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Azap L, Woldesenbet S, Lima H, Munir MM, Diaz A, Endo Y, Yang J, Mokadam NA, Ganapathi A, Pawlik TM. The Association of Persistent Poverty and Outcomes Among Patients Undergoing Cardiac Surgery. J Surg Res 2023; 292:30-37. [PMID: 37572411 DOI: 10.1016/j.jss.2023.07.030] [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: 03/13/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION We sought to evaluate the association of county-level poverty duration and cardiac surgical outcomes. METHODS Patients who underwent coronary artery bypass graft, surgical aortic valve replacement, and mitral valve repair and replacement between 2016 and 2020 were identified using the Medicare Standard Analytical Files Database. County-level poverty data were acquired from the American Community Survey and US Department of Agriculture (1980-2015). High poverty was defined as ≥19.5% of residents in poverty. Patients were stratified into never-high poverty (NHP), intermittent low poverty, intermittent high poverty, and persistent poverty (PP). A mixed-effect hierarchical generalized linear model and Cox regression models that adjusted for patient-level covariates were used to evaluate outcomes. RESULTS Among 237,230 patients, 190,659 lived in NHP counties, while 10,273 resided in PP counties. Compared with NHP patients, PP patients were more likely to present at a younger median age (NHP: 75 y versus PP: 74 y), be non-Hispanic Black (5388, 2.9% versus PP: 1030, 10.1%), and live in the south (NHP: 66,012, 34.6% versus PP: 87,815, 76.1%) (all P < 0.001). PP patients also had more nonelective surgical operations (NHP: 58,490, 30.8% versus 3645, 35.6%, P < 0.001). Notably, PP patients had increased odds of 30-d mortality (odds ratio 1.13, 95% confidence interval [CI] 1.02-1.26), 90-d mortality (odds ratio 1.14, 95% CI 1.05-1.24), and risk of long-term mortality (hazard ratio 1.13, 95% CI 1.09-1.19) compared with patients in NHP counties (all P < 0.05). CONCLUSIONS County-level poverty was associated with a greater risk of short- and long-term mortality among cardiac surgical patients.
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Affiliation(s)
- Lovette Azap
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio; Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Selamawit Woldesenbet
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Henrique Lima
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Muhammad Musaab Munir
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Adrian Diaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Yutaka Endo
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Jason Yang
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Asvin Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio.
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De Marco S, Marziali E, Nachira L, Arcaro P, Villani L, Galasso V, Bruno S, Laurenti P. A multidisciplinary primary prevention intervention to increase adherence to the Mediterranean diet: a pilot study. BMC Public Health 2023; 23:2051. [PMID: 37980473 PMCID: PMC10657599 DOI: 10.1186/s12889-023-16893-0] [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] [Received: 04/21/2023] [Accepted: 10/04/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND The role of the Mediterranean Diet (MD) in reducing cardiovascular (CV) risk is widely demonstrated and many studies have shown the effectiveness of educational interventions in primary prevention. This study aimed to evaluate the impact of a multidisciplinary educational intervention, that included nutritional, psychological and physical activity coaching, on adherence to MD and on CV risk. METHODS In a Roman neighborhood, general practitioners enrolled 41 subjects to take part in the educational intervention from November 2018 (T0) to November 2019 (T1). Participants' anthropometric measures, haematochemical parameters and CV risk score were assessed before and after the intervention. Furthermore, their adherence to MD was evaluated through the analysis of food frequency questionnaires using Medi-Lite. RESULTS The study found a significant reduction of 2.5 points in individual CV risk score, and an increase of 2.5 point in adherence to the MD. The stratification by gender showed statistically significant decreases in weight of 1.16 kg, BMI of 0.47, LDL cholesterol of 14.00 mg/dL, and individual CV risk score of 1.16 points among female participants. CONCLUSIONS These results show that a multidisciplinary educational intervention model including the adoption of MD could be an effective strategy in Public Health for CV primary prevention and improvement of people's lifestyles.
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Affiliation(s)
- Silvia De Marco
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eleonora Marziali
- Department of Life Science and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Lorenza Nachira
- Department of Life Science and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paola Arcaro
- Department of Life Science and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Leonardo Villani
- Department of Life Science and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Stefania Bruno
- Department of Life Science and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
- Women, Children and Public Health Sciences Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Laurenti
- Department of Life Science and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
- Women, Children and Public Health Sciences Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Oude Wolcherink MJ, Behr CM, Pouwels XGLV, Doggen CJM, Koffijberg H. Health Economic Research Assessing the Value of Early Detection of Cardiovascular Disease: A Systematic Review. PHARMACOECONOMICS 2023; 41:1183-1203. [PMID: 37328633 PMCID: PMC10492754 DOI: 10.1007/s40273-023-01287-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is the most prominent cause of death worldwide and has a major impact on healthcare budgets. While early detection strategies may reduce the overall CVD burden through earlier treatment, it is unclear which strategies are (most) efficient. AIM This systematic review reports on the cost effectiveness of recent early detection strategies for CVD in adult populations at risk. METHODS PubMed and Scopus were searched to identify scientific articles published between January 2016 and May 2022. The first reviewer screened all articles, a second reviewer independently assessed a random 10% sample of the articles for validation. Discrepancies were solved through discussion, involving a third reviewer if necessary. All costs were converted to 2021 euros. Reporting quality of all studies was assessed using the CHEERS 2022 checklist. RESULTS In total, 49 out of 5552 articles were included for data extraction and assessment of reporting quality, reporting on 48 unique early detection strategies. Early detection of atrial fibrillation in asymptomatic patients was most frequently studied (n = 15) followed by abdominal aortic aneurysm (n = 8), hypertension (n = 7) and predicted 10-year CVD risk (n = 5). Overall, 43 strategies (87.8%) were reported as cost effective and 11 (22.5%) CVD-related strategies reported cost reductions. Reporting quality ranged between 25 and 86%. CONCLUSIONS Current evidence suggests that early CVD detection strategies are predominantly cost effective and may reduce CVD-related costs compared with no early detection. However, the lack of standardisation complicates the comparison of cost-effectiveness outcomes between studies. Real-world cost effectiveness of early CVD detection strategies will depend on the target country and local context. REGISTRATION OF SYSTEMATIC REVIEW CRD42022321585 in International Prospective Registry of Ongoing Systematic Reviews (PROSPERO) submitted at 10 May 2022.
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Affiliation(s)
- Martijn J Oude Wolcherink
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Carina M Behr
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Xavier G L V Pouwels
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Carine J M Doggen
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Hendrik Koffijberg
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands.
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Klau JH, Maj C, Klinkhammer H, Krawitz PM, Mayr A, Hillmer AM, Schumacher J, Heider D. AI-based multi-PRS models outperform classical single-PRS models. Front Genet 2023; 14:1217860. [PMID: 37441549 PMCID: PMC10335560 DOI: 10.3389/fgene.2023.1217860] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
Polygenic risk scores (PRS) calculate the risk for a specific disease based on the weighted sum of associated alleles from different genetic loci in the germline estimated by regression models. Recent advances in genetics made it possible to create polygenic predictors of complex human traits, including risks for many important complex diseases, such as cancer, diabetes, or cardiovascular diseases, typically influenced by many genetic variants, each of which has a negligible effect on overall risk. In the current study, we analyzed whether adding additional PRS from other diseases to the prediction models and replacing the regressions with machine learning models can improve overall predictive performance. Results showed that multi-PRS models outperform single-PRS models significantly on different diseases. Moreover, replacing regression models with machine learning models, i.e., deep learning, can also improve overall accuracy.
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Affiliation(s)
- Jan Henric Klau
- Department of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Carlo Maj
- Center for Human Genetics, University of Marburg, Marburg, Germany
| | - Hannah Klinkhammer
- Institute for Genomic Statistics and Bioinformatics, Medical Faculty, University Bonn, Bonn, Germany
- Institute for Medical Biometry, Informatics and Epidemiology, Medical Faculty, University Bonn, Bonn, Germany
| | - Peter M. Krawitz
- Institute for Genomic Statistics and Bioinformatics, Medical Faculty, University Bonn, Bonn, Germany
| | - Andreas Mayr
- Institute for Medical Biometry, Informatics and Epidemiology, Medical Faculty, University Bonn, Bonn, Germany
| | - Axel M. Hillmer
- Institute of Pathology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | | | - Dominik Heider
- Department of Mathematics and Computer Science, University of Marburg, Marburg, Germany
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Grant WB, Boucher BJ, Al Anouti F, Pilz S. Comparing the Evidence from Observational Studies and Randomized Controlled Trials for Nonskeletal Health Effects of Vitamin D. Nutrients 2022; 14:3811. [PMID: 36145186 PMCID: PMC9501276 DOI: 10.3390/nu14183811] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 12/12/2022] Open
Abstract
Although observational studies of health outcomes generally suggest beneficial effects with, or following, higher serum 25-hydroxyvitamin D [25(OH)D] concentrations, randomized controlled trials (RCTs) have generally not supported those findings. Here we review results from observational studies and RCTs regarding how vitamin D status affects several nonskeletal health outcomes, including Alzheimer's disease and dementia, autoimmune diseases, cancers, cardiovascular disease, COVID-19, major depressive disorder, type 2 diabetes, arterial hypertension, all-cause mortality, respiratory tract infections, and pregnancy outcomes. We also consider relevant findings from ecological, Mendelian randomization, and mechanistic studies. Although clear discrepancies exist between findings of observational studies and RCTs on vitamin D and human health benefits these findings should be interpreted cautiously. Bias and confounding are seen in observational studies and vitamin D RCTs have several limitations, largely due to being designed like RCTs of therapeutic drugs, thereby neglecting vitamin D's being a nutrient with a unique metabolism that requires specific consideration in trial design. Thus, RCTs of vitamin D can fail for several reasons: few participants' having low baseline 25(OH)D concentrations, relatively small vitamin D doses, participants' having other sources of vitamin D, and results being analyzed without consideration of achieved 25(OH)D concentrations. Vitamin D status and its relevance for health outcomes can usefully be examined using Hill's criteria for causality in a biological system from results of observational and other types of studies before further RCTs are considered and those findings would be useful in developing medical and public health policy, as they were for nonsmoking policies. A promising approach for future RCT design is adjustable vitamin D supplementation based on interval serum 25(OH)D concentrations to achieve target 25(OH)D levels suggested by findings from observational studies.
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Affiliation(s)
- William B. Grant
- Sunlight, Nutrition and Health Research Center, San Francisco, CA 94164-1603, USA
| | - Barbara J. Boucher
- The London School of Medicine and Dentistry, The Blizard Institute, Barts, Queen Mary University of London, London E1 2AT, UK
| | - Fatme Al Anouti
- Department of Health Sciences, College of Natural and Health Sciences, Zayed University, Abu Dhabi 144534, United Arab Emirates
| | - Stefan Pilz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
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Miller RG, Costacou T. Cardiovascular Disease in Adults with Type 1 Diabetes: Looking Beyond Glycemic Control. Curr Cardiol Rep 2022; 24:1467-1475. [PMID: 35947333 DOI: 10.1007/s11886-022-01763-9] [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] [Accepted: 08/01/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Despite improvements in treatment, people with type 1 diabetes continue to have increased cardiovascular disease (CVD) risk. Glycemic control does not fully explain this excess CVD risk, so a greater understanding of other risk factors is needed. RECENT FINDINGS The authors review the relationship between glycemia and CVD risk in adults with type 1 diabetes and summarize evidence regarding other factors that may explain risk beyond glycemia. Insulin resistance, weight gain, sex differences, genetics, inflammation, emerging markers of risk, including lipid subclasses and epigenetic modifications, and future directions are discussed. As glycemic control improves, an increased focus on other CVD risk factors is warranted in type 1 diabetes. Novel markers and precision medicine approaches may improve CVD prediction, but a lack of type 1 diabetes-specific guidelines for lipids, blood pressure, and physical activity are likely impediments to optimal CVD prevention in this high-risk population.
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Affiliation(s)
- Rachel G Miller
- Department of Epidemiology, School of Public Health, University of Pittsburgh, 130 N. Bellefield Avenue, Pittsburgh, PA, 15213, USA
| | - Tina Costacou
- Department of Epidemiology, School of Public Health, University of Pittsburgh, 130 N. Bellefield Avenue, Pittsburgh, PA, 15213, USA.
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Xu Y, Greene TH, Bress AP, Sauer BC, Bellows BK, Zhang Y, Weintraub WS, Moran AE, Shen J. Estimating the optimal individualized treatment rule from a cost-effectiveness perspective. Biometrics 2022; 78:337-351. [PMID: 33215693 PMCID: PMC8134511 DOI: 10.1111/biom.13406] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/30/2020] [Accepted: 11/06/2020] [Indexed: 11/27/2022]
Abstract
Optimal individualized treatment rules (ITRs) provide customized treatment recommendations based on subject characteristics to maximize clinical benefit in accordance with the objectives in precision medicine. As a result, there is growing interest in developing statistical tools for estimating optimal ITRs in evidence-based research. In health economic perspectives, policy makers consider the tradeoff between health gains and incremental costs of interventions to set priorities and allocate resources. However, most work on ITRs has focused on maximizing the effectiveness of treatment without considering costs. In this paper, we jointly consider the impact of effectiveness and cost on treatment decisions and define ITRs under a composite-outcome setting, so that we identify the most cost-effective ITR that accounts for individual-level heterogeneity through direct optimization. In particular, we propose a decision-tree-based statistical learning algorithm that uses a net-monetary-benefit-based reward to provide nonparametric estimations of the optimal ITR. We provide several approaches to estimating the reward underlying the ITR as a function of subject characteristics. We present the strengths and weaknesses of each approach and provide practical guidelines by comparing their performance in simulation studies. We illustrate the top-performing approach from our simulations by evaluating the projected 15-year personalized cost-effectiveness of the intensive blood pressure control of the Systolic Blood Pressure Intervention Trial (SPRINT) study.
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Affiliation(s)
- Yizhe Xu
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Tom H. Greene
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah,Department of Internal Medicine, University of Utah, Salt Lake City, Utah,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah
| | - Adam P. Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Brian C. Sauer
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah,Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Brandon K. Bellows
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yue Zhang
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah,Department of Internal Medicine, University of Utah, Salt Lake City, Utah,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah
| | | | - Andrew E. Moran
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah,Department of Internal Medicine, University of Utah, Salt Lake City, Utah,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah
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Psychological resilience predicting cardiometabolic conditions in adulthood in the Midlife in the United States Study. Proc Natl Acad Sci U S A 2021; 118:2102619118. [PMID: 34341103 DOI: 10.1073/pnas.2102619118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Early adversity is associated with poor cardiometabolic health, potentially via psychological distress. However, not everyone exposed to adversity develops significant distress. Psychological resilience and positive psychological health despite adversity may protect against unfavorable cardiometabolic outcomes that are otherwise more likely. We examined early adversity, psychological resilience, and cardiometabolic risk among 3,254 adults in the Midlife in the United States Study. Psychological resilience was defined according to both early psychosocial adversity and adult psychological health (characterized by low distress and high wellbeing) at Wave 1 (1994 to 1995). Categorical resilience was derived by cross-classifying adversity (exposed versus unexposed) and psychological health (higher versus lower). We also assessed count of adversities experienced and psychological symptoms as separate variables. Incident cardiometabolic conditions (e.g., heart attack, stroke, and diabetes) were self-reported at Waves 2 (2004 to 2005) and 3 (2013 to 2014). Secondary analyses examined biological cardiometabolic risk using a composite of biomarkers available within a Wave-2 subsample. Logistic and Poisson regressions evaluated associations of resilience with cardiometabolic health across 20 follow-up y, adjusting for relevant covariates. In this initially healthy sample, nonresilient (adversity-exposed, lower psychological health) versus resilient (adversity-exposed, high psychological health) individuals had 43% higher odds of cardiometabolic conditions (95% CI 1.10 to 1.85). Odds of cardiometabolic conditions were similar among resilient versus unexposed, psychologically healthy individuals. More adversity experiences were associated with increased odds, while better psychological health with decreased odds of cardiometabolic conditions, and effects were largely independent. Patterns were similar for objectively assessed cardiometabolic risk. Psychological resilience in midlife may protect against negative cardiometabolic impacts of early adversity.
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Ferrannini E. A Journey in Diabetes: From Clinical Physiology to Novel Therapeutics: The 2020 Banting Medal for Scientific Achievement Lecture. Diabetes 2021; 70:338-346. [PMID: 33472943 PMCID: PMC7881861 DOI: 10.2337/dbi20-0028] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022]
Abstract
Insulin resistance and β-cell dysfunction are the core pathophysiological mechanisms of all hyperglycemic syndromes. Advances in in vivo investigative techniques have made it possible to quantify insulin resistance in multiple sites (skeletal and myocardial muscle, subcutaneous and visceral fat depots, liver, kidney, vascular tissues, brain and intestine), to clarify its consequences for tissue substrate selection, and to establish its relation to tissue perfusion. Physiological modeling of β-cell function has provided a uniform tool to measure β-cell glucose sensitivity and potentiation in response to a variety of secretory stimuli, thereby allowing us to establish feedbacks with insulin resistance, to delineate the biphasic time course of conversion to diabetes, to gauge incretin effects, and to identify primary insulin hypersecretion. As insulin resistance also characterizes several of the comorbidities of diabetes (e.g., obesity, hypertension, dyslipidemia), with shared genetic and acquired influences, the concept is put forward that diabetes is a systemic disease from the outset, actually from the prediabetic stage. In fact, early multifactorial therapy, particularly with newer antihyperglycemic agents, has shown that the burden of micro- and macrovascular complications can be favorably modified despite the rising pressure imposed by protracted obesity.
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Affiliation(s)
- Ele Ferrannini
- National Research Council (CNR) Institute of Clinical Physiology, Pisa, Italy
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Miller RG, Orchard TJ. Understanding Metabolic Memory: A Tale of Two Studies. Diabetes 2020; 69:291-299. [PMID: 32079705 PMCID: PMC7034186 DOI: 10.2337/db19-0514] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022]
Abstract
The results of the Diabetes Control and Complications Trial (DCCT) have given rise to much encouragement in the battle to stave off the complications of type 1 diabetes, showing dramatic declines in the development of severe retinopathy, nephropathy, and neuropathy in those treated intensively compared with conventional therapy. Particularly encouraging has been the continuing difference between the two groups despite both having similar HbA1c (∼8%) since the end of DCCT, when 96% of participants entered the observational Epidemiology of Diabetes Interventions and Complications (EDIC) study. This continuing relative benefit has been termed "metabolic memory," which implies altered metabolic regulation. Based on evidence from both the Epidemiology of Diabetes Complications (EDC) prospective cohort study of childhood-onset type 1 diabetes and DCCT/EDIC, we show that the metabolic memory effect can be largely explained by lower cumulative glycemic exposure in the intensive therapy group, and, on average, the development of complications increases with greater glycemic exposure, irrespective of whether this results from a high exposure for a short time or a lower exposure for a longer time. Thus, there is no need for a concept like "metabolic memory" to explain these observations. Potential mechanisms explaining the cumulative glycemic effect are also briefly discussed.
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Affiliation(s)
- Rachel G Miller
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Trevor J Orchard
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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García-Gómez MC, Vilahur G. Osteoporosis and vascular calcification: A shared scenario. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2019; 32:33-42. [PMID: 31221532 DOI: 10.1016/j.arteri.2019.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/11/2019] [Indexed: 12/12/2022]
Abstract
Osteoporosis is a systemic skeletal disease, characterised by low bone mass and deterioration in the micro-architecture of bone tissue, which causes increased bone fragility and consequently greater susceptibility to fractures. It is the most frequent metabolic bone disease in our population, and fractures resulting from osteoporosis are becoming more common. Furthermore, vascular calcification is a recognised risk factor of cardiovascular morbidity and mortality that historically has been considered a passive and degenerative process. However, it is currently recognised as an active process, which has histopathological characteristics, mineral composition and initiation and development mechanisms characteristic of bone formation. Paradoxically, patients with osteoporosis frequently show vascular calcifications. Traditionally, they have been considered as independent processes related to age, although more recent epidemiological studies have shown that there is a close relationship between the loss of bone mass and vascular calcification, regardless of age. In fact, both conditions share risk factors and pathophysiological mechanisms. These include the relationship between proteins of bone origin, such as osteopontin and osteoprotegerin (OPG), with vascular pathology, and the intercellular protein system RANK/RANKL/OPG and the Wnt signalling pathway. The mechanisms linked in both pathologies should be considered in clinical decisions, given that treatments for osteoporosis could have unforeseen effects on vascular calcification, and vice versa. In short, a better understanding of the relationship between both entities can help in proposing strategies to reduce the increasing prevalence of vascular calcification and osteoporosis in the aging population.
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Affiliation(s)
| | - Gemma Vilahur
- Programa ICCC-Institut de Recerca Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, España; CIBERCV Instituto de Salud Carlos III, Madrid, España.
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Machine Learning-Augmented Propensity Score-Adjusted Multilevel Mixed Effects Panel Analysis of Hands-On Cooking and Nutrition Education versus Traditional Curriculum for Medical Students as Preventive Cardiology: Multisite Cohort Study of 3,248 Trainees over 5 Years. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5051289. [PMID: 29850526 PMCID: PMC5925138 DOI: 10.1155/2018/5051289] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/28/2018] [Indexed: 01/01/2023]
Abstract
Background Cardiovascular disease (CVD) annually claims more lives and costs more dollars than any other disease globally amid widening health disparities, despite the known significant reductions in this burden by low cost dietary changes. The world's first medical school-based teaching kitchen therefore launched CHOP-Medical Students as the largest known multisite cohort study of hands-on cooking and nutrition education versus traditional curriculum for medical students. Methods This analysis provides a novel integration of artificial intelligence-based machine learning (ML) with causal inference statistics. 43 ML automated algorithms were tested, with the top performer compared to triply robust propensity score-adjusted multilevel mixed effects regression panel analysis of longitudinal data. Inverse-variance weighted fixed effects meta-analysis pooled the individual estimates for competencies. Results 3,248 unique medical trainees met study criteria from 20 medical schools nationally from August 1, 2012, to June 26, 2017, generating 4,026 completed validated surveys. ML analysis produced similar results to the causal inference statistics based on root mean squared error and accuracy. Hands-on cooking and nutrition education compared to traditional medical school curriculum significantly improved student competencies (OR 2.14, 95% CI 2.00–2.28, p < 0.001) and MedDiet adherence (OR 1.40, 95% CI 1.07–1.84, p = 0.015), while reducing trainees' soft drink consumption (OR 0.56, 95% CI 0.37–0.85, p = 0.007). Overall improved competencies were demonstrated from the initial study site through the scale-up of the intervention to 10 sites nationally (p < 0.001). Discussion This study provides the first machine learning-augmented causal inference analysis of a multisite cohort showing hands-on cooking and nutrition education for medical trainees improves their competencies counseling patients on nutrition, while improving students' own diets. This study suggests that the public health and medical sectors can unite population health management and precision medicine for a sustainable model of next-generation health systems providing effective, equitable, accessible care beginning with reversing the CVD epidemic.
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Bonanni P, Chiamenti G, Conforti G, Maio T, Odone A, Russo R, Scotti S, Signorelli C, Villani A. The 2016 Lifetime Immunization Schedule, approved by the Italian scientific societies: A new paradigm to promote vaccination at all ages. Hum Vaccin Immunother 2017; 13:2531-2537. [PMID: 29048980 PMCID: PMC5703359 DOI: 10.1080/21645515.2017.1366394] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/13/2017] [Accepted: 08/06/2017] [Indexed: 11/17/2022] Open
Abstract
Medical scientific societies have the core mission of producing, pooling and disseminating solid and updated scientific information. We report the successful experience of the partnership of four national Medical Scientific Societies active in Italy in producing scientific advice on vaccines and vaccination. In particular, i) the Italian Society of Hygiene, Preventive Medicine and Public Health; SitI, ii) the Italian Society of Paediatrics; SIP, iii) the "Italian Federation of General Practitioners"; FIMP, and iv) the Italian Federation of General Medicine FIMMG) have worked together since 2012 to produce shared evidence-based recommendations on vaccination schedules, namely the "Lifetime Immunization Schedule" which introduced for the first time in Italy a life-course approach to vaccination. The 2014 edition of the "Lifetime Immunization Schedule" was used as a basis to develop the 2017-2019 Italian National Prevention Plan, approved by The Italian Ministry of Health in February 2017. In this report, we present the structure, content and supporting evidence of the new 2016 "Lifetime Immunization Schedule" and we expand on the influential role of medical scientific societies in researching and advocating for effective and safe vaccination programmes' implementation at the national level.
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Affiliation(s)
- Paolo Bonanni
- Italian Society of Hygiene, Preventive Medicine and Public Health (SitI), Rome, Italy
| | | | | | - Tommasa Maio
- Italian Federation of General Practitioners (FIMMG), Rome, Italy
| | - Anna Odone
- Italian Society of Hygiene, Preventive Medicine and Public Health (SitI), Rome, Italy
| | - Rocco Russo
- Italian Society of Paediatrics (SIP), Rome, Italy
| | - Silvestro Scotti
- Italian Federation of General Practitioners (FIMMG), Rome, Italy
| | - Carlo Signorelli
- Italian Society of Hygiene, Preventive Medicine and Public Health (SitI), Rome, Italy
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14
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Zhou B, Wen D, Nye K, Gilkeson RC, Eck B, Jordan D, Wilson DL. Detection and quantification of coronary calcium from dual energy chest x-rays: Phantom feasibility study. Med Phys 2017; 44:5106-5119. [PMID: 28710871 DOI: 10.1002/mp.12474] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 05/25/2017] [Accepted: 06/28/2017] [Indexed: 01/05/2023] Open
Abstract
PURPOSE We have demonstrated the ability to identify coronary calcium, a reliable biomarker of coronary artery disease, using nongated, 2-shot, dual energy (DE) chest x-ray imaging. Here we will use digital simulations, backed up by measurements, to characterize DE calcium signals and the role of potential confounds such as beam hardening, x-ray scatter, cardiac motion, and pulmonary artery pulsation. For the DE calcium signal, we will consider quantification, as compared to CT calcium score, and visualization. METHODS We created stylized and anatomical digital 3D phantoms including heart, lung, coronary calcium, spine, ribs, pulmonary artery, and adipose. We simulated high and low kVp x-ray acquisitions with x-ray spectra, energy dependent attenuation, scatter, ideal detector, and automatic exposure control (AEC). Phantoms allowed us to vary adipose thickness, cardiac motion, etc. We used specialized dual energy coronary calcium (DECC) processing that includes corrections for scatter and beam hardening. RESULTS Beam hardening over a wide range of adipose thickness (0-30 cm) reduced the change in intensity of a coronary artery calcification (ΔICAC ) by < 3% in DECC images. Scatter correction errors of ±50% affected the calcium signal (ΔICAC ) in DECC images ±9%. If a simulated pulmonary artery fills with blood between exposures, it can give rise to a residual signal in DECC images, explaining pulmonary artery visibility in some clinical images. Residual misregistration can be mostly compensated by integrating signals in an enlarged region encompassing registration artifacts. DECC calcium score compared favorably to CT mass and volume scores over a number of phantom perturbations. CONCLUSION Simulations indicate that proper DECC processing can faithfully recover coronary calcium signals. Beam hardening, errors in scatter estimation, cardiac motion, calcium residual misregistration etc., are all manageable. Simulations are valuable as we continue to optimize DE coronary calcium image processing and quantitative analysis.
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Affiliation(s)
- Bo Zhou
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Di Wen
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | | | - Robert C Gilkeson
- University Hospitals of Cleveland, Cleveland Medical Center, Cleveland, OH, 44106, USA.,Department of Radiology, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Brendan Eck
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - David Jordan
- University Hospitals of Cleveland, Cleveland Medical Center, Cleveland, OH, 44106, USA.,Department of Radiology, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - David L Wilson
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA.,Department of Radiology, Case Western Reserve University, Cleveland, OH, 44106, USA
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15
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Folse HJ, Mukherjee J, Sheehan JJ, Ward AJ, Pelkey RL, Dinh TA, Qin L, Kim J. Delays in treatment intensification with oral antidiabetic drugs and risk of microvascular and macrovascular events in patients with poor glycaemic control: An individual patient simulation study. Diabetes Obes Metab 2017; 19:1006-1013. [PMID: 28211604 DOI: 10.1111/dom.12913] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/02/2017] [Accepted: 02/14/2017] [Indexed: 11/30/2022]
Abstract
AIMS To use the Archimedes model to estimate the consequences of delays in oral antidiabetic drug (OAD) treatment intensification on glycaemic control and long-term outcomes at 5 and 20 years. MATERIALS AND METHODS Using real-world data, we modelled a cohort of hypothetical patients with glycated haemoglobin (HbA1c) ≥8%, on metformin, with no history of insulin use. The cohort included 3 strata based on the number of OADs taken at baseline. The first add-on in the intensification sequence was a sulphonylurea, next was a dipeptidyl peptidase-4 inhibitor, and last, a thiazolidinedione. The scenarios included either no delay or delay, based on observed and extrapolated times to intensification. RESULTS At 1 year, HbA1c was 6.8% for patients intensifying without delay, and 8.2% for those delaying intensification. For no delay vs delay, risks of major adverse cardiac events, myocardial infarction, heart failure and amputations were reduced by 18.0%, 25.0%, 13.7%, and 20.4%, respectively, at 5 years; severe hypoglycaemia risk, however, increased to 19% for the no delay scenario vs 12.5% for delay. At 20 years, the results showed similar trends to those at 5 years. CONCLUSIONS Timing of intensification of OAD therapy according to guideline recommendations led to greater reductions in HbA1c and lower risks of complications, but higher risks of hypoglycaemia than delaying intensification. These results highlight the potential impact of timely treatment intensification on long-term outcomes.
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Affiliation(s)
| | | | - John J Sheehan
- AstraZeneca Pharmaceuticals, Fort Washington, Pennsylvania
| | | | | | | | - Lei Qin
- AstraZeneca, One MedImmune Way, Gaithersburg, Maryland
| | - Jennifer Kim
- AstraZeneca, One MedImmune Way, Gaithersburg, Maryland
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16
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van Koeverden ID, van Haelst STW, Haitjema S, de Vries JPPM, Moll FL, den Ruijter HM, Hoefer IE, Dalmeijer GW, de Borst GJ, Pasterkamp G. Time-dependent trends in cardiovascular adverse events during follow-up after carotid or iliofemoral endarterectomy. Br J Surg 2017. [PMID: 28650577 DOI: 10.1002/bjs.10576] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Recent observations have suggested a decline in vulnerable carotid artery and iliofemoral atherosclerotic plaque characteristics over the past decade. The aim of this study was to determine whether, in the presence of clinically manifest carotid or peripheral artery disease, secondary adverse cardiovascular events decreased over this period. METHODS Patients included in the Athero-Express biobank between 2003 and 2012 were analysed. During 3-year follow-up, composite cardiovascular endpoints were documented yearly, including: myocardial infarction, coronary interventions, stroke, peripheral interventions and cardiovascular death. The major cardiovascular endpoint consisted of myocardial infarction, stroke and cardiovascular death. RESULTS Some 1684 patients who underwent carotid endarterectomy (CEA) and another 530 who had iliofemoral endarterectomy (IFE) were analysed. In total, 405 (25·2 per cent) and 236 (45·9 per cent) patients had a composite cardiovascular endpoint within 3 years after CEA and IFE respectively. Corrected for possible confounders, the percentage of patients with a secondary cardiovascular event after CEA did not change over time (hazard ratio (HR) 0·91, 95 per cent c.i. 0·65 to 1·28; P = 0·590, for 2011-2012 versus 2003-2004). In patients who had IFE, the incidence of secondary cardiovascular events significantly decreased only in the last 2 years (HR 0·62, 0·41 to 0·94; P = 0·024), owing to a decrease in peripheral (re)interventions in 2011-2012 (HR 0·59, 0·37 to 0·94; P = 0·028). No decrease in major cardiovascular events was observed in either group. CONCLUSION In patients who had undergone either CEA or IFE there was no evidence of a decrease in all secondary cardiovascular events. There were no differences in major cardiovascular events.
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Affiliation(s)
- I D van Koeverden
- Laboratory of Experimental Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - S T W van Haelst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - S Haitjema
- Laboratory of Experimental Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J-P P M de Vries
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - F L Moll
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I E Hoefer
- Laboratory of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G W Dalmeijer
- Julius Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G Pasterkamp
- Laboratory of Experimental Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Laboratory of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Alfaqeeh G, Cook EJ, Randhawa G, Ali N. Access and utilisation of primary health care services comparing urban and rural areas of Riyadh Providence, Kingdom of Saudi Arabia. BMC Health Serv Res 2017; 17:106. [PMID: 28153002 PMCID: PMC5288856 DOI: 10.1186/s12913-017-1983-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 01/04/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The Kingdom of Saudi Arabia (KSA) has seen an increase in chronic diseases. International evidence suggests that early intervention is the best approach to reduce the burden of chronic disease. However, the limited research available suggests that health care access remains unequal, with rural populations having the poorest access to and utilisation of primary health care centres and, consequently, the poorest health outcomes. This study aimed to examine the factors influencing the access to and utilisation of primary health care centres in urban and rural areas of Riyadh province of the KSA. METHODS A questionnaire survey was carried out to identify the barriers and enablers to accessing PHCS in rural (n = 5) and urban (n = 5) areas of Riyadh province, selected on the classification of the population density of the governorates. An adapted version of the NHS National Survey Programme was administered that included 50 questions over 11 sections that assessed a wide range of factors related to respondent's access and experience of the PHCS. A total of 935 responses were obtained with 52.9% (n = 495) from urban areas and the remaining 47.1% (n = 440) from rural areas of Riyadh province. RESULTS This study highlights that there are high levels of satisfaction among patients among all PHCS. In relation to differences between urban and rural respondents, the findings indicated that there were significant variations in relation to: education level, monthly income, medical investigations, receiving blood tests on time, extra opening hours, distance, cleanliness and health prevention. Core barriers for rural patients related to the distance to reach PHCS, cleanliness of the PHCS, receiving health prevention and promotion services, which should serve to improve health outcomes. CONCLUSIONS This study highlighted important differences in access to and utilisation of PHCS between urban and rural populations in Riyadh province in the KSA. These findings have implications for policy and planning of PHCCs and reducing inequalities in health care between rural and urban populations and contributing to a reduction in the chronic disease burden in Riyadh province.
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Affiliation(s)
| | - Erica J. Cook
- Department of Psychology, University of Bedfordshire, Park Square, Luton, UK
| | - Gurch Randhawa
- Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton, UK
| | - Nasreen Ali
- Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton, UK
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Pisinger C, Nielsen HØ, Kuhlmann C, Rosthøj S. Obesity Might Be a Predictor of Weight Reduction after Smoking Cessation. J Obes 2017; 2017:2504078. [PMID: 28890832 PMCID: PMC5584347 DOI: 10.1155/2017/2504078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/27/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Approximately one in five ex-smokers reduces or maintains weight after smoking cessation but little is known about who succeeds to avoid weight gain. The purpose of this study was to identify predictors of weight reduction after long-term smoking cessation in a general population. METHODS Data was obtained from two Danish population-based cohorts (the Inter99 and the Helbred2006 study). Anthropometric measurements were performed by trained research staff. Out of 3.577 daily smokers at baseline 317 participants had quit smoking at the five-year follow-up for at least one year. Multiple logistic regression analysis was performed to determine predictors of weight reduction. RESULTS Thirteen percent reduced weight by at least 1 kg and 4% maintained their weight. Quitters with obesity had more than seven times higher odds than normal weight quitters to lose weight (OR 7.13 (95% CI 2.76-19.71)), and they had the largest median weight loss of 4.45 kg. The only other significant predictor of weight reduction was low tobacco consumption at baseline. CONCLUSIONS Predictors of weight reduction after smoking cessation were high body mass index and low tobacco consumption at baseline. This study might motivate smokers with obesity to quit smoking and health professionals to give them support.
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Affiliation(s)
- Charlotta Pisinger
- Research Centre for Prevention and Health, Glostrup Hospital, Building 84/85, 2600 Glostrup, Denmark
| | - Helle Øster Nielsen
- Faculty of Health and Medical Sciences, University of Copenhagen, 1123 Copenhagen K, Denmark
| | - Caroline Kuhlmann
- Faculty of Health and Medical Sciences, University of Copenhagen, 1123 Copenhagen K, Denmark
- *Caroline Kuhlmann:
| | - Susanne Rosthøj
- Section of Biostatistics, Institute of Public Health, University of Copenhagen, 1014 Copenhagen, Denmark
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19
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Kreider KE, Padilla BI. Type 1 diabetes & cardiovascular disease. Nurse Pract 2016; 41:18-25. [PMID: 27623295 DOI: 10.1097/01.npr.0000497007.02127.fa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Individuals with type 1 diabetes mellitus (T1DM) have a high risk of developing cardiovascular disease (CVD), but some risk factors can be mediated by lifestyle modification and medication. NPs should understand evidence-based management approaches to counsel patients with T1DM on appropriate self-management interventions to reduce the likelihood of CVD.
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Affiliation(s)
- Kathryn Evans Kreider
- Kathryn Evans Kreider is an assistant professor at Duke University School of Nursing, Durham, N.C., and currently practices as an NP in Endocrinology at Duke University Medical Center. Blanca I. Padilla is an assistant professor at Duke University School of Nursing, Durham, N.C., and currently practices as an NP in Endocrinology at Duke University Medical Center
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20
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Hartaigh BÓ, Valenti V, Cho I, Schulman-Marcus J, Gransar H, Knapper J, Kelkar AA, Xie JX, Chang HJ, Shaw LJ, Callister TQ, Min JK. 15-Year prognostic utility of coronary artery calcium scoring for all-cause mortality in the elderly. Atherosclerosis 2016; 246:361-6. [PMID: 26841073 DOI: 10.1016/j.atherosclerosis.2016.01.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/04/2016] [Accepted: 01/21/2016] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Prior studies have demonstrated a decline in the predictive ability of conventional risk factors (RF) with advancing age, emphasizing the need for novel tools to improve risk stratification in the elderly. Coronary artery calcification (CAC) is a robust predictor of adverse cardiovascular events, but its long-term prognostic utility beyond RFs in elderly persons is unknown. METHODS A consecutive series of 9715 individuals underwent CAC scoring and were followed for a mean of 14.6 ± 1.1 years. Multivariable Cox proportional hazards regression (HR) with 95% confidence intervals (95% CI) was employed to assess the independent relationship of CAC and RFs with all-cause death. The incremental value of CAC, stratified by age, was examined by using an area under the receiver operator characteristic curve (AUC) and category-free net reclassification improvement (NRI). RESULTS Of the overall study sample, 728 (7.5%) adults (mean age 74.2 ± 4.2 years; 55.6% female) were 70 years or older, of which 157 (21.6%) died. The presence of any CAC was associated with a >4-fold (95% CI = 2.84-6.59) adjusted risk of death for those over the age of 70, which was higher compared with younger study counterparts, or other measured RFs. For individuals 70 years or older, the discriminatory ability of CAC improved upon that of RFs alone (C statistics 0.764 vs. 0.675, P < 0.001). CAC also enabled improved reclassification (category-free NRI = 84%, P < 0.001) when added to RFs. CONCLUSION In a large-scale observational cohort registry, CAC improves prediction, discrimination, and reclassification of elderly individuals at risk for future death.
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Affiliation(s)
- Bríain Ó Hartaigh
- Department of Radiology and Medicine, Dalio Institute of Cardiovascular Imaging, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Valentina Valenti
- Department of Radiology and Medicine, Dalio Institute of Cardiovascular Imaging, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Iksung Cho
- Department of Radiology and Medicine, Dalio Institute of Cardiovascular Imaging, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Joshua Schulman-Marcus
- Department of Radiology and Medicine, Dalio Institute of Cardiovascular Imaging, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Heidi Gransar
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Knapper
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Anita A Kelkar
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph X Xie
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Leslee J Shaw
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - James K Min
- Department of Radiology and Medicine, Dalio Institute of Cardiovascular Imaging, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA.
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Association between High Blood Pressure and Intakes of Sodium and Potassium among Korean Adults: Korean National Health and Nutrition Examination Survey, 2007-2012. J Acad Nutr Diet 2015; 115:1950-7. [DOI: 10.1016/j.jand.2015.04.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 04/22/2015] [Indexed: 01/07/2023]
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22
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High Risk versus Proportional Benefit: Modelling Equitable Strategies in Cardiovascular Prevention. PLoS One 2015; 10:e0140793. [PMID: 26529507 PMCID: PMC4631497 DOI: 10.1371/journal.pone.0140793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 09/30/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To examine the performances of an alternative strategy to decide initiating BP-lowering drugs called Proportional Benefit (PB). It selects candidates addressing the inequity induced by the high-risk approach since it distributes the gains proportionally to the burden of disease by genders and ages. STUDY DESIGN AND SETTING Mild hypertensives from a Realistic Virtual Population by genders and 10-year age classes (range 35-64 years) received simulated treatment over 10 years according to the PB strategy or the 2007 ESH/ESC guidelines (ESH/ESC). Primary outcomes were the relative life-year gain (life-years gained-to-years of potential life lost ratio) and the number needed to treat to gain a life-year. A sensitivity analysis was performed to assess the impact of changes introduced by the ESH/ESC guidelines appeared in 2013 on these outcomes. RESULTS The 2007 ESH/ESC relative life-year gains by ages were 2%; 10%; 14% in men, and 0%; 2%; 11% in women, this gradient being abolished by the PB (relative gain in all categories = 10%), while preserving the same overall gain in life-years. The redistribution of benefits improved the profile of residual events in younger individuals compared to the 2007 ESH/ESC guidelines. The PB strategy was more efficient (NNT = 131) than the 2013 ESH/ESC guidelines, whatever the level of evidence of the scenario adopted (NNT = 139 and NNT = 179 with the evidence-based scenario and the opinion-based scenario, respectively), although the 2007 ESH/ESC guidelines remained the most efficient strategy (NNT = 114). CONCLUSION The Proportional Benefit strategy provides the first response ever proposed against the inequity of resource use when treating highest risk people. It occupies an intermediate position with regards to the efficiency expected from the application of historical and current ESH/ESC hypertension guidelines. Our approach allows adapting recommendations to the risk and resources of a particular country.
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Vazquez-Benitez G, Desai JR, Xu S, Goodrich GK, Schroeder EB, Nichols GA, Segal J, Butler MG, Karter AJ, Steiner JF, Newton KM, Morales LS, Pathak RD, Thomas A, Reynolds K, Kirchner HL, Waitzfelder B, Elston Lafata J, Adibhatla R, Xu Z, O'Connor PJ. Preventable major cardiovascular events associated with uncontrolled glucose, blood pressure, and lipids and active smoking in adults with diabetes with and without cardiovascular disease: a contemporary analysis. Diabetes Care 2015; 38:905-12. [PMID: 25710922 PMCID: PMC4876667 DOI: 10.2337/dc14-1877] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 01/28/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to assess the incidence of major cardiovascular (CV) hospitalization events and all-cause deaths among adults with diabetes with or without CV disease (CVD) associated with inadequately controlled glycated hemoglobin (A1C), high LDL cholesterol (LDL-C), high blood pressure (BP), and current smoking. RESEARCH DESIGN AND METHODS Study subjects included 859,617 adults with diabetes enrolled for more than 6 months during 2005-2011 in a network of 11 U.S. integrated health care organizations. Inadequate risk factor control was classified as LDL-C ≥100 mg/dL, A1C ≥7% (53 mmol/mol), BP ≥140/90 mm Hg, or smoking. Major CV events were based on primary hospital discharge diagnoses for myocardial infarction (MI) and acute coronary syndrome (ACS), stroke, or heart failure (HF). Five-year incidence rates, rate ratios, and average attributable fractions were estimated using multivariable Poisson regression models. RESULTS Mean (SD) age at baseline was 59 (14) years; 48% of subjects were female, 45% were white, and 31% had CVD. Mean follow-up was 59 months. Event rates per 100 person-years for adults with diabetes and CVD versus those without CVD were 6.0 vs. 1.7 for MI/ACS, 5.3 vs. 1.5 for stroke, 8.4 vs. 1.2 for HF, 18.1 vs. 40 for all CV events, and 23.5 vs. 5.0 for all-cause mortality. The percentages of CV events and deaths associated with inadequate risk factor control were 11% and 3%, respectively, for those with CVD and 34% and 7%, respectively, for those without CVD. CONCLUSIONS Additional attention to traditional CV risk factors could yield further substantive reductions in CV events and mortality in adults with diabetes.
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Affiliation(s)
| | - Jay R Desai
- HealthPartners Institute for Education and Research, Minneapolis, MN
| | - Stanley Xu
- Kaiser Permanente Institute for Health Research, Denver, CO
| | | | | | | | | | - Melissa G Butler
- Kaiser Permanente Georgia, Center for Health Research Southeast, Atlanta, GA
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - John F Steiner
- Kaiser Permanente Institute for Health Research, Denver, CO
| | | | - Leo S Morales
- University of Washington School of Medicine, Seattle, WA
| | - Ram D Pathak
- Department of Endocrinology, Marshfield Clinic, Marshfield, WI
| | | | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | | | - Jennifer Elston Lafata
- Lutheran Medical Center, Brooklyn, NY Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Renuka Adibhatla
- HealthPartners Institute for Education and Research, Minneapolis, MN
| | - Zhiyuan Xu
- HealthPartners Institute for Education and Research, Minneapolis, MN
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Corella D, Ordovás JM. Aging and cardiovascular diseases: the role of gene-diet interactions. Ageing Res Rev 2014; 18:53-73. [PMID: 25159268 DOI: 10.1016/j.arr.2014.08.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 08/15/2014] [Accepted: 08/18/2014] [Indexed: 12/21/2022]
Abstract
In the study of longevity, increasing importance is being placed on the concept of healthy aging rather than considering the total number of years lived. Although the concept of healthy lifespan needs to be defined better, we know that cardiovascular diseases (CVDs) are the main age-related diseases. Thus, controlling risk factors will contribute to reducing their incidence, leading to healthy lifespan. CVDs are complex diseases influenced by numerous genetic and environmental factors. Numerous gene variants that are associated with a greater or lesser risk of the different types of CVD and of intermediate phenotypes (i.e., hypercholesterolemia, hypertension, diabetes) have been successfully identified. However, despite the close link between aging and CVD, studies analyzing the genes related to human longevity have not obtained consistent results and there has been little coincidence in the genes identified in both fields. The APOE gene stands out as an exception, given that it has been identified as being relevant in CVD and longevity. This review analyzes the genomic and epigenomic factors that may contribute to this, ranging from identifying longevity genes in model organisms to the importance of gene-diet interactions (outstanding among which is the case of the TCF7L2 gene).
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A naturopathic approach to the prevention of cardiovascular disease: cost-effectiveness analysis of a pragmatic multi-worksite randomized clinical trial. J Occup Environ Med 2014; 56:171-6. [PMID: 24451612 PMCID: PMC3921268 DOI: 10.1097/jom.0000000000000066] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of a worksite-based naturopathic (individualized lifestyle counseling and nutritional medicine) approach to primary prevention of cardiovascular disease (CVD). METHODS Economic evaluation alongside a pragmatic, multi-worksite, randomized controlled trial comparing enhanced usual care (EUC; usual care plus biometric screening) to the addition of a naturopathic approach to CVD prevention (NC+EUC). RESULTS After 1 year, NC+EUC resulted in a net decrease of 3.3 (confidence interval: 1.7 to 4.8) percentage points in 10-year CVD event risk (number needed to treat = 30). These risk reductions came with average net study-year savings of $1138 in societal costs and $1187 in employer costs. There was no change in quality-adjusted life years across the study year. CONCLUSIONS A naturopathic approach to CVD primary prevention significantly reduced CVD risk over usual care plus biometric screening and reduced costs to society and employers in this multi-worksite-based study. Trial Registration clinicaltrials.gov Identifier: NCT00718796.
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Laboratory Aspirin Resistance Reversibility in Diabetic Patients: a Pilot Study Using Different Pharmaceutical Formulations. Cardiovasc Drugs Ther 2014; 28:323-9. [DOI: 10.1007/s10557-014-6536-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wilson KJ, Brown HS, Bastida E. Cost-effectiveness of a community-based weight control intervention targeting a low-socioeconomic-status Mexican-origin population. Health Promot Pract 2014; 16:101-8. [PMID: 24893680 DOI: 10.1177/1524839914537274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The objective of our study was to evaluate the cost-effectiveness of a community-based intervention designed to improve physical activity levels and dietary intake and to reduce diabetes risk in a largely Hispanic population residing along the U.S.-Mexico border. METHOD We forecasted disease outcomes, quality-adjusted life-years (QALYs) gained, and lifetime costs associated with actual and projected attainment of 2% and 5% weight loss taking a societal cost perspective. We extrapolated changes in beverage calorie consumption between baseline and 6-month follow-up to attain projected weight loss measures. Outcomes were projected 5, 10, and 20 years into the future and discounted at a 3.0% rate. RESULTS The incremental cost-effectiveness ratio was $57,430 and $61,893, respectively, per QALY gained when compared with usual care for the 2% and 5% weight loss scenarios. The intervention was particularly cost-effective for morbidly obese participants. Cost-effectiveness improves when using 3-year weight loss projections based on changes in sugar-sweetened beverage caloric consumption to $49,478 and $24,092 for the 2% and 5% weight loss scenarios. CONCLUSIONS This analysis demonstrates that a culturally sensitive community-based weight loss and maintenance intervention can be cost-effective even when healthy weight individuals participate.
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Affiliation(s)
| | - H Shelton Brown
- University of Texas Health Science Center Houston, Austin, TX, USA
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Harmon BE, Adams SA, Scott D, Gladman YS, Ezell B, Hebert JR. Dash of faith: a faith-based participatory research pilot study. JOURNAL OF RELIGION AND HEALTH 2014; 53:747-59. [PMID: 23224838 PMCID: PMC3773027 DOI: 10.1007/s10943-012-9664-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The Dash of Faith pilot used a community-based participatory research approach to design an experiential dietary intervention based on two African-American churches, one intervention and one comparison. Congregation members identified components that were incorporated into 12 weekly and 4 monthly sessions, with a goal of increasing fruit and vegetable and lowering fat intake. At 2 months, a marginally significant (p = 0.07) increase in fruit and vegetable consumption was observed in the intervention group but was not maintained at study conclusion. We propose that these mixed findings may be attributable, in part, to bias introduced by the participatory nature of the design.
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Affiliation(s)
- Brook E Harmon
- South Carolina Statewide Cancer Prevention and Control Program, Department of Health Promotion, Education, and Behavior, University of South Carolina, 915 Greene Street, Ste 200, Columbia, SC, 20208, USA,
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Gao Y, Babazono A, Nishi T, Maeda T, Lkhagva D. Could investment in preventive health care services reduce health care costs among those insured with health insurance societies in Japan? Popul Health Manag 2013; 17:42-7. [PMID: 24134788 DOI: 10.1089/pop.2013.0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study examined the impact of expenditures for preventive health care services on health care costs among those insured with health insurance societies in Japan using cross-sectional and longitudinal designs. The subjects of the study were those insured with Japan's 1481 health insurance societies belonging to the National Federation of Health Insurance Societies in 2003 and 2007. Multiple regression analyses were conducted using the forced entry method. Case rates, number of service days, and health care costs were used as dependent variables, and preventive health care expenditures, average age, number of the insured, gender ratio, average monthly salary, and dependents ratio were used as independent variables. Expenditures for preventive health care services showed significant negative correlations with both the number of service days and health care costs for inpatient and outpatient services in 2003 and 2007. The results showed that expenditures for preventive health care services had a negative relationship with health care costs. Thus, these findings support the effects of investment in preventive health activities as promoted by health insurance societies to reduce health care costs.
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Affiliation(s)
- Yan Gao
- 1 Department of Health Services Management and Policy, Graduate School of Medical Sciences, Kyushu University , Fukuoka, Japan
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Abstract
CONTEXT The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs. METHODS We developed the Quality-Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources. FINDINGS The Quality-Cost Framework describes how health-related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance-specific (e.g., disease-specific) structural characteristics, and quality-improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health-status-related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain. CONCLUSIONS The Quality-Cost Framework describes the mechanisms by which health-related quality of care affects health care and health status-related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality.
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Affiliation(s)
- Teryl K Nuckols
- David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA.
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Jones DS, Greene JA. The contributions of prevention and treatment to the decline in cardiovascular mortality: lessons from a forty-year debate. Health Aff (Millwood) 2013; 31:2250-8. [PMID: 23048106 DOI: 10.1377/hlthaff.2011.0639] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mortality from coronary heart disease in the United States has fallen 60 percent from its peak in the mid-1960s. Cardiologists and epidemiologists have debated whether this decline reflects better control of risk factors, including lifestyle interventions to reduce smoking or intake of dietary fats, or the power of medical interventions, including defibrillators and therapeutics such as statins. Attempts to resolve this debate and guide health policy have generated sophisticated data sets and techniques for modeling cardiovascular mortality. Neither effort has provided specific guidance for health policy. Historical analysis of the debate over the causes of the decline, concomitant with development of cardiovascular modeling, offers valuable policy lessons about tensions among medical and public health strategies, the changing meanings of disease prevention, and the ability of evidence-based research and models to guide health policy. Policy makers must learn to open up the "black box" of epidemiological models-and of their own decision-making processes-to produce the best evidence-informed policy.
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Hayashi T, Araki A, Kawashima S, Sone H, Watanabe H, Ohrui T, Yokote K, Takemoto M, Kubota K, Noda M, Noto H, Ina K, Nomura H. Metabolic predictors of ischemic heart disease and cerebrovascular attack in elderly diabetic individuals: difference in risk by age. Cardiovasc Diabetol 2013; 12:10. [PMID: 23302697 PMCID: PMC3598716 DOI: 10.1186/1475-2840-12-10] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 01/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High LDL-cholesterol (LDL-C) and glucose levels are risk factors for ischemic heart disease (IHD) in middle-aged diabetic individuals; however, the risk among the elderly, especially the very elderly, is not well known. The aim of this study was to identify factors that predict IHD and cerebrovascular attack (CVA) in the elderly and to investigate their differences by age. METHODS We performed a prospective cohort study (Japan Cholesterol and Diabetes Mellitus Study) with 5.5 years of follow-up. A total of 4,014 patients with type 2 diabetes and without previous IHD or CVA (1,936 women; age 67.4 ± 9.5 years, median 70 years; <65 years old, n = 1,261; 65 to 74 years old, n = 1,731; and ≥ 75 years old, n = 1,016) were recruited on a consecutive outpatient basis from 40 hospitals throughout Japan. Lipids, glucose, and other factors related to IHD or CVA risk, such as blood pressure (BP), were investigated using the multivariate Cox hazard model. RESULTS One hundred fifty-three cases of IHD and 104 CVAs (7.8 and 5.7/1,000 people per year, respectively) occurred over 5.5 years. Lower HDL-cholesterol (HDL-C) and female gender were correlated with IHD in patients ≥75 years old (hazard ratio (HR):0.629, P < 0.01 and 1.132, P < 0.05, respectively). In contrast, systolic BP (SBP), HbA1C, LDL-C and non-HDL-C were correlated with IHD in subjects <65 years old (P < 0.05), and the LDL-C/HDL-C ratio was correlated with IHD in all subjects. HDL-C was correlated with CVA in patients ≥75 years old (HR: 0.536, P < 0.01). Kaplan-Meier estimator curves showed that IHD occurred more frequently in patients <65 years old in the highest quartile of the LDL-C/HDL-C ratio. In patients ≥75 years old, IHD and CVA were both the most frequent among those with the lowest HDL-C levels. CONCLUSIONS IHD and CVA in late elderly diabetic patients were predicted by HDL-C. LDL-C, HbA1C, SBP and non-HDL-C are risk factors for IHD in the non-elderly. The LDL-C/HDL-C ratio may represent the effects of both LDL-C and HDL-C. These age-dependent differences in risk are important for developing individualized strategies to prevent atherosclerotic disease. TRIAL REGISTRATION UMIN-CTR, UMIN00000516.
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Affiliation(s)
- Toshio Hayashi
- Department of Geriatrics, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, Japan
| | - Atsushi Araki
- Division of Diabetes, Metabolism and Endocrinology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | | | - Hirohito Sone
- Department of Internal Medicine, Endocrinology and Metabolism, Niigata Graduate School of Medicine, Niigata, Japan
| | - Hiroshi Watanabe
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takashi Ohrui
- Department of Geriatric Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Koutaro Yokote
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Chiba University Hospital, Chiba, Japan
| | - Minoru Takemoto
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Chiba University Hospital, Chiba, Japan
| | - Kiyoshi Kubota
- Department of Pharmacoepidemiology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Mitsuhiko Noda
- Department of Diabetes and Metabolic Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroshi Noto
- Department of Diabetes and Metabolic Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Koichiro Ina
- Department of Geriatrics, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, Japan
| | - Hideki Nomura
- Department of Geriatrics, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, Japan
- Department of Geriatrics, Nagoya Kita Hospital, Nagoya, Japan
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Schwartz J, Allison MA, Rifkin DE, Wright CM. Influence of patients' coronary artery calcium on subsequent medication use patterns. Am J Health Behav 2012; 36:628-38. [PMID: 22584090 DOI: 10.5993/ajhb.36.5.5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine whether information on the presence and extent of coronary artery calcium (CAC) is associated with the likelihood of physicians' prescribing preventive therapies. METHOD In a longitudinal design, asymptomatic participants (N=510) were evaluated by computed tomography for CAC. Changes to medications were at the discretion of the patient's primary care provider, who received the CT report. RESULTS In multivariable analysis, the likelihood of patients reporting that their primary care physician prescribed preventive therapies was significantly associated with the presence and extent of CAC. CONCLUSIONS This study suggests that physicians' prescribing practices are influenced by patients' CAC scores obtained via CT.
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Affiliation(s)
- Jennifer Schwartz
- San Diego State University/University of California, San Diego, Joint Doctoral Program in Public Health, San Diego, CA, USA.
| | - Matthew A. Allison
- Division of Preventive Medicine, University of California, San Diego School of Medicine, La Jolla, CA, USA
| | - Dena E. Rifkin
- Division of Nephrology, Department of Family and Preventive Medicine, University of California, San Diego School of Medicine and the Veterans' Affairs Medical Center, San Diego, CA, USA
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Impact of delaying blood pressure control in patients with Type 2 diabetes: results of a decision analysis. J Gen Intern Med 2012; 27:640-6. [PMID: 22215265 PMCID: PMC3358401 DOI: 10.1007/s11606-011-1951-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 10/25/2011] [Accepted: 11/22/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND In patients with diabetes, delays in controlling blood pressure are common, but the harms of delays have not been quantified. OBJECTIVE To estimate the harms of delays in controlling systolic blood pressure in middle-aged adults with newly diagnosed Type 2 diabetes. DESIGN Decision analysis using diabetes complication equations from the United Kingdom Prospective Diabetes Study (UKPDS). PARTICIPANTS Hypothetical population of adults aged 50 to 59 years old with newly diagnosed Type 2 diabetes based on characteristics from the National Health and Nutrition Examination Surveys. INTERVENTION Delays in lowering systolic blood pressure from 150 (uncontrolled) to 130 mmHg (controlled). MAIN MEASURES Lifetime complication rates (amputation, congestive heart failure, end-stage renal disease, ischemic heart disease, myocardial infarction, and stroke), average life expectancy and quality-adjusted life expectancy (QALE). KEY RESULTS Compared to a lifetime of controlled blood pressure, a lifetime of uncontrolled blood pressure increased complications by 1855 events per 10,000 patients and decreased QALE by 332 days. A 1-year delay increased complications by 14 events per 10,000 patients and decreased QALE by 2 days. A 10-year delay increased complications by 428 events per 10,000 patients and decreased QALE by 145 days. Among complications, rates of stroke and myocardial infarction increased to the greatest extent due to delays. With a 20-year delay in achieving controlled blood pressure, a baseline blood pressure of 160 mmHg decreased QALE by 477 days, whereas a baseline of 140 mmHg decreased QALE by 142 days. CONCLUSIONS Among middle-aged adults with diabetes, the harms of a 1-year delay in controlling blood pressure may be small; however, delays of ten years or more are expected to lower QALE to the same extent as smoking in patients with cardiovascular disease.
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Epidemiology of the metabolic syndrome in Hungary. Public Health 2012; 126:143-9. [DOI: 10.1016/j.puhe.2011.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 08/03/2011] [Accepted: 11/08/2011] [Indexed: 01/25/2023]
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Gray B, Schuetz CA, Weng W, Peskin B, Rosner B, Lipner RS. Physicians’ Actions And Influence, Such As Aggressive Blood Pressure Control, Greatly Improve The Health Of Diabetes Patients. Health Aff (Millwood) 2012; 31:140-9. [DOI: 10.1377/hlthaff.2011.0895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Bradley Gray
- Bradley Gray ( ) is a health services researcher at the American Board of Internal Medicine, in Philadelphia, Pennsylvania
| | - C. Andy Schuetz
- C. Andy Schuetz is a scientist at Archimedes, a firm specializing in health care modeling, in San Francisco, California
| | - Weifeng Weng
- Weifeng Weng is a health services researcher at the American Board of Internal Medicine
| | - Barbara Peskin
- Barbara Peskin was director of science at Archimedes from 2005 to 2011
| | - Benjamin Rosner
- Benjamin Rosner is a consulting medical director at Archimedes
| | - Rebecca S. Lipner
- Rebecca S. Lipner is vice president of psychometrics and research analysis at the American Board of Internal Medicine
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Kastorini CM, Milionis HJ, Ioannidi A, Kalantzi K, Nikolaou V, Vemmos KN, Goudevenos JA, Panagiotakos DB. Adherence to the Mediterranean diet in relation to acute coronary syndrome or stroke nonfatal events: a comparative analysis of a case/case-control study. Am Heart J 2011; 162:717-24. [PMID: 21982665 DOI: 10.1016/j.ahj.2011.07.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 07/19/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although the role of Mediterranean diet on cardiovascular disease prevention has long been evaluated and understood, its association with the development of stroke has been rarely examined. The aim of the present work was to comparatively evaluate the association between adherence to the Mediterranean diet and the development of an acute coronary syndrome (ACS) or ischemic stroke. METHODS During the period from 2009 to 2010, 1,000 participants were enrolled; 250 were consecutive patients with a first ACS, 250 were consecutive patients with a first ischemic stroke, and 500 population-based, control subjects, 1-for-1 matched to the patients by age and sex. Sociodemographic, clinical, psychological, dietary, and other lifestyle characteristics were measured. Adherence to the Mediterranean diet was assessed by the validated MedDietScore (theoretical range 0-55). RESULTS After various adjustments were made, it was observed that for each 1-of-55-unit increase of the MedDietScore, the corresponding odds ratio for having an ACS was 0.91 (95% CI 0.87-0.96), whereas regarding stroke, it was 0.88 (95% CI 0.82-0.94). CONCLUSIONS The present work extended the current knowledge about the cardioprotective benefits from the adoption of the Mediterranean diet by showing an additional protective effect on ischemic stroke development.
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Paxton RJ, Jones LA, Chang S, Hernandez M, Hajek RA, Flatt SW, Natarajan L, Pierce JP. Was race a factor in the outcomes of the Women's Health Eating and Living Study? Cancer 2011; 117:3805-13. [PMID: 21319157 PMCID: PMC3135701 DOI: 10.1002/cncr.25957] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 12/09/2010] [Accepted: 01/03/2011] [Indexed: 01/06/2023]
Abstract
BACKGROUND The objective of this study was to determine whether women who were participating in the Women's Healthy Eating and Living (WHEL) Study exhibited similar dietary changes, second breast cancer events, and overall survival regardless of race/ethnicity. METHODS For this secondary analysis, the authors used data from 3013 women who were self-identified as Asian American, African American, Hispanic, or white and who were assigned randomly to a dietary intervention or a comparison group. Changes in dietary intake over time by race/ethnicity and intervention status were examined using linear mixed-effects models. Cox proportional hazards models were used to examine the effects of the intervention on the occurrence of second breast cancer events and overall survival. Statistical tests were 2-sided. RESULTS African Americans and Hispanics consumed significantly more calories from fat (+3.2%) and less fruit (-0.7 servings daily) than Asians and whites at baseline (all P < .01). Overall, intervention participants significantly improved their dietary pattern from baseline to the end of Year 1, reducing calories from fat by 4.9% and increasing intake of fiber (+6.6 grams daily), fruit (+1.1 servings daily), and vegetables (+1.6 servings daily; all P < .05). Despite improvements in the overall dietary pattern of these survivors, the intervention did not significantly influence second breast cancer events or overall survival. CONCLUSIONS Overall, all racial groups significantly improved their dietary pattern over time, but the maintenance of these behaviors were lower among African-American women. More research and larger minority samples are needed to determine the specific factors that improve breast cancer-specific outcomes in diverse populations of survivors.
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Affiliation(s)
- Raheem J Paxton
- Department of Health Disparities Research, Center for Research on Minority Health, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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Nuckols TK, McGlynn EA, Adams J, Lai J, Go MH, Keesey J, Aledort JE. Cost implications to health care payers of improving glucose management among adults with type 2 diabetes. Health Serv Res 2011; 46:1158-79. [PMID: 21457256 PMCID: PMC3165182 DOI: 10.1111/j.1475-6773.2011.01257.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective. To assess the cost implications to payers of improving glucose management among adults with type 2 diabetes. Data Source/Study Setting. Medical-record data from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare Fee Schedule (2009), published literature. Study Design. Probability tree depicting glucose management over 1 year. Data Collection/Extraction Methods. We determined how frequently CQI study subjects received recommended care processes and attained Health Care Effectiveness Data and Information Set (HEDIS) treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided. Principal Findings. Relative to current care, improved glucose management would cost U.S.$327 (U.S.$192-711 in sensitivity analyses) more per person with diabetes annually, largely due to antihyperglycemic medications. Cost-effectiveness to payers, defined as incremental annual cost per patient newly attaining any one of three HEDIS goals, would be U.S.$1,128; including glycemic crises reduces this to U.S.$555-1,021. Conclusions. The cost of improving glucose management appears modest relative to diabetes-related health care expenditures. The incremental cost per patient newly attaining HEDIS goals enables payers to consider costs as well as outcomes that are linked to future profitability.
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Affiliation(s)
- Teryl K Nuckols
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California-Los Angeles, 911 Broxton Avenue, Los Angeles, CA 90024, USA.
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Nuckols TK, Aledort JE, Adams J, Lai J, Go MH, Keesey J, McGlynn E. Cost implications of improving blood pressure management among U.S. adults. Health Serv Res 2011; 46:1124-57. [PMID: 21306365 PMCID: PMC3165181 DOI: 10.1111/j.1475-6773.2010.01239.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the cost-effectiveness of improving blood pressure management from the payer perspective. DATA SOURCE/STUDY SETTING Medical record data for 4,500 U.S. adults with hypertension from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare fee schedule (2009), and published literature. STUDY DESIGN A probability tree depicted blood pressure management over 2 years. DATA COLLECTION/EXTRACTION METHODS We determined how frequently CQI study subjects received recommended care processes and attained accepted treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided. PRINCIPAL FINDINGS Relative to current care, improved care would cost payers U.S.$170 more per hypertensive person annually (2009 dollars). The incremental cost per person newly attaining treatment goals over 2 years would be U.S.$1,696 overall, U.S.$801 for moderate hypertension, and U.S.$850 for severe hypertension. Among people with severe hypertension, blood pressure would decline substantially but seldom reach goal; the incremental cost per person attaining a relaxed goal (≤ stage 1) would be U.S.$185. CONCLUSIONS Under the Health Care Effectiveness Data and Information Set program, which monitors the attainment of blood pressure treatment goals, payers will find it slightly more cost-effective to improve care for moderate than severe hypertension. Having a secondary, relaxed goal would substantially increase payers' incentive to improve care for severe hypertension.
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Affiliation(s)
- Teryl K Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA.
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Homocysteine and asymmetric dimethylarginine in relation to B vitamins in elderly people. Wien Klin Wochenschr 2011; 123:496-501. [PMID: 21833599 DOI: 10.1007/s00508-011-0002-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Accepted: 05/13/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Homocysteine is a cardiovascular risk factor, its metabolism is influenced by certain B vitamins and it is associated with endothelial dysfunction probably due to impaired bioavailability of NO caused by homocysteine-induced accumulation of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of NO synthase. On this basis, we investigated the cardiovascular risk factors homocysteine and ADMA in relation to vitamins B(6), B(12) and folate in elderly people. METHODS A total of 102 subjects were recruited and divided into three groups according to age: A (70-74y, n = 48), B (75-79y, n = 35) and C (≥80y, n = 19). Plasma levels of vitamin B(6) were determined with HPLC, vitamin B(12) and folate by RIA. Plasma concentrations of homocysteine were analyzed with HPLC and levels of ADMA were measured by ELISA. RESULTS Plasma levels of vitamins B(6), B(12) and folate were found to be adequate in 93, 67 and 55% of participants, respectively. This study showed a significant age-associated decrease in vitamins B(6) (A > B, A > C: p < 0.05), B(12) and folate (A > C: p < 0.05) in parallel to a significant age-related increase in the cardiovascular risk factors homocysteine (A < C, B < C: p < 0.05) and ADMA (A < B: p < 0.05; A < C: p < 0.001). Moreover, homocysteine was significantly negatively (p < 0.01) related to vitamins B(6), B(12) and folate, and significantly positively (p < 0.01) correlated to ADMA. CONCLUSIONS The significant correlation between homocysteine and ADMA observed in this study may be an important mechanism decreasing NO bioavailability and so causing endothelial dysfunction. Due to the significant relation of vitamins B(6), B(12) and folate to plasma homocysteine, these vitamins may thus indirectly influence endothelial function and cardiovascular risk in elderly people.
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Hasnain M, Vieweg WVR, Lesnefsky EJ, Pandurangi AK. Depression screening in patients with coronary heart disease: a critical evaluation of the AHA guidelines. J Psychosom Res 2011; 71:6-12. [PMID: 21665006 DOI: 10.1016/j.jpsychores.2010.10.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Revised: 10/21/2010] [Accepted: 10/21/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We lack evidence that routine screening for depression in patients with coronary heart disease (CHD) improves patient outcome. This lack has challenged the advisory issued by the American Heart Association (AHA) to routinely screen for depression in CHD patients. We assess the AHA advisory in the context of well-established criteria of screening for diseases. METHODS Using principles and criteria for screening developed by the World Health Organization and the United Kingdom National Screening Committee, we generated criteria pertinent to screening for depression in CHD patients. To find publications relevant to these criteria and clinical setting, we performed a broadly based literature search on "depression and CHD," supplemented by more focused literature searches. RESULTS Evidence for an association between depression and CHD is strong. Despite this, the AHA advisory has several limitations. It did not account for the complexity of the association between depression and CHD. It acknowledged there was no evidence that screening for depression leads to improved outcomes in cardiovascular populations but still recommended routine screening without providing an alternative evidence-based explanation. It ignored the paucity of literature about the safety and cost-effectiveness of routine screening for depression in CHD and failed to define the nature and extent of resources needed to implement such a program effectively. CONCLUSION We conclude that the AHA advisory is premature. We must first demonstrate the efficacy, safety, and cost-effectiveness of screening and define the resources necessary for its implementation and monitoring. Meanwhile, organizations representing cardiologists, psychiatrists, and general practitioners must coordinate efforts to manage depression and CHD through collaborative care, and work with the policy makers to develop the necessary infrastructure and services delivery system needed to optimize the outcome of depressed and at-risk-for-depression patients suffering from CHD.
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Affiliation(s)
- Mehrul Hasnain
- Department of Psychiatry, Memorial University of Newfoundland, St. John's, Newfoundland, Canada.
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Pietzsch JB, Garner A, Cipriano LE, Linehan JH. An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea. Sleep 2011; 34:695-709. [PMID: 21629357 DOI: 10.5665/sleep.1030] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is a common disorder associated with substantially increased cardiovascular risks, reduced quality of life, and increased risk of motor vehicle collisions due to daytime sleepiness. This study evaluates the cost-effectiveness of three commonly used diagnostic strategies (full-night polysomnography, split-night polysomnography, unattended portable home-monitoring) in conjunction with continuous positive airway pressure (CPAP) therapy in patients with moderate-to-severe OSA. DESIGN A Markov model was created to compare costs and effectiveness of different diagnostic and therapeutic strategies over a 10-year interval and the expected lifetime of the patient. The primary measure of cost-effectiveness was incremental cost per quality-adjusted life year (QALY) gained. PATIENTS OR PARTICIPANTS Baseline computations were performed for a hypothetical average cohort of 50-year-old males with a 50% pretest probability of having moderate-to-severe OSA (apnea-hypopnea index [AHI] ≥ 15 events per hour). MEASUREMENTS AND RESULTS For a patient with moderate-to-severe OSA, CPAP therapy has an incremental cost-effectiveness ratio (ICER) of $15,915 per QALY gained for the lifetime horizon. Over the lifetime horizon in a population with 50% prevalence of OSA, full-night polysomnography in conjunction with CPAP therapy is the most economically efficient strategy at any willingness-to-pay greater than $17,131 per-QALY gained because it dominates all other strategies in comparative analysis. CONCLUSIONS Full-night polysomnography (PSG) is cost-effective and is the preferred diagnostic strategy for adults suspected to have moderate-to-severe OSA when all diagnostic options are available. Split-night PSG and unattended home monitoring can be considered cost-effective alternatives when full-night PSG is not available.
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Courtney MR, Conard SE, Dunn P, Scarborough K. The Game of Health©: An innovative lifestyle change program implemented in a family practice. ACTA ACUST UNITED AC 2011; 23:289-97. [DOI: 10.1111/j.1745-7599.2011.00604.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Butalia S, Leung AA, Ghali WA, Rabi DM. Aspirin effect on the incidence of major adverse cardiovascular events in patients with diabetes mellitus: a systematic review and meta-analysis. Cardiovasc Diabetol 2011; 10:25. [PMID: 21453547 PMCID: PMC3098148 DOI: 10.1186/1475-2840-10-25] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 04/01/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Aspirin has been recommended for the prevention of major adverse cardiovascular events (MACE, composite of non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death) in diabetic patients without previous cardiovascular disease. However, recent meta-analyses have prompted re-evaluation of this practice. The study objective was to evaluate the relative and absolute benefits and harms of aspirin for the prevention of incident MACE in patients with diabetes. METHODS We performed a systematic review and meta-analysis on seven studies (N=11,618) reporting on the use of aspirin for the primary prevention of MACE in patients with diabetes. Two reviewers conducted a systematic search of electronic databases (MEDLINE, EMBASE, the Cochrane Library, and BIOSIS) and hand searched bibliographies and clinical trial registries. Reviewers extracted data in duplicate, evaluated the quality of the trials, and calculated pooled estimates. RESULTS A total of 11,618 participants were included in the analysis. The overall risk ratio (RR) for MACE was 0.91 (95% confidence intervals, CI, 0.82-1.00) with little heterogeneity among trials (I2 0.0%). Secondary outcomes of interest included myocardial infarction (RR, 0.85; 95% CI, 0.66-1.10), stroke (RR, 0.84; 95% CI, 0.64-1.11), cardiovascular death (RR, 0.95; 95% CI, 0.71-1.27), and all-cause mortality (RR, 0.95; 95% CI, 0.85-1.06). There were higher rates of hemorrhagic and gastrointestinal events. In absolute terms, these relative risks indicate that for every 10,000 diabetic patients treated with aspirin, 109 MACE may be prevented at the expense of 19 major bleeding events (with the caveat that the relative risk for the latter is not statistically significant). CONCLUSIONS The studies reviewed suggest that aspirin reduces the risk of MACE in patients with diabetes without cardiovascular disease, while also causing a trend toward higher rates of bleeding and gastrointestinal complications. These findings and our absolute benefit and risk calculations suggest that those with diabetes but without cardiovascular disease lie somewhere between primary and secondary prevention patients on the spectrum of benefit and risk. This underscores the importance of considering individual risk in clinical decision making regarding aspirin in those with diabetes.
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Affiliation(s)
- Sonia Butalia
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Polycystic ovary syndrome and early-onset preeclampsia: reproductive manifestations of increased cardiovascular risk. Menopause 2011; 17:990-6. [PMID: 20551845 DOI: 10.1097/gme.0b013e3181ddf705] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Primary prevention of cardiovascular disease (CVD) in women is a major healthcare issue. Detection of premenopausal women with increased risk of CVD could enhance prevention strategies and reduce first event-related morbidity and mortality. In this study, we argue that an unfavorable metabolic constitution in women may present itself early in life as a reproductive complication, such as polycystic ovary syndrome (PCOS) and preeclampsia. We evaluated the cardiovascular risk of women with a history of early-onset preeclampsia and women with PCOS and assessed their need for implementation of early risk factor-reduction strategies. METHODS We performed a standardized evaluation of 240 women with a history of early-onset preeclampsia and 456 women diagnosed with PCOS for established major CVD risk factors. Metabolic syndrome characteristics were analyzed per body mass index category. RESULTS Mean age was 30.6 and 29.0 years for women with preeclampsia and PCOS, respectively. High percentages of metabolic syndrome were found in both groups (preeclampsia group, 14.6%; and PCOS group, 18.4%), with an incidence of greater than 50% in both groups of women if body mass index was greater than 30 kg/m. Overall, more than 90% of the women qualified for either lifestyle or medical intervention according to the American Heart Association guideline for CVD prevention in women. CONCLUSIONS Women with PCOS and early-onset preeclampsia already show an unfavorable cardiovascular risk profile with high need for lifestyle or medical intervention at a young age. We therefore recommend an active role of the gynecologist in routine screening and follow-up of women with reproductive conditions linked to future cardiovascular risk.
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Incretin therapy for type 2 diabetes mellitus. Adv Ther 2010; 27:881-94. [PMID: 20978879 DOI: 10.1007/s12325-010-0077-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Indexed: 10/18/2022]
Abstract
In addition to progressive pancreatic β-cell failure resulting in impaired insulin secretion, and increased insulin resistance in muscle and liver, incretin hormone-related abnormalities have been identified as key underlying defects in patients with type 2 diabetes mellitus. Treatment goals for patients with type 2 diabetes should be aligned with the basic defects of the disease. Many of the available antidiabetes agents correct hyperglycemia but do not impact other cardiovascular risk factors, and may actually aggravate some. This paper reviews the role of defects in the incretin system in the pathophysiology of type 2 diabetes, and discusses recent advances in the use of incretinbased agents that target the fundamental disease mechanisms of type 2 diabetes. The incretinbased agents reduce hyperglycemia and provide beneficial effects on surrogate markers of cardiovascular risk, including weight gain, elevated blood pressure, and dyslipidemia.
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Yudkin JS, Richter B, Gale EAM. Intensified glucose lowering in type 2 diabetes: time for a reappraisal. Diabetologia 2010; 53:2079-85. [PMID: 20686748 DOI: 10.1007/s00125-010-1864-z] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 07/16/2010] [Indexed: 10/19/2022]
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Kurukulasuriya LR, Sowers JR. Therapies for type 2 diabetes: lowering HbA1c and associated cardiovascular risk factors. Cardiovasc Diabetol 2010; 9:45. [PMID: 20804556 PMCID: PMC2940872 DOI: 10.1186/1475-2840-9-45] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 08/30/2010] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To summarize data supporting the effects of antidiabetes agents on glucose control and cardiovascular risk factors in patients with type 2 diabetes. METHODS Studies reporting on the effects of antidiabetes agents on glycemic control, body weight, lipid levels, and blood pressure parameters are reviewed and summarized for the purpose of selecting optimal therapeutic regimens for patients with type 2 diabetes. RESULTS National guidelines recommend the aggressive management of cardiovascular risk factors in patients with type 2 diabetes, including weight loss and achieving lipid and blood pressure treatment goals. All antidiabetes pharmacotherapies lower glucose; however, effects on cardiovascular risk factors vary greatly among agents. While thiazolidinediones, sulfonylureas, and insulin are associated with weight gain, dipeptidyl peptidase-4 inhibitors are considered weight neutral and metformin can be weight neutral or associated with a small weight loss. Glucagon-like peptide-1 receptor agonists and amylinomimetics (e.g. pramlintide) result in weight loss. Additionally, metformin, thiazolidinediones, insulin, and glucagon-like peptide-1 receptor agonists have demonstrated beneficial effects on lipid and blood pressure parameters. CONCLUSION Management of the cardiovascular risk factors experienced by patients with type 2 diabetes requires a multidisciplinary approach with implementation of treatment strategies to achieve not only glycemic goals but to improve and/or correct the underlying cardiovascular risk factors.
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Affiliation(s)
- L Romayne Kurukulasuriya
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, D109 Diabetes Center, UMC, One Hospital Drive, Columbia, MO 65212, USA
| | - James R Sowers
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, D109 Diabetes Center, UMC, One Hospital Drive, Columbia, MO 65212, USA
- Harry S. Truman Memorial Veterans' Hospital, 800 Hospital Drive, Columbia, MO 65201, USA
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Kavanagh A, Bentley RJ, Turrell G, Shaw J, Dunstan D, Subramanian SV. Socioeconomic position, gender, health behaviours and biomarkers of cardiovascular disease and diabetes. Soc Sci Med 2010; 71:1150-60. [PMID: 20667641 DOI: 10.1016/j.socscimed.2010.05.038] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 03/26/2010] [Accepted: 05/29/2010] [Indexed: 01/09/2023]
Abstract
Socio-economic gradients in cardiovascular disease (CVD) and diabetes have been found throughout the developed world and there is some evidence to suggest that these gradients may be steeper for women. Research on social gradients in biological risk factors for CVD and diabetes has received less attention and we do not know the extent to which gradients in biomarkers vary for men and women. We examined the associations between two indicators of socio-economic position (education and household income) and biomarkers of diabetes and cardiovascular disease (CVD) for men and women in a national, population-based study of 11,247 Australian adults. Multi-level linear regression was used to assess associations between education and income and glucose tolerance, dyslipidaemia, blood pressure (BP) and waist circumference before and after adjustment for behaviours (diet, smoking, physical activity, TV viewing time, and alcohol use). Measures of glucose tolerance included fasting plasma glucose and insulin and the results of a glucose tolerance test (2 h glucose) with higher levels of each indicating poorer glucose tolerance. Triglycerides and High Density Lipoprotein (HDL) Cholesterol were used as measures of dyslipidaemia with higher levels of the former and lower levels of the later being associated with CVD risk. Lower education and low income were associated with higher levels of fasting insulin, triglycerides and waist circumference in women. Women with low education had higher systolic and diastolic BP and low income women had higher 2 h glucose and lower HDL cholesterol. With only one exception (low income and systolic BP), all of these estimates were reduced by more than 20% when behavioural risk factors were included. Men with lower education had higher fasting plasma glucose, 2 h glucose, waist circumference and systolic BP and, with the exception of waist circumference, all of these estimates were reduced when health behaviours were included in the models. While low income was associated with higher levels of 2-h glucose and triglycerides it was also associated with better biomarker profiles including lower insulin, waist circumference and diastolic BP. We conclude that low socio-economic position is more consistently associated with a worse profile of biomarkers for CVD and diabetes for women.
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Affiliation(s)
- Anne Kavanagh
- Centre for Women's Health, Gender & Society, Melbourne School of Population Health, The University of Melbourne, Australia.
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