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Nyarambi D, Osedeme F, Mamudu HM, Littleton MA, Poole AM, Blair C, Voigt C, Gregory R, Drozek D, Stewart DW, Weierbach FM, Paul TK, Flores EK, Wei H. Setting Patient-Centered Priorities for Cardiovascular Disease in Central Appalachia: Engaging Stakeholder Experts to Develop a Research Agenda. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095660. [PMID: 37174178 PMCID: PMC10178300 DOI: 10.3390/ijerph20095660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 03/30/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Abstract
The disproportionate burden of cardiovascular diseases (CVD) and associated risk factors continues to exist in the Central Appalachian Region (CAR) of the United States. Previous studies to gather data about patient-centered care for CVD in the region were conducted through focus group discussions. There have not been any studies that used a collaborative framework where patients, providers, and community stakeholders were engaged as panelists. The objective of this study was to identify patient-centered research priorities for CVD in the CAR. We used a modified Delphi approach to administer questionnaires to forty-two stakeholder experts in six states representing the CAR between the fall of 2018 and the summer of 2019. Their responses were analyzed for rankings and derived priorities by research gaps. Six of the fifteen research priorities identified were patient-centered. These patient-centered priorities included shorter wait times for appointments; educating patients at their level; empowering patients to take responsibility for their health; access to quality providers; heart disease specialists for rural areas; and lifestyle changes. The participants' commitments to identify patient-centered research priorities indicate the potential to engage in community-based collaboration to address the burden of CVD in the CAR.
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Affiliation(s)
- Dumisa Nyarambi
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - Fenose Osedeme
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - Hadii M Mamudu
- Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
- Center for Cardiovascular Risk Research, East Tennessee State University, Johnson City, TN 37614, USA
| | - Mary A Littleton
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - Amy M Poole
- Center for Cardiovascular Risk Research, East Tennessee State University, Johnson City, TN 37614, USA
| | - Cynthia Blair
- Center for Cardiovascular Risk Research, East Tennessee State University, Johnson City, TN 37614, USA
| | - Carl Voigt
- Center for Cardiovascular Risk Research, East Tennessee State University, Johnson City, TN 37614, USA
| | - Rob Gregory
- Karing Hearts Cardiology, Johnson City, TN 37604, USA
| | - David Drozek
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH 45701, USA
| | - David W Stewart
- Center for Cardiovascular Risk Research, East Tennessee State University, Johnson City, TN 37614, USA
- Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, USA
| | - Florence M Weierbach
- Center for Cardiovascular Risk Research, East Tennessee State University, Johnson City, TN 37614, USA
- College of Nursing, East Tennessee State University, Johnson City, TN 37614, USA
| | - Timir K Paul
- Center for Cardiovascular Risk Research, East Tennessee State University, Johnson City, TN 37614, USA
- College of Medicine, Health Science Center, University of Tennessee-Nashville, Nashville, TN 37203, USA
| | - Emily K Flores
- Center for Cardiovascular Risk Research, East Tennessee State University, Johnson City, TN 37614, USA
- Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, USA
| | - Holly Wei
- College of Nursing, East Tennessee State University, Johnson City, TN 37614, USA
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Ahuja M, Cimilluca J, Stamey J, Doshi RP, Wani RJ, Al-Ksir K, Adebayo-Abikoye EE, Karki A, Annor EN, Nwaneki CM. Association between Financial Barriers to Healthcare Access and Mental Health Outcomes in Tennessee. South Med J 2023; 116:176-180. [PMID: 36724532 DOI: 10.14423/smj.0000000000001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES A large number of people cannot afford healthcare services in the United States. Researchers have studied the impact of lack of affordability of health care on the outcomes of various physical conditions. Mental health disorders have emerged as a major public health challenge during the past decade. The lack of affordability of health care also may contribute to the burden of mental health. This research focuses on the association between financial barriers to health care and mental health outcomes in the US state of Tennessee. METHODS We used cross-sectional data contained in the 2019 US Behavioral Risk Factor Surveillance System (BRFSS). We extracted data for the state of Tennessee, which included 6242 adults aged 18 years or older. Multinomial regression analyses were conducted to test the association between not being able to see a doctor with the number of mentally unhealthy days during the past month. We coded the outcome as a three-level variable, ≥20 past-month mentally unhealthy days, 1 to 20 past-month mentally unhealthy days, and 0 past-month mentally unhealthy days. The covariates examined included self-reported alcohol use, self-reported marijuana use, and other demographic variables. RESULTS Overall, 11.0% of participants reported ≥20 past-month mentally unhealthy days and 24.0% reported 1 to 20 past-month mentally unhealthy days. More than 13% of study participants reported they could not see a doctor because of the cost in the past 12 months. The inability to see a doctor because of the cost of care was associated with a higher risk of ≥20 past-month mentally unhealthy days (relative risk ratio 3.18; 95% confidence interval 2.57-3.92, P < 0.001) and 1 to 19 past-month mentally unhealthy days (relative risk ratio 1.94; 95% confidence interval 1.63-2.32, P < 0.001). CONCLUSIONS Statistically significant associations were observed between the inability to see a doctor when needed because of cost and increased days of poorer mental health outcomes. This research has potential policy implications in the postcoronavirus disease 2019 era with healthcare transformation and significant financial impact.
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Affiliation(s)
- Manik Ahuja
- From the College of Public Health, East Tennessee State University, Johnson City
| | - Johanna Cimilluca
- From the College of Public Health, East Tennessee State University, Johnson City
| | - Jessica Stamey
- the College of Nursing, East Tennessee State University, Johnson City
| | - Riddhi P Doshi
- the Center for Population Health, University of Connecticut, Farmington
| | - Rajvi J Wani
- the University of Nebraska Medical Center, Omaha
| | - Kawther Al-Ksir
- From the College of Public Health, East Tennessee State University, Johnson City
| | | | - Aparna Karki
- From the College of Public Health, East Tennessee State University, Johnson City
| | - Eugene N Annor
- From the College of Public Health, East Tennessee State University, Johnson City
| | - Chisom M Nwaneki
- From the College of Public Health, East Tennessee State University, Johnson City
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Liu F, Liu Y, Du Y, Li Y. MiRNA-130a promotes inflammation to accelerate atherosclerosis via the regulation of proliferator-activated receptor γ (PPARγ) expression. Anatol J Cardiol 2021; 25:630-637. [PMID: 34498594 DOI: 10.5152/anatoljcardiol.2021.56721] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE In this study, we aimed to evaluate the possible function of miR-130a in atherosclerosis (AS), protection against AS, and its molecular biological mechanism. METHODS Apoe-/- mice were fed a high-fat diet as the AS mice model. Human umbilical vein endothelial cells (HUVECs) were used as in vitro model. Serum samples or cells were used to measure the expression of inflammation. Serum samples or cells were used to determine MiRNA expression profiles using the edgeR tool from Bioconductor. Western Blot analysis was used to assess protein expressions of proliferator-activated receptor γ (PPARγ) and nuclear factor (NF)-κB. RESULTS MiRNA-130a expression was up-regulated in atherosclerotic mice. In addition, over-expression of miRNA-130a promoted inflammation factors [tumor necrosis factor (TNF)-α and interleukin (IL)-1β, IL-6, and IL-8] in the in vitro model of AS. However, down-regulation of miRNA-130a reduced inflammation (suppressed TNF-α, IL-1β, IL-6 and IL-8) in the in vitro model. Furthermore, over-expression of miRNA-130a could also suppress the protein expression of PPARγ and induce NF-κB protein expression in the in vitro model. However, suppression of miRNA-130a induced the protein expression of PPARγ and suppressed NF-κB protein expression in the in vitro model of AS. Activation of PPARγ reduced the pro-inflammatory effects of miRNA-130a on the AS-induced in vitro model. CONCLUSION These results strongly support that miRNA-130a suppression can protect against atherosclerosis through inhibiting inflammation by regulating the PPARγ/ NF-κB expression.
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Affiliation(s)
- Fengtong Liu
- Department of Peripheral Vascular, Dongzhimen Hospital, Beijing University of Chinese Medicine; Beijing-China
| | - Yali Liu
- Department of Peripheral Vascular, Dongzhimen Hospital, Beijing University of Chinese Medicine; Beijing-China
| | - Yuqing Du
- Department of Peripheral Vascular, Dongzhimen Hospital, Beijing University of Chinese Medicine; Beijing-China
| | - Youshan Li
- Department of Peripheral Vascular, Dongzhimen Hospital, Beijing University of Chinese Medicine; Beijing-China
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Mamudu HM, Jones A, Paul TK, Osedeme F, Stewart D, Alamian A, Wang L, Orimaye S, Bledsoe J, Poole A, Blackwell G, Budoff M. The co-existence of diabetes and subclinical atherosclerosis in rural central Appalachia: Do residential characteristics matter? J Diabetes Complications 2021; 35:107851. [PMID: 33468398 DOI: 10.1016/j.jdiacomp.2021.107851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/02/2021] [Indexed: 10/22/2022]
Abstract
UNLABELLED Aim Disparities exist in cardiovascular diseases (CVD) and diabetes in the United States (U.S.) with Central Appalachia having disproportionate burden. This study examined prevalence and correlates of CVD risk-factors among patients with diabetes/subclinical atherosclerosis in Central Appalachia. METHODS During 2012-2016, 3000 patients from Central Appalachia were screened for subclinical atherosclerosis, using coronary artery calcium (CAC) scores; 419 participants had diabetes. Patients were categorized into four groups, with emphasis on those having subclinical atherosclerosis, CAC score ≥ 1. Descriptive statistics and multilevel multinomial logistic regression were conducted to identify CVD risk and spatial factors associated with co-existence of diabetes and subclinical atherosclerosis. RESULTS Among participants, prevalence of CVD risk-factors ranged from 11.7% for current smokers to 69.2% for those with CVD family history. Average BMI was 29.8. Compared to patients with diabetes only, age [RR = 1.07; p ≤ 0.0001], being male [RR = 5.33; p ≤ 0.0001], having hypertension [RR = 2.37; p ≤ 0.05] and being a former smoker were associated with increased likelihood of having diabetes/subclinical atherosclerosis. At the zip-code level, unemployment rate [RR = 1.37; p ≤ 0.05] was significantly associated with having diabetes/subclinical atherosclerosis. CONCLUSION Consistent with clinical guidelines, study results suggest the need to integrate CAC screening into primary care diabetes programs while addressing spatial issues that predispose patients to have diabetes/subclinical atherosclerosis.
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Affiliation(s)
- Hadii M Mamudu
- College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA.
| | - Antwan Jones
- Department of Sociology and Department of Epidemiology & Biostatistics, The George Washington University, Washington, DC 20052, USA
| | - Timir K Paul
- John H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37614, USA
| | - Fenose Osedeme
- College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - David Stewart
- Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, USA
| | - Arsham Alamian
- College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - Liang Wang
- College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - Sylvester Orimaye
- College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - James Bledsoe
- College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | - Amy Poole
- College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA
| | | | - Mathew Budoff
- Los Angeles Biomedical Research Institute, University of California in Los Angeles, Los Angeles, California 90502, USA
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Mamudu HM, Wang L, Poole AM, Blair CJ, Littleton MA, Gregory R, Frierson L, Voigt C, Paul TK. Cardiovascular Diseases Health Literacy among Patients, Health Professionals, and Community-Based Stakeholders in a Predominantly Medically Underserved Rural Environment. South Med J 2020; 113:508-513. [PMID: 33005968 DOI: 10.14423/smj.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The central Appalachian region of the United States is disproportionately burdened with cardiovascular disease (CVD); however, the level of literacy about CVD among residents has not been well studied. This study aimed to examine the prevalence and factors of CVD health literacy (HL) among a sample of patients/caregivers, providers/professionals, and community stakeholders. METHODS In 2018, data were collected from central Appalachian residents in six states: Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. CVD HL status was determined by assessing correct responses to five interrelated questions about basic knowledge of CVD. Multiple logistic regression analyses were used to examine the associations between potential factors and CVD HL status. RESULTS Of the total respondents (N = 82), <50% correctly answered all 5 CVD HL questions. Multiple logistic regression analyses showed that compared with respondents with advanced college degrees, those with a college degree or less were more likely to have low HL for "typical symptom of CVD," "physical exercise and CVD," "blood pressure and CVD," and "stress and CVD." In addition, compared with respondents younger than 50 years, those 50 years and older were 3.79 times more likely to have low HL for "physical exercise and CVD." CONCLUSIONS These results suggest the incorporation of CVD HL into CVD care and that educational attainments should be part of CVD policies and programs in the region.
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Affiliation(s)
- Hadii M Mamudu
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
| | - Liang Wang
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
| | - Amy M Poole
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
| | - Cynthia J Blair
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
| | - Mary Ann Littleton
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
| | - Rob Gregory
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
| | - Lynn Frierson
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
| | - Carl Voigt
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
| | - Timir K Paul
- From the College of Public Health, East Tennessee State University, Johnson City, Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, Karing Hearts Cardiology Services, Johnson City, Mended Hearts, Johnson City Chapter, Johnson City, and the James H. Quillen College of Medicine, East Tennessee State University, Johnson City
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Mamudu HM, Alamian A, Paul T, Subedi P, Wang L, Jones A, Alamin AE, Stewart D, Blackwell G, Budoff M. Diabetes, subclinical atherosclerosis and multiple cardiovascular risk factors in hard-to-reach asymptomatic patients. Diab Vasc Dis Res 2018; 15:519-527. [PMID: 30113211 DOI: 10.1177/1479164118791654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM To examine the association of cardiovascular disease risk factors with and their cumulative effect on coronary artery calcium in hard-to-reach asymptomatic patients with diabetes. METHODS A total of 2563 community-dwelling asymptomatic subjects from Central Appalachia participated in coronary artery calcium screening at a heart centre. Binary variable was used to indicate that coronary artery calcium was either present or absent. Independent variables consisted of demographic and modifiable risk factors and medical conditions. Descriptive statistics and multinomial logistic regression analyses were conducted. RESULTS In total, 55.8% and 13.7% of study participants had subclinical atherosclerosis (coronary artery calcium ⩾1) and diabetes, respectively. The presence of coronary artery calcium was higher in subjects with diabetes (68.5%) than those without (53.8%). Compared to subjects without diabetes with coronary artery calcium = 0, obesity, hypertension, hypercholesterolaemia and smoking increased the odds of the presence of coronary artery calcium (coronary artery calcium score ⩾1) regardless of diabetes status; however, with larger odds ratios in subjects with diabetes. Compared to subjects without diabetes with coronary artery calcium score = 0, having 3, 4 and ⩾5 risk factors increased the odds of presence of coronary artery calcium in subjects with diabetes by 14.06 (confidence interval = 3.26-62.69), 32.30 (confidence interval = 7.41-140.82) and 47.12 (confidence interval = 10.35-214.66) times, respectively. CONCLUSION There is a need for awareness about subclinical atherosclerosis in patients with diabetes and more research about coronary artery calcium in subpopulations of patients.
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Affiliation(s)
- Hadii M Mamudu
- 1 Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Arsham Alamian
- 2 East Tennessee State University, Johnson City, TN, USA
| | - Timir Paul
- 2 East Tennessee State University, Johnson City, TN, USA
| | - Pooja Subedi
- 2 East Tennessee State University, Johnson City, TN, USA
| | - Liang Wang
- 2 East Tennessee State University, Johnson City, TN, USA
| | - Antwan Jones
- 3 The George Washington University, Washington, DC, USA
| | - Ali E Alamin
- 2 East Tennessee State University, Johnson City, TN, USA
| | - David Stewart
- 2 East Tennessee State University, Johnson City, TN, USA
| | - Gerald Blackwell
- 4 Wellmont Health System (now part of Ballad Health), Kingsport, TN, USA
| | - Matthew Budoff
- 5 University of California, Los Angeles, Los Angeles, CA, USA
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Mamudu HM, Subedi P, Paul T, Alamin AE, Alamian A, Wang L, Stewart D, Jones A, Harirforoosh S, Blackwell G, Budoff M. The associated risk factors for coronary artery calcium in asymptomatic individuals with and without diabetes in rural Central Appalachia. J Diabetes Complications 2018; 32:900-905. [PMID: 30082173 DOI: 10.1016/j.jdiacomp.2018.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 11/29/2022]
Abstract
AIM To examine the risk factor of coronary artery calcium (CAC) in individuals with diabetes and those without diabetes in Central Appalachia. METHODS Study population included 2479 asymptomatic participants who underwent CAC screening between August 2012 and November 2016. CAC score was classified into four categories [0 (no plaque), 1-99 (mild plaque), 100-399 (moderate plaque), and ≥400 (severe plaque)]. Multinomial logistic regression analyses were conducted to test the association between CAC and cardiovascular disease (CVD) risk factors among participants with diabetes, age and gender matched controls, and randomly selected controls. RESULTS 13.6% of total participants had diabetes. Around 69%, 59.8%, and 57.7% of the participants with diabetes, matched controls, and randomly selected controls had CAC score ≥1, respectively. Participants with diabetes had higher prevalence of all CVD risk factors than controls. Among participants with diabetes, hypertension and physical inactivity increased the odds of CAC = 100-399, while among those without diabetes, hypertension and hypercholesteremia increased the odds of having CAC = 1-99 and CAC ≥ 400. CONCLUSION Half of study participants had subclinical atherosclerosis (i.e., CAC), and individuals with diabetes had higher CAC scores. This study suggests that individuals with diabetes in Central Appalachia might benefit from screening for CAC.
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Affiliation(s)
- Hadii M Mamudu
- Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA.
| | - Pooja Subedi
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA; Department of Epidemiology, College of Public Health and Health Professions College of Medicine, University of Florida, Gainesville, FL 32610, USA.
| | - Timir Paul
- Division of Cardiology, James. H. Quillen College of Medicine, East Tennessee State University, 329 N State of Franklin Rd, Johnson City, TN 37604, USA.
| | - Ali E Alamin
- Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA.
| | - Arsham Alamian
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA.
| | - Liang Wang
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, USA.
| | - David Stewart
- Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, USA.
| | - Antwan Jones
- Department of Sociology, George Washington University, Washington, DC 20052, USA.
| | - Sam Harirforoosh
- Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, USA.
| | | | - Matthew Budoff
- Los Angeles Biomedical Research Institute, 1124 W Carson Street, Torrance, CA 90502, USA.
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