1
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Utzschneider KM, Younes N, Butera NM, Balasubramanyam A, Bergenstal RM, Barzilay J, DeSouza C, DeFronzo RA, Elasy T, Krakoff J, Kahn SE, Rasouli N, Valencia WM, Sivitz WI. Impact of Insulin Sensitivity and β-Cell Function Over Time on Glycemic Outcomes in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE): Differential Treatment Effects of Dual Therapy. Diabetes Care 2024; 47:571-579. [PMID: 38190619 PMCID: PMC10973903 DOI: 10.2337/dc23-1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/08/2023] [Accepted: 10/10/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To compare the effects of insulin sensitivity and β-cell function over time on HbA1c and durability of glycemic control in response to dual therapy. RESEARCH DESIGN AND METHODS GRADE participants were randomized to glimepiride (n = 1,254), liraglutide (n = 1,262), or sitagliptin (n = 1,268) added to baseline metformin and followed for mean ± SD 5.0 ± 1.3 years, with HbA1c assessed quarterly and oral glucose tolerance tests at baseline, 1, 3, and 5 years. We related time-varying insulin sensitivity (HOMA 2 of insulin sensitivity [HOMA2-%S]) and early (0-30 min) and total (0-120 min) C-peptide (CP) responses to changes in HbA1c and glycemic failure (primary outcome HbA1c ≥7% [53 mmol/mol] and secondary outcome HbA1c >7.5% [58 mmol/mol]) and examined differential treatment responses. RESULTS Higher HOMA2-%S was associated with greater initial HbA1c lowering (3 months) but not subsequent HbA1c rise. Greater CP responses were associated with a greater initial treatment response and slower subsequent HbA1c rise. Higher HOMA2-%S and CP responses were each associated with lower risk of primary and secondary outcomes. These associations differed by treatment. In the sitagliptin group, HOMA2-%S and CP responses had greater impact on initial HbA1c reduction (test of heterogeneity, P = 0.009 HOMA2-%S, P = 0.018 early CP, P = 0.001 total CP) and risk of primary outcome (P = 0.005 HOMA2-%S, P = 0.11 early CP, P = 0.025 total CP) but lesser impact on HbA1c rise (P = 0.175 HOMA2-%S, P = 0.006 early CP, P < 0.001 total CP) in comparisons with the glimepiride and liraglutide groups. There were no differential treatment effects on secondary outcome. CONCLUSIONS Insulin sensitivity and β-cell function affected treatment outcomes irrespective of drug assignment, with greater impact in the sitagliptin group on initial (short-term) HbA1c response in comparison with the glimepiride and liraglutide groups.
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Affiliation(s)
- Kristina M. Utzschneider
- VA Puget Sound Health Care System and Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - Naji Younes
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Nicole M. Butera
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | | | - Joshua Barzilay
- Department of Endocrinology, Kaiser Permanente of Georgia, Duluth, GA
| | - Cyrus DeSouza
- Division of Diabetes, Endocrinology and Metabolism, University of Nebraska and Omaha VA Medical Center, Omaha, NE
| | - Ralph A. DeFronzo
- Diabetes Division, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Tom Elasy
- Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan Krakoff
- Division of General Internal Medicine and Public Health, Southwestern American Indian Center, Phoenix, AZ
| | - Steven E. Kahn
- VA Puget Sound Health Care System and Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - Neda Rasouli
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, and VA Eastern Colorado Health Care System, Aurora, CO
| | - Willy M. Valencia
- Geriatric Research Education and Clinical Center, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL
- Department of Public Health Sciences, University of Miami, Miami, FL
- Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL
- Endocrinology & Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - William I. Sivitz
- Department of Internal Medicine, Endocrinology and Metabolism, University of Iowa, Iowa City, IA
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2
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Green JB, Everett BM, Ghosh A, Younes N, Krause-Steinrauf H, Barzilay J, Desouza C, Inzucchi SE, Pokharel Y, Schade D, Scrymgeour A, Tan MH, Utzschneider KM, Mudaliar S. Cardiovascular Outcomes in GRADE (Glycemia Reduction Approaches in Type 2 Diabetes: A Comparative Effectiveness Study). Circulation 2024; 149:993-1003. [PMID: 38344820 PMCID: PMC10978227 DOI: 10.1161/circulationaha.123.066604] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Cardiovascular disease is a major cause of morbidity and mortality in patients with type 2 diabetes. The effects of glucose-lowering medications on cardiovascular outcomes in individuals with type 2 diabetes and low cardiovascular risk are unclear. We investigated cardiovascular outcomes by treatment group in participants randomly assigned to insulin glargine, glimepiride, liraglutide, or sitagliptin, added to baseline metformin, in GRADE (Glycemia Reduction Approaches in Type 2 Diabetes: A Comparative Effectiveness Study). METHODS A total of 5047 participants with a mean±SD age of 57.2±10.0 years, type 2 diabetes duration of 4.0±2.7 years, and low baseline prevalence of cardiovascular disease (myocardial infarction, 5.1%; cerebrovascular accident, 2.0%) were followed for a median of 5 years. Prespecified outcomes included between-group time-to-first event analyses of MACE-3 (composite of major adverse cardiovascular events: cardiovascular death, myocardial infarction, and stroke), MACE-4 (MACE-3+unstable angina requiring hospitalization or revascularization), MACE-5 (MACE-4+coronary revascularization), MACE-6 (MACE-5+hospitalization for heart failure), and the individual components. MACE outcomes and hospitalization for heart failure in the liraglutide-treated group were compared with the other groups combined using Cox proportional hazards models. MACE-6 was also analyzed as recurrent events using a proportional rate model to compare all treatment groups. RESULTS We observed no statistically significant differences in the cumulative incidence of first MACE-3, MACE-4, MACE-5, or MACE-6, or their individual components, by randomized treatment group. However, when compared with the other treatment groups combined, the liraglutide-treated group had a significantly lower risk of MACE-5 (adjusted hazard ratio, 0.70 [95% CI, 0.54-0.91]; P=0.021), MACE-6 (adjusted hazard ratio, 0.70 [95% CI, 0.55-0.90]; P=0.021), and hospitalization for heart failure (adjusted hazard ratio, 0.49 [95% CI, 0.28-0.86]; P=0.022). Compared with the liraglutide group, significantly higher rates of recurrent MACE-6 events occurred in the groups treated with glimepiride (rate ratio, 1.61 [95% CI, 1.13-2.29]) or sitagliptin (rate ratio 1.75; [95% CI, 1.24-2.48]). CONCLUSIONS This comparative effectiveness study of a contemporary cohort of adults with type 2 diabetes, largely without established cardiovascular disease, suggests that liraglutide treatment may reduce the risk of cardiovascular events in patients at relatively low risk compared with other commonly used glucose-lowering medications. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01794143.
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Affiliation(s)
- Jennifer B. Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Brendan M. Everett
- Divisions of Cardiovascular and Preventive Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Alokananda Ghosh
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Rockville, MD
| | - Naji Younes
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Rockville, MD
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Rockville, MD
| | - Joshua Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia, and Department of Endocrinology, Emory University School of Medicine, Atlanta, GA
| | - Cyrus Desouza
- Division of Diabetes, Endocrinology & Metabolism, University of Nebraska Medical Center, Omaha VA Medical Center, Omaha, NE
| | | | - Yashashwi Pokharel
- Division of Cardiology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - David Schade
- Division of Endocrinology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Alexandra Scrymgeour
- VA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM
| | - Meng H. Tan
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Sunder Mudaliar
- VA San Diego Healthcare System and University of California, San Diego, CA
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Luchsinger JA, Kazemi EJ, Sanchez DL, Larkin ME, Valencia WM, Desouza C, Carlson AL, Pop-Busui R, Seaquist ER, Florez HJ, Barzilay J. BMI, insulin sensitivity, and cognition in early type 2 diabetes: The Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study. Obesity (Silver Spring) 2023; 31:1812-1824. [PMID: 37368512 PMCID: PMC11103776 DOI: 10.1002/oby.23785] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 08/10/2022] [Revised: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE This study explored the association of BMI and insulin sensitivity with cognitive performance in type 2 diabetes. METHODS A cross-sectional analysis of data from the baseline assessment of the Glycemia Reduction Approaches in Diabetes: a Comparative Effectiveness Study (GRADE) was conducted. BMI was used as a surrogate of adiposity and the Matsuda index as the measure of insulin sensitivity. Cognitive tests included the Spanish English Verbal Learning Test, the Digit Symbol Substitution Test, and the letter and animal fluency tests. RESULTS Cognitive assessments were completed by 5018 (99.4%) of 5047 participants aged 56.7 ± 10.0 years, of whom 36.4% were female. Higher BMI and lower insulin sensitivity were related to better performance on memory and verbal fluency tests. In models including BMI and insulin sensitivity simultaneously, only higher BMI was related to better cognitive performance. CONCLUSIONS In this study, higher BMI and lower insulin sensitivity in type 2 diabetes were cross-sectionally associated with better cognitive performance. However, only higher BMI was related to cognitive performance when both BMI and insulin sensitivity were considered simultaneously. The causality and mechanisms for this association need to be determined in future studies.
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Affiliation(s)
- José A. Luchsinger
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Erin J. Kazemi
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute of Public Health, The George Washington University, Rockville, Maryland, USA
| | - Danurys L. Sanchez
- Department of Neurology, Gertrude H. Hergievsky Center, Columbia University Irving Medical Center, New York, New York, USA
| | - Mary E. Larkin
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Willy Marcos Valencia
- Department of Medicine, University of Miami, Miami, Florida, USA
- Geriatric Research Education and Clinical Center, Miami VA Healthcare System, Miami, Florida, USA
- Department of Humanities, Health and Society, Florida International University, Miami, Florida, USA
| | - Cyrus Desouza
- Omaha VA Medical Center and University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Rodica Pop-Busui
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Hermes J. Florez
- Department of Medicine, University of Miami, Miami, Florida, USA
- Geriatric Research Education and Clinical Center, Miami VA Healthcare System, Miami, Florida, USA
- Medical College of South Carolina, Charleston, South Carolina, USA
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4
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Luchsinger JA, Younes N, Manly JJ, Barzilay J, Valencia W, Larkin ME, Falck-Ytter C, Krause-Steinrauf H, Pop-Busui R, Florez H, Seaquist E. Association of Glycemia, Lipids, and Blood Pressure With Cognitive Performance in People With Type 2 Diabetes in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). Diabetes Care 2021; 44:2286-2292. [PMID: 34285097 PMCID: PMC8740937 DOI: 10.2337/dc20-2858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 06/19/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Type 2 diabetes is a risk factor for cognitive impairment. We examined the relation of glycemia, lipids, blood pressure (BP), hypertension history, and statin use with cognition in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). RESEARCH DESIGN AND METHODS Cross-sectional analyses from GRADE at baseline examined the association of glycemia (hemoglobin A1c [HbA1c]), LDL, systolic BP (SBP) and diastolic BP (DBP), hypertension history, and statin use with cognition assessed by the Spanish English Verbal Learning Test, letter and animal fluency tests, and Digit Symbol Substitution Test (DSST). RESULTS Among 5,047 GRADE participants, 5,018 (99.4%) completed cognitive assessments. Their mean age was 56.7 ± 10.0 years, and 36.4% were women. Mean diabetes duration was 4.0 ± 2.7 years. HbA1c was not related to cognition. Higher LDL was related to modestly worse DSST scores, whereas statin use was related to modestly better DSST scores. SBP between 120 and 139 mmHg and DBP between 80 and 89 mmHg were related to modestly better DSST scores. Hypertension history was not related to cognition. CONCLUSIONS In people with type 2 diabetes of a mean duration of <5 years, lower LDL and statin use were related to modestly better executive cognitive function. SBP levels in the range of 120-139 mmHg and DBP levels in the range of 80-89 mmHg, but not lower levels, were related to modestly better executive function. These differences may not be clinically significant.
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Affiliation(s)
- José A Luchsinger
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, NY
| | - Naji Younes
- The Biostatistics Center, Department of Bios-tatistics and Bioinformatics, Milken Institute of Public Health, The George Washington University, Rockville, MD
| | - Jennifer J Manly
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | | | - Willy Valencia
- Department of Medicine, University of Miami, Miami, FL.,Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL
| | - Mary E Larkin
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, MA
| | - Corinna Falck-Ytter
- Department of Medicine, VA North East Ohio Healthcare System, Case Western Reserve University, Cleveland, OH
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Bios-tatistics and Bioinformatics, Milken Institute of Public Health, The George Washington University, Rockville, MD
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Hermes Florez
- Department of Medicine, University of Miami, Miami, FL.,Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL
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Utzschneider KM, Younes N, Rasouli N, Barzilay J, Banerji MA, Cohen RM, Gonzalez EV, Mather KJ, Ismail-Beigi F, Raskin P, Wexler DJ, Lachin JM, Kahn SE. Association of glycemia with insulin sensitivity and β-cell function in adults with early type 2 diabetes on metformin alone. J Diabetes Complications 2021; 35:107912. [PMID: 33752962 PMCID: PMC8048071 DOI: 10.1016/j.jdiacomp.2021.107912] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/17/2021] [Accepted: 03/06/2021] [Indexed: 12/31/2022]
Abstract
AIMS Evaluate the relationship between measures of glycemia with β-cell function and insulin sensitivity in adults with early type 2 diabetes mellitus (T2DM). METHODS This cross-sectional analysis evaluated baseline data from 3108 adults with T2DM <10 years treated with metformin alone enrolled in the Glycemia Reduction Approaches in Diabetes. A Comparative Effectiveness (GRADE) Study. Insulin and C-peptide responses and insulin sensitivity were calculated from 2-h oral glucose tolerance tests. Regression models evaluated the relationships between glycemic measures (HbA1c, fasting and 2-h glucose), measures of β-cell function and insulin sensitivity. RESULTS Insulin and C-peptide responses were inversely associated with insulin sensitivity. Glycemic measures were inversely associated with insulin and C-peptide responses adjusted for insulin sensitivity. HbA1c demonstrated modest associations with β-cell function (range: r - 0.22 to -0.35). Fasting and 2-h glucose were associated with early insulin and C-peptide responses (range: r - 0.37 to -0.40) as well as late insulin and total insulin and C-peptide responses (range: r - 0.50 to -0.60). CONCLUSION Glycemia is strongly associated with β-cell dysfunction in adults with early T2DM treated with metformin alone. Efforts to improve glycemia should focus on interventions aimed at improving β-cell function. This Trial is registered in Clinicaltrials.gov as NCT01794143.
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Affiliation(s)
| | - Naji Younes
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | | | | | - Mary Ann Banerji
- State University of New York (SUNY), Downstate Medical Center; Brooklyn, NY
| | - Robert M Cohen
- University of Cincinnati and Cincinnati VA Medical Center; Cincinnati, OH
| | | | | | | | - Philip Raskin
- University of Texas – Southwestern Medical Center; Dallas, Texas
| | - Deborah J Wexler
- Diabetes Research Center, Massachusetts General Hospital, Harvard Medical School; Boston, MA
| | - John M Lachin
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Steven E Kahn
- VA Puget Sound Health Care System and University of Washington; Seattle, WA
| | - GRADE Research Group
- A Listing of GRADE Research Group Members is available on the GRADE Study Webpage: https://grade.bsc.gwu.edu/ancillary-study-info
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6
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Barzilay J, Garvey WT. Arterial Stiffness: Comment on the Article by Pavloska et al. Endocr Pract 2021; 27:640-641. [PMID: 33895316 DOI: 10.1016/j.eprac.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Joshua Barzilay
- Kaiser Permanente of Georgia, Emory University School of Medicine, Georgia.
| | - W Timothy Garvey
- University of Alabama School of Medicine at Birmingham, Birmingham, Alabama
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7
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Garg PK, Biggs ML, Barzilay J, Djousse L, Hirsch C, Ix JH, Kizer JR, Tracy RP, Newman AB, Siscovick DS, Mukamal KJ. Advanced glycation end product carboxymethyl-lysine and risk of incident peripheral artery disease in older adults: The Cardiovascular Health Study. Diab Vasc Dis Res 2019; 16:483-485. [PMID: 31064218 PMCID: PMC6697602 DOI: 10.1177/1479164119847481] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Carboxymethyl-lysine is an advanced glycation end product that is detectable in the serum. Higher carboxymethyl-lysine levels have been associated with increased risk of coronary heart disease, stroke and cardiovascular mortality. We determined whether high carboxymethyl-lysine levels are also associated with the risk of peripheral artery disease in Cardiovascular Health Study participants who were all aged 65 years and older at baseline. Multivariate Cox proportional hazards models were used to determine the association of baseline carboxymethyl-lysine levels with incident peripheral artery disease in 3267 individuals followed for a median length of 10.0 years. A total of 157 cases of incident peripheral artery disease occurred during follow-up. No significant relationship between carboxymethyl-lysine and risk of peripheral artery disease was found (hazard ratio per standard deviation increment = 1.03; 95% confidence interval = 0.87, 1.23).
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Affiliation(s)
- Parveen K Garg
- 1 Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mary L Biggs
- 2 Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Luc Djousse
- 4 Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Calvin Hirsch
- 5 Department of Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Joachim H Ix
- 6 Division of Nephrology-Hypertension, School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Jorge R Kizer
- 7 Cardiology Section, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
- 8 Departments of Medicine, and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Russell P Tracy
- 9 Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Anne B Newman
- 10 Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Kenneth J Mukamal
- 12 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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8
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Owen-Smith AA, Gerth J, Sineath RC, Barzilay J, Becerra-Culqui TA, Getahun D, Giammattei S, Hunkeler E, Lash TL, Millman A, Nash R, Quinn VP, Robinson B, Roblin D, Sanchez T, Silverberg MJ, Tangpricha V, Valentine C, Winter S, Woodyatt C, Song Y, Goodman M. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals. J Sex Med 2018; 15:591-600. [PMID: 29463478 DOI: 10.1016/j.jsxm.2018.01.017] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [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: 12/01/2017] [Revised: 01/19/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transgender individuals sometimes seek gender confirmation treatments (GCT), including hormone therapy (HT) and/or surgical change of the chest and genitalia ("top" and "bottom" gender confirmation surgeries). These treatments may ameliorate distress resulting from the incongruence between one's physical appearance and gender identity. AIM The aim was to examine the degree to which individuals' body-gender congruence, body image satisfaction, depression, and anxiety differed by GCT groups in cohorts of transmasculine (TM) and transfeminine (TF) individuals. METHODS The Study of Transition, Outcomes, and Gender is a cohort study of transgender individuals recruited from 3 health plans located in Georgia, Northern California, and Southern California; cohort members were recruited to complete a survey between 2015-2017. Participants were asked about: history of GCT; body-gender congruence; body image satisfaction; depression; and anxiety. Participants were categorized as having received: (1) no GCT to date; (2) HT only; (3) top surgery; (4) partial bottom surgery; and (5) definitive bottom surgery. OUTCOMES Outcomes of interest included body-gender congruence, body image satisfaction, depression, and anxiety. RESULTS Of the 2,136 individuals invited to participate, 697 subjects (33%) completed the survey, including 347 TM and 350 TF individuals. The proportion of participants with low body-gender congruence scores was significantly higher in the "no treatment" group (prevalence ratio [PR] = 3.96, 95% CI 2.72-5.75) compared to the definitive bottom surgery group. The PR for depression comparing participants who reported no treatment relative to those who had definitive surgery was 1.94 (95% CI 1.42-2.66); the corresponding PR for anxiety was 4.33 (95% CI 1.83-10.54). CLINICAL TRANSLATION Withholding or delaying GCT until depression or anxiety have been treated may not be the optimal treatment course given the benefits of reduced levels of distress after undergoing these interventions. CONCLUSIONS Strengths include the well-defined sampling frame, which allowed correcting for non-response, a sample with approximately equal numbers of TF and TM participants, and the ability to combine data on HT and gender confirmation surgeries. Limitations include the cross-sectional design and the fact that participants may not be representative of the transgender population in the United States. Body-gender congruence and body image satisfaction were higher, and depression and anxiety were lower among individuals who had more extensive GCT compared to those who received less treatment or no treatment at all. Owen-Smith AA, Gerth J, Sineath RC, et al. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction and Mental Health in a Cohort Of Transgender Individuals. J Sex Med 2018;15:591-600.
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Affiliation(s)
- Ashli A Owen-Smith
- Department of Health Management and Policy, School of Public Health, Georgia State University, Atlanta, GA; Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA.
| | - Joseph Gerth
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Joshua Barzilay
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA
| | - Tracy A Becerra-Culqui
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Shawn Giammattei
- Rockway Institute, Alliant International University, San Francisco, CA
| | - Enid Hunkeler
- Emeritus, Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Andrea Millman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Virginia P Quinn
- Emeritus, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Travis Sanchez
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Vin Tangpricha
- School of Medicine, Emory University, Atlanta, GA; Atlanta US Department of Veterans Affairs Medical Center, Atlanta, GA
| | - Cadence Valentine
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Savannah Winter
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, GA
| | - Cory Woodyatt
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Yongjia Song
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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9
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Clase CM, Barzilay J, Gao P, Smyth A, Schmieder RE, Tobe S, Teo KK, Yusuf S, Mann JF. Acute change in glomerular filtration rate with inhibition of the renin-angiotensin system does not predict subsequent renal and cardiovascular outcomes. Kidney Int 2017; 91:683-690. [DOI: 10.1016/j.kint.2016.09.038] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 09/12/2016] [Accepted: 09/22/2016] [Indexed: 01/13/2023]
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10
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Oparil S, Puttnam R, Davis B, Pressel S, Whelton P, Cushman W, Louis G, Margolis K, Williamson J, Ghosh A, Einhorn P, Barzilay J. Abstract 100: Hip and Pelvic Fracture Risk in Adults Treated with Three Different Classes of Antihypertensive Medications: The ALLHAT Study. Hypertension 2016. [DOI: 10.1161/hyp.68.suppl_1.100] [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] [Indexed: 11/16/2022]
Abstract
Observational studies suggest that thiazide-type diuretics reduce fracture risk compared to other antihypertensive medications. The effects of calcium channel blockers (CCB) and angiotensin converting-enzyme inhibitors (ACEi) on fracture risk have not been well studied. We examined the relationship of antihypertensive drug therapy and hip and pelvic fracture hospitalizations in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack
Trial
(
ALLHAT
). It included >33,000 participants randomized to the thiazide-type diuretic chlorthalidone (C), ACEi lisinopril (L), or CCB amlodipine (A) as first line hypertension (HTN) therapy. Mean follow up was 4.9 years during the randomized phase (in-trial), and 5 additional years after the conclusion of the trial (post-trial) using linkage to national data bases. Risks of hip and pelvic fractures for L and A relative to C were derived from Cox models. There were 341 hip and pelvic fractures in-trial.
Participants assigned C had the lowest risk and those assigned L the highest (
Figure 1a).
The adjusted risk for L compared to C was 1.33 (95% CI 1.02-1.73; p=.04). Participants assigned A had intermediate risk compared to C (HR 1.22, 95% CI 0.93-1.59). During the combined in-trial and post-trial periods (
Figure 1b
), there were 646 fractures; the results were similar to the in-trial results, although differences were not statistically significant. Participants randomized to C continued to have the lowest risk of fractures after in-trial period, suggesting a legacy effect from prior C use. These findings have public health importance given the high prevalence of HTN in older adults and the widespread use of A and L in older adults.
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Affiliation(s)
| | | | - Barry Davis
- Univ of Texas Sch of Public Health, Houston, TX
| | | | - Paul Whelton
- Tulane Univ Sch of Public Health, New Orleans, LA
| | | | - Gail Louis
- Tulance Univ Sch of Public Health, New Orleans, LA
| | - Karen Margolis
- HealthPartners Institute for Education and Rsch, Minneapolis, MN
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11
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Roblin DW, Goodman M, Cromwell L, Schild L, Hunkeler E, Quinn V, Robinson B, Braun H, Nash R, Gerth J, Barzilay J, Tangpricha V. A Novel Method for Estimating Transgender Status Using EMR Data. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Fleg JL, Evans GW, Margolis KL, Barzilay J, Basile JN, Bigger JT, Cutler JA, Grimm R, Pedley C, Peterson K, Pop-Busui R, Sperl-Hillen J, Cushman WC. Orthostatic Hypotension in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) Blood Pressure Trial: Prevalence, Incidence, and Prognostic Significance. Hypertension 2016; 68:888-95. [PMID: 27504006 DOI: 10.1161/hypertensionaha.116.07474] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [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: 03/08/2016] [Accepted: 07/12/2016] [Indexed: 12/18/2022]
Abstract
Orthostatic hypotension (OH) is associated with hypertension and diabetes mellitus. However, in populations with both hypertension and diabetes mellitus, its prevalence, the effect of intensive versus standard systolic blood pressure (BP) targets on incident OH, and its prognostic significance are unclear. In 4266 participants in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) BP trial, seated BP was measured 3×, followed by readings every minute for 3 minutes after standing. Orthostatic BP change, calculated as the minimum standing minus the mean seated systolic BP and diastolic BP, was assessed at baseline, 12 months, and 48 months. The relationship between OH and clinical outcomes (total and cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, heart failure hospitalization or death and the primary composite outcome of nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death) was assessed using proportional hazards analysis. Consensus OH, defined by orthostatic decline in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg, occurred at ≥1 time point in 20% of participants. Neither age nor systolic BP treatment target (intensive, <120 mm Hg versus standard, <140 mm Hg) was related to OH incidence. Over a median follow-up of 46.9 months, OH was associated with increased risk of total death (hazard ratio, 1.61; 95% confidence interval, 1.11-2.36) and heart failure death/hospitalization (hazard ratio, 1.85, 95% confidence interval, 1.17-2.93), but not with the primary outcome or other prespecified outcomes. In patients with type 2 diabetes mellitus and hypertension, OH was common, not associated with intensive versus standard BP treatment goals, and predicted increased mortality and heart failure events.
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Affiliation(s)
- Jerome L Fleg
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.).
| | - Gregory W Evans
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - Karen L Margolis
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - Joshua Barzilay
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - Jan N Basile
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - J Thomas Bigger
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - Jeffrey A Cutler
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - Richard Grimm
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - Carolyn Pedley
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - Kevin Peterson
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - Rodica Pop-Busui
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - JoAnn Sperl-Hillen
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
| | - William C Cushman
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., J.A.C.); Wake Forest University School of Medicine, Winston-Salem, NC (G.W.E., C.P.); Health Partners Institute for Education and Research, Minneapolis, MN (K.L.M., J.S.-H.); Kaiser Permanente of Georgia, Atlanta (J.B.); Medical University of South Carolina, Charleston (J.N.B.); Columbia University School of Medicine, New York, NY (J.T.B.); Berman Center for Outcomes and Clinical Research, Minneapolis, MN (R.G.); University of Minnesota School of Medicine, Minneapolis (K.P.); University of Michigan School of Medicine, Ann Arbor (R.P.-B.); and Veterans Affairs Medical Center, Memphis, TN (W.C.C.)
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13
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Roblin D, Barzilay J, Tolsma D, Robinson B, Schild L, Cromwell L, Braun H, Nash R, Gerth J, Hunkeler E, Quinn VP, Tangpricha V, Goodman M. A novel method for estimating transgender status using electronic medical records. Ann Epidemiol 2016; 26:198-203. [PMID: 26907539 PMCID: PMC4772142 DOI: 10.1016/j.annepidem.2016.01.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/30/2015] [Accepted: 01/06/2016] [Indexed: 01/27/2023]
Abstract
PURPOSE We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system. METHODS A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews. RESULTS Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014. CONCLUSIONS The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.
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Affiliation(s)
- Douglas Roblin
- School of Public Health, Georgia State University, Atlanta; Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Joshua Barzilay
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Dennis Tolsma
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Laura Schild
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Lee Cromwell
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Hayley Braun
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Rebecca Nash
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Enid Hunkeler
- Division of Research, Kaiser Permanente, Oakland, CA
| | | | - Vin Tangpricha
- Emory University, School of Medicine, Atlanta, GA; The Atlanta VA Medical Center, Atlanta, GA
| | - Michael Goodman
- Rollins School of Public Health, Emory University, Atlanta, GA.
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14
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Roblin D, Barzilay J, Tolsma D, Robinson B, Schild L, Cromwell L, Braun H, Nash R, Gerth J, Hunkeler E, Quinn VP, Tangpricha V, Goodman M. A novel method for estimating transgender status using electronic medical records. Ann Epidemiol 2016. [PMID: 26907539 DOI: 10.1016/j.annepidem.2016.01.004.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system. METHODS A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews. RESULTS Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014. CONCLUSIONS The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.
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Affiliation(s)
- Douglas Roblin
- School of Public Health, Georgia State University, Atlanta; Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Joshua Barzilay
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Dennis Tolsma
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Brandi Robinson
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Laura Schild
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Lee Cromwell
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta
| | - Hayley Braun
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Rebecca Nash
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Enid Hunkeler
- Division of Research, Kaiser Permanente, Oakland, CA
| | | | - Vin Tangpricha
- Emory University, School of Medicine, Atlanta, GA; The Atlanta VA Medical Center, Atlanta, GA
| | - Michael Goodman
- Rollins School of Public Health, Emory University, Atlanta, GA.
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Isakova T, Craven TE, Scialla JJ, Nickolas TL, Schnall A, Barzilay J, Schwartz AV. Change in estimated glomerular filtration rate and fracture risk in the Action to Control Cardiovascular Risk in Diabetes Trial. Bone 2015; 78:23-7. [PMID: 25937184 PMCID: PMC4466209 DOI: 10.1016/j.bone.2015.04.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/15/2015] [Accepted: 04/23/2015] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Patients with type 2 diabetes (T2DM) are at increased risk of fracture. High prevalence of chronic kidney disease (CKD) in T2DM may contribute to bone fragility, but whether dynamic change in kidney function is associated with fracture risk is unclear. RESEARCH DESIGN AND METHODS To evaluate the association of pre-randomization baseline estimated glomerular filtration (eGFR) and its change over time with subsequent fracture risk in the Bone substudy of Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial, we conducted an observational study of 2262 women and 4737 men with T2DM and with at least 2 eGFR values. RESULTS During a mean follow-up of 4.40±1.54 years, 235 women and 223 men sustained a new non-vertebral fracture. In multivariable adjusted sex-specific models, pre-randomization baseline eGFR was not a significant predictor of fracture risk in either men or women. However, a steeper decline in eGFR was associated with greater risk of fracture in women (hazard ratio [HR] per standard deviation [SD] decrement in eGFR slope, 1.30; 95% CI 1.17-1.44) but not men (HR per SD decrement in eGFR slope, 0.97; 95%CI 0.82-1.13). Accounting for competing risk of death modestly attenuated the association in women (HR per SD decrement in eGFR slope, 1.19; 95% CI 1.04-1.37), with the relationship in men remaining non-significant (HR per SD decrement in eGFR slope, 0.96; 95% CI 0.77-1.18). CONCLUSIONS Declining kidney function predicts fracture risk in women but not in men with T2DM. Future studies should investigate the mechanisms for these associations.
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Affiliation(s)
- Tamara Isakova
- Department of Medicine, Division of Nephrology, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Timothy E Craven
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Julia J Scialla
- Department of Medicine, Division of Nephrology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Thomas L Nickolas
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA
| | - Adrian Schnall
- University Suburban Health Center, South Euclid, OH, USA
| | - Joshua Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia and Division of Endocrinology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ann V Schwartz
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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16
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Chatterjee R, Biggs ML, de Boer IH, Brancati FL, Svetkey LP, Barzilay J, Djoussé L, Ix JH, Kizer JR, Siscovick DS, Mozaffarian D, Edelman D, Mukamal KJ. Potassium and glucose measures in older adults: the Cardiovascular Health Study. J Gerontol A Biol Sci Med Sci 2014; 70:255-61. [PMID: 24895271 DOI: 10.1093/gerona/glu071] [Citation(s) in RCA: 15] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We sought to determine the impacts of serum and dietary potassium measures on glucose metabolism and diabetes risk in older adults. METHODS Among participants of the Cardiovascular Health Study, a community-based cohort of older American adults, we examined a) cross-sectional associations between potassium and measures of insulin sensitivity and secretion estimated from oral glucose tolerance tests and b) longitudinal associations of serum and dietary potassium with diabetes risk. RESULTS Among 4,754 participants aged ≥65 years at baseline, there were 445 cases of incident diabetes during a median follow-up of 12 years. In multivariate models, baseline serum and dietary potassium were both associated with lower insulin sensitivity and greater insulin secretion. Compared with those with a serum potassium ≥4.5 mEq/L, participants with a serum potassium <4.0mEq/L had an adjusted mean difference in Matsuda insulin sensitivity index of -0.18 (-0.39, 0.02). Compared with those in the highest quartile, participants in the lowest quartile of dietary potassium intake had a corresponding adjusted mean difference in Matsuda insulin sensitivity index of -0.61 (-0.94, -0.29). In multivariate models, neither serum nor dietary potassium intake was associated with long-term diabetes risk. CONCLUSIONS Although we did not identify serum and dietary potassium as risk factors for incident diabetes in older adults, results from cross-sectional analyses suggest that both may be associated with increased insulin resistance. This relationship with insulin resistance needs to be confirmed, and its importance on diabetes risk, cardiovascular risk, and conditions specific to older adults should be determined as well.
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Affiliation(s)
- Ranee Chatterjee
- Department of Medicine, Duke University, Durham, North Carolina.
| | - Mary L Biggs
- Department of Biostatistics, Collaborative Studies Coordinating Center
| | - Ian H de Boer
- Department of Medicine, and Department of Epidemiology, University of Washington, Seattle
| | | | - Laura P Svetkey
- Department of Medicine, Duke University, Durham, North Carolina
| | - Joshua Barzilay
- Kaiser Permanente of Georgia and Department of Medicine, Emory University School of Medicine, Atlanta
| | - Luc Djoussé
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, and Boston Veterans Affairs Healthcare System, Massachusetts
| | - Joachim H Ix
- Department of Medicine, University of California, San Diego and Veterans Affairs San Diego Healthcare System
| | - Jorge R Kizer
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - David S Siscovick
- Department of Medicine, and Department of Epidemiology, University of Washington, Seattle
| | - Dariush Mozaffarian
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - David Edelman
- Department of Medicine, Duke University, Durham, North Carolina
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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17
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Shah RV, Abbasi SA, Yamal JM, Davis BR, Barzilay J, Einhorn PT, Goldfine AB, Goldfine A. Impaired fasting glucose and body mass index as determinants of mortality in ALLHAT: is the obesity paradox real? J Clin Hypertens (Greenwich) 2014; 16:451-8. [PMID: 24779706 DOI: 10.1111/jch.12325] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/15/2014] [Accepted: 03/18/2014] [Indexed: 11/27/2022]
Abstract
Emerging literature suggests that obesity may be "protective" against mortality and cardiovascular outcomes, while dysglycemia may worsen outcomes regardless of obesity. The authors measured the association of weight, smoking, and glycemia with mortality in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Among 5423 ALLHAT participants without established diabetes or cardiovascular disease, 3980 (73%) had normal fasting glucose and 1443 (27%) had impaired fasting glucose (IFG) levels at study entry. After a median of 4.9 years follow-up, 554 (10%) had died (37% cardiovascular). IFG was associated with higher all-cause mortality (adjusted hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.02-1.50), while obesity was associated with lower all-cause mortality (adjusted HR, 0.76; 95% CI, 0.60-0.96). However, after excluding underweight individuals (body mass index [BMI] <22 kg/m(2) ) and smokers, neither obesity nor IFG was associated with all-cause mortality [corrected]. Although obesity appeared protective against mortality, this association was not significant in never-smokers or after exclusion of BMI <22 kg/m(2) . The obesity paradox may result from confounding by a sicker, underweight referent population and smoking.
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Affiliation(s)
- Ravi V Shah
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
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Williamson JD, Launer LJ, Bryan RN, Coker LH, Lazar RM, Gerstein HC, Murray AM, Sullivan MD, Horowitz KR, Ding J, Marcovina S, Lovato L, Lovato J, Margolis KL, Davatzikos C, Barzilay J, Ginsberg HN, Linz PE, Miller ME. Cognitive function and brain structure in persons with type 2 diabetes mellitus after intensive lowering of blood pressure and lipid levels: a randomized clinical trial. JAMA Intern Med 2014; 174:324-33. [PMID: 24493100 PMCID: PMC4423790 DOI: 10.1001/jamainternmed.2013.13656] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Persons with type 2 diabetes mellitus (T2DM) are at increased risk for decline in cognitive function, reduced brain volume, and increased white matter lesions in the brain. Poor control of blood pressure (BP) and lipid levels are risk factors for T2DM-related cognitive decline, but the effect of intensive treatment on brain function and structure is unknown. OBJECTIVE To examine whether intensive therapy for hypertension and combination therapy with a statin plus a fibrate reduces the risk of decline in cognitive function and total brain volume (TBV) in patients with T2DM. DESIGN, SETTING, AND PARTICIPANTS A North American multicenter clinical trial including 2977 participants without baseline clinical evidence of cognitive impairment or dementia and with hemoglobin A1c (HbA1c) levels less than 7.5% randomized to a systolic BP goal of less than 120 vs less than 140 mm Hg (n = 1439) or to a fibrate vs placebo in patients with low-density lipoprotein cholesterol levels less than 100 mg/dL (n = 1538). Participants were recruited from August 1, 2003, through October 31, 2005, with the final follow-up visit by June 30, 2009. MAIN OUTCOME MEASURES Cognition was assessed at baseline and 20 and 40 months. A subset of 503 participants underwent baseline and 40-month brain magnetic resonance imaging to assess for change in TBV and other structural measures of brain health. RESULTS Baseline mean HbA1c level was 8.3%; mean age, 62 years; and mean duration of T2DM, 10 years. At 40 months, no differences in cognitive function were found in the intensive BP-lowering trial or in the fibrate trial. At 40 months, TBV had declined more in the intensive vs standard BP-lowering group (difference, -4.4 [95% CI, -7.8 to -1.1] cm(3); P = .01). Fibrate therapy had no effect on TBV compared with placebo. CONCLUSIONS AND RELEVANCE In participants with long-standing T2DM and at high risk for cardiovascular events, intensive BP control and fibrate therapy in the presence of controlled low-density lipoprotein cholesterol levels did not produce a measurable effect on cognitive decline at 40 months of follow-up. Intensive BP control was associated with greater decline in TBV at 40 months relative to standard therapy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00000620.
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Affiliation(s)
- Jeff D Williamson
- Roena B. Kulynych Center for Memory and Cognition Research, Department of Internal Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Lenore J Launer
- Intramural Research Program, National Institute on Aging, National Institutes of Health, Bethesda, Maryland
| | - R Nick Bryan
- Department of Radiology, University of Pennsylvania Health System, Philadelphia
| | - Laura H Coker
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest University, Winston-Salem, North Carolina
| | - Ronald M Lazar
- Departments of Neurology and Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hertzel C Gerstein
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada7Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Anne M Murray
- Hennepin County Medical Center and Chronic Disease Research Group, Minneapolis, Minnesota
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Karen R Horowitz
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jingzhong Ding
- Roena B. Kulynych Center for Memory and Cognition Research, Department of Internal Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Santica Marcovina
- Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle
| | - Laura Lovato
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Lovato
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Karen L Margolis
- Division of Epidemiology and Community Health, University of Minnesota Medical School, Minneapolis
| | - Christos Davatzikos
- Department of Radiology, University of Pennsylvania Health System, Philadelphia
| | - Joshua Barzilay
- Kaiser Permanente, Crescent Center Medical Office, Tucker, Georgia
| | - Henry N Ginsberg
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Peter E Linz
- Cardiology Division, Naval Medical Center San Diego, San Diego, California
| | - Michael E Miller
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Banerjee D, Biggs ML, Mercer L, Mukamal K, Kaplan R, Barzilay J, Kuller L, Kizer JR, Djousse L, Tracy R, Zieman S, Lloyd-Jones D, Siscovick D, Carnethon M. Insulin resistance and risk of incident heart failure: Cardiovascular Health Study. Circ Heart Fail 2013; 6:364-70. [PMID: 23575256 DOI: 10.1161/circheartfailure.112.000022] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [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: 11/16/2022]
Abstract
BACKGROUND Patients with heart failure (HF) have higher fasting insulin levels and a higher prevalence of insulin resistance as compared with matched controls. Insulin resistance leads to structural abnormalities in the heart, such as increased left atrial size, left ventricular mass, and alterations in transmitral velocity that can precede the diagnosis of HF. It is not known whether insulin resistance precedes the development of HF or whether the relationship between insulin resistance and HF is present among adults with HF caused by nonischemic heart disease. METHODS AND RESULTS We examined 4425 participants (60% women) from the Cardiovascular Health Study after excluding those with HF, myocardial infarction, or treated diabetes mellitus at baseline. We used Cox proportional hazards models to estimate the relative risk of incident HF associated with fasting insulin measured at study entry. There were 1216 cases of incident HF (1103 without antecedent myocardial infarction) during a median follow-up of 12 years (maximum, 19 years). Fasting insulin levels were positively associated with the risk of incident HF (hazard ratio, 1.10; 95% confidence interval, 1.05-1.15, per SD change) when adjusted for age, sex, race, field center, physical activity, smoking, alcohol intake, high-density lipoprotein-cholesterol, total cholesterol, systolic blood pressure, and waist circumference. The association between fasting insulin levels and incident HF was similar for HF without antecedent myocardial infarction (hazard ratio, 1.10; 95% confidence interval, 1.05-1.15). Measures of left atrial size, left ventricular mass, and peak A velocity at baseline were associated both with fasting insulin levels and with HF; however, additional statistical adjustment for these parameters did not completely attenuate the insulin-HF estimate (hazard ratio, 1.08; 95% confidence interval, 1.03-1.14 per 1-SD increase in fasting insulin). CONCLUSIONS Fasting insulin was positively associated with adverse echocardiographic features and risk of subsequent HF in Cardiovascular Health Study participants, including those without an antecedent myocardial infarction. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00005133.
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Luchsinger JA, Biggs ML, Kizer JR, Barzilay J, Fitzpatrick A, Newman A, Longstreth WT, Lopez O, Siscovick D, Kuller L. Adiposity and cognitive decline in the cardiovascular health study. Neuroepidemiology 2013; 40:274-81. [PMID: 23445925 PMCID: PMC4044822 DOI: 10.1159/000345136] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 10/05/2012] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Studies relating adiposity to cognition in the elderly show conflicting results, which may be explained by the choice of adiposity measures. Thus, we studied the longitudinal associations of different adiposity measures, fat mass by bioelectrical impedance analysis, body mass index (BMI) and waist circumference (WC), with cognitive performance in the Cardiovascular Health Study. METHODS Cognitive performance was assessed with the modified Mini-Mental State Examination, the Digit Symbol Substitution Test, and a composite of both. We used linear mixed models to estimate rates of change in cognitive function scores associated with adiposity measured at baseline. RESULTS The final sample was comprised of 2,681 women (57.9%) and 1,949 men (42.1%) aged 73 ± 5.2 and 73.9 ± 5.6 years, respectively. Adiposity was associated with slower cognitive decline in most analyses. Results were similar for fat mass, BMI and WC. Higher fat-free mass was also related to slower cognitive decline. Results were similar in analyses excluding persons with cancer, smokers, and persons with short follow-up, poor self-reported health, or persons with cardiovascular disease. CONCLUSIONS Higher adiposity and higher fat-free mass in the elderly was related to better cognitive performance. This finding was not explained by confounding by preexisting conditions.
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Affiliation(s)
- José A Luchsinger
- Departments of Medicine and Epidemiology, Columbia University Medical Center, Bronx, NY 10032, USA.
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Zieman SJ, Kamineni A, Ix JH, Barzilay J, Djoussé L, Kizer JR, Biggs ML, de Boer IH, Chonchol M, Gottdiener JS, Selvin E, Newman AB, Kuller LH, Siscovick DS, Mukamal KJ. Hemoglobin A1c and arterial and ventricular stiffness in older adults. PLoS One 2012; 7:e47941. [PMID: 23118911 PMCID: PMC3484154 DOI: 10.1371/journal.pone.0047941] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [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: 07/06/2012] [Accepted: 09/24/2012] [Indexed: 11/19/2022] Open
Abstract
Objective Arterial and ventricular stiffening are characteristics of diabetes and aging which confer significant morbidity and mortality; advanced glycation endproducts (AGE) are implicated in this stiffening pathophysiology. We examined the association between HbA1c, an AGE, with arterial and ventricular stiffness measures in older individuals without diabetes. Research Design & Methods Baseline HbA1c was measured in 830 participants free of diabetes defined by fasting glucose or medication use in the Cardiovascular Health Study, a population-based cohort study of adults aged ≥65 years. We performed cross-sectional analyses using baseline exam data including echocardiography, ankle and brachial blood pressure measurement, and carotid ultrasonography. We examined the adjusted associations between HbA1c and multiple arterial and ventricular stiffness measures by linear regression models and compared these results to the association of fasting glucose (FG) with like measures. Results HbA1c was correlated with fasting and 2-hour postload glucose levels (r = 0.21; p<0.001 for both) and positively associated with greater body-mass index and black race. In adjusted models, HbA1c was not associated with any measure of arterial or ventricular stiffness, including pulse pressure (PP), carotid intima-media thickness, ankle-brachial index, end-arterial elastance, or left ventricular mass (LVM). FG levels were positively associated with systolic, diastolic and PP and LVM. Conclusions In this sample of older adults without diabetes, HbA1c was not associated with arterial or ventricular stiffness measures, whereas FG levels were. The role of AGE in arterial and ventricular stiffness in older adults may be better assessed using alternate AGE markers.
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Affiliation(s)
- Susan J. Zieman
- National Institute on Aging, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Aruna Kamineni
- Group Health Research Institute, Group Health, Seattle, Washington, United States of America
| | - Joachim H. Ix
- Division of Nephrology-Hypertension, University of California San Diego, and Veterans Affairs San Diego Healthcare System, La Jolla, California, United States of America
| | - Joshua Barzilay
- Division of Endocrinology, Kaiser-Permanente, Tucker, Georgia, United States of America
| | - Luc Djoussé
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, and Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Jorge R. Kizer
- Departments of Medicine and Public Health, Weill Medical College of Cornell University, New York, New York, United States of America
| | - Mary L. Biggs
- Departments of Biostatistics and Medicine, University of Washington, Seattle, Washington, United States of America
| | - Ian H. de Boer
- Departments of Biostatistics and Medicine, University of Washington, Seattle, Washington, United States of America
| | - Michel Chonchol
- Department of Medicine, University of Colorado Denver Health Sciences Center, Denver, Colorado, United States of America
| | - John S. Gottdiener
- Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Elizabeth Selvin
- National Institute on Aging, National Institutes of Health, Bethesda, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Anne B. Newman
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Lewis H. Kuller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - David S. Siscovick
- Departments of Biostatistics and Medicine, University of Washington, Seattle, Washington, United States of America
| | - Kenneth J. Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
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Carnethon MR, Biggs ML, Barzilay J, Kuller LH, Mozaffarian D, Mukamal K, Smith NL, Siscovick D. Diabetes and coronary heart disease as risk factors for mortality in older adults. Am J Med 2010; 123:556.e1-9. [PMID: 20569763 PMCID: PMC3145803 DOI: 10.1016/j.amjmed.2009.11.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 11/10/2009] [Accepted: 11/13/2009] [Indexed: 01/14/2023]
Abstract
BACKGROUND Type 2 diabetes has been described as a coronary heart disease (CHD) "risk equivalent." We tested whether cardiovascular and all-cause mortality rates were similar between participants with prevalent CHD vs diabetes in an older adult population in whom both glucose disorders and preexisting atherosclerosis are common. METHODS The Cardiovascular Health Study is a longitudinal study of men and women (n=5784) aged > or =65 years at baseline who were followed from baseline (1989/1992-1993) through 2005 for mortality. Diabetes was defined by fasting plasma glucose > or =7.0 mmol/L or use of diabetes control medications. Prevalent CHD was determined by confirmed history of myocardial infarction, angina, or coronary revascularization. RESULTS Following multivariable adjustment for other cardiovascular disease risk factors and subclinical atherosclerosis, CHD mortality risk was similar between participants with CHD alone vs diabetes alone (hazard ratio [HR] 1.04, 95% confidence interval [CI], 0.83-1.30). The proportion of mortality attributable to prevalent diabetes (population-attributable risk percent=8.4%) and prevalent CHD (6.7%) was similar in women, but the proportion of mortality attributable to CHD (16.5%) as compared with diabetes (6.4%) was markedly higher in men. Patterns were similar for cardiovascular disease mortality. By contrast, the adjusted relative hazard of total mortality was lower among participants with CHD alone (HR 0.85, 95% CI, 0.75-0.96) as compared with those who had diabetes alone. CONCLUSIONS Among older adults, diabetes alone confers a risk for cardiovascular mortality similar to that from established clinical CHD. The public health burden of both diabetes and CHD is substantial, particularly among women.
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Affiliation(s)
- Mercedes R Carnethon
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Goyal A, Thomas TN, Barzilay J, Davis RL, Vaccarino V, Wilson PW. RACIAL DIFFERENCES IN THE ATTAINMENT OF CARDIOVASCULAR RISK FACTOR GOALS AMONG INSURED ADULTS WITH DIABETES MELLITUS. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61333-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Grimm RH, Davis BR, Piller LB, Cutler JA, Margolis KL, Barzilay J, Dart RA, Graumlich JF, Murden RA, Randall OS. Heart failure in ALLHAT: did blood pressure medication at study entry influence outcome? J Clin Hypertens (Greenwich) 2009; 11:466-74. [PMID: 19751458 PMCID: PMC2788785 DOI: 10.1111/j.1751-7176.2009.00149.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [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] [Received: 04/24/2009] [Accepted: 05/28/2009] [Indexed: 01/28/2023]
Abstract
J Clin Hypertens (Greenwich). 2009;11:466-474. (c)2009 Wiley Periodicals, Inc.Lower heart failure (HF) rates in individuals taking chlorthalidone vs amlodipine, lisinopril, or doxazosin were unanticipated in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). HF differences appeared early, leading to questions about the possible influence of pre-enrollment antihypertensive drugs. A post hoc study evaluated hospitalized HF events. During year 1479 individuals had HF, with pre-entry antihypertensive medication data obtained on 301 patients (63%). Case-only analysis examined interactive effects (interaction odds ratio [OR, ratio of ORs]) of previous medication and ALLHAT treatment on HF outcomes, eg, did treatment effect differ by pre-entry antihypertensive class? Among cases, 39%, 37%, 17%, and 47% were taking pre-entry diuretics, angiotensin-converting enzyme inhibitors, beta-blockers, and calcium channel blockers, respectively. Interaction OR for year 1 HF for amlodipine vs chlorthalidone for patients taking vs not taking diuretics pre-entry was 1.08 (95% confidence interval [CI], 0.53-2.21; P=.83); for lisinopril vs chlorthalidone, 1.33 (95% CI, 0.65-2.74; P=.44); and for doxazosin vs chlorthalidone, 1.13 (95% CI, 0.57-2.25; P=.73). Controlling for other pre-entry antihypertensives yielded similar results. There was no significant evidence that pre-entry drug type explained observed hospitalized HF differences by ALLHAT treatment.
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Affiliation(s)
- Richard H. Grimm
- From the Department of Internal Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Barry R. Davis
- The University of Texas School of Public Health, Houston, TX
| | - Linda B. Piller
- The University of Texas School of Public Health, Houston, TX
| | | | | | | | - Richard A. Dart
- the Department of Nephrology and Hypertension, Marshfield Clinic, Marshfield, WI
| | - James F. Graumlich
- the Department of Medicine, University of Illinois College of Medicine, Peoria, IL
| | - Robert A. Murden
- the Department of Internal Medicine, Ohio State University, Columbus, OH
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Rahman M, Baimbridge C, Davis BR, Barzilay J, Basile JN, Henriquez MA, Huml A, Kopyt N, Louis GT, Pressel SL, Rosendorff C, Sastrasinh S, Stanford C. Progression of kidney disease in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin versus usual care: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Am J Kidney Dis 2008; 52:412-24. [PMID: 18676075 DOI: 10.1053/j.ajkd.2008.05.027] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Accepted: 05/12/2008] [Indexed: 01/13/2023]
Abstract
BACKGROUND Dyslipidemia is common in patients with chronic kidney disease. The role of statin therapy in the progression of kidney disease is unclear. STUDY DESIGN Prospective randomized clinical trial, post hoc analyses. SETTING & PARTICIPANTS 10,060 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (lipid-lowering component) stratified by baseline estimated glomerular filtration rate (eGFR): less than 60, 60 to 89, and 90 or greater mL/min/1.73 m(2). Mean follow-up was 4.8 years. INTERVENTION Randomized; pravastatin, 40 mg/d, or usual care. OUTCOMES & MEASUREMENTS Total, high-density lipoprotein, and low-density lipoprotein cholesterol; end-stage renal disease (ESRD), eGFR. RESULTS Through year 6, total cholesterol levels decreased in the pravastatin (-20.7%) and usual-care groups (-11.2%). No significant differences were seen between groups for rates of ESRD (1.36 v 1.45/100 patient-years; P = 0.9), composite end points of ESRD and 50% or 25% decrease in eGFR, or rate of change in eGFR. Findings were consistent across eGFR strata. In patients with eGFR of 90 mL/min/1.73 m(2) or greater, the pravastatin arm tended to have a higher eGFR. LIMITATIONS Proteinuria data unavailable, post hoc analyses, unconfirmed validity of the Modification of Diet in Renal Disease Study equation in normal eGFR range, statin drop-in rate in usual-care group with small cholesterol differential between groups. CONCLUSIONS In hypertensive patients with moderate dyslipidemia and decreased eGFR, pravastatin was not superior to usual care in preventing clinical renal outcomes. This was consistent across the strata of baseline eGFR. However, benefit from statin therapy may depend on the degree of the cholesterol level decrease achieved.
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Affiliation(s)
- Mahboob Rahman
- Case Western Reserve University, University Hospitals of Cleveland Case Medical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
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Cao JJ, Biggs ML, Barzilay J, Konen J, Psaty BM, Kuller L, Bleyer AJ, Olson J, Wexler J, Summerson J, Cushman M. Cardiovascular and mortality risk prediction and stratification using urinary albumin excretion in older adults ages 68–102: The cardiovascular Health Study. Atherosclerosis 2008; 197:806-13. [PMID: 17875308 DOI: 10.1016/j.atherosclerosis.2007.07.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [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: 10/11/2006] [Revised: 07/16/2007] [Accepted: 07/27/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Elevated urinary albumin excretion (UAE) is associated with the risk of cardiovascular disease (CVD) and all-cause mortality. We tested the hypothesis that elevated UAE improves cardiovascular risk stratification in an elderly cohort aged 68-102 years. METHODS We evaluated UAE in 3112 participants of the Cardiovascular Health Study who attended the 1996-1997 examination and had median follow up of 5.4 years. Elevated UAE was defined as urinary albumin to creatinine ratio > or =30 microg/mg. Microalbuminuria and macroalbuminuria were defined as urinary albumin to creatinine ratio 30-300 microg/mg and >300 microg/mg, respectively. Outcomes included CVD (myocardial infarction, stroke, cardiovascular death) and all-cause mortality. Cox proportional hazards models were used to assess the risk of outcomes associated with elevated UAE. RESULTS The prevalence of elevated UAE was 14.3%, 17.1% and 26.9% in those aged 68-74, 75-84 and 85-102 years, respectively. CVD incidence and all-cause mortality were doubled (7.2% and 8.1% per year) in those with microalbuminuria and tripled (11.1% and 12.3% per year) in those with macroalbuminuria compared to those with normal UAE (3.3% and 3.8% per year). The increased CVD and mortality risks were observed in all age groups after adjustment for conventional risk factors. The adjusted population attributable risk percent of CVD and all-cause mortality for elevated UAE was 11% and 12%, respectively. When participants were cross-classified by UAE and Framingham Risk Score categories, the 5-year cumulative incidence of coronary heart disease among participants with elevated UAE and a 5-year predicted risk of 5-10% was 20%, substantially higher than 6.3% in those with UAE <30m microg/mg. CONCLUSION Elevated UAE was associated with an increased risk of CVD and all-cause mortality in all age groups from 68 to 102 years. Combining elevated UAE with the Framingham risk scores may improve risk stratification for CVD in the elderly.
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Affiliation(s)
- Jie J Cao
- Research Department, St Francis Hospital, Division of Cardiology, Stony Brook University, SUNY, 100 Port Washington Boulevard, Roslyn, NY 11576, United States.
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Barzilay J. Guest editorial. Metab Syndr Relat Disord 2008; 2:81. [PMID: 18370639 DOI: 10.1089/met.2004.2.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joshua Barzilay
- Kaiser Permanente of Georgia and Division Endocrinology, Emory University School of Medicine, Atlanta, Georgia
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Black HR, Davis B, Barzilay J, Nwachuku C, Baimbridge C, Marginean H, Wright JT, Basile J, Wong ND, Whelton P, Dart RA, Thadani U. Metabolic and clinical outcomes in nondiabetic individuals with the metabolic syndrome assigned to chlorthalidone, amlodipine, or lisinopril as initial treatment for hypertension: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Diabetes Care 2008; 31:353-60. [PMID: 18000186 DOI: 10.2337/dc07-1452] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Optimal initial antihypertensive drug therapy in people with the metabolic syndrome is unknown. RESEARCH DESIGN AND METHODS We conducted a subgroup analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to compare metabolic, cardiovascular, and renal outcomes in individuals assigned to initial hypertension treatment with a thiazide-like diuretic (chlorthalidone), a calcium channel blocker (CCB; amlodipine), or an ACE inhibitor (lisinopril) in nondiabetic individuals with or without metabolic syndrome. RESULTS In participants with metabolic syndrome, at 4 years of follow-up, the incidence of newly diagnosed diabetes (fasting glucose >or=126 mg/dl) was 17.1% for chlorthalidone, 16.0% for amlodipine (P = 0.49, chlorthalidone vs. amlodipine) and 12.6% for lisinopril (P < 0.05, lisinopril vs. chlorthalidone). For those without metabolic syndrome, the rate of newly diagnosed diabetes was 7.7% for chlorthalidone, 4.2% for amlodipine, and 4.7% for lisinopril (P < 0.05 for both comparisons). There were no differences in relative risks (RRs) for outcomes with amlodipine compared with chlorthalidone in those with metabolic syndrome; in those without metabolic syndrome, there was a higher risk for heart failure (RR 1.55 [95% CI 1.25-1.35]). In comparison with lisinopril, chlorthalidone was superior in those with metabolic syndrome with respect to heart failure (1.31 [1.04-1.64]) and combined cardiovascular disease (CVD) (1.19 [1.07-1.32]). No significant treatment group-metabolic syndrome interaction was noted. CONCLUSIONS Despite a less favorable metabolic profile, thiazide-like diuretic initial therapy for hypertension offers similar, and in some instances possibly superior, CVD outcomes in older hypertensive adults with metabolic syndrome, as compared with treatment with CCBs and ACE inhibitors.
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Affiliation(s)
- Henry R Black
- New York University School of Medicine, New York, New York, USA
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Wright JT, Harris-Haywood S, Pressel S, Barzilay J, Baimbridge C, Bareis CJ, Basile JN, Black HR, Dart R, Gupta AK, Hamilton BP, Einhorn PT, Haywood LJ, Jafri SZ, Louis GT, Whelton PK, Scott CL, Simmons DL, Stanford C, Davis BR. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med 2008; 168:207-17. [PMID: 18227370 PMCID: PMC2805022 DOI: 10.1001/archinternmed.2007.66] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Antihypertensive drugs with favorable metabolic effects are advocated for first-line therapy in hypertensive patients with metabolic/cardiometabolic syndrome (MetS). We compared outcomes by race in hypertensive individuals with and without MetS treated with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), an alpha-blocker (doxazosin mesylate), or an angiotensin-converting enzyme inhibitor (lisinopril). METHODS A subgroup analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind hypertension treatment trial of 42 418 participants. We defined MetS as hypertension plus at least 2 of the following: fasting serum glucose level of at least 100 mg/dL, body mass index (calculated as weight in kilograms divided by height in meters squared) of at least 30, fasting triglyceride levels of at least 150 mg/dL, and high-density lipoprotein cholesterol levels of less than 40 mg/dL in men or less than 50 mg/dL in women. RESULTS Significantly higher rates of heart failure were consistent across all treatment comparisons in those with MetS. Relative risks (RRs) were 1.50 (95% confidence interval, 1.18-1.90), 1.49 (1.17-1.90), and 1.88 (1.42-2.47) in black participants and 1.25 (1.06-1.47), 1.20 (1.01-1.41), and 1.82 (1.51-2.19) in nonblack participants for amlodipine, lisinopril, and doxazosin comparisons with chlorthalidone, respectively. Higher rates for combined cardiovascular disease were observed with lisinopril-chlorthalidone (RRs, 1.24 [1.09-1.40] and 1.10 [1.02-1.19], respectively) and doxazosin-chlorthalidone comparisons (RRs, 1.37 [1.19-1.58] and 1.18 [1.08-1.30], respectively) in black and nonblack participants with MetS. Higher rates of stroke were seen in black participants only (RR, 1.37 [1.07-1.76] for the lisinopril-chlorthalidone comparison, and RR, 1.49 [1.09-2.03] for the doxazosin-chlorthalidone comparison). Black patients with MetS also had higher rates of end-stage renal disease (RR, 1.70 [1.13-2.55]) with lisinopril compared with chlorthalidone. CONCLUSIONS The ALLHAT findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics in patients with the MetS, despite their more favorable metabolic profiles. This was particularly true for black participants.
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Affiliation(s)
- Jackson T. Wright
- General Clinical Research Center, University Hospitals of Cleveland, Cleveland, Ohio
| | | | - Sara Pressel
- University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | | | - Charles Baimbridge
- University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | | | | | - Henry R. Black
- Rush Presbyterian—St. Luke’s Medical Center, Chicago, Illinois
| | | | - Alok K. Gupta
- Pennington Biomedical Research Center, Baton Rouge, LA
| | | | - Paula T. Einhorn
- Division of Prevention and Population Sciences, National Heart Lung, and Blood Institute, Bethesda, Maryland
| | - L. Julian Haywood
- University of Southern California Medical Center, Los Angeles, California
| | | | - Gail T. Louis
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Paul K. Whelton
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | | | - Debra L. Simmons
- University of Arkansas for Medical Sciences--Endocrinology, Little Rock, Arkansas
| | | | - Barry R. Davis
- University of Texas Health Science Center at Houston School of Public Health, Houston, Texas (former); Amgen, Thousand Oaks, California
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Affiliation(s)
- Joshua Barzilay
- From Kaiser Permanente of Georgia, Tucker, GA;University of Minnesota, Minneapolis, MN;VA Medical Center, Memphis, TN;Wake Forest University, Winston Salem, NC; the Primary Care Service Line, Ralph H. Johnson VA Medical Center, Charleston, SC; and the Division of General Internal Medicine/Geriatrics, Medical University of South Carolina, Charleston, SC
| | - Richard Grimm
- From Kaiser Permanente of Georgia, Tucker, GA;University of Minnesota, Minneapolis, MN;VA Medical Center, Memphis, TN;Wake Forest University, Winston Salem, NC; the Primary Care Service Line, Ralph H. Johnson VA Medical Center, Charleston, SC; and the Division of General Internal Medicine/Geriatrics, Medical University of South Carolina, Charleston, SC
| | - William Cushman
- From Kaiser Permanente of Georgia, Tucker, GA;University of Minnesota, Minneapolis, MN;VA Medical Center, Memphis, TN;Wake Forest University, Winston Salem, NC; the Primary Care Service Line, Ralph H. Johnson VA Medical Center, Charleston, SC; and the Division of General Internal Medicine/Geriatrics, Medical University of South Carolina, Charleston, SC
| | - Alain G. Bertoni
- From Kaiser Permanente of Georgia, Tucker, GA;University of Minnesota, Minneapolis, MN;VA Medical Center, Memphis, TN;Wake Forest University, Winston Salem, NC; the Primary Care Service Line, Ralph H. Johnson VA Medical Center, Charleston, SC; and the Division of General Internal Medicine/Geriatrics, Medical University of South Carolina, Charleston, SC
| | - Jan Basile
- From Kaiser Permanente of Georgia, Tucker, GA;University of Minnesota, Minneapolis, MN;VA Medical Center, Memphis, TN;Wake Forest University, Winston Salem, NC; the Primary Care Service Line, Ralph H. Johnson VA Medical Center, Charleston, SC; and the Division of General Internal Medicine/Geriatrics, Medical University of South Carolina, Charleston, SC
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Rahman M, Pressel S, Davis BR, Nwachuku C, Wright JT, Whelton PK, Barzilay J, Batuman V, Eckfeldt JH, Farber MA, Franklin S, Henriquez M, Kopyt N, Louis GT, Saklayen M, Stanford C, Walworth C, Ward H, Wiegmann T. Cardiovascular outcomes in high-risk hypertensive patients stratified by baseline glomerular filtration rate. Ann Intern Med 2006; 144:172-80. [PMID: 16461961 DOI: 10.7326/0003-4819-144-3-200602070-00005] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.6] [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: 01/11/2023] Open
Abstract
BACKGROUND Chronic kidney disease is common in older patients with hypertension. OBJECTIVE To compare rates of coronary heart disease (CHD) and end-stage renal disease (ESRD) events; to determine whether glomerular filtration rate (GFR) independently predicts risk for CHD; and to report the efficacy of first-step treatment with a calcium-channel blocker (amlodipine) or an angiotensin-converting enzyme inhibitor (lisinopril), each compared with a diuretic (chlorthalidone), in modifying cardiovascular disease (CVD) outcomes in high-risk patients with hypertension stratified by GFR. DESIGN Post hoc subgroup analysis. SETTING Multicenter randomized, double-blind, controlled trial. PARTICIPANTS Persons with hypertension who were 55 years of age or older with 1 or more risk factors for CHD and who were stratified into 3 baseline GFR groups: normal or increased (> or = 90 mL/min per 1.73 m2; n = 8126 patients), mild reduction (60 to 89 mL/min per 1.73 m2; n = 18,109 patients), and moderate or severe reduction (< 60 mL/min per 1.73 m2; n = 5662 patients). INTERVENTIONS Random assignment to chlorthalidone, amlodipine, or lisinopril. MEASUREMENTS Rates of ESRD, CHD, stroke, and combined CVD (CHD, coronary revascularization, angina, stroke, heart failure, and peripheral arterial disease). RESULTS In participants with a moderate to severe reduction in GFR, 6-year rates were higher for CHD than for ESRD (15.4% vs. 6.0%, respectively). A baseline GFR of less than 53 mL/min per 1.73 m2 (compared with >104 mL/min per 1.73 m2) was independently associated with a 32% higher risk for CHD. Amlodipine was similar to chlorthalidone in reducing CHD (16.0% vs. 15.2%, respectively; hazard ratio, 1.06 [95% CI, 0.89 to 1.27]), stroke, and combined CVD (CHD, coronary revascularization, angina, stroke, heart failure, and peripheral arterial disease), but less effective in preventing heart failure. Lisinopril was similar to chlorthalidone in preventing CHD (15.1% vs. 15.2%, respectively; hazard ratio, 1.00 [CI, 0.84 to 1.20]), but was less effective in reducing stroke, combined CVD events, and heart failure. LIMITATIONS Proteinuria data were not available, and combination therapies were not tested. CONCLUSIONS Older high-risk patients with hypertension and reduced GFR are more likely to develop CHD than to develop ESRD. A low GFR independently predicts increased risk for CHD. Neither amlodipine nor lisinopril is superior to chlorthalidone in preventing CHD, stroke, or combined CVD, and chlorthalidone is superior to both for preventing heart failure, independent of level of renal function.
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Whelton PK, Barzilay J, Cushman WC, Davis BR, Iiamathi E, Kostis JB, Leenen FHH, Louis GT, Margolis KL, Mathis DE, Moloo J, Nwachuku C, Panebianco D, Parish DC, Pressel S, Simmons DL, Thadani U. Clinical outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ACTA ACUST UNITED AC 2005; 165:1401-9. [PMID: 15983290 DOI: 10.1001/archinte.165.12.1401] [Citation(s) in RCA: 223] [Impact Index Per Article: 11.7] [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]
Abstract
BACKGROUND Optimal first-step antihypertensive drug therapy in type 2 diabetes mellitus (DM) or impaired fasting glucose levels (IFG) is uncertain. We wished to determine whether treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor decreases clinical complications compared with treatment with a thiazide-type diuretic in DM, IFG, and normoglycemia (NG). METHODS Active-controlled trial in 31 512 adults, 55 years or older, with hypertension and at least 1 other risk factor for coronary heart disease, stratified into DM (n = 13 101), IFG (n = 1399), and NG (n = 17 012) groups on the basis of national guidelines. Participants were randomly assigned to double-blind first-step treatment with chlorthalidone, 12.5 to 25 mg/d, amlodipine besylate, 2.5 to 10 mg/d, or lisinopril, 10 to 40 mg/d. We conducted an intention-to-treat analysis of fatal coronary heart disease or nonfatal myocardial infarction (primary outcome), total mortality, and other clinical complications. RESULTS There was no significant difference in relative risk (RR) for the primary outcome in DM or NG participants assigned to amlodipine or lisinopril vs chlorthalidone or in IFG participants assigned to lisinopril vs chlorthalidone. A significantly higher RR (95% confidence interval) was noted for the primary outcome in IFG participants assigned to amlodipine vs chlorthalidone (1.73 [1.10-2.72]). Stroke was more common in NG participants assigned to lisinopril vs chlorthalidone (1.31 [1.10-1.57]). Heart failure was more common in DM and NG participants assigned to amlodipine (1.39 [1.22-1.59] and 1.30 [1.12-1.51], respectively) or lisinopril (1.15 [1.00-1.32] and 1.19 [1.02-1.39], respectively) vs chlorthalidone. CONCLUSION Our results provide no evidence of superiority for treatment with calcium channel blockers or angiotensin-converting enzyme inhibitors compared with a thiazide-type diuretic during first-step antihypertensive therapy in DM, IFG, or NG.
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Affiliation(s)
- Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
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Abstract
This review article presents data to show that insulin resistance and diabetes mellitus are conditions associated with low-grade inflammation. It shows that inflammation pre-dates the detection of diabetes and predicts its occurrence. Furthermore, it discusses the inter-relationship between inflammation associated with insulin resistance and diabetes, and the inflammation associated with atherosclerosis, the main complication of insulin resistance and diabetes. These data provide a new paradigm for understanding how insulin resistance, diabetes, and cardiovascular disease are related to one another. This paradigm also has the potential for opening up new areas of research and treatment.
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Affiliation(s)
- Joshua Barzilay
- Department of Medicine, Kaiser Permanente of Georgia, Tucker, Georgia 30084, USA.
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35
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Rahman M, Pressel S, Davis BR, Nwachuku C, Wright JT, Whelton PK, Barzilay J, Batuman V, Eckfeldt JH, Farber M, Henriquez M, Kopyt N, Louis GT, Saklayen M, Stanford C, Walworth C, Ward H, Wiegmann T. Renal outcomes in high-risk hypertensive patients treated with an angiotensin-converting enzyme inhibitor or a calcium channel blocker vs a diuretic: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ACTA ACUST UNITED AC 2005; 165:936-46. [PMID: 15851647 DOI: 10.1001/archinte.165.8.936] [Citation(s) in RCA: 265] [Impact Index Per Article: 13.9] [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: 12/24/2022]
Abstract
BACKGROUND This study was performed to determine whether, in high-risk hypertensive patients with a reduced glomerular filtration rate (GFR), treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers the incidence of renal disease outcomes compared with treatment with a diuretic. METHODS We conducted post hoc analyses of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertensive participants 55 years or older with at least 1 other coronary heart disease risk factor were randomized to receive chlorthalidone, amlodipine, or lisinopril for a mean of 4.9 years. Renal outcomes were incidence of end-stage renal disease (ESRD) and/or a decrement in GFR of 50% or more from baseline. Baseline GFR, estimated by the simplified Modification of Diet in Renal Disease equation, was stratified into normal or increased (> or =90 mL /min per 1.73 m(2), n = 8126), mild reduction (60-89 mL /min per 1.73 m(2), n = 18 109), or moderate-severe reduction (<60 mL /min per 1.73 m(2), n = 5662) in GFR. Each stratum was analyzed for effects of the treatments on outcomes. RESULTS In 448 participants, ESRD developed. Compared with patients taking chlorthalidone, no significant differences occurred in the incidence of ESRD in patients taking amlodipine in the mild (relative risk [RR], 1.47; 95% confidence interval [CI], 0.97-2.23) or moderate-severe (RR, 0.92; 95% CI, 0.68-1.24) reduction in GFR groups. Compared with patients taking chlorthalidone, no significant differences occurred in the incidence of ESRD in patients taking lisinopril in the mild (RR, 1.34; 95% CI, 0.87-2.06) or moderate-severe (RR, 0.98; 95% CI, 0.73-1.31) reduction in GFR groups. In patients with mild and moderate-severe reduction in GFR, the incidence of ESRD or 50% or greater decrement in GFR was not significantly different in patients treated with chlorthalidone compared with those treated with amlodipine (odds ratios, 0.96 [P = .74] and 0.85 [P = .23], respectively) and lisinopril (odds ratios, 1.13 [P = .31] and 1.00 [P = .98], respectively). No difference in treatment effects occurred for either end point for patients taking amlodipine or lisinopril compared with those taking chlorthalidone across the 3 GFR subgroups, either for the total group or for participants with diabetes at baseline. At 4 years of follow-up, estimated GFR was 3 to 6 mL /min per 1.73 m(2) higher in patients assigned to receive amlodipine compared with chlorthalidone, depending on baseline GFR stratum. CONCLUSIONS In hypertensive patients with reduced GFR, neither amlodipine nor lisinopril was superior to chlorthalidone in reducing the rate of development of ESRD or a 50% or greater decrement in GFR. Participants assigned to receive amlodipine had a higher GFR than those assigned to receive chlorthalidone, but rates of development of ESRD were not different between the groups.
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Affiliation(s)
- Mahboob Rahman
- Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals of Cleveland, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
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Wright JT, Cushman WC, Davis BR, Barzilay J, Colon P, Egan D, Lucente T, Nwachuku C, Pressel S, Leenen FH, Frolkis J, Letterer R, Walsh S, Tobin JN, Deger GE. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT): clinical center recruitment experience. Control Clin Trials 2001; 22:659-73. [PMID: 11738122 DOI: 10.1016/s0197-2456(01)00176-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized clinical outcome trial of antihypertensive and lipid-lowering therapy in a diverse population (including substantial numbers of women and minorities) of 42,419 high-risk hypertensives aged > or = 55 years with a planned mean follow-up of 6 years. In this paper, we describe our experience in the identification, recruitment, and selection of clinical centers for this large simple trial capable of meeting the recruitment goals outlined for ALLHAT, and we highlight factors associated with clinical center performance. Over 135,000 recruitment brochures were mailed to physicians. Requests for information and application packets were received from 9351 (6.8%) interested investigators. A total of 1053 completed applications were received and 909 sites (86%) were eventually approved to join the trial. Of the approved sites, 278 either later declined participation or were never activated, and 8 were closed within a year for lack of enrollment. The final 623 randomizing centers exceeded the trial's recruitment goal to enroll at least 40,000 participants into the trial, although the recruitment period was extended 1.5 years longer than planned. Fewer than a quarter of the sites (22.6%) were recruited from academic medical centers or Department of Veterans Affairs Medical Centers. More than half of the sites (54.7%) were private solo or group practices, which contributed 53% of randomized participants. Community health centers comprised about 8% of the ALLHAT sites and 2.9% were part of health maintenance organizations. More than 22% of the principal investigators reported that they had no previous clinical research experience. In summary, ALLHAT was successful in recruiting a diverse group of clinical centers to achieve its patient recruitment goals.
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Affiliation(s)
- J T Wright
- Clinical Hypertension Program, Division of Hypertension, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106-4982, USA.
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Kuller LH, Velentgas P, Barzilay J, Beauchamp NJ, O'Leary DH, Savage PJ. Diabetes mellitus: subclinical cardiovascular disease and risk of incident cardiovascular disease and all-cause mortality. Arterioscler Thromb Vasc Biol 2000; 20:823-9. [PMID: 10712409 DOI: 10.1161/01.atv.20.3.823] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.5] [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: 11/16/2022]
Abstract
Previously diagnosed diabetes mellitus, newly diagnosed diabetes mellitus, and impaired glucose tolerance are important determinants of the risk of clinical cardiovascular disease (CVD). We have evaluated the relation of patients with subclinical CVD, diabetes, and impaired glucose tolerance and "normal" subjects and the risk of clinical CVD in the Cardiovascular Health Study. Diabetes (1343), impaired glucose tolerance (1433), and normal (2421) were defined by World Health Organization criteria at baseline in 1989 to 1990. The average follow-up was 6.4 years (mean age 73 years). Diabetics had a higher prevalence of clinical and subclinical CVD at baseline. Compared with diabetes in the absence of subclinical disease, the presence of subclinical CVD and diabetes was associated with significant increased adjusted relative risk of death (1.5, CI 0.93 to 2.41), relative risk of incident coronary heart disease (1.99, CI 1.25 to 3.19), and incident myocardial infarction (1.93, CI 0.96 to 3.91). The risk of clinical events was greater for participants with a history of diabetes compared with newly diagnosed diabetics at baseline. Compared with nondiabetic nonhypertensive subjects without subclinical disease, patients with a combination of diabetes, hypertension, and subclinical disease had a 12-fold increased risk of stroke. Fasting blood glucose levels were a weak predictor of incident coronary heart disease as were most other risk factors. Subclinical CVD was the primary determinant of clinical CVD among diabetics in the Cardiovascular Health Study.
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Affiliation(s)
- L H Kuller
- Graduate School of Public Health, Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA 15261, USA. kuller+@pitt.edu
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Abstract
OBJECTIVE To provide a context for the interpretation of lactic acidosis risk among patients using metformin, we measured rates of lactic acidosis in patients with type 2 diabetes before metformin was approved for use in the U.S. RESEARCH DESIGN AND METHODS Using electronic databases of hospital discharge diagnoses and laboratory results maintained by a large, nonprofit health maintenance organization (HMO). we identified possible lactic acidosis events in three geographically and racially diverse populations with type 2 diabetes. We then reviewed hard-copy clinical records to confirm and describe each event and determine its likely cause(s). RESULTS From >41.000 person-years of experience, we found four confirmed, three possible, and three borderline cases of lactic acidosis. In each case, we identified at least one severe medical condition that could have caused the acidosis. The annual confirmed event rate is similar to published rates of metformin-associated lactic acidosis. CONCLUSIONS Lactic acidosis occurs regularly, although infrequently, among persons with type 2 diabetes, at rates similar to its occurrence among metformin users. The medical conditions with which both metformin-associated and naturally occurring lactic acidosis co-occur are also its potential causes. The observed association between metformin and lactic acidosis may be coincidental rather than causal. This possibility merits further study
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Affiliation(s)
- J B Brown
- Kaiser Permanente Center for Health Research, Portland, Oregon 97227-1098, USA.
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Haim M, Hod H, Kaplinsky E, Reicher-Reiss H, Barzilay J, Boyko V, Goldbourt U, Behar S. Frequency and prognostic significance of high-degree atrioventricular block in patients with a first non-Q-wave acute myocardial infarction. The SPRINT Study Group. Second Prevention Reinfarction Israeli Nifedipine Trial. Am J Cardiol 1997; 79:674-6. [PMID: 9068532 DOI: 10.1016/s0002-9149(96)00839-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients with a first non-Q-wave acute myocardial infarction with high-degree atrioventricular block were compared with patients without atrioventricular block. In-hospital complications and mortality were significantly higher among patients with atrioventricular block; atrioventricular block emerged as an important prognostic predictor of early mortality in these patients.
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Affiliation(s)
- M Haim
- Neufeld Cardiac Research Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Elliott S, Lorenzini T, Chang D, Barzilay J, Delorme E. Mapping of the active site of recombinant human erythropoietin. Blood 1997; 89:493-502. [PMID: 9002951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Recombinant human erythropoietin (rHuEPO) variants have been constructed to identify amino acid residues important for biological activity. Immunoassays were used to determine the effect of each mutation on rHuEPO folding. With this strategy, we could distinguish between mutations that affected bioactivity directly and those that affected bioactivity because the mutation altered rHuEPO conformation. Four regions were found to be important for bioactivity: amino acids 11 to 15, 44 to 51, 100 to 108, and 147 to 151. EPO variants could be divided into two groups according to the differential effects on EPO receptor binding activity and in vitro biologic activity. This suggests that rHuEPO has two separate receptor binding sites. Mutations in basic residues reduced the biologic activity, whereas mutations in acidic residues did not. This suggests that electrostatic interactions between rHuEPO and the human EPO receptor may involve positive charges on rHuEPO.
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Affiliation(s)
- S Elliott
- Amgen Center, Thousand Oaks, CA 91320, USA
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Elliott S, Lorenzini T, Chang D, Barzilay J, Delorme E, Giffin J, Hesterberg L. Fine-structure epitope mapping of antierythropoietin monoclonal antibodies reveals a model of recombinant human erythropoietin structure. Blood 1996; 87:2702-13. [PMID: 8639886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
We have isolated and mapped the rHuEPO epitopes for three noncompeting anti-EPO monoclonal antibodies (MoAbs). The MoAb 9G8A recognizes a linear epitope that includes amino acids 13, 16, and 17. MoAb F12 recognizes a conformational epitope that includes amino acids 31 through 33, 86 through 91, and 138. MoAb D11 recognizes a conformational epitope that includes amino acids 64 through 78 and 99 through 110. MoAb D11 neutralizes rHuEPO activity which suggests that its epitope may contain the receptor binding domain. Analysis of the effect of mutations on folding allowed the identification of buried residues, alpha-helical, and non alpha-helical regions. This data along with epitope mapping data of anti rHuEPO monoclonals was used to model rHuEPO protein structure. A model consistent with the data is a 4-helix bundle with short and long interconnecting loops.
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Barzilay J, Verhallen TM. The evaluation of food products as consequence of product applications. Appetite 1994; 22:275-6. [PMID: 7979344 DOI: 10.1006/appe.1994.1025] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/28/2023]
Affiliation(s)
- J Barzilay
- Unilever Research Laboratory, Vlaardingen, The Netherlands
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Abstract
A patient with erosive spondyloarthropathy (ESA) and primary hyperparathyroidism is described. In the past, ESA has been described exclusively in patients with chronic renal failure (CRF) and has been attributed to crystal deposition, amyloidosis, severe secondary hyperparathyroidism, or other abnormalities of chronic renal failure. This patient with normal renal function suggests that secondary hyperparathyroidism plays the major pathogenetic role in ESA in patients with renal failure.
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Affiliation(s)
- J Barzilay
- Department of Medicine, New England Deaconess Hospital, Boston, MA
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Barzilay J, Warram JH, Bak M, Laffel LM, Canessa M, Krolewski AS. Predisposition to hypertension: risk factor for nephropathy and hypertension in IDDM. Kidney Int 1992; 41:723-30. [PMID: 1513093 DOI: 10.1038/ki.1992.113] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.3] [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: 12/27/2022]
Abstract
Less than a quarter of the patients with juvenile-onset IDDM develop diabetic nephropathy during the first 20 years of diabetes. To study the determinants of this complication, we selected patients who had come with newly diagnosed IDDM to the Joslin Clinic between 1967 to 1972, and we examined them in 1986 to 1988, that is, 15 to 21 years after onset of diabetes. Using a case control design we compared three groups of cases, that is, advanced nephropathy (N = 43), only microalbuminuria (N = 41), and hypertension alone (N = 17), with a group of controls who remained normoalbuminuric and normotensive despite the long duration of IDDM (N = 61). In comparison with controls, patients with advanced nephropathy had more parents with hypertension (odds ratio 3.8), higher Vmax values of Na/Li countertransport in red blood cells (odds ratio 10.0 for the highest tertile), and higher mean arterial pressure during adolescence and early adulthood (odds ratio 3.1 for those above the median). They also had significantly poorer glycemic control during their first 12 years of diabetes. Patients with hypertension alone were similar to those with advanced nephropathy with regard to markers of predisposition to hypertension but differed from them with regard to glycemic control, having the best glycemic control of all the study groups. Patients who developed only microalbuminuria during 15 to 21 years of IDDM (some of whom will progress to overt proteinuria later) did not differ significantly from controls with regard to predisposition to hypertension. In conclusion, predisposition to hypertension is a major risk factor for the development of advanced diabetic nephropathy and essential hypertension during the first 20 years of IDDM.
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Affiliation(s)
- J Barzilay
- Epidemiology and Genetics Section, Brigham and Women's Hospital, Boston Massachusetts
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Barzilay J, Warram JH, Rand LI, Pfeifer MA, Krolewski AS. Risk for cardiovascular autonomic neuropathy is associated with the HLA-DR3/4 phenotype in type I diabetes mellitus. Ann Intern Med 1992; 116:544-9. [PMID: 1543308 DOI: 10.7326/0003-4819-116-7-544] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [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: 12/27/2022] Open
Abstract
OBJECTIVE To identify risk factors for the development of cardiovascular autonomic neuropathy in patients with juvenile-onset type I diabetes mellitus. DESIGN Cross-sectional examination of an inception cohort 15 to 21 years after the onset of diabetes. SETTING Outpatient diabetes clinic. PATIENTS Seventy-nine patients with type I diabetes who experienced onset of disease before 21 years of age and who were followed for 15 to 21 years. MEASUREMENTS Autonomic nerve function was evaluated in all patients using deep breathing and tilt tests. On the basis of these tests, an index of cardiovascular autonomic neuropathy was derived and patients were classified as having intact, mildly impaired, or significantly impaired autonomic function. RESULTS The group with significantly impaired function had a higher mean hemoglobin A1 at the time of examination than the group without impairment, yet the groups did not differ regarding glycemic control during the first decade of diabetes. The HLA-DR3/4 phenotype was present in more than 50% of the patients with significant autonomic dysfunction and conferred relative odds of 6.2 (95% CI, 1.7 to 23.3) for the development of autonomic neuropathy when compared with other HLA-DR phenotypes. Sex, percent ideal body weight, and smoking did not have a statistically significant effect on the development of autonomic neuropathy. CONCLUSIONS The development of cardiovascular autonomic neuropathy in type I diabetes mellitus is strongly associated with the HLA-DR3/4 phenotype. Thus, genetic predisposition may play an important role in the development of this complication.
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Affiliation(s)
- J Barzilay
- Joslin Diabetes Center, Boston, Massachusetts
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Krolewski AS, Barzilay J, Warram JH, Martin BC, Pfeifer M, Rand LI. Risk of early-onset proliferative retinopathy in IDDM is closely related to cardiovascular autonomic neuropathy. Diabetes 1992; 41:430-7. [PMID: 1607070 DOI: 10.2337/diab.41.4.430] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [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: 12/27/2022]
Abstract
Determinants of proliferative diabetic retinopathy (PDR) that occur during the 2nd decade of insulin-dependent diabetes mellitus (IDDM) (early-onset PDR) were investigated in a nested case-control study. From an inception cohort of patients with juvenile-onset IDDM that now has 15-21 yr diabetes duration, the patients with PDR (cases, n = 74) were selected for study along with a random sample of the patients in the cohort without PDR (control subjects, n = 88). The risk of PDR was associated with poor glycemic control during the first 12 yr of diabetes. Relative to patients in the first quartile of the index of hyperglycemia, those in higher quartiles and nonattenders had a four- to fivefold risk of developing PDR. A striking relationship with cardiovascular autonomic neuropathy (CAN) was found. Relative to patients without CAN, patients with significant and mild CAN had odds ratios of 77.5 and 34.6, respectively. Patients with albumin excretion rates greater than 30 micrograms/min had moderately increased risk of PDR (ranging from 4-fold for microalbuminuria to 7-fold for proteinuria). In contrast, patients with impaired renal function had an extremely high risk of PDR. All 20 of these patients were cases, therefore the odds ratio was infinite. All three factors (poor glycemic control, CAN, and various stages of nephropathy) were associated with PDR in multiple logistic regression analysis. However, in models including glycemic control, the association between microalbuminuria or proteinuria and PDR was weakened. In conclusion, our findings are consistent with a hypothesis that the level of glycemia is a primary determinant of early-onset PDR.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A S Krolewski
- Epidemiology and Genetics Section, Joslin Diabetes Center, Boston, Massachusetts 02215
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Barzilay J, Heatley GJ, Cushing GW. Benign and malignant tumors in patients with acromegaly. Arch Intern Med 1991; 151:1629-32. [PMID: 1678593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Growth hormone and its principal mediator insulinlike growth factor I are known promoters of normal growth. To determine whether excessive secretion of growth hormone is associated with an increased occurrence of benign and of malignant tumors, we studied records of 87 patients with acromegaly seen in the Lahey Clinic Medical Center (Burlington, Mass) from 1957 to 1988 and compared the rate of tumor occurrence with a control group of patients with pituitary tumors (198) and with findings from a cancer registry. Patients with acromegaly had a 2.45-fold increased rate of malignant tumors (95% confidence interval, 0.98 to 5.04) compared with findings from the tumor registry. Female patients had a higher rate than male patients. The rate of carcinoma of the thyroid was excessive and previously underscribed, but the rate of carcinoma of the colon was not increased as reported by others. Among benign lesions, goiters, predominantly nodular, were seen in 25% of patients in addition to a large number of mesenchymal lesions.
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Affiliation(s)
- J Barzilay
- Section of Endocrinology, Lahey Clinic Medical Center, Burlington, Mass 01805
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Abstract
A patient with long-standing, asymptomatic, primary hyperparathyroidism developed pain in the anterior neck area, with cough, dysphagia and increasing shortness of breath. This led to respiratory insufficiency, which required endotracheal intubation and respirator assistance. During the ensuing hours the patient developed an area of ecchymosis on the anterior chest. Chest x-ray showed widening of the superior mediastinum, and CT scan showed a large mass with a fluid level. Surgery revealed a large hematoma originating from a mediastinal parathyroid adenoma with a hemorrhagic infarct. Serum calcium, previously elevated, decreased to normal with the onset of neck pain, and the patient remains normocalcemic. Previous reported cases of this rare complication of parathyroid adenomas are reviewed. Hemorrhagic infarct of a parathyroid adenoma may present with a rapidly enlarging mediastinal mass, and/or hypercalcemic crisis. Surgical removal of the infarcted adenoma can return the serum calcium to normal.
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Affiliation(s)
- L S Hotes
- Department of Medicine, Brockton Hospital, Massachusetts
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