2022; 17:e195. [PMID: 35593424 DOI: 10.1017/dmp.2022.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder is one of the most studied outcomes after a disaster. Posttraumatic stress symptoms (PTSS) are maladaptive and disabling and can severely impair affected individuals' psychosocial functioning and quality of life. Consequently, the objective of this research is to investigate the prevalence of PTSS and physical illness among disaster victims. METHODS We analyzed disaster victims' survey data in South Korea 1 year after a natural disaster (n = 1659). Then, we performed multivariable comparisons of social and work adjustments between individuals with PTSS and individuals with physical illness to examine the association between PTSS and functional impairment. RESULTS Individuals with PTSS had a significant association with work and social maladjustments whether or not they had a physical illness; PTSS (+) physical illness (-) group (OR: 1.18, CI: 1.12-1.26, P < 0.001) and PTSS (+) physical illness (+) group (OR: 1.16, CI: 1.08-1.23, P < 0.001). Interestingly, this association was not significant in the group that exclusively presented physical illness. CONCLUSIONS Our results suggest that PTSS might be a critical factor in social maladjustment during the post-disaster period. Subsequently, an assessment of disaster victims' PTSS would help ensure effective medical and governmental approaches to assist disaster victims.
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Prieto Rodríguez MÁ, March Cerdá JC, Martín Barato A, Escudero Carretero M, López Doblas M, Luque Martín N. [Consequences of the COVID-19 lockdown in patients with chronic diseases in Andalusia]. GACETA SANITARIA 2022; 36:139-145. [PMID: 33342601 PMCID: PMC7680018 DOI: 10.1016/j.gaceta.2020.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To understand the consequences of the COVID-19 pandemic lockdown on the self-care of people living with chronic diseases and on their self-perceived health, and to identify factors that may influence the management of their disease in emergency situations. METHOD A qualitative study conducted in 2020 (March and April) in Andalusia (Spain) during the COVID-19 pandemic lockdown, through virtual focus groups, using the Zoom telematics tool. Three virtual focus groups were conducted, including 34 patients from Andalusia with different chronic conditions such as arthritis, diabetes, cardiovascular disease, inflammatory bowel disease, breast cancer and fibromyalgia. RESULTS People with chronic diseases reported effects of the lockdown in relation to their emotional experience, their coping resources, the information they received, the difficulties to manage self-care, and the contact or access to health services. They also suggested some lessons learned for the future. The need for more and better information, patient training, involving patient associations, and improving telematics access to health services are the main areas for improvement to minimize the impact of future quarantines on the self-care and the health of people with chronic diseases. CONCLUSIONS Besides the risk of contracting COVID-19, the difficulties encountered by people with chronic diseases during the lockdown include interferences in the self-care and the health care received. Health crisis situations demand more information, training for patients and improvements in the health services accessibility for patients with chronic conditions.
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Affiliation(s)
- M Ángeles Prieto Rodríguez
- CIBER de Epidemiología y Salud Pública (CIBERESP), España; Escuela Andaluza de Salud Pública, Granada, España; Instituto de Investigación Biosanitaria de Granada, Granada, España
| | - Joan Carles March Cerdá
- CIBER de Epidemiología y Salud Pública (CIBERESP), España; Escuela Andaluza de Salud Pública, Granada, España; Instituto de Investigación Biosanitaria de Granada, Granada, España
| | - Amelia Martín Barato
- Escuela Andaluza de Salud Pública, Granada, España; Instituto de Investigación Biosanitaria de Granada, Granada, España
| | - María Escudero Carretero
- CIBER de Epidemiología y Salud Pública (CIBERESP), España; Escuela Andaluza de Salud Pública, Granada, España; Instituto de Investigación Biosanitaria de Granada, Granada, España
| | - Manuela López Doblas
- Escuela Andaluza de Salud Pública, Granada, España; Instituto de Investigación Biosanitaria de Granada, Granada, España.
| | - Nuria Luque Martín
- Escuela Andaluza de Salud Pública, Granada, España; Instituto de Investigación Biosanitaria de Granada, Granada, España
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Shui X, Zhao L, Li W, Jia Y, Liu Z, Li C, Yang X, Huang H, Wu S, Chen S, Gao J, Li X, Wang A, Jin X, Guo L, Hou S. Association between exposure to earthquake in early life and diabetes mellitus incidence in adulthood with the modification of lifestyles: Results from the Kailuan study. Front Pediatr 2022; 10:1046086. [PMID: 36425399 PMCID: PMC9679373 DOI: 10.3389/fped.2022.1046086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exposure to disasters in early life may induce lifetime health risk, but investigation on earthquake exposure and DM in later life is still limited. The aim of the current study is to evaluate the association between exposure to the Tangshan Earthquake in early life and diabetes mellitus (DM) incidence in adulthood, and explore the modification of lifestyles on DM development. METHODS Participants who were free of DM at baseline from the Kailuan Study were included in this study. All participants were divided into fetal-exposed, infant-exposed, early childhood-exposed and nonexposed group. The effect of earthquake exposure on DM and modification of lifestyles were examined by multivariable-adjusted Cox proportional hazard model. RESULTS The exposed group had a higher risk of DM than nonexposed group, especially in infant-exposed and early childhood-exposed group, with hazard ratio (HR) of 1.62 [95% confidence intervals (CI), 1.21-2.17] and 1.46 (95% CI, 1.06-1.99), respectively. After stratifying by lifestyles, a significant modification was observed in alcohol consumption. CONCLUSION Exposing to earthquake in early life could increase DM incidence in later life, and alcohol consumption might modify the effect of earthquake exposure on DM development. More attention should be paid on the preventions of DM among adults who exposed to earthquake in their early life.
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Affiliation(s)
- Xinying Shui
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
| | - Lei Zhao
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
| | - Wenli Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
| | - Yaning Jia
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
| | - Chen Li
- Department of Occupational & Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, China
| | - Xueli Yang
- Department of Occupational & Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, China
| | - Haoran Huang
- Basic Medical Science College, Harbin Medical University, Harbin, China
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Shuohua Chen
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Jingli Gao
- Department of Intensive Medicine, Kailuan General Hospital, Tangshan, China
| | - Xiaolan Li
- Department of Intensive Medicine, Kailuan General Hospital, Tangshan, China
| | - Aitian Wang
- Department of Intensive Medicine, Kailuan General Hospital, Tangshan, China
| | - Xiaobin Jin
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Liqiong Guo
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
| | - Shike Hou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, Tianjin, China.,Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin University, Tianjin, China
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Oyama Y, Abiru N, Kit A, Eyama D, Noda A, Nagata A. Thoughts and attitudes toward disasters among Japanese patients with type 1 diabetes: A qualitative descriptive study. Jpn J Nurs Sci 2021; 19:e12459. [PMID: 34664359 DOI: 10.1111/jjns.12459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/25/2021] [Accepted: 09/25/2021] [Indexed: 12/01/2022]
Abstract
AIM The purpose of this study was to clarify the thoughts and attitudes of patients with type 1 diabetes during disasters. METHODS We conducted a qualitative descriptive study. The participants were 10 adult patients with type 1 diabetes who were selected through purposeful sampling. None of them had experienced a disaster. Data were collected through semi-structured interviews. Thematic analysis was used to analyze the data. RESULTS Type 1 diabetes patients described a variety of thoughts and attitudes regarding disaster and preparedness. Based on their experiences, 528 codes were extracted. The codes were categorized based on their patterns and similarities. Then, 11 sub-themes and three main themes were identified. The three main themes were (a) "being unprepared since one could not relate to disasters"; (b) "managing well with insulin and food"; and (c) "hiding the fact that one has diabetes." CONCLUSIONS This study identified three important characteristics of the thoughts and attitudes of patients with type 1 diabetes toward disasters. These provide perspectives for education in pre-disaster preparation and support when disasters occur. Patients with type 1 diabetes are aware of the importance of insulin, food adjustment, and self-management on a daily basis. Therefore, it is necessary to educate them so that they can apply their knowledge in times of disaster. In addition, healthcare providers who provide support in times of disaster need to be aware that there are victims who cannot talk readily about their illness.
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Affiliation(s)
- Yusuke Oyama
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Norio Abiru
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ayano Kit
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Daigo Eyama
- Nagasaki University School of Health Sciences, Nagasaki, Japan
| | - Arisa Noda
- Nagasaki University School of Health Sciences, Nagasaki, Japan
| | - Akira Nagata
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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11
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Patel SY, McCoy RG, Barnett ML, Shah ND, Mehrotra A. Diabetes Care and Glycemic Control During the COVID-19 Pandemic in the United States. JAMA Intern Med 2021; 181:1412-1414. [PMID: 34228043 PMCID: PMC8261690 DOI: 10.1001/jamainternmed.2021.3047] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cohort study compares rates at which patients with type 2 diabetes received diabetes-related health services prior to and during the COVID-19 pandemic.
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Affiliation(s)
- Sadiq Y Patel
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Rozalina G McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.,Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,OptumLabs, Eden Prairie, Minnesota
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Impact of SARS-CoV-2 Lockdown on Glycaemic Control: A Retrospective Observational Cohort Study in a Tertiary Setting. J Clin Med 2021; 10:jcm10184098. [PMID: 34575207 PMCID: PMC8466167 DOI: 10.3390/jcm10184098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 12/23/2022] Open
Abstract
We analysed the effects of Swiss national lockdown due to the COVID-19 pandemic on the glycaemic control in patients with diabetes mellitus. In a retrospective observational cohort study with observation period 16 December 2018–27 July 2020, we included tertiary care patients with diabetes and at least one glycated haemoglobin A1c (HbA1c) measurement before and after the lockdown beginning. Main outcome measure was change in HbA1c after the lockdown. We included 1078 patients (86% diabetes type 2) with a mean HbA1c of 55.63 mmol/mol (7.24%). Glycaemic control was susceptible to seasonal changes with higher mean HbA1c in winter as compared to spring (57.49 mmol/mol (7.41%) vs. 55.52 mmol/mol (7.23%), p = 0.013). The lockdown did not affect the mean HbA1c values of all patients. However, we found a higher proportion of type 2 diabetes patients with a worsening HbA1c after the lockdown as compared to the year before (32% vs. 22.9%, p = 0.02). In a mixed-model regression multivariable analysis, inappropriate alcohol intake and hypothyroidism were associated with an increase in HbA1c after the lockdown. In conclusion, the national lockdown had no effect on overall mean HbA1c values but affected a proportion of type 2 diabetes patients with worsening HbA1c, whose individual risk factors were identified.
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Ghazanchaei E, Khorasani-Zavareh D, Aghazadeh-Attari J, Mohebbi I. Identifying and Describing Impact of Disasters on Non-Communicable Diseases: A Systematic Review. IRANIAN JOURNAL OF PUBLIC HEALTH 2021; 50:1143-1155. [PMID: 34540735 PMCID: PMC8410956 DOI: 10.18502/ijph.v50i6.6413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 10/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with non-communicable diseases are vulnerable to disasters. This is a systematic review describing the impact of disasters on non-communicable diseases. METHODS A systematic review was conducted using PRISMA standards. Relevant articles published from 1997 to 2019 collected by searching the Scopus, PubMed, Science Direct, databases. We specifically examined reports describing NCDs and including the key words "non-communicable disease and Disasters". NCDs included cardiovascular, respiratory, diabetes, cancer and mental health diseases. RESULTS Of the 663 studies identified, only 48 articles met all the eligibility criteria. Most studies have shown the impact of all natural disasters on non-communicable diseases (39.8% n=19). The largest study was the effect of earthquakes on non-communicable diseases (29.2% n=14). For the NCDs targeted by this research, most of the included studies were a combination of four diseases: cardiovascular disease, respiratory disease, diabetes and cancer (44% n=21). Followed by cardiovascular disease (14.6% n=7), chronic respiratory disease (12.5% n=6), diabetes and cancer (6.2% n=3) and mental health (12.5% n=6). CONCLUSION The incidence of disasters affects the management of treatment and care for patients with NCDs. Specific measures include a multi-part approach to ensuring that patients with non-communicable diseases have access to life-saving services during and after disasters. The approach of the health system should be expanded from traditional approaches to disasters and requires comprehensive planning of health care by policy makers and health professionals to develop effective strategies to enable patients to access medical, therapeutic and diagnostic services in natural disasters.
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Affiliation(s)
- Elham Ghazanchaei
- Social Determinants of Health Research Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Davoud Khorasani-Zavareh
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Workplace Health Promotion Research Center, Department of Health in Emergencies and Disasters, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Javad Aghazadeh-Attari
- Social Determinants of Health Research Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Iraj Mohebbi
- Social Determinants of Health Research Center, Urmia University of Medical Sciences, Urmia, Iran
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14
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Munekawa C, Hosomi Y, Hashimoto Y, Okamura T, Takahashi F, Kawano R, Nakajima H, Osaka T, Okada H, Majima S, Senmaru T, Nakanishi N, Ushigome E, Hamaguchi M, Yamazaki M, Fukui M. Effect of coronavirus disease 2019 pandemic on the lifestyle and glycemic control in patients with type 2 diabetes: a cross-section and retrospective cohort study. Endocr J 2021; 68:201-210. [PMID: 32999133 DOI: 10.1507/endocrj.ej20-0426] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
To investigate the acute effects of the coronavirus disease 2019 (COVID-19) on the lifestyle and metabolic parameters in patients with type 2 diabetes mellites. This cross-sectional and retrospective cohort study induced 203 patients who completed a questionnaire regarding stress levels and lifestyles. Data regarding stress levels, sleep time, exercise, and total diet, snack, and prepared food intake were obtained from the questionnaires. The changes in the body weight or HbA1c levels were determined by comparing the values at the time the questionnaire was administered to those noted 3 months ago. Increased levels of stress and decreased exercise levels were reported in approximately 40% and >50%. During the COVID-19 pandemic. There was a negative correlation between stress and exercise (r = -0.285, p < 0.001) and a positive correlation between stress and prepared food intake (r = 0.193, p = 0.009). Decreased exercise levels (r = -0.33, p < 0.001) and increased snack consumption (r = 0.24, p = 0.002) were associated with increased body weight. Furthermore, increased total diet intake (r = 0.16, p = 0.031) was associated with increased HbA1c levels. These relationships remained significant for patients aged <65 years and patients who did not engage in regular exercise. Many patients experienced stress and lifestyle changes due to the COVID-19 pandemic, and these changes were associated with increased body weight and HbA1c levels.
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Affiliation(s)
- Chihiro Munekawa
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Yukako Hosomi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Yoshitaka Hashimoto
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Takuro Okamura
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Fuyuko Takahashi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Rena Kawano
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Hanako Nakajima
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Takafumi Osaka
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Hiroshi Okada
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Saori Majima
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Takafumi Senmaru
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Naoko Nakanishi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Emi Ushigome
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Masahide Hamaguchi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Masahiro Yamazaki
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
| | - Michiaki Fukui
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto 602-8566, Japan
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15
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Establishing the Status of Patients With Non-Communicable Diseases in Disaster: A Systematic Review. Disaster Med Public Health Prep 2021; 16:783-790. [PMID: 33583461 DOI: 10.1017/dmp.2020.364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE People with NCDs are particularly vulnerable to disasters. This research systematically reviewed reports describing studies on the status of patients with NCDs before, during and after disasters. METHOD Relevant articles published from 1997 to 2019 were collected by searching the Scopus, PubMed, and Science Direct databases. We specifically examined reports describing NCDs and including the key words 'Non-Communicable Disease and Disasters.' NCDs include cardiovascular, respiratory, diabetes and cancer diseases. RESULTS The review identified 42 relevant articles. Most of the included studies were found to have described the conditions of patients with NCDs after disasters - 14 (13.3%), during disasters - 11 (26.2%), before disasters - 6 (14.3%), within all stages of disasters: before, during and after - 6 (14.3%), only during and after disasters - 4 (9.5%), and includes before and during disasters - 1 (2.4%). CONCLUSION NCDs pose major health issues in disasters. Development of strong counter measures against the interruption of treatment, as well as surveillance systems to ascertain medical needs for NCDs are necessary as preparation for future disasters.
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Pan K, Beitsch L, Gonsoroski E, Sherchan SP, Uejio CK, Lichtveld MY, Harville EW. Effects of Hurricane Michael on Access to Care for Pregnant Women and Associated Pregnancy Outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:E390. [PMID: 33419129 PMCID: PMC7825524 DOI: 10.3390/ijerph18020390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 11/24/2022]
Abstract
Background: Disasters are associated with worse perinatal outcomes, perhaps due to inadequate prenatal care (PNC). Methods: Using 2017-2019 Florida vital statistics, we compared PNC use before and after Hurricane Michael. We categorized counties as most affected (Area A) or less affected (Area B and C). We examined whether Michael's effects on perinatal outcomes varied by maternity care availability and used the Baron and Kenny method to assess whether delayed PNC initiation mediated perinatal outcomes. Log-binomial regression and semi-parametric linear regression were used, controlling for maternal and ZIP code tabulation area characteristics. Results: Compared to the one-year period pre-Michael, the week of the first PNC was later in all areas in the one-year period post-Michael, with the largest change in Area A (adjusted difference 0.112, 95% CI: 0.055-0.169), where women were less likely to receive PNC overall (aRR = 0.994, 95% CI = 0.990-0.998) and more likely to have inadequate PNC (aRR = 1.193, 95% CI = 1.127-1.264). Michael's effects on perinatal outcomes did not vary significantly by maternity care availability within Area A. Delayed PNC initiation appeared to mediate an increased risk in small for gestational age (SGA) births after Michael. Conclusion: Women in Area A initiated PNC later and had a higher likelihood of inadequate PNC. Delayed PNC initiation may partially explain increased risk of SGA.
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Affiliation(s)
- Ke Pan
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA;
| | - Leslie Beitsch
- Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, Tallahassee, FL 32306, USA;
| | - Elaina Gonsoroski
- Department of Geography, College of Social Sciences and Public Policy, Florida State University, Tallahassee, FL 32306, USA; (E.G.); (C.K.U.)
| | - Samendra P. Sherchan
- Department of Environmental Health Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA; (S.P.S.); (M.Y.L.)
| | - Christopher K. Uejio
- Department of Geography, College of Social Sciences and Public Policy, Florida State University, Tallahassee, FL 32306, USA; (E.G.); (C.K.U.)
| | - Maureen Y. Lichtveld
- Department of Environmental Health Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA; (S.P.S.); (M.Y.L.)
| | - Emily W. Harville
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA;
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Cheruvu MS, Bhachu DS, Mulrain J, Resool S, Cool P, Ford DJ, Singh RA. Effect of COVID-19 on a rural orthopaedic hip fracture service. Bone Jt Open 2020; 1:500-507. [PMID: 33215145 PMCID: PMC7659701 DOI: 10.1302/2633-1462.18.bjo-2020-0082.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
AIMS Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures. METHODS We reviewed our prospectively maintained trust database and National Hip Fracture Database records for the months of March and April between the years 2016 and 2020. Our assessment included fracture pattern (intrascapular vs extracapsular hip fracture), treatment intervention, length of stay and mortality. RESULTS We treated 288 patients during March and April between 2016 and 2020, with a breakdown of 55, 58, 53, 68, and 54 from 2016 to 2020 respectively. Fracture pattern distribution in the pre-COVID-19 years of 2016 to 2019 was 58% intracapsular and 42% extracapsular. In 2020 (COVID-19 period) the fracture patterns were 65% intracapsular and 35% extracapsular. Our mean length of stay was 13.1 days (SD 8.2) between 2016 to 2019, and 5.0 days (6.3) days in 2020 (p < 0.001). Between 2016 and 2019 we had three deaths in hip fracture patients, and one death in 2020. Hemiarthroplasty and dynamic hip screw fixation have been the mainstay of operative intervention across the five years and this has continued in the COVID-19 period. We have experienced a rise in conservatively managed patients; ten in 2020 compared to 14 over the previous four years. CONCLUSION There has not been a reduction in the number of hip fractures during COVID-19 period compared to the same time period over previous years. In our experience, there has been an increase in conservative treatment and decreased length of stay during the COVID -19 period.Cite this article: Bone Joint Open 2020;1-8:500-507.
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Affiliation(s)
- Manikandar Srinivas Cheruvu
- Shrewsbury & Telford Hospitals NHS Trust, Shrewsbury, United Kingdom
- Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, United Kingdom
| | - Davinder Singh Bhachu
- Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, United Kingdom
| | - Jill Mulrain
- Shrewsbury & Telford Hospitals NHS Trust, Shrewsbury, United Kingdom
- Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, United Kingdom
| | - Shko Resool
- Shrewsbury & Telford Hospitals NHS Trust, Shrewsbury, United Kingdom
| | - Paul Cool
- Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, United Kingdom
| | - David James Ford
- Shrewsbury & Telford Hospitals NHS Trust, Shrewsbury, United Kingdom
- Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, United Kingdom
| | - Rohit Amol Singh
- Shrewsbury & Telford Hospitals NHS Trust, Shrewsbury, United Kingdom
- Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, United Kingdom
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18
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Brook RD, Levy P, Rajagopalan S. Cardiometabolic Risk Factor Control During Times of Crises and Beyond. Circ Cardiovasc Qual Outcomes 2020; 13:e006815. [PMID: 32524839 DOI: 10.1161/circoutcomes.120.006815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Robert D Brook
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (R.D.B.)
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI (P.L.)
| | - Sanjay Rajagopalan
- Division of Cardiovascular Medicine, Case Western Reserve University, Cleveland, OH (S.R.)
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