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Ali MR, Nacer H, Lawson CA, Khunti K. Racial and Ethnic Disparities in Primary Prevention of Cardiovascular Disease. Can J Cardiol 2024:S0828-282X(24)00076-X. [PMID: 38309463 DOI: 10.1016/j.cjca.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 02/05/2024] Open
Abstract
Cardiovascular disease (CVD) disproportionately affects ethnic-minority groups globally. Ethnic-minority groups face particularly high CVD burden and mortality, exacerbated by disparities across modifiable risk factors, wider determinants of health, and limited access to preventative interventions. This narrative review summarizes evidence on modifiable risk factors, such as physical activity, hypertension, diet, smoking, alcohol consumption, diabetes, and the polypill for the primary prevention of CVD in ethnic minorities. Across these factors, we find inequities in risk factor prevalence. The evidence underscores that inequalities in accessibility to interventions and treatments impede progress in reducing CVD risk using primary prevention interventions for ethnic-minority people. Although culturally tailored interventions show promise, further research is required across the different risk factors. Social determinants of health and structural inequities also exacerbate CVD risk for ethnic-minority people and warrant greater attention. Additionally, we find that only limited ethnicity-specific data and guidelines are available on CVD primary prevention interventions for most risk factors. To address these gaps in research, we provide recommendations that include the following: investigating the sustainability and real-world effectiveness of culturally sensitive interventions; ensuring that ethnic-minority peoples' perspectives are considered in research; longitudinal tracking of risk factors; interventions and outcomes in ethnic-minority people; and ensuring that data collection and reporting of ethnicity data are standardized.
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Affiliation(s)
- Mohammad R Ali
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom; Diabetes Research Centre, University of Leicester, Leicester, United Kingdom.
| | | | - Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands, University of Leicester, Leicester, UK
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Seidu S, Lawson CA, Kunutsor SK, Khunti K, Rosano GMC. Blood pressure levels and adverse cardiovascular outcomes in heart failure: A systematic review and meta-analysis. Eur J Heart Fail 2024. [PMID: 38214669 DOI: 10.1002/ejhf.3108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/28/2023] [Accepted: 12/19/2023] [Indexed: 01/13/2024] Open
Abstract
AIM Existing data on the association between blood pressure levels and adverse cardiovascular outcomes in patients with heart failure (HF) are inconsistent. The optimal blood pressure targets for patients with HF remain uncertain. This study sought to assess the associations between blood pressure (systolic [SBP] and diastolic blood pressure [DBP]) levels and adverse cardiovascular disease (CVD) outcomes in patients with HF. METHODS AND RESULTS A systematic review and meta-analysis were conducted using MEDLINE, Embase, the Cochrane Library, and Web of Science databases up to 5 May 2023. The outcomes of interest included adverse cardiovascular events and all-cause mortality. Pooled relative risks (RRs) with corresponding 95% confidence intervals (CIs) were calculated. Forty-three unique observational cohort studies, comprising 120 643 participants with HF, were included. The pooled RRs (95% CIs) for SBP thresholds of ≥140 mmHg versus <140 mmHg were 0.92 (0.83-1.01) for all-cause mortality, 0.83 (0.67-1.04) for CVD death, and 0.98 (0.80-1.21) for HF hospitalization. The pooled RR (95% CI) for SBP thresholds of ≥160 mmHg versus <160 mmHg and all-cause mortality was 0.67 (0.62-0.74). SBP levels below <130, <120, and <110 mmHg were each associated with an increased risk of various cardiovascular endpoints and all-cause mortality. The pooled RR (95% CI) for DBP thresholds of ≥80 mmHg versus <80 mmHg and all-cause mortality was 0.86 (0.67-1.10). A 10 mmHg increase in SBP or DBP was associated with a reduction in all-cause mortality and other cardiovascular endpoints. CONCLUSIONS The findings suggest that lower and normal baseline SBP levels (<130, <120, and <110 mmHg) may be associated with future risk of worse outcomes in patients with HF. Optimal baseline blood pressure levels for these patients may lie within the range of ≥140 mmHg for SBP. In the absence of observational studies with repeated blood pressure measurements or definitive trials evaluating optimal blood pressure targets, individualized blood pressure targets based on patients' unique circumstances are warranted in HF management.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Setor K Kunutsor
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
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Lawson CA, Benson L, Squire I, Zaccardi F, Ali M, Hand S, Kadam U, Tay WT, Dahlstrom U, Lund LH, Savarese G, Lam CS, Khunti K, Strömberg A. Changing health related quality of life and outcomes in heart failure by age, sex and subtype. EClinicalMedicine 2023; 64:102217. [PMID: 37745020 PMCID: PMC10514432 DOI: 10.1016/j.eclinm.2023.102217] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/26/2023] Open
Abstract
Background There are calls to integrate serial recordings of health related quality of life (HRQoL) into routine care, clinical trials and prognosis. Little is known about the relationship between change in HRQoL and outcomes in heart failure (HF) patients by age, sex and HF subtype. Method From the Swedish Heart Failure Registry (SwedeHF; 2008-2019), patients were categorised by reduced (<40%, HFrEF), mildly-reduced (40-49%, HFmrEF) and preserved (≥50%, HFpEF) ejection fraction. HRQoL was measured using Euro-QoL-5D visual analogue scale (EQ5D-vas), collected at baseline and 1-year. Baseline EQ5D-vas scores were categorised by: "best" (76-100), "good" (51-75), "bad" (26-50), and "worst" (0-25). Change in EQ5D-vas was categorised as 'no significant change' (<5 points increase/decrease); some worsening (5-9 points decrease); considerable worsening (≥10 points decrease); some improvement (5-9 points increase); considerable improvement (≥10 points increase). Associations with admission and death were estimated and interactions with patient sub-groups tested. Findings Among 23,553 patients (median age 74 [66-81] years, 8000 [34%] female), baseline EQ5D-vas was worse in older patients, women, and those with HFpEF compared to their respective counterparts. Compared to patients with the "best" EQ5D-vas, the adjusted associations for admission for those with "good", "bad" and "worst" EQ5D-vas were, respectively: HR 1.09 (1.04, 1.14), 1.27 (1.21, 1.33) and 1.39 (1.28, 1.51). Compared to no significant change in EQ5D-vas, the adjusted estimates for admission following some improvement, considerable improvement, some worsening and considerable worsening were, respectively: HR 0.91 (0.82, 1.01), 0.75 (0.70, 0.81), 1.04 (0.92, 1.16) and 1.25 (1.16, 1.35). Results were similar amongst groups and for HF admission and death. Interpretation Change in HRQoL was an independent indicator of risk of admission and death in people with all HF subtypes, irrespective of age and sex. Funding NIHR.
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Affiliation(s)
- Claire A. Lawson
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre –Cardiology, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicestershire, United Kingdom
| | | | - Iain Squire
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre –Cardiology, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicestershire, United Kingdom
- Karolinska Institutet, Stockholm, Sweden
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, University of Leicester, Leicestershire, United Kingdom
- Diabetes Centre, University of Leicester, Leicestershire, United Kingdom
- National Institute for Health Research (NIHR) Applied Research Collaboration - East Midlands (ARC-EM), University of Leicester, Leicestershire, United Kingdom
| | - Mohammad Ali
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre –Cardiology, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicestershire, United Kingdom
| | - Simon Hand
- Health Sciences, University of Leicester, Leicestershire, United Kingdom
| | - Umesh Kadam
- Health Sciences, University of Leicester, Leicestershire, United Kingdom
| | | | - Ulf Dahlstrom
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Lars H. Lund
- Karolinska Institutet, Stockholm, Sweden
- Duke-National University of Singapore, Singapore
| | | | | | - Kamlesh Khunti
- Leicester Real World Evidence Unit, University of Leicester, Leicestershire, United Kingdom
- Diabetes Centre, University of Leicester, Leicestershire, United Kingdom
- National Institute for Health Research (NIHR) Applied Research Collaboration - East Midlands (ARC-EM), University of Leicester, Leicestershire, United Kingdom
| | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences, and Department of Cardiology, Linkoping University, Sweden
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Ali MR, Lawson CA, Wood AM, Khunti K. Addressing ethnic and global health inequalities in the era of artificial intelligence healthcare models: a call for responsible implementation. J R Soc Med 2023; 116:260-262. [PMID: 37467785 PMCID: PMC10469966 DOI: 10.1177/01410768231187734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Affiliation(s)
- Mohammad R Ali
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 7RH, UK
| | - Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 7RH, UK
| | - Angela M Wood
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, CB2 0SR, UK
| | - Kamlesh Khunti
- Ethnic Health Research, Diabetes Research Centre, University of Leicester, Leicester, LE5 4PW, UK
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Lawson CA, Tay WT, Bernhardt L, Richards AM, Zaccardi F, Tromp J, Katherine Teng TH, Hung CL, Chandramouli C, Wander GS, Ouwerkerk W, Seidu S, Khunti K, Lam CS. Association Between Diabetes, Chronic Kidney Disease, and Outcomes in People With Heart Failure From Asia. JACC Asia 2023; 3:611-621. [PMID: 37614542 PMCID: PMC10442874 DOI: 10.1016/j.jacasi.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 08/25/2023]
Abstract
Background Diabetes mellitus (DM), chronic kidney disease (CKD), and heart failure (HF) are pathophysiologically linked and increasing in prevalence in Asian populations, but little is known about the interplay of DM and CKD on outcomes in HF. Objectives This study sought to investigate outcomes in patients with heart failure with preserved ejection fraction (HFpEF) vs heart failure with reduced ejection fraction (HFrEF) in relation to the presence of DM and CKD. Methods Using the multinational ASIAN-HF registry, we investigated associations between DM only, CKD only, and DM+CKD with: 1) composite of 1-year mortality or HF hospitalization; and 2) Kansas City Cardiomyopathy Questionnaire scores, according to HF subtype. Results In 5,239 patients with HF (74.6% HFrEF, 25.4% HFpEF; mean age 63 years; 29.1% female), 1,107 (21.1%) had DM only, 1,087 (20.7%) had CKD only, and 1,400 (26.7%) had DM+CKD. Compared with patients without DM nor CKD, DM+CKD was associated with 1-year all-cause mortality or HF hospitalization in HFrEF (adjusted HR: 2.07; 95% CI: 1.68-2.55) and HFpEF (HR: 2.37; 95% CI: 1.40-4.02). In HFrEF, DM only and CKD only were associated with 1-year all-cause mortality or HF hospitalization (both HRs: 1.43; 95% CI: 1.14-1.80), while in HFpEF, CKD only (HR: 2.54; 95% CI: 1.46-4.41) but not DM only (HR: 1.01; 95% CI: 0.52-1.95) was associated with increased risk (interaction P < 0.01). Adjusted Kansas City Cardiomyopathy Questionnaire scores were lower in patients with DM+CKD (HFrEF: mean 60.50, SEM 0.77, HFpEF: mean 70.10, SEM 1.06; P < 0.001) than with no DM or CKD (HFrEF: mean 66.00, SEM 0.65; and HFpEF: mean 75.80, SEM 0.99). Conclusions Combined DM and CKD adversely effected outcomes independently of HF subtype, with CKD a consistent predictor of worse outcomes. Strategies to prevent and treat DM and CKD in HF are urgently required.
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Affiliation(s)
- Claire A. Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Leicester Real World Evidence Unit, Leicester, United Kingdom
| | - Wan Ting Tay
- National Heart Centre Singapore, Singapore, Singapore
| | - Lizelle Bernhardt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - A. Mark Richards
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
- National University Heart Centre, Singapore
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, Leicester, United Kingdom
- Diabetes Research Centre, Leicester, United Kingdom
- National Institute for Health Research Applied Research Collaboration–East Midlands, University of Leicester, Leicester, United Kingdom
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Tiew-Hwa Katherine Teng
- National Heart Centre Singapore, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- School of Allied Health, University of Western Australia, Perth, Western Australia, Australia
| | - Chung-Lieh Hung
- Department of Cardiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chanchal Chandramouli
- National Heart Centre Singapore, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Gurpreet Singh Wander
- Department of Cardiology, Hero Heart Institute, Dayanand Medical College and Hospital, Ludhiana, India
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore, Singapore
- Department of Dermatology, University of Amsterdam Medical Center, Amsterdam, the Netherlands
| | - Sam Seidu
- Leicester Real World Evidence Unit, Leicester, United Kingdom
- Diabetes Research Centre, Leicester, United Kingdom
- National Institute for Health Research Applied Research Collaboration–East Midlands, University of Leicester, Leicester, United Kingdom
| | - Kamlesh Khunti
- Leicester Real World Evidence Unit, Leicester, United Kingdom
- Diabetes Research Centre, Leicester, United Kingdom
- National Institute for Health Research Applied Research Collaboration–East Midlands, University of Leicester, Leicester, United Kingdom
| | - Carolyn S.P. Lam
- National Heart Centre Singapore, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Department of Cardiology, University of Groningen, Groningen, the Netherlands
| | - ASIAN-HF Investigators
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Leicester Real World Evidence Unit, Leicester, United Kingdom
- National Heart Centre Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
- National University Heart Centre, Singapore
- Diabetes Research Centre, Leicester, United Kingdom
- National Institute for Health Research Applied Research Collaboration–East Midlands, University of Leicester, Leicester, United Kingdom
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- School of Allied Health, University of Western Australia, Perth, Western Australia, Australia
- Department of Cardiology, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Cardiology, Hero Heart Institute, Dayanand Medical College and Hospital, Ludhiana, India
- Department of Dermatology, University of Amsterdam Medical Center, Amsterdam, the Netherlands
- Department of Cardiology, University of Groningen, Groningen, the Netherlands
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Lawson CA, Tay WT, Richards M, Zaccardi F, Tromp J, Teng THK, Hung CL, Chandramouli C, Wander GS, Ouwerkerk W, Teramoto K, Ali M, Kadam U, Hand S, Harrison M, Anand I, Naik A, Squire I, Khunti K, Stromberg A, Lam CS. Patient-Reported Status and Heart Failure Outcomes in Asia by Sex, Ethnicity, and Socioeconomic Status. JACC Asia 2023; 3:349-362. [PMID: 37323861 PMCID: PMC10261894 DOI: 10.1016/j.jacasi.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
Background In heart failure (HF), symptoms and health-related quality of life (HRQoL) are known to vary among different HF subgroups, but evidence on the association between changing HRQoL and outcomes has not been evaluated. Objectives The authors sought to investigate the relationship between changing symptoms, signs, and HRQoL and outcomes by sex, ethnicity, and socioeconomic status (SES). Methods Using the ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) Registry, we investigated associations between the 6-month change in a "global" symptoms and signs score (GSSS), Kansas City Cardiomyopathy Questionnaire overall score (KCCQ-OS), and visual analogue scale (VAS) and 1-year mortality or HF hospitalization. Results In 6,549 patients (mean age: 62 ± 13 years], 29% female, 27% HF with preserved ejection fraction), women and those in low SES groups had higher symptom burden but lower signs and similar KCCQ-OS to their respective counterparts. Malay patients had the highest GSSS (3.9) and lowest KCCQ-OS (58.5), and Thai/Filipino/others (2.6) and Chinese patients (2.7) had the lowest GSSS scores and the highest KCCQ-OS (73.1 and 74.6, respectively). Compared to no change, worsening of GSSS (>1-point increase), KCCQ-OS (≥10-point decrease) and VAS (>1-point decrease) were associated with higher risk of HF admission/death (adjusted HR: 2.95 [95% CI: 2.14-4.06], 1.93 [95% CI: 1.26-2.94], and 2.30 [95% CI: 1.51-3.52], respectively). Conversely, the same degrees of improvement in GSSS, KCCQ-OS, and VAS were associated with reduced rates (HR: 0.35 [95% CI: 0.25-0.49], 0.25 [95% CI: 0.16-0.40], and 0.64 [95% CI: 0.40-1.00], respectively). Results were consistent across all sex, ethnicity, and SES groups (interaction P > 0.05). Conclusions Serial measures of patient-reported symptoms and HRQoL are significant and consistent predictors of outcomes among different groups with HF and provide the potential for a patient-centered and pragmatic approach to risk stratification.
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Affiliation(s)
- Claire A. Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
- Leicester Real World Evidence Unit, Leicester, United Kingdom
- NIHR Applied Research Collaboration–East Midlands, University of Leicester, Leicester, United Kingdom
| | | | - Mark Richards
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
- National University Heart Centre, Singapore
| | - Francesco Zaccardi
- NIHR Applied Research Collaboration–East Midlands, University of Leicester, Leicester, United Kingdom
- Diabetes Research Centre, Leicester, United Kingdom
| | - Jasper Tromp
- National Heart Centre Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Tiew-Hwa Katherine Teng
- National Heart Centre Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- School of Allied Health, University of Western Australia, Australia
| | - Chung-Lieh Hung
- Department of Cardiology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chanchal Chandramouli
- National Heart Centre Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Gurpreet S. Wander
- Department of Cardiology, Hero Dayanand Medical College Heart Institute, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore
- Department of Dermatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | | | - Mohammad Ali
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Umesh Kadam
- Diabetes Research Centre, Leicester, United Kingdom
- Department of Health Sciences, University of Leicester, Leicestershire, United Kingdom
| | - Simon Hand
- Department of Health Sciences, University of Leicester, Leicestershire, United Kingdom
| | - Mary Harrison
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Inder Anand
- Cardiovascular Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ajay Naik
- Care Institute of Medical Sciences, Ahmedabad, India
| | - Iain Squire
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Kamlesh Khunti
- Leicester Real World Evidence Unit, Leicester, United Kingdom
- NIHR Applied Research Collaboration–East Midlands, University of Leicester, Leicester, United Kingdom
- Diabetes Research Centre, Leicester, United Kingdom
| | - Anna Stromberg
- Department of Health, Medicine and Caring Sciences, and Department of Cardiology, Linkoping University, Sweden
| | - Carolyn S.P. Lam
- National Heart Centre Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- George Institute for Global Health, Sydney, Australia
- Department of Cardiology, University of Groningen, Groningen, the Netherlands
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Aslam S, Patsalides MA, Stoma S, Alfuhied A, Nelson CP, Squire IB, Lawson CA, Khunti K, McCann GP, Singh A. Aortic valve intervention rates in patients of different ethnicity with severe aortic stenosis in Leicestershire, UK. Open Heart 2023; 10:openhrt-2023-002266. [PMID: 37156572 PMCID: PMC10173973 DOI: 10.1136/openhrt-2023-002266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/14/2023] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVES To explore the ethnic differences in patients undergoing aortic valve (AV) intervention for severe aortic stenosis (AS) in Leicestershire, UK. METHODS Retrospective cohort study of all surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) at a single tertiary centre between April 2017 and March 2022, using local registry data. RESULTS Of the 1231 SAVR and 815 TAVI performed, 6.5% and 3.7% were in ethnic minority patients, respectively. Based on the 2011 Census data for those with a Leicestershire postcode, crude cumulative rate of SAVR (n=489) was 0.64 per 1000 population overall and 0.69, 0.46 and 0.36 in White, Asian and Black populations, respectively; and 0.50 per 1000 population overall for TAVI (n=383), with 0.59, 0.16 and 0.06 for White, Asian and Black populations, respectively. Asians undergoing SAVR and TAVI were 5 and 3 years younger, respectively, than white patients with more comorbidities and a worse functional status.The age-adjusted cumulative rates for SAVR were 0.62 vs 0.72 per 1000 population for White and Asian patients and 0.51 vs 0.39 for TAVI. Asians were less likely to undergo SAVR and TAVI than White patients, with a risk ratio (RR) of 0.66 (0.50-0.87) and 0.27 (0.18-0.43), respectively, but the age-adjusted RR was not statistically significant. CONCLUSION The crude rates of AV interventions are lower in Asian patients compared with the White population in Leicestershire, although age-adjusted rates were not statistically different. Further research to determine the sociodemographic differences in prevalence, incidence, mechanisms and treatment of AS across the UK is required.
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Affiliation(s)
- Saadia Aslam
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Michalis A Patsalides
- Department of Cardiology, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - Svetlana Stoma
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Aseel Alfuhied
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Christopher P Nelson
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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Coles B, Welch CA, Motiwale RS, Teece L, Oliver-Williams C, Weston C, de Belder MA, Lambert PC, Rutherford MJ, Paley L, Kadam UT, Lawson CA, Deanfield J, Peake MD, McDonagh T, Sweeting MJ, Adlam D. Acute heart failure presentation, management and outcomes in cancer patients: a national longitudinal study. Eur Heart J Acute Cardiovasc Care 2023; 12:315-327. [PMID: 36888552 PMCID: PMC10156472 DOI: 10.1093/ehjacc/zuad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/22/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Currently, little evidence exists on survival and quality of care in cancer patients presenting with acute heart failure (HF). To investigate the presentation and outcomes of hospital admission with acute HF in a national cohort of patients with prior cancer. METHODS This retrospective, population-based cohort study, identified 221,953 patients admitted to hospital in England for HF during 2012-2018 (12,867 with a breast, prostate, colorectal or lung cancer diagnosis in the previous 10 years). We examined the impact of cancer on 1) HF presentation and in-hospital mortality, 2) place of care, 3) HF medication prescribing, and 4) post-discharge survival, using propensity score weighting and model-based adjustment. RESULTS HF presentation was similar between cancer and non-cancer patients. A lower percentage of patients with prior cancer were cared for in a cardiology ward (-2.4 percentage point difference [ppd] [95% CI -3.3, -1.6]) or were prescribed ACEi/ARB for HFrEF (-2.1 ppd [-3.3, -0.9]) than non-cancer patients. Survival after HF discharge was poor with median survival of 1.6 years in prior cancer and 2.6 years in non-cancer patients. Mortality in prior cancer patients was driven primarily by non-cancer causes (68% of post-discharge deaths). CONCLUSIONS Survival in prior cancer patients presenting with acute HF was poor, with a significant proportion due to non-cancer causes of death. Despite this, cardiologists were less likely to manage cancer patients with HF. Cancer patients who develop HF were less likely to be prescribed guideline-based HF medications compared with non-cancer patients. This was particularly driven by patients with a poorer cancer prognosis.
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Affiliation(s)
- Briana Coles
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Catherine A Welch
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK.,National Disease Registration Service, NHS Digital, Leeds, UK
| | - Rishabh S Motiwale
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK.,School of Medicine, University of Leicester, Leicester, UK
| | - Lucy Teece
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK.,National Disease Registration Service, NHS Digital, Leeds, UK
| | - Clare Oliver-Williams
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Clive Weston
- Department of Cardiology, Glangwili General Hospital, Carmarthen, UK
| | - Mark A de Belder
- National Institute for Cardiovascular Outcomes Research, Arden & GEM Commissioning Support Unit, London, UK
| | - Paul C Lambert
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Mark J Rutherford
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Lizz Paley
- National Disease Registration Service, NHS Digital, Leeds, UK
| | - Umesh T Kadam
- Diabetes Research Centre, University of Leicester, Leicester, UK.,Department of Health Sciences, University of Leicester, Leicester, UK
| | - Claire A Lawson
- Diabetes Research Centre, University of Leicester, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - John Deanfield
- National Institute for Cardiovascular Outcomes Research, Arden & GEM Commissioning Support Unit, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Michael D Peake
- National Disease Registration Service, NHS Digital, Leeds, UK.,Department of Respiratory Medicine, University of Leicester, Leicester, UK
| | | | - Michael J Sweeting
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK.,Statistical Innovation, Oncology Biometrics, Oncology R&D, AstraZeneca, Cambridge, UK
| | - David Adlam
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
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9
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Teramoto K, Tay WT, Tromp J, Katherine Teng TH, Chandramouli C, Ouwerkerk W, Lawson CA, Huang W, Hung CL, Chopra V, Anand I, Mark Richards A, Lam CSP. Patient-Reported Versus Physician-Assessed Health Status in Heart Failure With Reduced and Preserved Ejection Fraction From ASIAN-HF Registry. Circ Cardiovasc Qual Outcomes 2023; 16:e009134. [PMID: 36484254 DOI: 10.1161/circoutcomes.122.009134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to assess if discordance between patient-reported Kansas City Cardiomyopathy Questionnaire (KCCQ)-overall summary (os) score and physician-assessed New York Heart Association (NYHA) class is common among patients with heart failure (HF) with reduced or preserved ejection fraction, and determine its association with outcomes. METHODS A total of 4818 patients with HF were classified according to KCCQ-os score (range 0-100, dichotomized by median value 71.9 into high [good] versus low [bad]) and NYHA class (I/II [good] or III/IV [bad]) as concordant good (low NYHA class, high KCCQ-os score), concordant bad (high NYHA class, low KCCQ-os score), discordant worse NYHA class (high NYHA class, high KCCQ-os score), and discordant worse KCCQ-os score (low NYHA class, low-KCCQ-os score). The composite of HF hospitalization or death at 1 year was compared across groups. RESULTS There were 2070 (43.0%) concordant good, 1099 (22.8%) concordant bad, 331 (6.9%) discordant worse NYHA class, and 1318 (27.4%) discordant worse KCCQ-os score patients. Compared with concordant good, adverse outcomes were the highest in concordant bad (HR, 2.7 [95% CI, 2.2-3.5]) followed by discordant worse KCCQ-os score (HR, 1.8 [95% CI, 1.4-2.2]) and discordant worse NYHA class (HR, 1.5 [95% CI, 1.0-2.3]); with no modification by HF phenotype (preserved versus reduced ejection fraction, Pinteraction=0.52). At 6 months, 1403 (48%) experienced clinically significant improvement in KCCQ-os score (≥5 points increase over 6 months). Patients with improved KCCQ-os at 6 months (HR, 0.65 [95% CI, 0.47-0.92]) had better outcomes and the association was not modified by HF phenotype (Pinteraction=0.40). CONCLUSIONS One-third of patients with HF had discordance between patient-reported and clinician-assessed health status, largely attributable to worse patient-reported outcomes. Such discordance, particularly in those with discordantly worse KCCQ, should alert physicians to an increased risk of HF hospitalization and death, and prompt further assessment for potential drivers of worse patient-reported outcomes relative to physicians' assessment.
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Affiliation(s)
- Kanako Teramoto
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,National Cerebral and Cardiovascular Center, Osaka, Japan (K.T.)
| | - Wan Ting Tay
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.)
| | - Jasper Tromp
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,Saw Swee Hock School of Public Health National University of Singapore and the National University Health System (J.T.)
| | - Tiew-Hwa Katherine Teng
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,School of Allied Health, University of Western Australia, Perth, Australia (T.-H.K.T.)
| | - Chanchal Chandramouli
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,Duke-NUS Medical School, Singapore (J.T., T.-H.K.T., C.C., C.S.P.L.)
| | - Wouter Ouwerkerk
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,Amsterdam Medical Center, Department of Dermatology, The Netherlands (W.O.)
| | - Claire A Lawson
- Department of Cardiovascular Research, University of Leicester, United Kingdom (C.A.L.)
| | - Weiting Huang
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.)
| | | | - Vijay Chopra
- Max Super Specialty Hospital, New Delhi, India (V.C.)
| | - Inder Anand
- Cardiovascular division, University of Minnesota, Minneapolis (I.A.)
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore (A.M.R.).,Christchurch Heart Institute, University of Otago, New Zealand (A.M.R.)
| | - Carolyn S P Lam
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,Duke-NUS Medical School, Singapore (J.T., T.-H.K.T., C.C., C.S.P.L.).,Department of Cardiology, University Medical Center Groningen, The Netherlands (C.S.P.L.)
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10
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Lawson CA, Lam C, Jaarsma T, Kadam U, Stromberg A, Ali M, Tay WT, Clayton L, Khunti K, Squire I. Developing a core outcome set for patient-reported symptom monitoring to reduce hospital admissions for patients with heart failure. Eur J Cardiovasc Nurs 2022; 21:830-839. [PMID: 35404418 DOI: 10.1093/eurjcn/zvac019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 12/29/2022]
Abstract
AIMS In patients with heart failure (HF), hospitalization rates are increasing, particularly for non-HF causes and over half may be avoidable. Self-monitoring of symptoms plays a key part in the early identification of deterioration. Our objective was to develop expert consensus for a core outcome set (COS) of symptoms to be monitored by patients, using validated single-item patient-reported outcome measures (PROMs), focused on the key priority of reducing admissions in HF. METHODS AND RESULTS A rigorous COS development process incorporating systematic review, modified e-Delphi and nominal group technique (NGT) methods. Participants included 24 HF patients, 4 carers, 29 HF nurses, and 9 doctors. In three Delphi and NGT rounds, participants rated potential outcomes on their importance before a HF or a non-HF admission using a 5-point Likert scale. Opinion change between rounds was assessed and a two-thirds threshold was used for outcome selection.Item generation using systematic review identified 100 validated single-item PROMs covering 34 symptoms or signs, relevant to admission for people with HF. De-duplication and formal consensus processes, resulted in a COS comprising eight symptoms and signs; shortness of breath, arm or leg swelling, abdomen bloating, palpitations, weight gain, chest pain, anxiety, and overall health. In the NGT, a numerical rating scale was selected as the optimal approach to symptom monitoring. CONCLUSION Recognition of a range of HF-specific and general symptoms, alongside comorbidities, is an important consideration for admission prevention. Further work is needed to validate and integrate the COS in routine care with the aim of facilitating faster identification of clinical deterioration.
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Affiliation(s)
- Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, Leicestershire LE5 4PW, UK
| | - Carolyn Lam
- National Heart Centre Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,University Medical Centre Groningen, Groningen, The Netherlands.,The George Institute for Global Health, Newton, NSW, Australia
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Umesh Kadam
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Anna Stromberg
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Mohammad Ali
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, Leicestershire LE5 4PW, UK
| | | | - Louise Clayton
- Department of Cardiology, University Hospitals of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Iain Squire
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, Leicestershire LE5 4PW, UK
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11
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Karsanji U, Evans RA, Quint JK, Khunti K, Lawson CA, Petherick E, Greening NJ, Singh SJ, Richardson M, Steiner MC. Mortality associated with Metabolic Syndrome in people with COPD managed in primary care. ERJ Open Res 2022; 8:00211-2022. [PMID: 36299367 PMCID: PMC9589337 DOI: 10.1183/23120541.00211-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/14/2022] [Indexed: 12/05/2022] Open
Abstract
Objective The prevalence of metabolic syndrome (MetS) has been reported to be higher in selected populations of people with COPD. The impact of MetS on mortality in COPD is unknown. We used routinely collected healthcare data to estimate the prevalence of MetS in people with COPD managed in primary care and determine its impact on 5-year mortality. Methods Records from 103 955 patients with COPD from the Clinical Practice Research Datalink (CPRD-GOLD) between 2009 to 2017 were scrutinised. MetS was defined as the presence of three or more of: obesity, hypertension, lowered high-density lipoprotein cholesterol, elevated triglycerides or type 2 diabetes mellitus (T2DM). Univariate and multivariable Cox regression models were constructed to determine the prognostic impact of MetS on 5-year mortality. Similar univariate models were constructed for individual components of the definition of MetS. Results The prevalence of MetS in the COPD cohort was 10.1%. Univariate analyses showed the presence of MetS increased mortality (hazard ratio (HR) 1.19, 95% CI: 1.12–1.27, p<0.001), but this risk was substantially attenuated in the multivariable analysis (HR 1.06, 95% CI: 0.99–1.13, p=0.085). The presence of hypertension (HR 1.70, 95% CI: 1.63–1.77, p<0.001) and T2DM (HR 1.41, 95% CI: 1.34–1.48, p<0.001) increased and obesity (HR 0.74, 95% CI: 0.71–0.78, p<0.001) reduced mortality risk. Conclusion MetS in patients with COPD is associated with higher 5-year mortality, but this impact was minimal when adjusted for indices of COPD disease severity and other comorbidities. Individual components of the MetS definition exerted differential impacts on mortality suggesting limitation to the use of MetS as a multicomponent condition in predicting outcome in COPD. The presence of MetS in COPD is not significantly associated with increased mortality over 5 years. The individual components of MetS exert differential effects on mortality, limiting the utility of the syndrome in predicting outcome.https://bit.ly/3PooGQd
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12
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Norris T, Razieh C, Yates T, Zaccardi F, Gillies CL, Chudasama YV, Rowlands A, Davies MJ, McCann GP, Banerjee A, Docherty AB, Openshaw PJ, Baillie JK, Semple MG, Lawson CA, Khunti K. Admission Blood Glucose Level and Its Association With Cardiovascular and Renal Complications in Patients Hospitalized With COVID-19. Diabetes Care 2022; 45:1132-1140. [PMID: 35275994 PMCID: PMC9174963 DOI: 10.2337/dc21-1709] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 01/30/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the association between admission blood glucose levels and risk of in-hospital cardiovascular and renal complications. RESEARCH DESIGN AND METHODS In this multicenter prospective study of 36,269 adults hospitalized with COVID-19 between 6 February 2020 and 16 March 2021 (N = 143,266), logistic regression models were used to explore associations between admission glucose level (mmol/L and mg/dL) and odds of in-hospital complications, including heart failure, arrhythmia, cardiac ischemia, cardiac arrest, coagulation complications, stroke, and renal injury. Nonlinearity was investigated using restricted cubic splines. Interaction models explored whether associations between glucose levels and complications were modified by clinically relevant factors. RESULTS Cardiovascular and renal complications occurred in 10,421 (28.7%) patients; median admission glucose level was 6.7 mmol/L (interquartile range 5.8-8.7) (120.6 mg/dL [104.4-156.6]). While accounting for confounders, for all complications except cardiac ischemia and stroke, there was a nonlinear association between glucose and cardiovascular and renal complications. For example, odds of heart failure, arrhythmia, coagulation complications, and renal injury decreased to a nadir at 6.4 mmol/L (115 mg/dL), 4.9 mmol/L (88.2 mg/dL), 4.7 mmol/L (84.6 mg/dL), and 5.8 mmol/L (104.4 mg/dL), respectively, and increased thereafter until 26.0 mmol/L (468 mg/dL), 50.0 mmol/L (900 mg/dL), 8.5 mmol/L (153 mg/dL), and 32.4 mmol/L (583.2 mg/dL). Compared with 5 mmol/L (90 mg/dL), odds ratios at these glucose levels were 1.28 (95% CI 0.96, 1.69) for heart failure, 2.23 (1.03, 4.81) for arrhythmia, 1.59 (1.36, 1.86) for coagulation complications, and 2.42 (2.01, 2.92) for renal injury. For most complications, a modifying effect of age was observed, with higher odds of complications at higher glucose levels for patients age <69 years. Preexisting diabetes status had a similar modifying effect on odds of complications, but evidence was strongest for renal injury, cardiac ischemia, and any cardiovascular/renal complication. CONCLUSIONS Increased odds of cardiovascular or renal complications were observed for admission glucose levels indicative of both hypo- and hyperglycemia. Admission glucose could be used as a marker for risk stratification of high-risk patients. Further research should evaluate interventions to optimize admission glucose on improving COVID-19 outcomes.
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Affiliation(s)
- Tom Norris
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, U.K
| | - Cameron Razieh
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, U.K
| | - Thomas Yates
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, U.K
| | - Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, U.K
| | - Clare L. Gillies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, U.K
| | - Yogini V. Chudasama
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, U.K
| | - Alex Rowlands
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, U.K
| | - Melanie J. Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, U.K
| | - Gerry P. McCann
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, U.K
- Cardiovascular Sciences Department, University of Leicester, Leicester, U.K
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, U.K
| | - Annemarie B. Docherty
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, U.K
- Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, U.K
| | | | | | - Malcolm G. Semple
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, U.K
- Respiratory Medicine, Alder Hey Children’s Hospital, Liverpool, U.K
| | - Claire A. Lawson
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, U.K
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, U.K
- National Institute for Health Research Applied Research Collaboration–East Midlands, Leicester General Hospital, Leicester, U.K
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13
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Teramoto K, Tay WT, Tromp J, Teng THK, Chandramouli C, Ouwerkerk W, Lawson CA, Huang W, Hung CL, Chopra V, Anand I, Richards AM, Lam CS. PATIENT REPORTED VERSUS PHYSICIAN-ASSESSED HEALTH STATUS IN HEART FAILURE WITH REDUCED AND PRESERVED EJECTION FRACTION FROM ASIAN-HF REGISTRY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Yates T, Zaccardi F, Islam N, Razieh C, Gillies CL, Lawson CA, Chudasama Y, Rowlands A, Davies MJ, Docherty AB, Openshaw PJM, Baillie JK, Semple MG, Khunti K. Obesity, chronic disease, age, and in-hospital mortality in patients with covid-19: analysis of ISARIC clinical characterisation protocol UK cohort. BMC Infect Dis 2021; 21:717. [PMID: 34330226 PMCID: PMC8324452 DOI: 10.1186/s12879-021-06466-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background Although age, obesity and pre-existing chronic diseases are established risk factors for COVID-19 outcomes, their interactions have not been well researched. Methods We used data from the Clinical Characterisation Protocol UK (CCP-UK) for Severe Emerging Infection developed by the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC). Patients admitted to hospital with COVID-19 from 6th February to 12th October 2020 were included where there was a coded outcome following hospital admission. Obesity was determined by an assessment from a clinician and chronic disease by medical records. Chronic diseases included: chronic cardiac disease, hypertension, chronic kidney disease, chronic pulmonary disease, diabetes and cancer. Mutually exclusive categories of obesity, with or without chronic disease, were created. Associations with in-hospital mortality were examined across sex and age categories. Results The analysis included 27,624 women with 6407 (23.2%) in-hospital deaths and 35,065 men with 10,001 (28.5%) in-hospital deaths. The prevalence of chronic disease in women and men was 66.3 and 68.5%, respectively, while that of obesity was 12.9 and 11.1%, respectively. Association of obesity and chronic disease status varied by age (p < 0.001). Under 50 years of age, obesity and chronic disease were associated with in-hospital mortality within 28 days of admission in a dose-response manner, such that patients with both obesity and chronic disease had the highest risk with a hazard ratio (HR) of in-hospital mortality of 2.99 (95% CI: 2.12, 4.21) in men and 2.16 (1.42, 3.26) in women compared to patients without obesity or chronic disease. Between the ages of 50–69 years, obesity and chronic disease remained associated with in-hospital COVID-19 mortality, but survival in those with obesity was similar to those with and without prevalent chronic disease. Beyond the age of 70 years in men and 80 years in women there was no meaningful difference between those with and without obesity and/or chronic disease. Conclusion Obesity and chronic disease are important risk factors for in-hospital mortality in younger age groups, with the combination of chronic disease and obesity being particularly important in those under 50 years of age. These findings have implications for targeted public health interventions, vaccination strategies and in-hospital clinical decision making. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06466-0.
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Affiliation(s)
- Thomas Yates
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK. .,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC), Leicester General Hospital, Leicester, LE5 4PW, UK.
| | - Francesco Zaccardi
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK.,Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Nazrul Islam
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Cameron Razieh
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC), Leicester General Hospital, Leicester, LE5 4PW, UK
| | - Clare L Gillies
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK.,Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Claire A Lawson
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK
| | - Yogini Chudasama
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Alex Rowlands
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC), Leicester General Hospital, Leicester, LE5 4PW, UK
| | - Melanie J Davies
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC), Leicester General Hospital, Leicester, LE5 4PW, UK
| | - Annemarie B Docherty
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.,Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, UK
| | | | | | - Malcolm G Semple
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections and Institute of Translational Medicine, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.,Respiratory Medicine, Alder Hey Children's Hospital, Institute in The Park, University of Liverpool, Alder Hey Children's Hospital, L12 2AP, Liverpool, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, LE5 4PW, UK.,Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK.,NIHR Applied Research Collaboration - East Midlands (ARC-EM), Leicester General Hospital, Leicester, UK
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15
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Yates T, Zaccardi F, Islam N, Razieh C, Gillies CL, Lawson CA, Chudasama Y, Rowlands A, Davies MJ, Docherty AB, Openshaw PJM, Baillie JK, Semple MG, Khunti K. Obesity, Ethnicity, and Risk of Critical Care, Mechanical Ventilation, and Mortality in Patients Admitted to Hospital with COVID-19: Analysis of the ISARIC CCP-UK Cohort. Obesity (Silver Spring) 2021; 29:1223-1230. [PMID: 33755331 PMCID: PMC8251439 DOI: 10.1002/oby.23178] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the association of obesity with in-hospital coronavirus disease 2019 (COVID-19) outcomes in different ethnic groups. METHODS Patients admitted to hospital with COVID-19 in the United Kingdom through the Clinical Characterisation Protocol UK (CCP-UK) developed by the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) were included from February 6 to October 12, 2020. Ethnicity was classified as White, South Asian, Black, and other minority ethnic groups. Outcomes were admission to critical care, mechanical ventilation, and in-hospital mortality, adjusted for age, sex, and chronic diseases. RESULTS Of the participants included, 54,254 (age = 76 years; 45.0% women) were White, 3,728 (57 years; 41.1% women) were South Asian, 2,523 (58 years; 44.9% women) were Black, and 5,427 (61 years; 40.8% women) were other ethnicities. Obesity was associated with all outcomes in all ethnic groups, with associations strongest for black ethnicities. When stratified by ethnicity and obesity status, the odds ratios for admission to critical care, mechanical ventilation, and mortality in black ethnicities with obesity were 3.91 (3.13-4.88), 5.03 (3.94-6.63), and 1.93 (1.49-2.51), respectively, compared with White ethnicities without obesity. CONCLUSIONS Obesity was associated with an elevated risk of in-hospital COVID-19 outcomes in all ethnic groups, with associations strongest in Black ethnicities.
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Affiliation(s)
- Thomas Yates
- Diabetes Research CentreUniversity of LeicesterLeicester General HospitalLeicesterUK
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC)University Hospitals of Leicester NHS Trust and University of LeicesterLeicesterUK
| | - Francesco Zaccardi
- Diabetes Research CentreUniversity of LeicesterLeicester General HospitalLeicesterUK
- Leicester Real World Evidence UnitDiabetes Research CentreUniversity of LeicesterLeicesterUK
| | - Nazrul Islam
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU)Nuffield Department of Population HealthUniversity of OxfordOxfordUK
- Medical Research Council Epidemiology UnitUniversity of CambridgeCambridgeUK
| | - Cameron Razieh
- Diabetes Research CentreUniversity of LeicesterLeicester General HospitalLeicesterUK
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC)University Hospitals of Leicester NHS Trust and University of LeicesterLeicesterUK
| | - Clare L. Gillies
- Diabetes Research CentreUniversity of LeicesterLeicester General HospitalLeicesterUK
- Leicester Real World Evidence UnitDiabetes Research CentreUniversity of LeicesterLeicesterUK
| | - Claire A. Lawson
- Diabetes Research CentreUniversity of LeicesterLeicester General HospitalLeicesterUK
| | - Yogini Chudasama
- Leicester Real World Evidence UnitDiabetes Research CentreUniversity of LeicesterLeicesterUK
| | - Alex Rowlands
- Diabetes Research CentreUniversity of LeicesterLeicester General HospitalLeicesterUK
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC)University Hospitals of Leicester NHS Trust and University of LeicesterLeicesterUK
| | - Melanie J. Davies
- Diabetes Research CentreUniversity of LeicesterLeicester General HospitalLeicesterUK
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre (BRC)University Hospitals of Leicester NHS Trust and University of LeicesterLeicesterUK
| | - Annemarie B. Docherty
- Centre for Medical InformaticsUsher InstituteUniversity of EdinburghEdinburghUK
- Intensive Care UnitRoyal Infirmary EdinburghEdinburghUK
| | | | | | - Malcolm G. Semple
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections and Institute of Translational Medicine, Faculty of Health and Life SciencesUniversity of LiverpoolLiverpoolUK
- Respiratory MedicineAlder Hey Children’s HospitalInstitute in The ParkUniversity of LiverpoolAlder Hey Children’s HospitalLiverpoolUK
| | | | - Kamlesh Khunti
- Diabetes Research CentreUniversity of LeicesterLeicester General HospitalLeicesterUK
- Leicester Real World Evidence UnitDiabetes Research CentreUniversity of LeicesterLeicesterUK
- NIHR Applied Research Collaboration – East Midlands (ARC‐EM)University Hospitals of Leicester NHS Trust and University of LeicesterLeicesterUK
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16
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Teng THK, Tay WT, Richards AM, Chew TSM, Anand I, Ouwerkerk W, Chandramouli C, Huang W, Lawson CA, Kadam UT, Yap J, Lim S, Hung CL, MacDonald MR, Loh SY, Shimizu W, Tromp J, Lam CSP. Socioeconomic Status and Outcomes in Heart Failure With Reduced Ejection Fraction From Asia. Circ Cardiovasc Qual Outcomes 2021; 14:e006962. [PMID: 33757307 DOI: 10.1161/circoutcomes.120.006962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Little is known regarding the impact of socioeconomic factors on the use of evidence-based therapies and outcomes in patients with heart failure with reduced ejection fraction across Asia. METHODS We investigated the association of both patient-level (household income, education levels) and country-level (regional income level by World Bank classification, income disparity by Gini index) socioeconomic indicators on use of guideline-directed therapy and clinical outcomes (composite of 1-year mortality or HF hospitalization, quality of life) in the prospective multinational ASIAN-HF study (Asian Sudden Cardiac Death in Heart Failure). RESULTS Among 4540 patients (mean age: 60±13 years, 23% women) with heart failure with reduced ejection fraction, 39% lived in low-income regions; 34% in regions with high-income disparity (Gini ≥42.8%); 64.4% had low monthly household income (<US$1000); and 29.5% had no/only primary education. The largest disparity in treatment across regional income levels pertained to β-blocker and device therapies, with patients from low-income regions being less likely to receive these treatments compared with those from high-income regions and even greater disparity among patients with lower education status and lower household income within each regional income strata. Higher country- and patient-level socioeconomic indicators related to higher quality of life scores and lower risk of the primary composite outcome. Notably, we found a significant interaction between regional income level and both household income and education status (Pinteraction <0.001 for both), where the association of low household income and low education status with poor outcomes was more pronounced in high-income compared with lower income regions. CONCLUSIONS These findings highlight the importance of socioeconomic determinants among patients with heart failure in Asia and suggest that attention should be paid to address disparities in access to care among the poor and less educated, including those from wealthy regions. Registration: URL: https://clinicaltrials.gov; Unique Identifier: NCT01633398.
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Affiliation(s)
- Tiew-Hwa K Teng
- National Heart Centre Singapore (T.-H.K.T., W.T.T., W.O., C.C., W.H., J.Y., J.T., C.S.P.L.).,Duke-National University of Singapore Medical School (T.-H.K.T., J.T., C.S.P.L.).,School of Population & Global Health, University of Western Australia (T.-H.K.T.)
| | - Wan Ting Tay
- National Heart Centre Singapore (T.-H.K.T., W.T.T., W.O., C.C., W.H., J.Y., J.T., C.S.P.L.)
| | - Arthur Mark Richards
- National University Heart Centre, Singapore (A.M.R., S.L.).,University of Otago, New Zealand (A.M.R.)
| | | | - Inder Anand
- Veterans Affairs Medical Center, University of Minnesota, Minneapolis (I.A.)
| | - Wouter Ouwerkerk
- National Heart Centre Singapore (T.-H.K.T., W.T.T., W.O., C.C., W.H., J.Y., J.T., C.S.P.L.).,Department of Dermatology, Amsterdam Medical Center, the Netherlands (W.O.)
| | - Chanchal Chandramouli
- National Heart Centre Singapore (T.-H.K.T., W.T.T., W.O., C.C., W.H., J.Y., J.T., C.S.P.L.)
| | - Weiting Huang
- National Heart Centre Singapore (T.-H.K.T., W.T.T., W.O., C.C., W.H., J.Y., J.T., C.S.P.L.)
| | | | - Umesh T Kadam
- University of Leicester, United Kingdom (C.A.L., U.T.K.)
| | - Jonathan Yap
- National Heart Centre Singapore (T.-H.K.T., W.T.T., W.O., C.C., W.H., J.Y., J.T., C.S.P.L.)
| | - Shirlynn Lim
- National University Heart Centre, Singapore (A.M.R., S.L.)
| | | | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan (W.S.)
| | - Jasper Tromp
- National Heart Centre Singapore (T.-H.K.T., W.T.T., W.O., C.C., W.H., J.Y., J.T., C.S.P.L.).,Duke-National University of Singapore Medical School (T.-H.K.T., J.T., C.S.P.L.).,University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands (J.T., C.S.P.L.)
| | - Carolyn Su Ping Lam
- National Heart Centre Singapore (T.-H.K.T., W.T.T., W.O., C.C., W.H., J.Y., J.T., C.S.P.L.).,Duke-National University of Singapore Medical School (T.-H.K.T., J.T., C.S.P.L.).,University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands (J.T., C.S.P.L.)
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17
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Lawson CA, Seidu S, Zaccardi F, McCann G, Kadam UT, Davies MJ, Lam CSP, Heerspink HL, Khunti K. Outcome trends in people with heart failure, type 2 diabetes mellitus and chronic kidney disease in the UK over twenty years. EClinicalMedicine 2021; 32:100739. [PMID: 33688855 PMCID: PMC7910705 DOI: 10.1016/j.eclinm.2021.100739] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Heart failure (HF) together with type 2 diabetes (T2D) and chronic kidney disease (CKD) are major pandemics of the twenty first century. It is not known in people with new onset HF, what the distinct and combined associations are between T2D and CKD comorbidities and cause-specific hospital admissions and death, over the past 20 years. METHODS An observational study using the UK Clinical Practice Research Datalink linked to the Hospital Episode Statistics in England (1998-2017). Participants were people aged ≥30 years with new onset HF. Exposure groups were HF with: (i) no T2D and no CKD (reference group); (ii) CKD-only (estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m2); (iii) T2D-only; (iv) T2D and CKD. CKD severity groups were: CKD-3a (eGFR 45-59); CKD-3b (30-44); CKD-4 (15-29); CKD-5 (<15). Outcomes were cardiovascular and non-cardiovascular hospitalisations and all-cause death. FINDINGS In 87,709 HF patients (mean age, 78 years; 49% female), 40% had CKD-only, 12% T2D-only, and 16% both. Age-standardised first-year CVD hospitalisation rates were significantly higher in HF patients with CKD-only (46.4; 95% CI 44.9,47.9 per 100 person years) and T2D-only (49.2; 46.7,58.8) than in the reference group (35.1; 34.0,36.1); the highest rate was in patients with T2D-CKD-5: 89.1 (65.8,112.4). Similar patterns were observed for non-CVD hospitalisations and deaths. Group differences remained significant after adjustment for potential confounders. Median survival was highest in the reference (4.4 years) and HF-T2D-only (4.1 years) groups, compared to HF-CKD-only (2.2 years). HF-T2D-CKD group survival ranged from 2.8 (CKD-3a) to 0.7 years (CKD-5). Over time, CVD hospitalisation rates significantly increased for HF-CKD-only (+26%) and reduced (-24%) for HF-T2D-only groups; no reductions were observed in any of the HF-T2D-CKD groups. Trends were similar for non-CVD hospitalisations and death: whilst death rates significantly reduced for HF-T2D-only (-37%), improvement was not observed in any of the T2D-CKD groups. INTERPRETATION In a cohort of people with new onset HF, hospitalisations and deaths are high in patients with T2D or CKD, and worst in those with both comorbidities. Whilst outcomes have improved over time for patients with HF and comorbid T2D, similar trends were not seen in those with comorbid CKD. Strategies to prevent and manage CKD in people with HF are urgently needed. FUNDING NIHR fellowship [reference: NIHR 30011].
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Affiliation(s)
- Claire A Lawson
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Samuel Seidu
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
- Corresponding author.
| | - Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Gerry McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Umesh T Kadam
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Carolyn SP Lam
- National Heart Centre Singapore, Duke-NUS, Singapore, University Medical Centre Groningen, the Netherlands
| | - Hiddo L. Heerspink
- The George Institute for Global Health, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
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18
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Huang W, Teng THK, Tay WT, Richards AM, Kadam U, Lawson CA, Shimizu W, Loh SY, Anand I, Lam CSP. Patient-reported outcomes in heart failure with preserved vs. reduced ejection fraction: focus on physical independence. ESC Heart Fail 2020; 7:2051-2062. [PMID: 32862518 PMCID: PMC7524068 DOI: 10.1002/ehf2.12950] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 07/19/2020] [Indexed: 12/21/2022] Open
Abstract
Aims The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a widely used patient‐reported outcome measure in heart failure (HF). The KCCQ was validated in patients with HF with reduced ejection fraction (HFrEF), leaving knowledge gaps regarding its applicability in HF with preserved ejection fraction (HFpEF). This study addresses the psychometric properties of internal consistency and reliability, construct, and known‐group validity of KCCQ in both HFrEF and HFpEF. We aimed to evaluate the psychometric properties of the KCCQ and their prognostic significance in HFpEF and HFrEF, within a large prospective multinational HF cohort. Methods and results We examined the 23‐item KCCQ in the prospective multinational ASIAN‐HF study [4470 HFrEF (ejection fraction <40%); 921 HFpEF (ejection fraction ≥50%)]. Internal consistency (using Cronbach's alpha) showed high reliability in HFrEF and HFpeF: functional status score: 0.89 and 0.91 and clinical summary score: 0.89 and 0.90, respectively. Confirmatory factor analysis in HFrEF validated the five original domains of KCCQ (physical function, symptoms, self‐efficacy, social limitation, and quality of life); in HFpEF, questions measuring physical function and social limitation had strong correlation (r = 0.66) and different domains emerged. We proposed an additional physical independence summary score, especially in HFpEF (comprising the original physical function and social limitation domains), which showed good internal consistency (α = 0.89) and has comparable receiver operating characteristic curve 0.766 ± 0.037 with the clinical summary score (receiver operating characteristic curve 0.774 ± 0.037), in predicting 1 year death and/or HF hospitalization. Conclusions Our results confirmed the robustness of the KCCQ clinical summary score in HF regardless of ejection fraction group. In the assessment of physical capacity in HFpEF, our results suggest strong interaction with social limitation, and we propose a summary score comprising both components be used.
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Affiliation(s)
- Weiting Huang
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Tiew-Hwa Katherine Teng
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore.,School of Population & Global Health, The University of Western Australia, Crawley, WA, Australia.,The George Institute for Global Health, Sydney, NSW, Australia
| | - Wan Ting Tay
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore.,Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
| | - Umesh Kadam
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Claire A Lawson
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | | | - Inder Anand
- Veterans Affairs Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Carolyn Su Ping Lam
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore.,Department of Cardiology, Groningen University Medical Center, Groningen, The Netherlands
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19
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Rashid M, Curzen N, Kinnaird T, Lawson CA, Myint PK, Kontopantelis E, Mohamed MO, Shoaib A, Gale CP, Timmis A, Mamas MA. Baseline risk, timing of invasive strategy and guideline compliance in NSTEMI: Nationwide analysis from MINAP. Int J Cardiol 2020; 301:7-13. [DOI: 10.1016/j.ijcard.2019.11.146] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 01/09/2023]
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20
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Abstract
Background:
There are multiple risk factors for heart failure, but contemporary temporal trends according to sex, socioeconomic status, and ethnicity are unknown.
Methods:
Using a national UK general practice database linked to hospitalizations (1998–2017), 108 638 incident heart failure patients were identified. Differences in risk factors among patient groups adjusted for sociodemographic factors and age-adjusted temporal trends were investigated using logistic and linear regression.
Results:
Over time, a 5.3 year (95% CI, 5.2–5.5) age difference between men and women remained. Women had higher blood pressure, body mass index, and cholesterol than men (
P
<0.0001). Ischemic heart disease prevalence increased for all to 2006 before reducing in women by 0.5% per annum, reaching 42.7% (95% CI, 41.7–43.6), but not in men, remaining at 57.7% (95% CI, 56.9–58.6; interaction
P
=0.002). Diabetes mellitus prevalence increased more in men than in women (interaction
P
<0.0001). Age between the most deprived (74.6 years [95% CI, 74.1–75.1]) and most affluent (79.9 [95% CI, 79.6–80.2]) diverged (interaction
P
<0.0001), generating a 5-year gap. The most deprived had significantly higher annual increases in comorbidity numbers (+0.14 versus +0.11), body mass index (+0.14 versus +0.11 kg/m
2
), and lower smoking reductions (−1.2% versus −1.7%) than the most affluent. Ethnicity trend differences were insignificant, but South Asians were overall 6 years and the black group 9 years younger than whites. South Asians had more ischemic heart disease (+16.5% [95% CI, 14.3–18.6]), hypertension (+12.5% [95% CI, 10.5–14.3]), and diabetes mellitus (+24.3% [95% CI, 22.0–26.6]), and the black group had more hypertension (+12.3% [95% CI, 9.7–14.8]) and diabetes mellitus (+13.1% [95% CI, 10.1–16.0]) but lower ischemic heart disease (−10.6% [95% CI, −13.6 to −7.6]) than the white group.
Conclusions:
Population groups show distinct risk factor trend differences, indicating the need for contemporary tailored prevention programs.
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Affiliation(s)
- Claire A. Lawson
- Diabetes Research Centre (C.A.L., F.Z., H.O., M.D., K.K., U.T.K.), University of Leicester, United Kingdom
| | - Francesco Zaccardi
- Diabetes Research Centre (C.A.L., F.Z., H.O., M.D., K.K., U.T.K.), University of Leicester, United Kingdom
| | - Iain Squire
- Cardiovascular Research Centre, Glenfield General Hospital (I.S.), University of Leicester, United Kingdom
| | - Hajra Okhai
- Diabetes Research Centre (C.A.L., F.Z., H.O., M.D., K.K., U.T.K.), University of Leicester, United Kingdom
| | - Melanie Davies
- Diabetes Research Centre (C.A.L., F.Z., H.O., M.D., K.K., U.T.K.), University of Leicester, United Kingdom
| | - Weiting Huang
- National Heart Centre, Duke-NUS Medical School, Singapore (H.W., C.S.P.L.)
| | - Mamas Mamas
- Keele Cardiovascular Group, Keele University, United Kingdom (M.M.)
| | - Carolyn S.P. Lam
- National Heart Centre, Duke-NUS Medical School, Singapore (H.W., C.S.P.L.)
- University Medical Centre Groningen, the Netherlands (C.S.P.L.)
- The George Institute for Global Health, Newton, NSW, Australia (C.S.P.L.)
| | - Kamlesh Khunti
- Diabetes Research Centre (C.A.L., F.Z., H.O., M.D., K.K., U.T.K.), University of Leicester, United Kingdom
| | - Umesh T. Kadam
- Diabetes Research Centre (C.A.L., F.Z., H.O., M.D., K.K., U.T.K.), University of Leicester, United Kingdom
- Department of Health Sciences (U.T.K.), University of Leicester, United Kingdom
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21
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Lawson CA, Zaccardi F, McCann GP, Davies MJ, Kadam UT, Khunti K. Trends in Cause-Specific Outcomes Among Individuals With Type 2 Diabetes and Heart Failure in the United Kingdom, 1998-2017. JAMA Netw Open 2019; 2:e1916447. [PMID: 31790564 PMCID: PMC6902744 DOI: 10.1001/jamanetworkopen.2019.16447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE The phenotype of individuals with type 2 diabetes and heart failure (HF) is changing. Successful public health interventions for type 2 diabetes mean that patients more frequently present with HF without a prior ischemic event, which is likely to change outcomes, but trends in cause-specific outcomes are unknown. OBJECTIVE To investigate cause-specific outcomes and trends associated with type 2 diabetes among individuals with incident HF. DESIGN, SETTING, AND PARTICIPANTS This cohort study used UK primary care data, linked to hospital admissions and mortality, for 87 709 patients with incident HF from 1998 to 2017. Patients were 30 years or older and observed to death or July 31, 2017. Data analysis was conducted in March and April 2019. EXPOSURE Preexisting type 2 diabetes at diagnosis of HF. Individuals with type 1 diabetes were excluded. MAIN OUTCOMES AND MEASURES All-cause, cardiovascular (CVD), and non-CVD unplanned hospitalizations and mortality rates. RESULTS Of 87 709 patients with HF (43 173 [49.2%] women; 78 211 [89.2%] white), 20 858 (23.8%) had type 2 diabetes (median [interquartile range] age, 78.0 [70.0 to 84.0] years), and 66 851 (76.2%) had no diabetes (median [interquartile range] age, 80.0 [72.0 to 86.0] years). In patients with HF, type 2 diabetes was associated with an increase in the risk of unplanned hospital admission (adjusted incidence rate ratio for CVD hospitalizations: 1.24; 95% CI, 1.19 to 1.30; for non-CVD hospitalizations: 1.26; 95% CI, 1.22 to 1.30) and an increase in the risk of mortality (adjusted hazard ratio for CVD mortality: 1.06; 95% CI, 1.02 to 1.10; for non-CVD mortality: 1.24; 95% CI, 1.19 to 1.29). Age-standardized mortality risk at 1 year was 35.6% (95% CI, 35.1% to 36.1%) in the type 2 diabetes group vs 29.2% (95% CI, 29.0% to 29.5%) in the group with no diabetes. During the study period (ie, 1998 to 2017), associations of type 2 diabetes with hospitalization and mortality rates decreased for CVD outcomes but not for non-CVD outcomes. Age-adjusted hospitalization rates during the first year following HF diagnosis increased similarly for both groups over time (eg, HF with type 2 diabetes, 1998 to 2001: 133.3 per 100 person-years; 95% CI, 102.2 to 105.4 per 100 person-years; 2012 to 2015: 152.5 per 100 person-years; 95% CI, 145.5 to 159.5 per 100 person-years; P for difference in trend = .06), but trends diverged by cause. For example, hospitalizations for HF decreased for patients with type 2 diabetes at approximately the same annual rate (-2.2%; 95% CI, -3.9% to -0.5%) as they increased for those without diabetes (1.7%; 95% CI, 1.1% to 2.3%; P for difference in trend < .001). After 2004, a trend emerged showing a greater increase in non-CVD admissions among patients with HF and type 2 diabetes than among patients with no diabetes (2.3% [95% CI, 0.9% to 3.6%] vs 1.1% [95% CI, 0.8% to 1.4%]). In contrast to hospitalization rates, mortality rates reduced over time in both groups, but the reduction was greater among those with type 2 diabetes than without (-1.4% [95% CI, -1.8% to -0.9%] vs -0.7% [95% CI, -1.2% to -0.2%]; P for difference in trend < .001). CONCLUSIONS AND RELEVANCE In this study, the higher risk of all cause-specific outcomes and emerging non-CVD trends associated with patients with type 2 diabetes who experienced HF indicated an urgent need for earlier comorbidity management and patient-centered multimorbidity care.
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Affiliation(s)
- Claire A. Lawson
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Gerry P. McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - Melanie J. Davies
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - Umesh T. Kadam
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
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22
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Bernhardt L, Lawson CA. Early menopause and risk of cardiovascular disease: an issue for young women. Lancet Public Health 2019; 4:e539-e540. [PMID: 31588030 DOI: 10.1016/s2468-2667(19)30184-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/19/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Lizelle Bernhardt
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE5 4PW, UK
| | - Claire A Lawson
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK.
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23
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Lawson CA, Zaccardi F, Squire I, Ling S, Davies MJ, Lam CSP, Mamas MA, Khunti K, Kadam UT. 20-year trends in cause-specific heart failure outcomes by sex, socioeconomic status, and place of diagnosis: a population-based study. Lancet Public Health 2019; 4:e406-e420. [PMID: 31376859 PMCID: PMC6686076 DOI: 10.1016/s2468-2667(19)30108-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/29/2019] [Accepted: 06/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Heart failure is an important public health issue affecting about 1 million people in the UK, but contemporary trends in cause-specific outcomes among different population groups are unknown. METHODS In this retrospective, population-based study, we used the UK Clinical Practice Research Datalink and Hospital Episodes Statistics databases to identify a cohort of patients who had a diagnosis of incident heart failure between Jan 1, 1998, and July 31, 2017. Patients were eligible for inclusion if they were aged 30 years or older with a first code for heart failure in their primary care or hospital record during the study period. We assessed cause-specific admission to hospital (ie, hospitalisation) and mortality, by age, sex, socioeconomic status, and place of diagnosis (ie, hospital vs community diagnosis). We calculated outcome rates separately for the first year (first-year rates) and for the second-year onwards (subsequent-year rates). Patients were followed up until death or study end. This study is registered with Clinical Practice Research Datalink Independent Scientific Advisory Committee, protocol number 18_037R. FINDINGS We identified 88 416 individuals with incident heart failure over the study period, of whom 43 461 (49%) were female. The mean age was 77·8 years (SD 11·3) and median follow-up was 2·4 years (IQR 0·5 to 5·7). Age-adjusted first-year rates of hospitalisation increased by 28% for all-cause admissions, from 97·1 (95% CI 94·3 to 99·9) to 124·2 (120·9 to 127·5) per 100 person-years; by 28% for heart failure-specific admissions, from 17·2 (16·2 to 18·2) to 22·1 (20·9 to 23·2) per 100 person-years; and by 42% for non-cardiovascular admissions, from 59·2 (57·2 to 61·2) to 83·9 (81·3 to 86·5) per 100 person-years. 167 641 (73%) of 228 113 hospitalisations were for non-cardiovascular causes and annual rate increases were higher for women (3·9%, 95% CI 2·8 to 4·9) than for men (1·4%, 0·6 to 2·1; p<0·0001); and for patients diagnosed with heart failure in hospital (2·4%, 1·4 to 3·3) than those diagnosed in the community (1·2%, 0·3 to 2·2). Annual increases in hospitalisation due to heart failure were 2·6% (1·9 to 3·4) for women compared with stable rates in men (0·6%, -0·9 to 2·1), and 1·6% (0·6 to 2·6) for the most deprived group compared with stable rates for the most affluent group (1·2%, -0·3 to 2·8). A significantly higher risk of all-cause hospitalisation was found for the most deprived than for the most affluent (incident rate ratio 1·34, 95% CI 1·32 to 1·35) and for the hospital-diagnosed group than for the community-diagnosed group (1·76, 1·73 to 1·80). Age-adjusted first-year rates of all-cause mortality decreased by 6% from 24·5 (95% CI 23·4 to 39·2) to 23·0 (22·0 to 24·1) per 100 person-years. Annual change in mortality was -1·4% (95% CI -2·3 to -0·5) in men but was stable for women (0·3%, -0·5 to 1·1), and -2·7% (-3·2 to -2·2) for the community-diagnosed group compared with -1·1% (-1·8 to -0·4) in the hospital-diagnosed group (p<0·0001). A significantly higher risk of all-cause mortality was seen in the most deprived group than in the most affluent group (hazard ratio 1·08, 95% CI 1·05 to 1·11) and in the hospital-diagnosed group than in the community-diagnosed group (1·55, 1·53 to 1·58). INTERPRETATION Tailored management strategies and specialist care for patients with heart failure are needed to address persisting and increasing inequalities for men, the most deprived, and for those who are diagnosed with heart failure in hospital, and to address the worrying trends in women. FUNDING Wellcome Trust.
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Affiliation(s)
- Claire A Lawson
- Diabetes Research Centre, University of Leicester, Leicester, UK.
| | | | - Iain Squire
- NIHR Leicester Biomedical Research Centre, Cardiovascular Research Centre, Glenfield General Hospital, Leicester University, Leicester, UK
| | - Suping Ling
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Carolyn S P Lam
- National Heart Centre, Duke-NUS Medical School, Singapore; University Medical Centre Groningen, Groningen, Netherlands; The George Institute for Global Health, Newton, NSW, Australia
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Staffordshire, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Umesh T Kadam
- Diabetes Research Centre, University of Leicester, Leicester, UK
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Lawson CA, Mamas MA, Jones PW, Teece L, McCann G, Khunti K, Kadam UT. Association of Medication Intensity and Stages of Airflow Limitation With the Risk of Hospitalization or Death in Patients With Heart Failure and Chronic Obstructive Pulmonary Disease. JAMA Netw Open 2018; 1:e185489. [PMID: 30646293 PMCID: PMC6324325 DOI: 10.1001/jamanetworkopen.2018.5489] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE In heart failure (HF), chronic obstructive pulmonary disease (COPD) increases the risk of poor outcomes, but the effect of COPD severity is unknown. This information is important for early intervention tailored to the highest-risk groups. OBJECTIVES To determine the associations between COPD medication intensity or stage of airflow limitation and the risk of hospitalization or death in patients with HF. DESIGN, SETTING, AND PARTICIPANTS This UK population-based, nested case-control study with risk-set sampling used the Clinical Practice Research Datalink linked to Hospital Episode Statistics between January 1, 2002, to January 1, 2014. Participants included patients aged 40 years and older with a new diagnosis of HF in their family practice clinical record. Data analysis was conducted from 2017 to 2018. EXPOSURES In patients with HF, those with COPD were compared with those without it. International COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD]) guidelines were used to stratify patients with COPD by 7 medication intensity levels and 4 airflow limitation severity stages using automatically recorded prescriptions and routinely requested forced expiratory volume in 1 second (FEV1) data. MAIN OUTCOMES AND MEASURES First all-cause admission or all-cause death. RESULTS There were 50 114 patients with new HF (median age, 79 years [interquartile range, 71-85 years]; 46% women) during the study period. In patients with HF, COPD (18 478 [13.8%]) was significantly associated with increased mortality (adjusted odds ratio [AOR], 1.31; 95% CI, 1.26-1.36) and hospitalization (AOR, 1.33; 95% CI, 1.26-1.39). The 3 most severe medication intensity levels showed significantly increasing mortality associations from full inhaler therapy (AOR, 1.17; 95% CI, 1.06-1.29) to oral corticosteroids (AOR, 1.69; 95% CI, 1.57-1.81) to oxygen therapy (AOR, 2.82; 95% CI, 2.42-3.28). The respective estimates for hospitalization were AORs of 1.17 (95% CI, 1.03-1.33), 1.75 (95% CI, 1.59-1.92), and 2.84 (95% CI, 1.22-3.63). Availability of spirometry data was limited but showed that increasing airflow limitation was associated with increased risk of mortality, with the following AORs: FEV1 80% or more, 1.63 (95% CI, 1.42-1.87); FEV1 50% to 79%, 1.69 (95% CI, 1.56-1.83); FEV1 30% to 49%, 2.21 (95% CI, 2.01-2.42); FEV1 less than 30%, 2.93 (95% CI, 2.49-3.43). The strength of associations between FEV1 and hospitalization risk were similar among stages ranging from FEV1 80% or more (AOR, 1.48; 95% CI, 1.31-1.68) to FEV1 less than 30% (AOR, 1.73; 95% CI, 1.40-2.12). CONCLUSIONS AND RELEVANCE In the UK HF community setting, increasing COPD severity was associated with increasing risk of mortality and hospitalization. Prescribed COPD medication intensity and airflow limitation provide the basis for targeting high-risk groups.
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Affiliation(s)
- Claire A Lawson
- Leicester Diabetes Centre, University of Leicester, Leicester, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keel University, Stoke-on-Trent, United Kingdom
| | - Peter W Jones
- Faculty of Medicine and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Lucy Teece
- Faculty of Medicine and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Gerry McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, United Kingdom
| | - Umesh T Kadam
- Leicester Diabetes Centre, University of Leicester, Leicester, United Kingdom
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
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Kadam UT, Roberts I, White S, Bednall R, Khunti K, Nilsson PM, Lawson CA. Conceptualizing multiple drug use in patients with comorbidity and multimorbidity: proposal for standard definitions beyond the term polypharmacy. J Clin Epidemiol 2018; 106:98-107. [PMID: 30385327 DOI: 10.1016/j.jclinepi.2018.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/28/2018] [Accepted: 10/24/2018] [Indexed: 12/22/2022]
Abstract
With older and aging populations, patients experience multiple chronic diseases at the same time. Individual chronic disease guidelines often recommend pharmacological therapies as a key intervention, resulting in patients being prescribed multiple regular medications for their different diseases. Although the term "polypharmacy" has been applied to the use of multiple medications, there is no consistent definition, and this term is now being used all inclusively. To improve both scientific rigor and optimal patient care, it is crucial that a standard terminology is used, which reclassifies the term "polypharmacy" into distinct phenotypes relating to the index chronic disease, additional conditions to the index (comorbidity), or the experience of multiple chronic conditions at the same time (multimorbidity). Using three exemplar index conditions; heart failure, type 2 diabetes, and breast cancer, we propose the reclassification of the term "polypharmacy" into three distinct phenotypes. First, index drug or multi-index drug therapy, where each index condition creates multiple drug use for that condition; second, codrug therapy, where addition of other comorbid conditions increases the multiple drug use and may influence the management of the index disease and third, multidrug therapy, where adult population with multimorbidity may be on many drugs. This article reviews guidelines for the individual exemplars to develop the basis for the new terms and then develops the pharmacoepidemiology of multiple drug use further by reviewing the evidence on the relationship between the phenotypic classification and important outcomes. The importance of standardizing "polypharmacy" terminology for the scientific agenda and clinical practice is that it relates to an index condition or disease safety outcomes including drug interactions, adverse side effects in hospital admissions, and related "polypill" concept.
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Affiliation(s)
- Umesh T Kadam
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK; Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK.
| | - Isobel Roberts
- Pharmacy Directorate, University Hospitals of North Staffordshire, Stoke-on-Trent ST4 6QG, UK
| | - Simon White
- School of Pharmacy, Keele University, Keele ST5 5BG, UK
| | - Ruth Bednall
- Pharmacy Directorate, University Hospitals of North Staffordshire, Stoke-on-Trent ST4 6QG, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Peter M Nilsson
- Department of Clinical Sciences, Lund University, Malmö S-205 02, Sweden
| | - Claire A Lawson
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK
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Lawson CA, Testani JM, Mamas M, Damman K, Jones PW, Teece L, Kadam UT. Chronic kidney disease, worsening renal function and outcomes in a heart failure community setting: A UK national study. Int J Cardiol 2018; 267:120-127. [PMID: 29957251 PMCID: PMC6024224 DOI: 10.1016/j.ijcard.2018.04.090] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/06/2018] [Accepted: 04/20/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Routine heart failure (HF) monitoring and management is in the community but the natural course of worsening renal function (WRF) and its influence on HF prognosis is unknown. We investigated the influence of routinely monitored renal decline and related comorbidities on imminent hospitalisation and death in the HF community population. METHODS A nested case-control study within an incident HF cohort (N = 50,114) with 12-years follow-up. WRF over 6-months before first hospitalisation and 12-months before death was defined by >20% reduction in estimated glomerular filtration rate (eGFR). Additive interactions between chronic kidney disease (CKD) and comorbidities were investigated. RESULTS Prevalence of CKD (eGFR<60 ml/min/1.73m2) in the HF community was 63%, which was associated with an 11% increase in hospitalisation and 17% in mortality. Both risk associations were significantly worse in the presence of diabetes. Compared to HF patients with eGFR,60-89, there was no or minimal increase in risk for mild to moderate CKD (eGFR,30-59) for both outcomes. Adjusted risk estimates for hospitalisation were increased only for severe CKD(eGFR,15-29); Odds Ratio 1.49 (95%CI;1.36,1.62) and renal failure(eGFR,<15); 3.38(2.67,4.29). The relationship between eGFR and mortality was U-shaped; eGFR, ≥90; 1.32(1.17,1.48), eGFR,15-29; 1.68(1.58,1.79) and eGFR,<15; 3.04(2.71,3.41). WRF is common and associated with imminent hospitalisation (1.50;1.37,1.64) and mortality (1.92;1.79,2.06). CONCLUSIONS In HF, the risk associated with CKD differs between the community and the acute HF setting. In the community setting, moderate CKD confers no risk but severe CKD, WRF or CKD with other comorbidities identifies patients at high risk of imminent hospitalisation and death.
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Affiliation(s)
- Claire A Lawson
- Leicester Diabetes Centre, Leicester University, UK; Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, UK.
| | - J M Testani
- Yale University, New Haven, CT, United States
| | - M Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, UK
| | - K Damman
- University of Groningen, University Medical Center, Groningen, The Netherlands
| | - P W Jones
- Faculty of Medicine and Health Sciences, Keele University, England, UK
| | - L Teece
- Faculty of Medicine and Health Sciences, Keele University, England, UK
| | - U T Kadam
- Leicester Diabetes Centre, Leicester University, UK; Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, UK
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Sargeant JA, Yates T, McCann GP, Lawson CA, Davies MJ, Gulsin GS, Henson J. Physical activity and structured exercise in patients with type 2 diabetes mellitus and heart failure. Pract Diab 2018. [DOI: 10.1002/pdi.2180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Jack A Sargeant
- Diabetes Research Centre; University of Leicester and the NIHR Leicester Biomedical Research Centre; Leicester General Hospital, Leicester UK
| | - Thomas Yates
- Diabetes Research Centre; University of Leicester and the NIHR Leicester Biomedical Research Centre; Leicester General Hospital, Leicester UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences; University of Leicester and the NIHR Leicester Biomedical Research Centre; Glenfield Hospital, Leicester UK
| | - Claire A Lawson
- Diabetes Research Centre; University of Leicester and the NIHR Leicester Biomedical Research Centre; Leicester General Hospital, Leicester UK
| | - Melanie J Davies
- Diabetes Research Centre; University of Leicester and the NIHR Leicester Biomedical Research Centre; Leicester General Hospital, Leicester UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences; University of Leicester and the NIHR Leicester Biomedical Research Centre; Glenfield Hospital, Leicester UK
| | - Joseph Henson
- Diabetes Research Centre; University of Leicester and the NIHR Leicester Biomedical Research Centre; Leicester General Hospital, Leicester UK
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Kadam UT, Lawson CA, Moody DK, Teece L, Uttley J, Harvey J, Iqbal Z, Jones PW. Consumer segmentation and time interval between types of hospital admission: a clinical linkage database study. J Public Health (Oxf) 2018; 40:154-162. [PMID: 28334927 DOI: 10.1093/pubmed/fdx028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Indexed: 11/13/2022] Open
Abstract
Background Healthcare policies target unplanned hospital admissions and 30-day re-admission as key measures of efficiency, but do not focus on factors that influence trajectories of different types of admissions in the same patient over time. Objectives To investigate the influence of consumer segmentation and patient factors on the time intervals between different types of hospital admission. Research design, subjects and measures A cohort design was applied to an anonymised linkage database for adults aged 40 years and over (N = 58 857). Measures included Mosaic segmentation, multimorbidity defined on six chronic condition registers and hospital admissions over a 27-month time period. Results The shortest mean time intervals between two consecutive planned admissions were: 90 years and over (160 days (95% confidence interval (CI): 146-175)), Mosaic groups 'Twilight subsistence' (171 days (164-179)) or 'Welfare borderline' and 'Municipal dependency' (177 days (172-182)) compared to the reference Mosaic groups (186 days (180-193)), and multimorbidity count of four or more (137 days (130-145)). Mosaic group 'Twilight subsistence' (rate ratio (RR) 1.22 (95% CI: 1.08-1.36)) or 'Welfare borderline' and 'Municipal dependency' RR 1.20 (1.10-1.31) were significantly associated with higher rate to an unplanned admission following a planned event. However, associations between patient factors and unplanned admissions were diminished by adjustment for planned admissions. Conclusion Specific consumer segmentation and patient factors were associated with shorter time intervals between different types of admissions. The findings support innovation in public health approaches to prevent by a focus on long-term trajectories of hospital admissions, which include planned activity.
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Affiliation(s)
- Umesh T Kadam
- Health Services Research Unit, Guy Hilton Research Centre, Keele University, Stoke-on-Trent ST4 7QB, UK
| | - Claire A Lawson
- Health Services Research Unit, Guy Hilton Research Centre, Keele University, Stoke-on-Trent ST4 7QB, UK
| | - Dawn K Moody
- Health Services Research Unit, Guy Hilton Research Centre, Keele University, Stoke-on-Trent ST4 7QB, UK
| | - Lucy Teece
- Health Services Research Unit, Guy Hilton Research Centre, Keele University, Stoke-on-Trent ST4 7QB, UK
| | - John Uttley
- e-Innovation Unit, Midlands and Lancashire Commissioning Support Unit, Stoke-on-Trent ST4 4LX, UK
| | - John Harvey
- North Staffordshire Clinical Commissioning Group, Morston House, Newcastle-under-Lyme ST5 1QG, UK
| | - Z Iqbal
- Public Health Directorate, City of Stoke-on-Trent, Civic Centre, Stoke-on-Trent ST4 1HH, UK
| | - P W Jones
- Health Services Research Unit, Guy Hilton Research Centre, Keele University, Stoke-on-Trent ST4 7QB, UK
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Lawson CA, Jones PW, Teece L, Dunbar SB, Seferovic PM, Khunti K, Mamas M, Kadam UT. Association Between Type 2 Diabetes and All-Cause Hospitalization and Mortality in the UK General Heart Failure Population: Stratification by Diabetic Glycemic Control and Medication Intensification. JACC Heart Fail 2017; 6:18-26. [PMID: 29032131 DOI: 10.1016/j.jchf.2017.08.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/14/2017] [Accepted: 08/07/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study sought to investigate in the general heart failure (HF) population, whether the associations between type 2 diabetes (T2D) and risk of hospitalization and death, are modified by changing glycemic or drug treatment intensity. BACKGROUND In the general HF population, T2D confers a higher risk of poor outcomes, but whether this risk is modified by the diabetes status is unknown. METHODS A nested case-control study in an incident HF database cohort (2002 to 2014) compared patients with T2D with those without for risk of all-cause first hospitalization and death. T2D was stratified by categories of glycosylated hemoglobin (HbA1c) or drug treatments measured 6 months before hospitalization and 1 year before death and compared with the HF group without T2D. RESULTS In HF, T2D was associated with risk of first hospitalization (adjusted odds ratio [aOR]: 1.29; 95% confidence interval [CI]: 1.24 to 1.34) and mortality (aOR: 1.24; 95% CI: 1.29 to 1.40). Stratification of T2D by HbA1c levels, compared with the reference HF group without T2D, showed U-shaped associations with both outcomes. Highest risk categories were HbA1c >9.5% (hospitalization, aOR: 1.75; 95% CI: 1.52 to 2.02; mortality, aOR: 1.30; 95% CI: 1.24 to 1.47) and <5.5% (hospitalization, aOR: 1.42; 95% CI: 1.12 to 1.80; mortality, aOR: 1.29; 95% CI: 1.10 to 1.51, respectively). T2D group with change in HbA1c of >1% decrease was associated with hospitalization (aOR: 1.33; 95% CI: 1.18 to 1.49) and mortality (aOR: 1.36; 95% CI: 1.24 to 1.48). T2D drug group associations with hospitalization were no medication (aOR: 1.12; 95% CI: 1.04 to 1.19), oral antihyperglycemic only (aOR: 1.34; 95% CI: 1.27 to 1.41), oral antihyperglycemic+insulin (aOR: 1.36; 95% CI: 1.21 to 1.52), and insulin only (aOR: 1.61; 95% CI: 1.43 to 1.81); and with mortality for the same drug groups were 1.31 (95% CI: 1.23 to 1.39), 1.16 (95% CI: 1.11 to 1.22), 1.19 (95% CI: 1.06 to 1.34), and 1.43 (95% CI: 1.31 to 1.57), respectively. The T2D group with reduced drug treatments were associated with hospitalization (aOR: 2.13; 95% CI: 1.68 to 2.69) and mortality (aOR: 2.09; 95% CI: 1.81 to 2.41). CONCLUSIONS In the general HF population, T2D stratified by glycemic control and drug treatments showed differential risk associations. Routine measures of dynamic diabetes status provide important prognostic indication of poor outcomes in HF.
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Affiliation(s)
- Claire A Lawson
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Leicester LE5 4PW, United Kingdom; Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom.
| | - Peter W Jones
- Faculty of Medicine and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
| | - Lucy Teece
- Faculty of Medicine and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
| | | | | | - Kamlesh Khunti
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
| | - Umesh T Kadam
- University of Leicester, Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, Leicester LE5 4PW, United Kingdom; Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
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Burgoyne CH, Field SL, Brown AK, Hensor EM, English A, Bingham SL, Verburg R, Fearon U, Lawson CA, Hamlin PJ, Straszynski L, Veale D, Conaghan P, Hull MA, van Laar JM, Tennant A, Emery P, Isaacs JD, Ponchel F. Abnormal T cell differentiation persists in patients with rheumatoid arthritis in clinical remission and predicts relapse. Ann Rheum Dis 2007; 67:750-7. [PMID: 17644540 DOI: 10.1136/ard.2007.073833] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES An abnormal CD4+ T cell subset related to inflammation exposure (inflammation-related cells, IRC) has been identified in rheumatoid arthritis (RA). Patients with inflammatory and non-inflammatory diseases were used to examine the relationship between inflammation and this T cell subset in vivo. METHODS Blood was collected from healthy controls and patients with RA (active disease or in clinical remission), Crohn's disease and osteoarthritis. IRC and chemokine receptors were quantified by flow cytometry. Thymic activity and apoptotic factors were measured by real-time polymerase chain reaction. Circulating cytokines were measured by enzyme-linked immunosorbent assay. CXCR4 and SDF1 in synovial biopsies were measured using immunohistochemistry. RESULTS IRC were identified in patients with RA (p<0.0001) and Crohn's disease (p = 0.005), but not in those with osteoarthritis. In RA in remission, IRC persisted (p<0.001). In remission, hyperproliferation of IRC was lost, chemokine receptor expression was significantly lowered (p<0.007), Bax expression dropped significantly (p<0.001) and was inversely correlated with IRC (rho = -0.755, p = 0.03). High IRC frequency in remission was associated with relapse within 18 months (OR = 6.4, p<0.001) and a regression model predicted 72% of relapse. CONCLUSIONS These results suggest a model in which, despite the lack of systemic inflammation, IRC persist in remission, indicating that IRC are an acquired feature of RA. They have, however, lost their hyper-responsiveness, acquired a potential for survival, and no longer express chemokine receptors. IRC persistence in remission confirms their important role in chronic inflammation as circulating precursors of pathogenic cells. This was further demonstrated by much higher incidence of relapse in patients with high IRC frequency in remission.
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Affiliation(s)
- C H Burgoyne
- Academic Unit of Musculoskeletal Disease, University of Leeds, Leeds, UK
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Lawson CA, Brown AK, Bejarano V, Douglas SH, Burgoyne CH, Greenstein AS, Boylston AW, Emery P, Ponchel F, Isaacs JD. Early rheumatoid arthritis is associated with a deficit in the CD4+CD25high regulatory T cell population in peripheral blood. Rheumatology (Oxford) 2006; 45:1210-7. [PMID: 16571607 DOI: 10.1093/rheumatology/kel089] [Citation(s) in RCA: 153] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Our aim was to test the hypothesis that there is a deficit in the CD4+CD25high regulatory T-cell population in early rheumatoid arthritis (RA), either in size or functional activity. METHODS Peripheral blood mononuclear cells were examined from subjects with early active RA who had received no previous disease-modifying therapy (n = 43), from individuals with self-limiting reactive arthritis (n = 14), from subjects with stable, well-controlled RA (n = 82) and from healthy controls (n = 72). The frequencies of CD4+CD25high T-cells were quantified using flow cytometry, and function was assessed by the ability to suppress proliferation of CD4+CD25- T-cells. Paired blood and synovial fluid was analysed from a small number of RA and reactive arthritis patients. RESULTS There was a smaller proportion of CD4+CD25high T-cells in the peripheral blood of early active RA patients (mean 4.25%) than in patients with reactive arthritis or in controls (mean 5.90 and 5.30%, respectively, P = 0.001 in each case). Frequencies in stable, well-controlled RA (mean 4.63%) were not significantly different from early active RA or controls. There were no differences in suppressor function between groups. Higher frequencies of CD4+CD25high T-cells were found in synovial fluid than blood in both RA and reactive arthritis. CONCLUSIONS These data demonstrate a smaller CD4+CD25high regulatory T-cell population in peripheral blood of individuals with early active RA prior to disease-modifying treatment. This may be a contributory factor in the susceptibility to RA and suggests novel approaches to therapy.
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Affiliation(s)
- C A Lawson
- Academic Unit of Musculoskeletal Disease, IMMECR, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
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Lawson CA, Donaldson IJ, Bowman SJ, Shefta J, Morgan AW, Gough A, Isaacs JD, Griffiths B, Emery P, Pease CT, Boylston AW. Analysis of the insertion/deletion related polymorphism within T cell antigen receptor beta variable genes in primary Sjögren's syndrome. Ann Rheum Dis 2005; 64:468-70. [PMID: 15708895 PMCID: PMC1755407 DOI: 10.1136/ard.2003.012823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To analyse T cell receptor beta variable (TCRBV) gene polymorphisms (insertion/deletion related polymorphism (IDRP) and BV6S7) in primary Sjögren's syndrome (PSS). METHODS Genomic DNA was extracted from blood samples from patients fulfilling the modified European criteria for PSS (n = 61). Healthy control blood samples were obtained from the Blood Transfusion Service (n = 121). As a disease control group, samples from patients with systemic lupus erythematosus (n = 42) were analysed. BV6S7 was genotyped using an established PCR/RFLP method. The IDRP was determined by comparison of the intensity of PCR product bands from within BV9S2 and an internal control region (BV9S1), to ascertain whether 0, 1, or 2 copies of the insertion were present. RESULTS There was a decrease (p = 0.018) in the proportion of PSS patients with the deleted/deleted genotype. There was no association with specific BV6S7 alleles or genotypes with either the PSS group or the hypergammaglobulinaemic subgroup. There were no significant differences in haplotype frequencies after Bonferroni correction. CONCLUSIONS A reduced proportion of patients with PSS have the deleted/deleted genotype. Eighty nine per cent of PSS patients have at least one extra germline copy of BV13S2*1. This may relate to previous observations of increased BV13 specific T cells and mRNA in the salivary glands.
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Affiliation(s)
- C A Lawson
- Molecular Medicine Unit, University of Leeds, Leeds, UK
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Morgan AW, Keyte VH, Babbage SJ, Robinson JI, Ponchel F, Barrett JH, Bhakta BB, Bingham SJ, Buch MH, Conaghan PG, Gough A, Green M, Lawson CA, Pease CT, Markham AF, Ollier WER, Emery P, Worthington J, Isaacs JD. FcgammaRIIIA-158V and rheumatoid arthritis: a confirmation study. Rheumatology (Oxford) 2003; 42:528-33. [PMID: 12649399 DOI: 10.1093/rheumatology/keg169] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To develop a robust assay for genotyping the FcgammaRIIIA-158V/F polymorphism and to confirm the putative association between the FcgammaRIIIA-158V allele and rheumatoid arthritis (RA). METHODS This allelic association study examined the FcgammaRIIIA-158V/F polymorphism for association with RA. A novel single-stranded conformational polymorphism assay was used to genotype 828 RA patients and 581 controls from the UK. RESULTS The FcgammaRIIIA-158V allele was associated with both RA (P=0.02) and nodules (P=0.04). Individuals homozygous for this higher affinity allele had a significantly increased risk of RA (OR 1.53, 95% CI 1.08-2.18) and the development of nodules (OR 2.20, 95% CI 1.20-4.01). There was no evidence of an interaction with the shared epitope. CONCLUSIONS We have developed a novel assay to genotype the FcgammaRIIIA-158F/V polymorphism and confirmed that homozygosity for the FcgammaRIIIA-158V allele is associated with UK Caucasian RA, particularly in those individuals with nodules, suggesting FcgammaRIIIA may play a role in determining disease severity or in the development of nodules per se.
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Affiliation(s)
- A W Morgan
- Rheumatology and Rehabilitation Research Unit, University of Leeds, UK.
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Karim Z, Wakefield RJ, Conaghan PG, Lawson CA, Goh E, Quinn MA, Astin P, O'Connor P, Gibbon WW, Emery P. The impact of ultrasonography on diagnosis and management of patients with musculoskeletal conditions. Arthritis Rheum 2001; 44:2932-3. [PMID: 11762954 DOI: 10.1002/1529-0131(200112)44:12<2932::aid-art481>3.0.co;2-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pinsky DJ, Liao H, Lawson CA, Yan SF, Chen J, Carmeliet P, Loskutoff DJ, Stern DM. Coordinated induction of plasminogen activator inhibitor-1 (PAI-1) and inhibition of plasminogen activator gene expression by hypoxia promotes pulmonary vascular fibrin deposition. J Clin Invest 1998; 102:919-28. [PMID: 9727060 PMCID: PMC508957 DOI: 10.1172/jci307] [Citation(s) in RCA: 149] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Oxygen deprivation, as occurs during tissue ischemia, tips the natural anticoagulant/procoagulant balance of the endovascular wall to favor activation of coagulation. To investigate the effects of low ambient oxygen tension on the fibrinolytic system, mice were placed in a hypoxic environment with pO2 < 40 Torr. Plasma levels of plasminogen activator inhibitor-1 (PAI-1) antigen, detected by ELISA, increased in a time-dependent fashion after hypoxic exposure (increased as early as 4 h, P < 0.05 vs. normoxic controls), and were accompanied by an increase in plasma PAI-1 activity by 4 h (P < 0.05 vs. normoxic controls). Northern analysis of hypoxic murine lung demonstrated an increase in PAI-1 mRNA compared with normoxic controls; in contrast, transcripts for both tissue-type plasminogen activator (tPA) and urokinase-type plasminogen activator (uPA) decreased under hypoxic conditions. Immunocolocalization studies identified macrophages as the predominant source of increased PAI-1 within hypoxic lung. Using a transformed murine macrophage line, striking induction of PAI-1 transcripts occurred under hypoxic conditions, due to both increased de novo transcription as well as increased mRNA stability. Consistent with an important role of the fibrinolytic system in hypoxia-induced fibrin accumulation, PAI-1 +/+ mice exposed to hypoxia exhibited increased pulmonary fibrin deposition based upon a fibrin immunoblot, intravascular fibrin identified by immunostaining, and increased accumulation of 125I-fibrinogen/fibrin in hypoxic tissue. In contrast, mice deficient for the PAI-1 gene (PAI-1 -/-) similarly exposed to hypoxic conditions did not display increased fibrin accumulation compared with normoxic PAI-1 +/+ controls. Furthermore, homozygous null uPA (uPA -/-) and tPA (tPA -/-) mice subjected to oxygen deprivation showed increased fibrin deposition compared with wild-type controls. These studies identify enhanced expression of PAI-1 as an important mechanism suppressing fibrinolysis under conditions of low oxygen tension, a response which may be further amplified by decreased expression of plasminogen activators. Taken together, these data provide insight into an important potential role of macrophages and the fibrinolytic system in ischemia-induced thrombosis.
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Affiliation(s)
- D J Pinsky
- Columbia University College of Physicians and Surgeons, New York 10032, USA.
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Yan SF, Lawson CA, Stern DM, Pinsky DJ. Hypoxia-mediated modulation of vascular function--implications for organ preservation and thrombogenesis: Roger S. Mitchell lecture. Chest 1998; 114:46S-50S. [PMID: 9676625 DOI: 10.1378/chest.114.1_supplement.46s] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- S F Yan
- Columbia University, College of Physicians and Surgeons, New York, USA
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Abstract
UNLABELLED Thermoregulatory arteriovenous shunt vasoconstriction may facilitate deep-vein thrombosis by producing relative venous stasis and hypoxia. Accordingly, we evaluated the effect of vasomotion on leg blood flow and venous oxygen tension. We studied five male volunteers, each of whom was warmed enough to trigger vasodilation and then cooled sufficiently to provoke thermoregulatory vasoconstriction. The process was then repeated during N2O/desflurane anesthesia. Venous oxygen tension and saturation (with a fraction of inspired oxygen of 1.0) were evaluated in blood samples taken from a catheter that was inserted into a saphenous vein at the ankle and advanced until the tip was proximal to the knee. Thermoregulatory vasodilation with or without general anesthesia significantly increased arteriovenous shunt flow by approximately 10-fold, and increased total leg flow approximately sixfold. However, vasodilated flows were similar with and without general anesthesia, as were vasoconstricted flows. Before induction of anesthesia, thermoregulatory vasodilation increased venous oxygen tension from 46 +/- 6 to 187 +/- 99 mm Hg and venous saturation from 79% +/- 6% to 99% +/- 2%. After induction of anesthesia, thermoregulatory vasodilation increased venous oxygen tension from 55 +/- 11 to 356 +/- 103 mm Hg and venous saturation from 84% +/- 8% to 100% +/- 0%. Our data thus indicate that thermoregulatory vasodilation markedly increases both leg flow and venous oxygenation; and that both factors may help prevent perioperative venous thrombosis. IMPLICATIONS Thermoregulatory arteriovenous shunt vasoconstriction may facilitate deep-vein thrombosis by producing related venous stasis and hypoxia. In male volunteers, the authors found that when vasodilation induced by warming was produced, both blood flow and venous oxygenation increased, both of which may help prevent perioperative venous thrombosis.
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Affiliation(s)
- F Tayefeh
- Department of Anesthesia, University of California, San Francisco 94143-0648, USA
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Lawson CA, Yan SD, Yan SF, Liao H, Zhou YS, Sobel J, Kisiel W, Stern DM, Pinsky DJ. Monocytes and tissue factor promote thrombosis in a murine model of oxygen deprivation. J Clin Invest 1997; 99:1729-38. [PMID: 9120018 PMCID: PMC507994 DOI: 10.1172/jci119337] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Clinical conditions associated with local or systemic hypoxemia can lead to prothrombotic diatheses. This study was undertaken to establish a model of whole-animal hypoxia wherein oxygen deprivation by itself would be sufficient to trigger tissue thrombosis. Furthermore, this model was used to test the hypothesis that hypoxia-induced mononuclear phagocyte (MP) recruitment and tissue factor (TF) expression may trigger the local deposition of fibrin which occurs in response to oxygen deprivation. Using an environmental chamber in which inhaled oxygen tension was lowered to 6%, hypoxic induction of thrombosis was demonstrated in murine pulmonary vasculature by 8 h based upon: (a) immunohistologic evidence of fibrin formation in hypoxic lung tissue using an antifibrin antibody, confirmed by 22.5-nm strand periodicity by electron microscopy; (b) immunoblots revealing fibrin gamma-gamma chain dimers in lungs from hypoxic but not normoxic mice or hypoxic mice treated with hirudin; (c) accelerated deposition of 125I-fibrin/fibrinogen and 111In-labeled platelets in the lung tissue of hypoxic compared with normoxic animals; (d) reduction of tissue 125I-fibrin/fibrinogen accumulation in animals which had either been treated with hirudin or depleted of platelets before hypoxic exposure. Because immunohistochemical analysis of hypoxic pulmonary tissue revealed strong MP staining for TF, confirmed by increased TF RNA in hypoxic lungs, and because 111In-labeled murine MPs accumulated in hypoxic pulmonary tissue, we evaluated whether recruited MPs might be responsible for initiation of hypoxia-induced thrombosis. This hypothesis was supported by several lines of evidence: (a) MP depletion before hypoxia reduced thrombosis, as measured by reduced 125I-fibrin/fibrinogen deposition and reduced accumulation of cross-linked fibrin by immunoblot; (b) isolated murine MPs demonstrated increased TF immunostaining when exposed to hypoxia; and (c) administration of an anti-rabbit TF antibody that cross-reacts with murine TF decreased 125I-fibrin/fibrinogen accumulation and cross-linked fibrin accumulation in response to hypoxia in vivo. In summary, these studies using a novel in vivo model suggest that MP accumulation and TF expression may promote hypoxia-induced thrombosis.
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Affiliation(s)
- C A Lawson
- Department of Anesthesiology, Columbia University, College of Physicians and Surgeons, New York, NY 10032, USA
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Abstract
Case manager responses to failed appointments were monitored for 83 seriously mentally ill persons in a rural community mental health center. Case manager actions taken were grouped into four categories of follow-up from most intensive to least intensive: home visit, phone call, letter, and no follow-up. On the whole, case managers most frequently did not follow-up missed appointments (56.7%), followed up by letters (21.3%), and telephone calls (18.7%), and home visits (3.3%). Analyses revealed that home visits were most intensive and all clients who were visited following failed appointments did not fail the subsequent appointment. Clients who received telephone calls or letters were about equally likely to fail the subsequent appointment, but were much more likely to attend the subsequent appointment than were clients who received no follow-up to the failed appointment. Interestingly, clients who failed appointments and received no follow-up were much more likely to need emergency services rather than a regular appointment as their next contact with the clinic.
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Affiliation(s)
- M B Blank
- Southeastern Rural Mental Health Research Center, University of Virginia, Charlottesville 22902, USA
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Pinsky DJ, Naka Y, Liao H, Oz MC, Wagner DD, Mayadas TN, Johnson RC, Hynes RO, Heath M, Lawson CA, Stern DM. Hypoxia-induced exocytosis of endothelial cell Weibel-Palade bodies. A mechanism for rapid neutrophil recruitment after cardiac preservation. J Clin Invest 1996; 97:493-500. [PMID: 8567972 PMCID: PMC507042 DOI: 10.1172/jci118440] [Citation(s) in RCA: 221] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The period of hypoxia is an important priming event for the vascular dysfunction that accompanies reperfusion, with endothelial cells (ECs) and neutrophils (PMNs) playing a central role. We hypothesized that EC Weibel-Palade (WP) body exocytosis during the hypoxic/ischemic period during organ preservation permits brisk PMN recruitment into postischemic tissue, a process further amplified in an oxidant-rich milieu. Exposure of human umbilical vein ECs to a hypoxic environment (pO2 approximately 20 torr) stimulated release of von Willebrand factor (vWF), stored in EC WP bodies, as well as increased expression of the WP body-derived PMN adhesion molecule P-selectin at the EC surface. Increased binding of 111In-labeled PMNs to hypoxic EC monolayers (compared with normoxic controls) was blocked with a blocking antibody to P-selectin, but was not affected by a nonblocking control antibody. Although increased P-selectin expression and vWF release were also noted during reoxygenation, hypoxia alone (even in the presence of antioxidants) was sufficient to increase WP body exocytosis. To determine the relevance of these observations to hypothermic cardiac preservation, during which the pO2 within the cardiac vasculature declines to similarly low levels, experiments were performed in a rodent (rat and mouse) cardiac preservation/transplantation model. Immunodepletion of recipient PMNs or administration of a blocking anti-P-selectin antibody before transplantation resulted in reduced graft neutrophil infiltration and improved graft survival, compared with identically preserved hearts transplanted into control recipients. To establish the important role of endothelial P-selectin expression on the donor vasculature, murine cardiac transplants were performed using homozygous P-selectin deficient and wild-type control donor hearts flushed free of blood/platelets before preservation/transplantation. P-selectin-null hearts transplanted into wild-type recipients demonstrated a marked (13-fold) reduction in graft neutrophil infiltration and increased graft survival compared with wild-type hearts transplanted into wild-type recipients. To determine whether coronary endothelial WP exocytosis may occur during cardiac preservation in humans, the release of vWF into the coronary sinus (CS) was measured in 32 patients during open heart surgery. CS samples obtained at the start and conclusion of the ischemic period demonstrated an increase in CS vWF antigen (by ELISA) consisting of predominantly high molecular weight multimers (by immunoelectrophoresis). These data suggest that EC WP exocytosis occurs during hypothermic cardiac preservation, priming the vasculature to recruit PMNs rapidly during reperfusion.
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Affiliation(s)
- D J Pinsky
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York 10032, USA
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Lawson CA, Smerling AJ, Naka Y, Burkhoff D, Dickstein ML, Stern DM, Pinsky DJ. Selective reduction of PVR by inhalation of a cGMP analogue in a porcine model of pulmonary hypertension. Am J Physiol 1995; 268:H2056-62. [PMID: 7771555 DOI: 10.1152/ajpheart.1995.268.5.h2056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Selective reduction of pulmonary vascular resistance (PVR) remains a therapeutic goal for the treatment of pulmonary hypertension, but current therapeutic options remain limited. Although the gas nitric oxide (NO) selectively dilates the pulmonary vascular bed, it requires special equipment for administration, has a short biologic half-life, and is potentially toxic. We hypothesized that stimulation of the NO pathway at the level of its second messenger, guanosine 3',5'-cyclic monophosphate (cGMP), by targeted pulmonary delivery of a membrane-permeable nonhydrolyzable cGMP analogue would cause selective pulmonary vasodilation. Pulmonary hypertension was induced in 21 pigs by the intravenous infusion of a thromboxane A2 analogue (9,11-dideoxy-9 alpha,11 alpha-epoxymethanoprostaglandin F2 alpha). Inhaled 8-bromoguanosine 3',5'-cyclic monophosphate (8-BrcGMP) lowered PVR in a time- and dose-dependent manner, with maximal effect achieved after 20 min. Compared with physiological saline control, 8-BrcGMP inhalation (3.0 micrograms/kg) lowered PVR by 25 +/- 3% (P < 0.01), whereas there was no significant decline in systemic vascular resistance (4 +/- 6%); mean pulmonary arterial pressure declined 13 +/- 3% (P < 0.01), whereas there was little change in mean arterial pressure; cardiac output increased 10 +/- 4% (P < 0.05). PVR did not decrease after inhalation of noncyclic 8-bromoguanosine 5'-monophosphate, indicating that stimulation of the NO-cGMP pathway beyond the level of NO results in pulmonary vasodilation independent of stimulation of purinergic receptors.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C A Lawson
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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McIntosh GH, McMurchie EJ, James M, Lawson CA, Bulman FH, Charnock JS. Influence of dietary fats on blood coagulation and prostaglandin production in the common marmoset. Arteriosclerosis 1987; 7:159-65. [PMID: 3107535 DOI: 10.1161/01.atv.7.2.159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Common marmosets were fed a standard marmoset diet (REF) or diets supplemented with 12% (wt/wt) sunflower seed oil (SSO) or sheep fat (SF) for a period of 90 weeks. The values for coagulation indices, clotting time, and Russel viper venom time were consistent with decreased thrombotic tendency of platelets from animals on the SSO diet relative to the low fat, REF diet animals, while an increased tendency to thrombosis was observed with SF-fed marmosets. The SSO- and SF-supplemented marmosets showed a significantly reduced thromboxane (TXB2) generation from platelets aggregating to collagen (ASC) relative to the REF group, while at 50 micrograms/ml ASC this difference was maintained only by the SSO group. The SF diet-fed marmosets showed a reduced prostacyclin (measured as 6-keto-PGF1 alpha) generation from incubated aorta relative to the REF or SSO-fed groups, which were not different from each other. A reduced proportion of platelet phospholipid arachidonic acid (20:4, n-6) and increased alpha-tocopherol concentration was consistent with the decreased aggregability and thromboxane generation of platelets from SSO-fed marmosets relative to the REF and SF groups. The SF diet-fed marmosets, on the other hand, showed minimal change in arachidonic acid, alpha-tocopherol or platelet reactivity from the REF group. These differing responses to dietary fats are discussed in relation to the potential for the development of thrombosis and atherosclerosis.
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Lawson CA, Werner R, Nugent SK. Parental stress during and after pediatric ICU hospitalization. Indiana Med 1985; 78:372-5. [PMID: 3998454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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McIntosh GH, McLennan PL, Lawson CA, Bulman FH, Charnock JS. The influence of dietary fats on plasma lipids, blood pressure and coagulation indices in the rat. Atherosclerosis 1985; 55:125-34. [PMID: 4004986 DOI: 10.1016/0021-9150(85)90091-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Male Hooded Wistar rats were fed a commercial rat diet supplemented 12% by weight with sheep fat, sunflower seed oil and fish oil (tuna) over a period of 8 months. The influence of these diets on plasma fatty acids, triglycerides and cholesterol, blood pressure, body weight and coagulation indices was assessed. The sheep fat (SF)-fed rats showed a significant increase in body weight over the reference group (C) of 18%, and systolic blood pressure increased by 9.4%, whereas other dietary groups were not significantly affected. The fish oil (TFO)-fed rats showed a significant lowering of plasma cholesterol (-16.6%) and triglyceride (-47%) relative to the reference group, while the sunflower seed oil (SSO) group showed only a lowered plasma triglyceride (-32%). Plasma fatty acids in general reflected closely the dietary fatty acids, with some exceptions. Coagulation indices provided a consistent picture of an increased tendency to thrombosis in SF-fed rats and a significantly reduced tendency in the TFO-fed rats relative to reference rats. Fish oil rich in 20:5 and 22:6 omega 3 long-chain polyunsaturated fatty acids and low in cholesterol appears to have advantages in terms of reducing those parameters identified as risk factors for coronary heart disease in man. Sheep fat supplements rich in saturated fatty acids produce the opposite trend.
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Morris RV, Lauer HV, Lawson CA, Gibson EK, Nace GA, Stewart C. Spectral and other physicochemical properties of submicron powders of hematite (alpha-Fe2O3), maghemite (gamma-Fe2O3), magnetite (Fe3O4), goethite (alpha-FeOOH), and lepidocrocite (gamma-FeOOH). J Geophys Res 1985; 90:3126-44. [PMID: 11542003 DOI: 10.1029/jb090ib04p03126] [Citation(s) in RCA: 112] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Spectral and other physicochemical properties were determined for a suite of submicron powders of hematite (alpha-Fe2O3), maghemite (gamma-Fe2O3), magnetite (Fe3O4), goethite (alpha-FeOOH), and lepidocrocite (gamma-FeOOH). The spectral reflectivity measurements were made between 0.35 and 2.20 micrograms over the temperature interval between about -110 degrees and 20 degrees C. Other physicochemical properties determined were mean particle diameter, particle shape, chemical composition, crystallographic phase, magnetic properties, and Mossbauer properties. Only the magnetite powders have significant departures from the stoichiometric phase; they are actually cation-deficient magnetites having down to about 18.0 wt % FeO as compared with 31.0 wt % FeO for stoichiometric magnetite. A structured absorption edge due to crystal field transitions and extending from weak absorption in the near-IR to intense absorption in the near-UV is characteristic of the ferric oxides and oxyhydroxides and is responsible for their intense color. Particularly for hematite, the number and position of the spectral features are consistent with significant splitting of the degenerate cubic levels by noncubic components of the crystal field. The position of the crystal-field band at lowest energy, assigned to the envelope of the components of the split cubic 4T1 level, is near 0.86, 0.91, 0.92, and 0.98 microgram at room temperature for hematite, goethite, maghemite, and lepidocrocite, respectively. Comparison with Mossbauer data suggests covalent character increases sequentially through the aforementioned series. The positions of the spectra features are relatively independent of temperature down to about -110 degrees C. The maximum shifts observed were on the order of about 0.02 microgram shortward for the ferric oxyhydroxides. Variations in the magnitude of the reflectivity of the hematite powders as a function of mean particle diameter are consistent with scattering theory. The absorption strength of the crystal-field bands increases with increasing mean particle diameter over the range 0.1-0.8 micrometer; visually this corresponds to a change in color from orange to deep purple. The position of the split cubic 4T1 band shifts longward by about 0.02 micrometer with decreasing mean particle diameter over the same range; this trend is consistent with wavelength-dependent scattering. The cation-deficient magnetite powders are very strong absorbers throughout the near-UV, visible and near-IR; their spectral properties are independent of temperature between about -110 and 20 degrees C.
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Affiliation(s)
- R V Morris
- Experimental Planetology Branch, NASA Johnson Space Center, Houston, Texas, USA
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McIntosh GH, Lawson CA, Rodgers SE, Lloyd JV. Haematological characteristics of the common marmoset (Callithrix jacchus jacchus). Res Vet Sci 1985; 38:109-14. [PMID: 3919433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Blood cell indices and parameters of haemostasis were studied in the common marmoset. The majority of the results were similar to those found in man. Differences from man were that the prothrombin time was shorter in the marmoset, higher concentrations of aggregating stimuli were required to cause platelet aggregation, and marmoset platelets did not aggregate under the influence of adrenalin. There was sexual dimorphism evident in the data for fibrinogen concentration and for platelet count, both of which were higher in females than in males. Marmoset platelets were very similar in ultrastructure to those of man.
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Overstreet DH, Crocker AD, Lawson CA, McIntosh GH, Crocker JM. Alterations in the dopaminergic system and behaviour in rats reared on iodine-deficient diets. Pharmacol Biochem Behav 1984; 21:561-5. [PMID: 6504954 DOI: 10.1016/s0091-3057(84)80040-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Male rats raised on an iodine-deficient diet were found to be retarded in growth rate, to have lowered body temperature, and to have poorer memory retention of a passive avoidance task than rats raised on a similar diet but with adequate iodine concentration. In addition, the iodine deficient rats showed increased locomotor activity and sniffing frequency after the dopamine agonist, apomorphine; while their operant performance was inhibited to a greater degree after apomorphine. However, the hypothermic effects of apomorphine were comparable in both iodine-deficient and normal rats. At sacrifice the iodine-deficient rats were found to have significantly depressed thyroxine levels (less than 10% of normal), significantly elevated TSH levels (greater than 700% of normal), and a significantly greater concentration of dopamine receptors in the striatum (28% increase). Thus, rats raised on iodine-deficient diets have considerable behavioural and physiological alterations, including an increased concentration of dopamine receptors.
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Abstract
Examination of synthetic ilmenite-hematite samples by transmission electron microscopy has for the first time revealed the presence of well-defined antiphase domains and antiphase domain boundaries in this mineral system. Samples quenched from 1300 degrees C have a high density of domain boundaries, whereas samples quenched from 900 degrees C have a much lower density. Only the high-temperature samples acquire reverse thermoremanent magnetism when cooled in an applied magnetic field. The presence of a high density of domain boundaries seems to be a necessary condition for the acquisition of reverse thermoremanent magnetism.
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