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Puissant MM, Agarwal I, Scharnetzki E, Cutler A, Gunnell H, Strout TD. Racial differences in triage assessment at rural vs urban Maine emergency departments. Intern Emerg Med 2024:10.1007/s11739-024-03560-4. [PMID: 38598085 DOI: 10.1007/s11739-024-03560-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 02/06/2024] [Indexed: 04/11/2024]
Abstract
Data continue to accumulate demonstrating that those belonging to racialized groups face implicit bias in the emergency care delivery system across many indices, including triage assessment. The Emergency Severity Index (ESI) was developed and widely implemented across the US to improve the objectivity of triage assessment and prioritization of care delivery; however, research continues to support the presence of subjective bias in triage assessment. We sought to assess the relationship between perceived race and/or need for translator and assigned ESI score and whether this was impacted by hospital geography. We performed retrospective EMR-based review of patients presenting to urban and rural emergency departments of a health system in Maine with one of the top ten most common chief complaints (CC) across a 5-year period, excluding psychiatric CCs. We used multivariable regression to analyze the relationships between perceived race, need for translator, and gender with ESI score, wait time, and hallway bed assignments. We found that patients perceived as non-white were more likely to receive lower acuity ESI scores and have longer wait times as compared to patients perceived as white. Patients perceived as female were more likely to receive lower acuity scores and wait longer to be seen than patients perceived as male. The need for an interpreter was associated with increased wait times but not significantly associated with ESI score. After stratification by hospital geography, evidence of subjective bias was limited to urban emergency departments and was not evident in rural emergency departments. Further investigation of subjective bias in emergency departments in Maine, particularly in urban settings, is warranted.
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Affiliation(s)
- Madeleine M Puissant
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.
- MHIR-CIPHR, 1 Riverfront Plaza, Westbrook, ME, 04092, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Isha Agarwal
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
- MHIR-CIPHR, 1 Riverfront Plaza, Westbrook, ME, 04092, USA
- Tufts University School of Medicine, Boston, MA, USA
| | | | - Anya Cutler
- MHIR-CIPHR, 1 Riverfront Plaza, Westbrook, ME, 04092, USA
| | - Hadley Gunnell
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Tania D Strout
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
- Tufts University School of Medicine, Boston, MA, USA
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Agarwal I, MacVane CZ. Shift Scheduling and Overnight Work Among Pregnant Emergency Medicine Residents. Ann Emerg Med 2024:S0196-0644(24)00041-6. [PMID: 38402481 DOI: 10.1016/j.annemergmed.2024.01.029] [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] [Received: 06/15/2023] [Revised: 01/11/2024] [Accepted: 01/22/2024] [Indexed: 02/26/2024]
Affiliation(s)
- Isha Agarwal
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine.
| | - Casey Z MacVane
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine
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Agarwal I, Wang S, Stuart J, Strohmaier S, Schernhammer E, Rich-Edwards J, Kang JH. First-trimester occupational exposures and hypertensive disorders of pregnancy among US nurses. Occup Med (Lond) 2023; 73:419-426. [PMID: 37587907 PMCID: PMC11009503 DOI: 10.1093/occmed/kqad089] [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] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Limited and conflicting data exist regarding the impact of first-trimester nursing occupational exposures on hypertensive disorders of pregnancy (HDP). AIMS To investigate whether first-trimester night shift work, work hours and work-related activities are associated with HDP. METHODS We conducted a cross-sectional analysis of 6610 women within the Nurses' Health Study II. We used multiple logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the relation of occupational exposures to HDP. RESULTS Nine per cent of respondents reported an HDP in the index pregnancy (gestational hypertension: n = 354, 5%, preeclampsia: n = 222, 3%). First-trimester fixed or rotating night shift work was not significantly associated with gestational hypertension or preeclampsia compared to day shift work only. Compared to those working 21-40 h/week, working overtime (≥41 h/week) was not associated with gestational hypertension but was associated with 43% higher odds of preeclampsia (95% CI 1.02, 2.00). For part-time work (≤20 h/week), the OR was 0.76 (95% CI 0.56, 1.02) for gestational hypertension and 0.64 (95% CI 0.43, 0.97) for preeclampsia. The odds of preeclampsia were 3% higher per additional hour worked per week (95% CI 1.01-1.04). Compared to 0-4 h spent standing or walking per day, standing or walking ≥9 h daily was associated with 32% lower odds of gestational hypertension (95% CI 0.47, 0.99) but was not significantly associated with preeclampsia. Frequency of heavy lifting was not associated with either hypertensive disorder or pregnancy. CONCLUSIONS Among nurses, working overtime was associated with higher odds of preeclampsia.
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Affiliation(s)
- I Agarwal
- Maine Health Institute for Research, Maine Medical Center, Scarborough 04074, MN, USA
| | - S Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - J Stuart
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - S Strohmaier
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna 1090, Austria
| | - E Schernhammer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna 1090, Austria
| | - J Rich-Edwards
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - J H Kang
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
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Agarwal I, Sarma D, Burke RC, Babineau M, Benson S, Strout T, Bilello LA, Sanchez LD. Resident Attitudes Toward Performing Pelvic Examinations in the Emergency Department. Womens Health Rep (New Rochelle) 2023; 4:89-93. [PMID: 36874233 PMCID: PMC9983135 DOI: 10.1089/whr.2022.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/19/2023]
Abstract
Mounting evidence suggests that emergency physicians tend to avoid patients with gynecologic chief complaints, and that avoidance may be higher for male physicians compared to females. One underlying reason could be discomfort with performing pelvic examinations. The goal of this study was to assess whether male residents report greater discomfort with pelvic examinations than females. We performed a cross-sectional, Institutional Review Board-approved survey of residents at 6 academic emergency medicine programs. Of 100 residents who completed the survey, 63 self-identified as male, 36 female, and one selected "prefer not to say" and was excluded. Responses were compared between male and females using chi-square tests. In secondary analysis, t-tests were used to compare preferences for various chief complaints. Self-reported comfort with pelvic examinations did not differ significantly between males and females (p = 0.4249). Barriers for male respondents in performing pelvic examinations included lack of training, general dislike, and concern the patient would prefer female providers. Male residents had a statistically significant higher aversion ranking towards patients with vaginal bleeding than female residents (mean difference = 0.48, confidence interval = 0.11-0.87). Aversion ranking was the same between males and females on other chief complaints. There is a gender disparity among male and female residents in attitudes towards patients with vaginal bleeding. However, the results from this study do not demonstrate a significant difference in self-reported comfort amongst male and female residents in performing pelvic examinations. This disparity may be driven by other barriers, including self-reported lack of training and concern about patients' physician gender preferences.
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Affiliation(s)
- Isha Agarwal
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine, USA.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Deesha Sarma
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ryan C Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Matthew Babineau
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Scarlet Benson
- Department of Emergency Medicine, Aventura Hospital and Medical Center, Aventura, Florida, USA
| | - Tania Strout
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine, USA
| | - Leslie A Bilello
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Leon D Sanchez
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, Massachusetts, USA
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MacVane CZ, Puissant M, Fix M, Strout TD, Bonney C, Welsh L, Mittelman A, Ricker J, Agarwal I. Scheduling practices for pregnant emergency medicine residents. AEM Educ Train 2022; 6:e10813. [PMID: 36425789 PMCID: PMC9677363 DOI: 10.1002/aet2.10813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/22/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
Background Night shift work is associated with adverse pathophysiologic effects on maternal and fetal well-being. Although emergency medicine (EM) residents work frequent night shifts, there is no existing guidance for residency program directors (PDs) regarding scheduling pregnant residents. Our study assessed scheduling practices for pregnant EM residents, differences based on program and PD characteristics, barriers and attitudes toward implementing a formal scheduling policy, and PDs' awareness of literature describing adverse effects of night shifts on maternal-fetal outcomes. Methods We conducted an anonymous, web-based survey of U.S. EM residencies (N = 276). Quantitative data were summarized; chi-square analysis and logistic regression were used to assess relationships between program and PD characteristics and schedule accommodations. Qualitative description was used to analyze an open-ended question, organizing findings into major and minor themes. Results Of the 167 completed surveys (response rate 61%), 67% of programs reported no formal policy for scheduling pregnant residents but made adjustments on an individual basis including block changes (85%), decreased (46%) or no night shifts (34%), and working shifts earlier in pregnancy to cover later shifts (20%). Barriers to adjustments included staffing constraints (60%), equity concerns (45%), or impact on wellness (41%) among all residents and privacy (28%). PDs endorsed scheduling adjustments as important (mean 8.1, 0-10 scale) and reported guidance from graduate medical education governance would be useful (60%). Larger program size, but not PD gender or proportion of female residents, was associated with an increased likelihood of scheduling modifications. Twenty-five percent of PDs reported little knowledge of literature regarding night shift work and pregnancy. Qualitative themes supported quantitative findings. Conclusions Most EM residency programs do not have formal scheduling policies for pregnant residents, but most PDs support making adjustments and do so informally. More education and guidance for PDs are needed to promote the development of formal policies.
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Affiliation(s)
- Casey Z. MacVane
- Department of Emergency Medicine, Maine Medical CenterTufts University School of MedicinePortlandMaineUSA
| | | | - Megan Fix
- Department of Emergency MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Tania D. Strout
- Department of Emergency Medicine, Maine Medical CenterTufts University School of MedicinePortlandMaineUSA
| | - Caitlin Bonney
- Department of Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
| | - Laura Welsh
- Department of Emergency Medicine, Boston Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Andrew Mittelman
- Department of Emergency Medicine, Boston Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Jana Ricker
- Department of Emergency MedicineMaine Medical CenterPortlandMaineUSA
| | - Isha Agarwal
- Department of Emergency Medicine, Maine Medical CenterTufts University School of MedicinePortlandMaineUSA
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Puissant M, Gunnell H, Cutler A, Scharnetzki E, Strout T, Agarwal I. 312 Racial Differences in Adult Emergency Department Triage Assignment Across An Urban-Rural Health System. Ann Emerg Med 2022. [DOI: 10.1016/j.annemergmed.2022.08.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Agarwal I, Tayade S, Sharma S. A Case Report of a Normal Pregnancy in a Bicornuate Uterus Through In Vitro Fertilization. Cureus 2022; 14:e29152. [PMID: 36259042 PMCID: PMC9573070 DOI: 10.7759/cureus.29152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022] Open
Abstract
The case report has been done to examine the possibility of normal pregnancy achieved in the case of a rare congenital anomaly, the bicornuate uterus. A bicornuate uterus is a very rare congenital anomaly of the uterus, which falls in the class 4 category according to the classification of Mullerian duct anomalies given by the American Society of Reproductive Medicine and is associated with several obstetrics complications like malpresentation, recurrent abortions, and growth restrictions. However, to have a normal pregnancy in a bicornuate uterus, close antenatal monitoring is required, and, depending on the individual, surgical unification can be done. A 30-year-old woman with G3A2 with 34.3 weeks of gestational age with in vitro fertilization (IVF) conception came with cervical stitch in situ and oligohydramnios with liquor index 7 for safe confinement. At the time of admission, amenorrhea was present for nine months. Ultrasound at 33 weeks three days showed a single uterine live fetus weighing about 2187 grams. The interpretation of the color Doppler was also normal. Fetal heart sound was heard in the Doppler. She was operated on at 36 weeks as an emergency lower-section cesarean section procedure. The indication was that it was an IVF baby, and the female had presented with oligohydramnios on performing investigations. The patient was counseled accordingly and discharged on 22 February 2022. She was advised to come back after 15 days or SOS at the time of emergency. All the measures were suggested, including adequate rest, plenty of fluids, and a good protein diet. Most cases of the bicornuate uterus do not present with any symptoms, i.e., they are asymptomatic and can be detected during routine evaluation of the patient. However, some patients can also have symptoms like menstrual problems such as dysmenorrhea and menorrhagia. Also, along with this anomaly, associated anomalies may be present, including agenesis of the kidney and ureter. The first and foremost investigation to be done is ultrasonography, which tells about the diagnosis of the bicornuate uterus. Magnetic resonance imaging is the gold standard test for its diagnosis. However, the diagnosis in the case of asymptomatic patients is relatively tricky and requires aggressive prenatal monitoring and needs to be kept in observation to make the pregnancy successful.
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8
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Agarwal I, Joseph JW, Sanchez LD. Time on shift in the emergency department and decision to prescribe opioids to patients without chronic opioid use. Clin Exp Emerg Med 2022; 9:108-113. [PMID: 35843610 PMCID: PMC9288880 DOI: 10.15441/ceem.22.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To study the effect of time on shift on the opioid prescribing practices of emergency physicians among patients without chronic opioid use.Methods We analyzed pain-related visits for five painful conditions from 2010 to 2017 at a single academic hospital in Boston. Visits were categorized according to national guidelines as conditions for which opioids are “sometimes indicated” (fracture and renal colic) or “usually not indicated” (headache, low back pain, and fibromyalgia). Using conditional logistic regression with fixed effects for clinicians, we estimated the probability of opioid prescribing for pain-related visits as a function of shift hour at discharge, time of day, and patient-level confounders (age, sex, and pain score).Results Among 16,115 visits for which opioids were sometimes indicated, opioid prescribing increased over the course of a shift (28% in the first hour compared with 40% in the last hour; adjusted odds ratio, 1.06; 95% confidence interval, 1.02–1.10; adjusted P-trend <0.01). However, among visits for which opioids are usually not indicated, relative to the first hour, opioid prescriptions progressively fell (40% in the first hour compared with 23% in the last hour; adjusted odds ratio, 0.93; 95% confidence interval, 0.91–0.96; adjusted P-trend <0.01).Conclusion As shift hour progressed, emergency physicians became more likely to prescribe opioids for conditions that are sometimes indicated, and less likely to prescribe opioids for nonindicated conditions. Our study suggests that clinical decision making in the emergency department can be substantially influenced by external factors such as clinician shift hour.
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9
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Agarwal I, Bajpayee N. A Review on the Incidence of Conjunctivitis Seen in COVID-19 Disease. JPRI 2021. [DOI: 10.9734/jpri/2021/v33i61a35117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Conjunctivitis is a pathological problem of the eye. It can be defined as an inflammatory condition consisting of membranes and conjunctiva. It can be caused by several organisms and has several possible causes. It may be caused by bacteria, viruses, fungus, or protozoa and may also occur due to infection. Conjunctivitis is a prevalent issue in developing and developed countries. In layman's language, it can also progress to red-eye very commonly and, therefore, the red disease. The treatment of conjunctivitis includes no such medications since some of them are self-healing. However, some require topical steroids to relieve the inflammation—moreover, antihistaminics, mast cell stabilizers, and NSAIDs. In bacterial conjunctivitis, antibiotics are given according to the causative organisms.
Since the virus outbreak started in India and the people of our country underwent several restrictions, including strict lockdowns, we people are bound to use electronic gadgets and online learning platforms, which has exceeded our screen time to several folds. This has increased the prevalence of different eye disorders causing refractive errors, vision loss, dry eye, eyes watering, etc. Even the toddlers who should ideally be put into a playschool and be physically active and kept away from any screen are bound to sit in front of their laptops for hours to learn something. Also, sometimes a patient may present with conjunctivitis as the only symptom. Therefore, this review article will shed light on the above sentences and discuss the severity.
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10
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Doussau A, Agarwal I, Fojo T, Tannock IF, Grady C. Design of placebo-controlled randomized trials of anticancer agents: Ethical considerations based on a review of published trials. Clin Trials 2021; 18:690-698. [PMID: 34693757 DOI: 10.1177/17407745211052474] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Limited information exists about the design of placebo-controlled cancer trials. Through a systematic review of trials published in 2013, we describe placebo use in randomized trials testing anticancer agents and analyze strategies that increase exposure to the experimental regimen. METHODS Trials were classified as add-on (placebo in combination with standard treatment) or placebo-only. Strategies to allow more than half of the participants to receive the experimental regimen were reviewed. The risk-benefit ratio of receiving the experimental agent was considered favorable if the difference in primary outcome was significant (p ≤ 0.05), neutral if there was no significant difference in the primary outcome and the experimental agent did not add substantial toxicity, and unfavorable otherwise. RESULTS Eighty trials were included (32,694 participants). Most trials were add-on (69%). The risk-benefit outcome was favorable, neutral, and unfavorable to the experimental agent in 52%, 32%, and 16% of placebo-only trials and 25%, 53%, and 22%, respectively, of add-on trials. Four strategies increased exposure to the experimental regimen: one-way crossover (23%), uneven randomization (21%), three-arms (13%), and randomized discontinuation design (4%); these strategies were used more often in placebo-only trials. CONCLUSION A minority of participants received placebo alone and strategies to increase experimental exposure were used commonly. Fewer than half of the studies had favorable outcomes, thus defending the use of placebo controls, when there is no established treatment. Strategies that increase patient exposure to experimental agents rather than placebo may expose them to non-beneficial, sometimes toxic, experimental agents.
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Affiliation(s)
- Adélaïde Doussau
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,St. Mary's Research Centre, Montreal, QC, Canada
| | - Isha Agarwal
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Tito Fojo
- Department of Medicine, Division of Hematology/Oncology, Columbia University in the City of New York, New York, NY, USA
| | - Ian F Tannock
- Princess Margaret Cancer Center and University of Toronto, Toronto, ON, Canada
| | - Christine Grady
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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Barak-Corren Y, Agarwal I, Michelson KA, Lyons TW, Neuman MI, Lipsett SC, Kimia AA, Eisenberg MA, Capraro AJ, Levy JA, Hudgins JD, Reis BY, Fine AM. Prediction of patient disposition: comparison of computer and human approaches and a proposed synthesis. J Am Med Inform Assoc 2021; 28:1736-1745. [PMID: 34010406 DOI: 10.1093/jamia/ocab076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 02/01/2021] [Revised: 03/20/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the accuracy of computer versus physician predictions of hospitalization and to explore the potential synergies of hybrid physician-computer models. MATERIALS AND METHODS A single-center prospective observational study in a tertiary pediatric hospital in Boston, Massachusetts, United States. Nine emergency department (ED) attending physicians participated in the study. Physicians predicted the likelihood of admission for patients in the ED whose hospitalization disposition had not yet been decided. In parallel, a random-forest computer model was developed to predict hospitalizations from the ED, based on data available within the first hour of the ED encounter. The model was tested on the same cohort of patients evaluated by the participating physicians. RESULTS 198 pediatric patients were considered for inclusion. Six patients were excluded due to incomplete or erroneous physician forms. Of the 192 included patients, 54 (28%) were admitted and 138 (72%) were discharged. The positive predictive value for the prediction of admission was 66% for the clinicians, 73% for the computer model, and 86% for a hybrid model combining the two. To predict admission, physicians relied more heavily on the clinical appearance of the patient, while the computer model relied more heavily on technical data-driven features, such as the rate of prior admissions or distance traveled to hospital. DISCUSSION Computer-generated predictions of patient disposition were more accurate than clinician-generated predictions. A hybrid prediction model improved accuracy over both individual predictions, highlighting the complementary and synergistic effects of both approaches. CONCLUSION The integration of computer and clinician predictions can yield improved predictive performance.
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Affiliation(s)
- Yuval Barak-Corren
- Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Isha Agarwal
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kenneth A Michelson
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Todd W Lyons
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark I Neuman
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amir A Kimia
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew A Eisenberg
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew J Capraro
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jason A Levy
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joel D Hudgins
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ben Y Reis
- Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew M Fine
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Saha D, Mahanta T, Roy P, Agarwal I, Maiti B, Kumar N. Does Micronucleus Score Significantly Correlate with Dysplasia in Cervical Pap Smears? J Med Sci 2020. [DOI: 10.4103/jmedsci.jmedsci_76_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Guliani BP, Agarwal I, Naik MP. Effect of Uncomplicated Cataract Surgery on Central Macular Thickness in Diabetic and Non-diabetic Subjects. J Ophthalmic Vis Res 2019; 14:442-447. [PMID: 31875099 PMCID: PMC6825692 DOI: 10.18502/jovr.v14i4.5447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 03/24/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose To assess the quantitative changes of macula in diabetic and non-diabetic eyes after uncomplicated cataract surgery. Methods In this prospective interventional study being performed in a tertiary healthcare hospital, a total of 660 eyes were divided into two groups. Group 1 included 330 eyes from healthy subjects and group 2 included 330 eyes from well-controlled diabetic subjects with no diabetic retinopathy planned for phacoemulsification with foldable IOL implantation by the same surgeon under similar settings. Optical Coherence Tomography (Heidelberg Spectralis SD-OCT) was used to assess preoperative and postoperative central macular thickness (CMT) at weeks 1 and 6. Results The mean CMT in group 1 preoperatively, at postoperative week 1, and at post-operative week 6 was 257.03 ± 20.904, 262.82 ± 17.010, and 265.15 ± 20.078 µm, respectively. The corresponding values in group 2 were 255.36 ± 17.852, 259.15 ± 16.644, and 266.09 ± 18.844 µm, respectively. There was no significant difference in the mean CMT values between the two groups on any of the three occasions when the CMT was measured (P = 0.374 and P = 0.313 at weeks 1 and 6, respectively). Conclusion There was no statistically significant difference in CMT between normal subjects and diabetic subjects without diabetic retinopathy preoperatively and in early postoperative period after uncomplicated phacoemulsification surgery.
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Affiliation(s)
- Brahm Prakash Guliani
- Department of Ophthalmology, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Isha Agarwal
- Department of Ophthalmology, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mayuresh P Naik
- Department of Ophthalmology, Hamdard Institute of Medical Sciences & Research, Hakeem Abdul Hameed Centenary Hospital, New Delhi, India
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14
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Barak-Corren Y, Agarwal I, Reis B, Fine A. 127 Predicting Patient Disposition from the Emergency Department: A Prospective Comparison of Attending Physician Gestalt vs. an Automated Computer Model. Ann Emerg Med 2019. [DOI: 10.1016/j.annemergmed.2019.08.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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15
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Agarwal I, Nisha M, Theophilus S V, David George V, Rebekah G. SAT-127 L-FABP - A PROMISING NOVEL PREDICTOR OF ADVERSE OUTCOME IN CRITICALLY ILL CHILDREN WITH SEPSIS-ASSOCIATED AKI. Kidney Int Rep 2019. [DOI: 10.1016/j.ekir.2019.05.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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16
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Agarwal I, Naik M, Sethi H. Idiopathic Isolated Acquired Steroid Dependent SO Palsy: A Rare Case Report. Case Rep Ophthalmol Med 2019; 2019:4812380. [PMID: 30809402 PMCID: PMC6364110 DOI: 10.1155/2019/4812380] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/24/2018] [Indexed: 11/19/2022] Open
Abstract
15-year-old boy presented with sudden onset, stable, nonprogressive painless diplopia (greatest in right gaze and inferior field of view) and hyperdeviation of left eye for a year. On ophthalmic examination, the patient had uncrossed diplopia with tilt and separation maximum in dextrodepression. On Park's three step test, left eye hypertropia increased on right gaze and left tilt suggestive of left superior oblique (SO) palsy. On prism bar cover test (PBCT), deviation was more than 25 PD base-down over the left eye for both distance and near in all gazes. MRI head and orbit revealed a normal study while the myasthenia and inflammatory work-up was unremarkable. A provisional diagnosis of "Idiopathic Acquired Left Superior Oblique Palsy" was made and the patient was given trial of oral steroids at 1 mg/kg body weight. At 6 weeks, patient's diplopia resolved and PBCT neutralised at 6PD. Oral steroids were gradually tapered off by 10 mg per week with weekly follow-up. Upon decreasing the dose of prednisolone to 5 mg, intermittent diplopia and 18 PD left hypertropia reappeared. When patient was again restarted on oral steroids at 1 mg/kg body weight, diplopia-hypertropia disappeared at 10 mg OD prednisolone only to reappear at 5 mg OD dosage, leading to the final diagnosis of a "Steroid Dependent Isolated Superior Oblique Palsy". Presently, the patient is maintained on a daily dose of 10 mg oral prednisolone.
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Affiliation(s)
- Isha Agarwal
- Department of Ophthalmology, V.M.M.C. & Safdarjung Hospital, Ring Road, Ansari Nagar, New Delhi 110029, India
| | - Mayuresh Naik
- Department of Ophthalmology, V.M.M.C. & Safdarjung Hospital, Ring Road, Ansari Nagar, New Delhi 110029, India
| | - HarinderSingh Sethi
- Department of Ophthalmology, V.M.M.C. & Safdarjung Hospital, Ring Road, Ansari Nagar, New Delhi 110029, India
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17
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Sanguansak T, Morley KE, Morley MG, Thinkhamrop K, Thuanman J, Agarwal I. Multimedia Appendix Removal and Editorial Warning Regarding the MMAS Scale (Two-Way Social Media Messaging in Post-Operative Cataract Surgical Patients: A Prospective Interventional Study). J Med Internet Res 2018; 20:e12120. [PMID: 30578176 PMCID: PMC6320430 DOI: 10.2196/12120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 10/04/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thuss Sanguansak
- Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Katharine E Morley
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Michael G Morley
- Harvard Medical School, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Kavin Thinkhamrop
- Ophthalmic Consultants of Boston, Department of Ophthalmology, Harvard Medical School, Boston, MA, United States
| | - Jaruwan Thuanman
- Ophthalmic Consultants of Boston, Department of Ophthalmology, Harvard Medical School, Boston, MA, United States
| | - Isha Agarwal
- Data Management and Statistical Analysis Center, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.,Harvard School of Public Health, Boston, MA, United States
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18
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Sanguansak T, Morley KE, Morley MG, Thinkhamrop K, Thuanman J, Agarwal I. Two-Way Social Media Messaging in Postoperative Cataract Surgical Patients: Prospective Interventional Study. J Med Internet Res 2017; 19:e413. [PMID: 29258973 PMCID: PMC5750422 DOI: 10.2196/jmir.8330] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 07/01/2017] [Revised: 10/06/2017] [Accepted: 11/07/2017] [Indexed: 12/14/2022] Open
Abstract
Background Social media offers a new way to provide education, reminders, and support for patients with a variety of health conditions. Most of these interventions use one-way, provider-patient communication. Incorporating social media tools to improve postoperative (postop) education and follow-up care has only been used in limited situations. Objective The aim of this study was to determine the feasibility and efficacy of two-way social media messaging to deliver reminders and educational information about postop care to cataract patients. Methods A total of 98 patients undergoing their first eye cataract surgery were divided into two groups: a no message group receiving usual pre- and postop care and a message group receiving usual care plus messages in a mobile social media format with standardized content and timing. Each patient in the message group received nine messages about hand and face hygiene, medication and postop visit adherence, and links to patient education videos about postop care. Patients could respond to messages as desired. Main outcome measures included medication adherence, postop visit adherence, clinical outcomes, and patients’ subjective assessments of two-way messaging. The number, types, content, and timing of responses by patients to messages were recorded. Results Medication adherence was better in the message group at postop day 7, with high adherence in 47 patients (96%, 47/49) versus 36 patients (73%, 36/49) in the no message group (P=.004), but no statistically significant differences in medication adherence between the groups were noted at preop and postop day 30. Visit adherence was higher at postop day 30 in the message group (100%, 49/49) versus the no message group (88%, 43/49; P=.03) but was 100% (49/49) in both groups at postop day 1 and 7. Final visual outcomes were similar between groups. A total of 441 standardized messages were sent to the message group. Out of 270 responses generated, 188 (70%) were simple acknowledgments or “thank you,” and 82 (30%) responses were questions that were divided into three general categories: administrative, postop care, and clinical issues. Out of the 82 question responses, 31 (11%) were about administrative issues, 28 (10%) about postop care, and 23 (9%) about clinical symptoms. All the messages about symptoms were triaged by nurses or ophthalmologists and only required reassurance or information. Patients expressed satisfaction with messaging. Conclusions Two-way social media messaging to deliver postop information to cataract patients is feasible and improves early medication compliance. Further design improvements can streamline work flow to optimize efficiency and patient satisfaction.
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Affiliation(s)
- Thuss Sanguansak
- Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Katharine E Morley
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Michael G Morley
- Harvard Medical School, Boston, MA, United States.,Ophthalmic Consultants of Boston, Department of Ophthalmology, Harvard Medical School, Boston, MA, United States
| | - Kavin Thinkhamrop
- Data Management and Statistical Analysis Center, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Jaruwan Thuanman
- Data Management and Statistical Analysis Center, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Isha Agarwal
- Harvard Medical School, Boston, MA, United States.,Harvard School of Public Health, Boston, MA, United States
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19
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Abstract
Nocturnal enuresis is a common problem affecting school-aged children worldwide. Although it has significant impact on child's psychology, it is always under-recognized in India and considered as a condition which will outgrow with advancing age. Nocturnal enuresis classified as primary or secondary and monosymptomatic or nonmonosymptomatic. Factors that cause enuresis include genetic factors, bladder dysfunction, psychological factors, and inappropriate antidiuretic hormone secretion, leading to nocturnal polyuria. Diagnosis consists of detailed medical history, clinical examination, frequency-volume charts, and appropriate investigations. The frequency-volume chart or voiding diary helps in establishing diagnosis and tailoring therapy. The first step in treating nocturnal enuresis is to counsel the parents and the affected child about the condition and reassure them that it can be cured. One of the effective strategies to manage enuresis is alarm therapy, but currently, it is not easily available in India. Desmopressin has been used in the treatment of nocturnal enuresis for close to 50 years. It provides an effective and safe option for the management of nocturnal enuresis. This review covers the diagnosis and management of nocturnal enuresis and introduces the concept of “bedwetting clinics” in India, which should help clinicians in the thorough investigation of bedwetting cases.
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Affiliation(s)
- N M Reddy
- Department of Urology, Rainbow Hospitals, Hyderabad, Telangana, India
| | - H Malve
- Medical Affairs, Ferring Pharmaceuticals Pvt. Ltd., Mumbai, Maharashtra, India
| | - R Nerli
- Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum, India
| | - P Venkatesh
- Department of Pediatric Urology, NU Hospitals, Bengaluru, Karnataka, India
| | - I Agarwal
- Department of Child Health Unit II, Christian Medical College, Vellore, Tamil Nadu, India
| | - V Rege
- Department of Pediatric Urology, Wadia Hospital for Children, Mumbai, Maharashtra, India
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20
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Skamene S, Agarwal I, Makar M, Krishnan M, Spektor A, Hertan L, Mouw KW, Taylor A, Noveroske Philbrick S, Balboni T. Impact of a dedicated palliative radiation oncology service on the use of single fraction and hypofractionated radiation therapy among patients with bone metastases. Ann Palliat Med 2017; 7:186-191. [PMID: 29307209 DOI: 10.21037/apm.2017.11.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 11/06/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Radiation therapy (RT) is frequently used to palliate symptomatic bone metastases. While high quality literature has shown that for uncomplicated bone metastases, shorter radiotherapy courses are just as effective as longer courses for the treatment of pain, shorter courses remain under-utilized. We aimed to assess the impact of a dedicated palliative radiation oncology service on the frequency of single fraction RT (SF-RT) and hypofractionated radiation (hypo-RT) (≤5 fractions) among patients with bone metastases. METHODS We identified 2,086 instances of palliative radiation (RT) for complicated and uncomplicated bone metastases between April 10, 2008 and September 17, 2014. We used multivariable logistic regression analysis (MVA) to estimate the association of the Supportive and Palliative Radiation Oncology (SPRO) service with the likelihood of receiving SF-RT or hypo-RT after controlling for age, sex, tumor type, and treatment site. RESULTS Prior to SPRO's implementation on July 1, 2011, the proportion of SF-RT and hypo-RT for bone metastases was 6.4% and 27.6% respectively. After SPRO's implementation, the proportion of SF-RT and hypo-RT increased to 22.3% (P<0.001) and 53.5% (P<0.001) respectively. In MVA, patients were more likely to receive SF-RT [odds ratio (OR) =3.3, 95% confidence interval (CI) =2.4-4.7, P<0.001], and hypo-RT (OR =2.5, 95% CI =2.0-3.1, P<0.001) after SPRO's implementation. Compared to sites without a dedicated palliative service, patients receiving care at the SPRO affiliated department were more likely to receive SF-RT (OR =1.9, 95% CI =1.1-3.2, P=0.02) and hypo-RT (OR =1.5, 95% CI =1.1-2.0, P=0.004) for bone metastases. After SPRO's implementation, the average number of RT courses delivered for bone metastases increased from 17.4 to 25.6 per month, (+8.3, 95% CI =4.99-11.55, P<0.001). Despite greater SF-RT and hypo-RT, the average total fractions per month of palliative RT for bone metastases increased from 163.5 pre-SPRO to 166.8 post-SPRO, though not significantly (+3.22, P=NS). CONCLUSIONS Implementation of a dedicated palliative radiation oncology service was associated with increased use of SF and hypo-RT and with greater courses of RT delivered for bone metastases.
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Affiliation(s)
- Sonia Skamene
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | | | - Maggie Makar
- Data Driven Inference Group, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Monica Krishnan
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Alex Spektor
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Lauren Hertan
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Kent W Mouw
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Allison Taylor
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Sarah Noveroske Philbrick
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tracy Balboni
- Department of Radiation Oncology and Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
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21
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Ferket BS, Hunink MGM, Khanji M, Agarwal I, Fleischmann KE, Petersen SE. Cost-effectiveness of the polypill versus risk assessment for prevention of cardiovascular disease. Heart 2017; 103:483-491. [PMID: 28077465 DOI: 10.1136/heartjnl-2016-310529] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 08/27/2016] [Revised: 11/29/2016] [Accepted: 12/02/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE There is an international trend towards recommending medication to prevent cardiovascular disease (CVD) in individuals at increasingly lower cardiovascular risk. We assessed the cost-effectiveness of a population approach with a polypill including a statin (simvastatin 20 mg) and three antihypertensive agents (amlodipine 2.5 mg, losartan 25 mg and hydrochlorothiazide 12.5 mg) and periodic risk assessment with different risk thresholds. METHODS We developed a microsimulation model for lifetime predictions of CVD events, diabetes, and death in 259 146 asymptomatic UK Biobank participants aged 40-69 years. We assessed incremental costs and quality-adjusted life-years (QALYs) for polypill scenarios with the same combination of agents and doses but differing for starting age, and periodic risk assessment with 10-year CVD risk thresholds of 10% and 20%. RESULTS Restrictive risk assessment, in which statins and antihypertensives were prescribed when risk exceeded 20%, was the optimal strategy gaining 123 QALYs (95% credible interval (CI) -173 to 387) per 10 000 individuals at an extra cost of £1.45 million (95% CI 0.89 to 1.94) as compared with current practice. Although less restrictive risk assessment and polypill scenarios prevented more CVD events and attained larger survival gains, these benefits were offset by the additional costs and disutility of daily medication use. Lowering the risk threshold for prescription of statins to 10% was economically unattractive, costing £40 000 per QALY gained. Starting the polypill from age 60 onwards became the most cost-effective scenario when annual drug prices were reduced below £240. All polypill scenarios would save costs at prices below £50. CONCLUSIONS Periodic risk assessment using lower risk thresholds is unlikely to be cost-effective. The polypill would become cost-effective if drug prices were reduced.
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Affiliation(s)
- Bart S Ferket
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - M G Myriam Hunink
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, The Netherlands.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Mohammed Khanji
- William Harvey Research Institute and NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK
| | - Isha Agarwal
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Steffen E Petersen
- William Harvey Research Institute and NIHR Cardiovascular Biomedical Research Unit at Barts, Queen Mary University of London, London, UK
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22
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Sanguansak T, Morley K, Morley M, Kusakul S, Lee R, Shieh E, Yospaiboon Y, Bhoomibunchoo C, Chai-Ear S, Joseph A, Agarwal I. Comparing smartphone camera adapters in imaging post-operative cataract patients. J Telemed Telecare 2016; 23:36-43. [PMID: 26851243 DOI: 10.1177/1357633x15625400] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 11/16/2022]
Abstract
Introduction The goal of this study is to compare image quality and clinical confidence for managing post-operative cataract patients based on anterior segment smartphone images obtained in real-world settings using four types of adapters: (a) macro lens (ML), (b) ML with augmented light-emitting diode (LED) illumination (ML-LED), (c) no adapter (NA) and (d) slit lamp (SL) adapter. Methods Anterior segment images were obtained from 190 eyes after cataract surgery using an eight-megapixel iPhone 6 smartphone camera with four adapters: ML, ML-LED, NA, and SL. Smartphone images were subjectively rated by ophthalmologists as acceptable or not acceptable for: (a) image quality for evaluating the anterior segment structures and (b) reader confidence in clinically managing post-operative patients based on smartphone images. Results NA, ML-LED, and SL had the highest scores for image quality with 100%, 93.7%, and 86.3% judged as acceptable, respectively. NA, SL, and ML-LED were also rated highest in clinical confidence with 100%, 98%, and 93.2% having acceptable levels, respectively. ML was judged lowest in both image quality (61.1% acceptable) and clinical confidence (37.4% acceptable). Discussion This study represents the first effort to compare different smartphone camera adapters' ability to image the anterior segment of the eye in a real-world setting. Our study shows that ML-LED, NA, and SL adapters were acceptable for visualizing anterior segment structures to physician readers in 86-100% of cases. When coupled with visual acuity, intro-ocular pressure and history, these images can result in acceptable clinical confidence in 93-100% of cases.
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Affiliation(s)
| | | | - Michael Morley
- 3 Ophthalmic Consultants of Boston, Harvard Medical School, USA
| | - Suwat Kusakul
- 4 Department of Ophthalmology, Nong Bua Lamphu Provincial Hospital, Thailand
| | - Ramon Lee
- 5 USC Eye Institute, University of Southern California, USA
| | - Eric Shieh
- 6 Jules Stein Eye Institute, David Geffen School of Medicine at UCLA, USA
| | | | | | | | - Anthony Joseph
- 8 Ophthalmic Consultants of Boston, Tufts University, USA
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23
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Prabha R, Mathew BS, Jeyaseelan V, Kumar TS, Agarwal I, Fleming DH. Development and validation of limited sampling strategy equation for mycophenolate mofetil in children with systemic lupus erythematosus. Indian J Nephrol 2016; 26:408-412. [PMID: 27942171 PMCID: PMC5131378 DOI: 10.4103/0971-4065.174242] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The aim of this study was to establish a limited sample strategy (LSS) to predict the mycophenolic acid (MPA) area under the curve (AUC)(0-12) in children with systemic lupus erythematosus (SLE). Three months after initiation of mycophenolate mofetil (MMF) 26 children with SLE presented for therapeutic drug monitoring of MPA. On the day of the test, 10 specimens were collected, analyzed, and MPA AUC(0-12) was calculated. Using step-wise regression analysis, LSS equations were developed. Using bootstrap validation, the predictive performance was calculated. The measured mean (standard deviation) for the trough concentration and AUC(0-12) were 2.55 (1.57) μg/ml and 62.6 (21.67) mg.h/L, respectively. The range of trough concentrations and AUC(0-12) were 0.7-5.54 μg/ml and 22.1-104.8 mg.h/L, respectively. The interindividual variability (%CV) for dose normalized AUC(0-12) and dose normalized Ctrough was 46.5% and 61.1%, respectively. The correlation between the concentrations at the different time points and MPA AUC(0-12) ranged from 0.05 (1.5 h) to 0.56 (4 h). Two LSS equations that included 4 or 5 time points up to 3 h were developed and validated. The 4 point LSS had a correlation (R2) of 0.88 and the 5 point LSS an R2 of 0.87. With respect to the 4 point and 5 point MPA LSS AUC(0-12), the bias was 1.92% and 1.96%, respectively, and the imprecision was 11.24% and 11.28%, respectively. A 4 point LSS which concludes within 3 h after the administration of the MMF dose was developed and validated, to determine the MPA AUC(0-12) in children with SLE.
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Affiliation(s)
- R Prabha
- Department of Pharmacology, Clinical Pharmacology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - B S Mathew
- Department of Pharmacology, Clinical Pharmacology Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - V Jeyaseelan
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - T S Kumar
- Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India
| | - I Agarwal
- Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India
| | - D H Fleming
- Department of Pharmacology, Clinical Pharmacology Unit, Christian Medical College, Vellore, Tamil Nadu, India
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Abstract
Hypertension is common in children with chronic kidney disease (CKD) and is a major determinant of CKD progression. Ambulatory blood pressure monitoring (ABPM) has been proposed to be better in detecting hypertension as compared to casual blood pressure (CBP). This study aims to study the usefulness of ABPM in detecting masked hypertension, evaluating the adequacy of blood pressure (BP) control and predicting left ventricular hypertrophy (LVH) amongst children with CKD. A prospective cross-sectional study of 46 children with stage 3–5 CKD was conducted at the Pediatric Nephrology department of a tertiary hospital in South India. All children underwent CBP, ABPM and an echocardiography. Results were categorized as normal BP; confirmed hypertension; masked hypertension and white coat hypertension. Out of 46 children studied, 11 were undergoing dialysis. While 39.1% children had stage 3 and 4 CKD each, 21.7% had stage 5 CKD. Masked hypertension was detected in 19.6% and 21.7% had confirmed hypertension. Thirty-four (73.9%) children were already receiving antihypertensive medication. In these, CBP was elevated in 23.5% and ABP in 47%. Among children with hypertension as defined by ABPM, LVH was detected in 32.2%. We found that higher the number of abnormal ABPM indices (assessed by BP Index, nocturnal dipping and BP Load) higher the likelihood of LVH (P = 0.046). ABPM is better in detecting hypertension and monitoring adequacy of treatment in children with CKD. The high prevalence of masked hypertension and its association with LVH supports early echocardiography and ambulatory BP monitoring to evaluate cardiovascular risks in this population.
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Affiliation(s)
- D Gupta
- Department of Community Medicine, Christian Medical College and Hospital, Vellore, India
| | - S Chaturvedi
- Department of Pediatric Nephrology, Christian Medical College and Hospital, Vellore, India
| | - S Chandy
- Department of Cardiology, Christian Medical College and Hospital, Vellore, India
| | - I Agarwal
- Department of Community Medicine, Christian Medical College and Hospital, Vellore, India
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Agarwal I, Makar M, Noveroske S, Krishnan M, Taylor A, Gorman D, Balboni T. Impact of a Dedicated Palliative Radiation Oncology Service on the Use of Single-Fraction and Hypofractionated Radiation Therapy Among Patients With Bone Metastases. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.151] [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: 11/28/2022]
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Agarwal I, Glazer NL, Barasch E, Djousse L, Gottdiener JS, Ix JH, Kizer JR, Rimm EB, Siscovick DS, King GL, Mukamal KJ. Associations between metabolic dysregulation and circulating biomarkers of fibrosis: the Cardiovascular Health Study. Metabolism 2015; 64:1316-23. [PMID: 26282733 PMCID: PMC4939831 DOI: 10.1016/j.metabol.2015.07.013] [Citation(s) in RCA: 5] [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] [Received: 04/24/2015] [Revised: 07/11/2015] [Accepted: 07/16/2015] [Indexed: 01/05/2023]
Abstract
AIM Fibrosis is one postulated pathway by which diabetes produces cardiac and other systemic complications. Our aim was to determine which metabolic parameters are associated with circulating fibrosis-related biomarkers transforming growth factor-β (TGF-β) and procollagen type III N-terminal propeptide (PIIINP). METHODS We used linear regression to determine the cross-sectional associations of diverse metabolic parameters, including fasting glucose, fasting insulin, body mass index, fatty acid binding protein 4, and non-esterified fatty acids, with circulating levels of TGF-β (n = 1559) and PIIINP (n = 3024) among community-living older adults in the Cardiovascular Health Study. RESULTS Among the main metabolic parameters we examined, only fasting glucose was associated with TGF-β (P = 0.03). In contrast, multiple metabolic parameters were associated with PIIINP, including fasting insulin, body mass index, and non-esterified fatty acids (P<0.001, P<0.001, P=0.001, respectively). These associations remained statistically significant after mutual adjustment, except the association between BMI and PIIINP. CONCLUSIONS Isolated hyperglycemia is associated with higher serum concentrations of TGF-β, while a broader phenotype of insulin resistance is associated with higher serum PIIINP. Whether simultaneous pharmacologic targeting of these two metabolic phenotypes can synergistically reduce the risk of cardiac and other manifestations of fibrosis remains to be determined.
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Affiliation(s)
- Isha Agarwal
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard School of Public Health, Boston, MA, USA.
| | | | - Eddy Barasch
- Department of Research and Education, St. Francis Hospital, The Heart Center, Roslyn, NY, USA; SUNY at Stony Brook, Stony Brook, NY, USA
| | - Luc Djousse
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John S Gottdiener
- Department of Medicine, University of Maryland Medical School, Baltimore, MD, USA
| | - Joachim H Ix
- Department of Medicine, University of California San Diego, San Diego, CA, USA; Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Jorge R Kizer
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Epidemiology, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eric B Rimm
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David S Siscovick
- The New York Academy of Medicine, New York, NY, USA; Department of Medicine, Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA; Department of Epidemiology, Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
| | - George L King
- Research Division, Joslin Diabetes Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Ken J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Agarwal I, Arnold A, Glazer NL, Barasch E, Djousse L, Fitzpatrick AL, Gottdiener JS, Ix JH, Jensen RA, Kizer JR, Rimm EB, Siscovick DS, Tracy RP, Wong TY, Mukamal KJ. Fibrosis-related biomarkers and large and small vessel disease: the Cardiovascular Health Study. Atherosclerosis 2015; 239:539-46. [PMID: 25725316 DOI: 10.1016/j.atherosclerosis.2015.02.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 12/21/2014] [Revised: 02/07/2015] [Accepted: 02/10/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Fibrosis has been implicated in a number of pathological, organ-based conditions of the liver, kidney, heart, and lungs. The objective of this study was to determine whether biomarkers of fibrosis are associated with vascular disease in the large and/or small vessels. METHODS We evaluated the associations of two circulating biomarkers of fibrosis, transforming growth factor-β (TGF-β) and procollagen type III N-terminal propeptide (PIIINP), with incident peripheral artery disease (PAD) and subclinical macrovascular (carotid intima-media thickness, flow-mediated vasodilation, ankle-brachial index, retinal vein diameter), and microvascular (retinal artery diameter and retinopathy) disease among older adults in the Cardiovascular Health Study. We measured TGF-β and PIIINP from samples collected in 1996 and ascertained clinical PAD through 2011. Measurements of large and small vessels were collected between 1996 and 1998. RESULTS After adjustment for sociodemographic, clinical, and biochemical risk factors, TGF-β was associated with incident PAD (hazard ratio [HR] = 1.36 per doubling of TGF-β, 95% confidence interval [CI] = 1.04, 1.78) and retinal venular diameter (1.63 μm per doubling of TGF-β, CI = 0.23, 3.02). PIIINP was not associated with incident PAD, but was associated with carotid intima-media thickness (0.102 mm per doubling of PIIINP, CI = 0.029, 0.174) and impaired brachial artery reactivity (-0.20% change per doubling of PIIINP, CI = -0.39, -0.02). Neither TGF-β nor PIIINP were associated with retinal arteriolar diameter or retinopathy. CONCLUSIONS Serum concentrations of fibrosis-related biomarkers were associated with several measures of large vessel disease, including incident PAD, but not with small vessel disease. Fibrosis may contribute to large vessel atherosclerosis in older adults.
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Affiliation(s)
- Isha Agarwal
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
| | - Alice Arnold
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Eddy Barasch
- Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, Stony Brook, NY, USA
| | - Luc Djousse
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Boston Veterans Healthcare System, Boston, MA, USA
| | | | - John S Gottdiener
- Department of Medicine, University of Maryland Medical School, Baltimore, MD, USA
| | - Joachim H Ix
- Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Richard A Jensen
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jorge R Kizer
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eric B Rimm
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David S Siscovick
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Russell P Tracy
- Department of Biochemistry, University of Vermont, Burlington, VT, USA
| | - Tien Y Wong
- Department of Ophthalmology, Singapore Eye Research Institute, National University of Singapore, Singapore
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Abstract
Coronary heart disease (CHD) accounts for one in every six deaths in US individuals. Great advances have been made in identifying important risk factors for CHD, such as hypertension, diabetes mellitus, smoking and hypercholesterolaemia, which have led to major developments in therapy. In particular, statins represent one of the greatest successes in the prevention of CHD. While these standard risk factors are important, an obvious opportunity exists to take advantage of ongoing scientific research to better risk-stratify individuals and to identify new treatment targets. In this Review, we summarize ongoing scientific research in a number of metabolic molecules or features, including lipoproteins, homocysteine, calcium metabolism and glycaemic markers. We evaluate the current state of the research and the strength of evidence supporting each emerging biomarker. We also discuss whether the associations with CHD are strong and consistent enough to improve current risk stratification metrics, and whether these markers enhance our understanding of the underlying biology of CHD and thus point towards new treatment options.
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Affiliation(s)
- Majken K Jensen
- Department of Nutrition, Harvard School of Public Health, 665 Huntington Avenue, 02115 Boston, MA, USA
| | - Monica L Bertoia
- Department of Nutrition, Harvard School of Public Health, 665 Huntington Avenue, 02115 Boston, MA, USA
| | - Leah E Cahill
- Department of Nutrition, Harvard School of Public Health, 665 Huntington Avenue, 02115 Boston, MA, USA
| | - Isha Agarwal
- Department of Nutrition, Harvard School of Public Health, 665 Huntington Avenue, 02115 Boston, MA, USA
| | - Eric B Rimm
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, 181 Longwood Avenue, 02115 Boston, MA, USA
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Centre, 1309 Beacon Street, 02446 Brookline, MA, USA
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Amarnath K, Dhanabal J, Agarwal I, Seshadry S. Cytotoxicity induction by ethanolic extract of Acalypha indica loaded casein-chitosan microparticles in human prostate cancer cell line in vitro. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.bionut.2013.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Agarwal I, Glazer NL, Barasch E, Biggs ML, Djousse L, Fitzpatrick AL, Gottdiener JS, Ix JH, Kizer JR, Rimm EB, Sicovick DS, Tracy RP, Mukamal KJ. Fibrosis-related biomarkers and incident cardiovascular disease in older adults: the cardiovascular health study. Circ Arrhythm Electrophysiol 2014; 7:583-9. [PMID: 24963008 DOI: 10.1161/circep.114.001610] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [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: 02/06/2023]
Abstract
BACKGROUND Fibrotic changes in the heart and arteries have been implicated in a diverse range of cardiovascular diseases (CVD), but whether circulating biomarkers that reflect fibrosis are associated with CVD is unknown. METHODS AND RESULTS We determined the associations of 2 biomarkers of fibrosis, transforming growth factor- β (TGF-β), and procollagen type III N-terminal propeptide (PIIINP), with incident heart failure, myocardial infarction, and stroke among community-living older adults in the Cardiovascular Health Study. We measured circulating TGF-β (n=1371) and PIIINP (n=2568) from plasma samples collected in 1996 and ascertained events through 2010. Given TGF-β's pleiotropic effects on inflammation and fibrogenesis, we investigated potential effect modification by C-reactive protein in secondary analyses. After adjustment for sociodemographic, clinical, and biochemical risk factors, PIIINP was associated with total CVD (hazard ratio [HR] per SD=1.07; 95% confidence interval [CI], 1.01-1.14) and heart failure (HR per SD=1.08; CI, 1.01-1.16) but not myocardial infarction or stroke. TGF-β was not associated with any CVD outcomes in the full cohort but was associated with total CVD (HR per SD=1.16; CI, 1.02-1.31), heart failure (HR per SD=1.16; CI, 1.01-1.34), and stroke (HR per SD=1.20; CI, 1.01-1.42) among individuals with C-reactive protein above the median, 2.3 mg/L (P interaction <0.05). CONCLUSIONS Our findings provide large-scale, prospective evidence that circulating biomarkers of fibrosis, measured in community-living individuals late in life, are associated with CVD. Further research on whether TGF-β has a stronger fibrogenic effect in the setting of inflammation is warranted.
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Affiliation(s)
- Isha Agarwal
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.).
| | - Nicole L Glazer
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Eddy Barasch
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Mary L Biggs
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Luc Djousse
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Annette L Fitzpatrick
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - John S Gottdiener
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Joachim H Ix
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Jorge R Kizer
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Eric B Rimm
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - David S Sicovick
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Russell P Tracy
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
| | - Kenneth J Mukamal
- From the Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA (I.A., E.B.R.); Department of Medicine, Boston University, MA (N.L.G.); Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, NY (E.B.); Department of Biostatistics (M.L.B.), Department of Epidemiology (A.L.F.), and Cardiovascular Health Research Unit, Department of Medicine (D.S.S.), University of Washington, Seattle; Department of Medicine (L.D.) and Channing Division of Network Medicine (E.B.R.), Brigham and Women's Hospital, Boston, MA; Department of Medicine, University of Maryland Medical School, Baltimore (J.S.G.); Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System (J.H.I.); Departments of Medicine, Epidemiology, and Population Health, Albert Einstein College of Medicine, Bronx, NY (J.R.K.); Department of Biochemistry, University of Vermont, Burlington (R.P.T.); and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
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Agarwal I, Glazer NL, Barasch E, Biggs ML, Djoussé L, Fitzpatrick AL, Gottdiener JS, Ix JH, Kizer JR, Rimm EB, Siscovick DS, Tracy RP, Zieman SJ, Mukamal KJ. Fibrosis-related biomarkers and risk of total and cause-specific mortality: the cardiovascular health study. Am J Epidemiol 2014; 179:1331-9. [PMID: 24771724 DOI: 10.1093/aje/kwu067] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Fibrosis has been implicated in diverse diseases of the liver, kidney, lungs, and heart, but its importance as a risk factor for mortality remains unconfirmed. We determined the prospective associations of 2 complementary biomarkers of fibrosis, transforming growth factor-β (TGF-β) and procollagen type III N-terminal propeptide (PIIINP), with total and cause-specific mortality risks among community-living older adults in the Cardiovascular Health Study (1996-2010). We measured circulating TGF-β and PIIINP levels in plasma samples collected in 1996 and ascertained the number of deaths through 2010. Both TGF-β and PIIINP were associated with elevated risks of total and pulmonary mortality after adjustment for sociodemographic, clinical, and biochemical risk factors. For total mortality, the hazard ratios per doubling of TGF-β and PIIINP were 1.09 (95% confidence interval (CI): 1.01, 1.17; P = 0.02) and 1.14 (CI: 1.03, 1.27; P = 0.01), respectively. The corresponding hazard ratios for pulmonary mortality were 1.27 (CI: 1.01, 1.60; P = 0.04) for TGF-β and 1.52 (CI: 1.11, 2.10; P = 0.01) for PIIINP. Associations of TGF-β and PIIINP with total and pulmonary mortality were strongest among individuals with higher C-reactive protein concentrations (P for interaction < 0.05). Our findings provide some of the first large-scale prospective evidence that circulating biomarkers of fibrosis measured late in life are associated with death.
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Ferket BS, van Kempen BJH, Hunink MGM, Agarwal I, Kavousi M, Franco OH, Steyerberg EW, Max W, Fleischmann KE. Predictive value of updating Framingham risk scores with novel risk markers in the U.S. general population. PLoS One 2014; 9:e88312. [PMID: 24558385 PMCID: PMC3928195 DOI: 10.1371/journal.pone.0088312] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/07/2014] [Indexed: 11/22/2022] Open
Abstract
Background According to population-based cohort studies CT coronary calcium score (CTCS), carotid intima-media thickness (cIMT), high-sensitivity C- reactive protein (CRP), and ankle-brachial index (ABI) are promising novel risk markers for improving cardiovascular risk assessment. Their impact in the U.S. general population is however uncertain. Our aim was to estimate the predictive value of four novel cardiovascular risk markers for the U.S. general population. Methods and Findings Risk profiles, CRP and ABI data of 3,736 asymptomatic subjects aged 40 or older from the National Health and Nutrition Examination Survey (NHANES) 2003–2004 exam were used along with predicted CTCS and cIMT values. For each subject, we calculated 10-year cardiovascular risks with and without each risk marker. Event rates adjusted for competing risks were obtained by microsimulation. We assessed the impact of updated 10-year risk scores by reclassification and C-statistics. In the study population (mean age 56±11 years, 48% male), 70% (80%) were at low (<10%), 19% (14%) at intermediate (≥10–<20%), and 11% (6%) at high (≥20%) 10-year CVD (CHD) risk. Net reclassification improvement was highest after updating 10-year CVD risk with CTCS: 0.10 (95%CI 0.02–0.19). The C-statistic for 10-year CVD risk increased from 0.82 by 0.02 (95%CI 0.01–0.03) with CTCS. Reclassification occurred most often in those at intermediate risk: with CTCS, 36% (38%) moved to low and 22% (30%) to high CVD (CHD) risk. Improvements with other novel risk markers were limited. Conclusions Only CTCS appeared to have significant incremental predictive value in the U.S. general population, especially in those at intermediate risk. In future research, cost-effectiveness analyses should be considered for evaluating novel cardiovascular risk assessment strategies.
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Affiliation(s)
- Bart S Ferket
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands ; Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
| | - Bob J H van Kempen
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands ; Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
| | - M G Myriam Hunink
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands ; Department of Radiology, Erasmus MC, Rotterdam, the Netherlands ; Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Isha Agarwal
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | | | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Kirsten E Fleischmann
- Division of Cardiology, University of California San Francisco, San Francisco, California, United States of America
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Abstract
BACKGROUND Fibroblast growth factor-23 (FGF-23) is a phosphaturic factor previously associated with left ventricular hypertrophy and systolic dysfunction among individuals with chronic kidney disease. Whether FGF-23 acts directly to induce left ventricular hypertrophy, potentially independent of its klotho coreceptor, remains uncertain. We investigated associations of FGF-23 with cardiac structural abnormalities among individuals with a broad range of kidney function and explored potential biological mechanisms using cardiac magnetic resonance imaging and histology in klotho-null mice, an established model of constitutively elevated FGF-23. METHODS AND RESULTS Among 887 participants with coronary artery disease in the Heart and Soul Study, FGF-23 was modestly associated with worse left ventricular ejection fraction (-1.0% per standard deviation increase in lnFGF-23; standard error, 0.4%), but was not associated with the overall prevalence of concentric hypertrophy (odds ratio, 1.5; CI, 0.9 to 2.4) or eccentric hypertrophy (odds ratio, 1.1; CI, 0.9 to 1.3). FGF-23 was only associated with concentric hypertrophy among individuals with diminished kidney function (eGFR <60 mL/min per 1.73 m(2); odds ratio, 2.3; CI, 1.0 to 5.3; P-interaction=0.28). Comparing klotho-null with wild-type mice, null mice did not have greater left ventricular mass (P=0.37) or a lower ejection fraction (P=0.94). CONCLUSIONS Together, our results suggest that FGF-23 is unlikely to have major effects on cardiovascular structure and function among patients free of substantial chronic kidney disease, and these effects may not be independent of the klotho coreceptor.
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MESH Headings
- Aged
- Animals
- Biomarkers/blood
- Coronary Artery Disease/blood
- Coronary Artery Disease/epidemiology
- Coronary Artery Disease/pathology
- Coronary Artery Disease/physiopathology
- Female
- Fibroblast Growth Factor-23
- Fibroblast Growth Factors/blood
- Glucuronidase/deficiency
- Glucuronidase/genetics
- Humans
- Hypertrophy, Left Ventricular/blood
- Hypertrophy, Left Ventricular/epidemiology
- Hypertrophy, Left Ventricular/pathology
- Hypertrophy, Left Ventricular/physiopathology
- Kidney/physiopathology
- Klotho Proteins
- Linear Models
- Logistic Models
- Longitudinal Studies
- Magnetic Resonance Imaging
- Male
- Mice
- Mice, Knockout
- Middle Aged
- Multivariate Analysis
- Odds Ratio
- Prevalence
- Renal Insufficiency, Chronic/blood
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/physiopathology
- Risk Factors
- Stroke Volume
- Systole
- United States/epidemiology
- Up-Regulation
- Ventricular Dysfunction, Left/blood
- Ventricular Dysfunction, Left/epidemiology
- Ventricular Dysfunction, Left/pathology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left
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Affiliation(s)
- Isha Agarwal
- Department of Epidemiology, Harvard School of Public Health, Boston, MA (I.A.)
| | - Noriko Ide
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA (N.I., B.L.)
| | - Joachim H. Ix
- Department of Medicine, University of California, San Diego and Veterans Affairs San Diego Healthcare System, CA (J.H.I.)
| | - Bryan Kestenbaum
- Department of Epidemiology, University of Washington, Seattle, WA (B.K.)
| | - Beate Lanske
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA (N.I., B.L.)
| | - Nelson B. Schiller
- Department of Medicine, University of California, San Francisco, CA (N.B.S., M.A.W.)
| | - Mary A. Whooley
- Department of Medicine, University of California, San Francisco, CA (N.B.S., M.A.W.)
| | - Kenneth J. Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (K.J.M.)
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Kortum RL, Balagopalan L, Alexander CP, Garcia J, Pinski JM, Merrill RK, Nguyen PH, Li W, Agarwal I, Akpan IO, Sommers CL, Samelson LE. The ability of Sos1 to oligomerize the adaptor protein LAT is separable from its guanine nucleotide exchange activity in vivo. Sci Signal 2013; 6:ra99. [PMID: 24222714 DOI: 10.1126/scisignal.2004494] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The activation of the small guanosine triphosphatase Ras by the guanine nucleotide exchange factor (GEF) Sos1 (Son of Sevenless 1) is a central feature of many receptor-stimulated signaling pathways. In developing T cells (thymocytes), Sos1-dependent activation of extracellular signal-regulated kinase (ERK) is required to stimulate cellular proliferation and differentiation. We showed that in addition to its GEF activity, Sos1 acted as a scaffold to nucleate oligomerization of the T cell adaptor protein LAT (linker for activation of T cells) in vivo. The scaffold function of Sos1 depended on its ability to bind to the adaptor protein Grb2. Furthermore, the GEF activity of Sos1 and the Sos1-dependent oligomerization of LAT were separable functions in vivo. Whereas the GEF activity of Sos1 was required for optimal ERK phosphorylation in response to T cell receptor (TCR) stimulation, the Sos1-dependent oligomerization of LAT was required for maximal TCR-dependent phosphorylation and activation of phospholipase C-γ1 and Ca(2+) signaling. Finally, both of these Sos1 functions were required for early thymocyte proliferation. Whereas transgenic restoration of either the GEF activity or the LAT oligomerization functions of Sos1 alone failed to rescue thymocyte development in Sos1-deficient mice, simultaneous reconstitution of these two signals in the same cell restored normal T cell development. This ability of Sos1 to act both as a RasGEF and as a scaffold to nucleate Grb2-dependent adaptor oligomerization may also occur in other Grb2-dependent pathways, such as those activated by growth factor receptors.
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Affiliation(s)
- Robert L Kortum
- Laboratory of Cellular and Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Abstract
Widespread antenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. The present guidelines update the recommendations published in 2000. Antenatal hydronephrosis (ANH) is transient and resolves by the third trimester in almost one-half cases. The presence of oligohydramnios and additional renal or extrarenal anomalies suggests significant pathology. All patients with ANH should undergo postnatal ultrasonography; the intensity of subsequent evaluation depends on anteroposterior diameter (APD) of the renal pelvis and/or Society for Fetal Urology (SFU) grading. Patients with postnatal APD exceeding 10 mm and/or SFU grade 3-4 should be screened for upper or lower urinary tract obstruction and vesicoureteric reflux (VUR). Infants with VUR should receive antibiotic prophylaxis through the first year of life, and their parents counseled regarding the risk of urinary tract infections. The management of patients with pelviureteric junction or vesicoureteric junction obstruction depends on clinical features and results of sequential ultrasonography and radionuclide renography. Surgery is considered in patients with increasing renal pelvic APD and/or an obstructed renogram with differential renal function <35-40% or its subsequent decline. Further studies are necessary to clarify the role of prenatal intervention, frequency of follow-up investigations and indications for surgery in these patients.
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Affiliation(s)
- A. Sinha
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, India
| | - A. Bagga
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, India
| | - A Krishna
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, India
| | - M. Bajpai
- Max Institute of Pediatrics and Pediatric Surgery, Vellore, Tamil Nadu, India
| | - M. Srinivas
- Max Institute of Pediatrics and Pediatric Surgery, Vellore, Tamil Nadu, India
| | - R. Uppal
- Uppal Radiology Center, Christian Medical College, Vellore, Tamil Nadu, India
| | - I. Agarwal
- Pediatrics, Christian Medical College, Vellore, Tamil Nadu, India
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Peterson RR, Sinha R, Agarwal I. End-stage renal disease with deafness in an adolescent child. Indian J Nephrol 2011; 21:293-4. [PMID: 22022095 PMCID: PMC3193678 DOI: 10.4103/0971-4065.85488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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37
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Abstract
A 7-month-old infant developed acute fatal hepatic failure owing to inadvertent duplication of paracetamol prescriptions. Paracetamol toxicity should be considered in the differential diagnosis of infants presenting with acute hepatic failure.
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Affiliation(s)
- K Ebenezer
- Paediatric Intensive Care Unit, Christian Medical College & Hospital, Vellore, Tamil Nadu, India.
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Abstract
In two experiments, rats received minimal (16) pairings of one auditory conditioned stimulus (CS) cue with a sucrose reinforcer, and extensive (112) pairings of another auditory CS with that reinforcer. After sucrose was devalued by pairing it with lithium chloride in some rats (Devalue groups) but not others (Maintain groups), taste reactivity (TR) and other responses to unflavored water were assessed in the presence of the auditory CSs alone. The minimally trained CS controlled substantially more evaluative TR responses than the extensively trained CS. Those TR responses were hedonic (positive) in the Maintain groups, but aversive (negative) in the Devalue groups. By contrast, food cup entry and other responses thought not to reflect evaluative taste processing were controlled more by the extensively trained cue. These responses were reduced by sucrose devaluation comparably, regardless of the amount of training. The results suggest rapid changes in the content of learning as conditioning proceeds. Early in training, CSs may be capable of activating preevaluative processing of an absent food reinforcer that includes information about its palatability, but that capability is lost as training proceeds.
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Kerfoot EC, Agarwal I, Lee HJ, Holland PC. Control of appetitive and aversive taste-reactivity responses by an auditory conditioned stimulus in a devaluation task: a FOS and behavioral analysis. Learn Mem 2007; 14:581-9. [PMID: 17761543 PMCID: PMC1994081 DOI: 10.1101/lm.627007] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [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: 05/11/2007] [Accepted: 07/11/2007] [Indexed: 11/24/2022]
Abstract
Through associative learning, cues for biologically significant reinforcers such as food may gain access to mental representations of those reinforcers. Here, we used devaluation procedures, behavioral assessment of hedonic taste-reactivity responses, and measurement of immediate-early gene (IEG) expression to show that a cue for food engages behavior and brain activity related to sensory and hedonic processing of that food. Rats first received a tone paired with intraoral infusion of sucrose. Then, in the absence of the tone, the value of sucrose was reduced (Devalue group) by pairing sucrose with lithium chloride (LiCl), or maintained (Maintain group) by presenting sucrose and LiCl unpaired. Finally, taste-reactivity responses to the tone were assessed in the absence of sucrose. Devalue rats showed high levels of aversive responses and minimal appetitive responses, whereas Maintain rats exhibited substantial appetitive responding but little aversive responding. Control rats that had not received tone-sucrose pairings did not display either class of behaviors. Devalue rats showed greater FOS expression than Maintain rats in several brain regions implicated in devaluation task performance and the display of aversive responses, including the basolateral amygdala, orbitofrontal cortex, gustatory cortex (GC), and the posterior accumbens shell (ACBs), whereas the opposite pattern was found in the anterior ACBs. Both Devalue and Maintain rats showed greater FOS expression than control rats in amygdala central nucleus, GC, and both subregions of ACBs. Thus, through associative learning, auditory cues for food gained access to neural processing in several brain regions importantly involved in the processing of taste memory information.
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Affiliation(s)
| | - Isha Agarwal
- Johns Hopkins University, Baltimore, Maryland 21218, USA
| | - Hongjoo J. Lee
- Johns Hopkins University, Baltimore, Maryland 21218, USA
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Agarwal N, Kamra DN, Chaudhary LC, Agarwal I, Sahoo A, Pathak NN. Microbial status and rumen enzyme profile of crossbred calves fed on different microbial feed additives. Lett Appl Microbiol 2002; 34:329-36. [PMID: 11967054 DOI: 10.1046/j.1472-765x.2002.01092.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.1] [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: 11/20/2022]
Abstract
AIMS To test various microbial cultures as cattle feed additives. METHODS AND RESULTS Four groups of newly born crossbred calves (average body weight 23.5 kg) were reared on green berseem and calf starter which was devoid of cereal grains. Milk was fed up to 8 weeks of age, starting with one tenths and gradually reducing to one twentieths of the body weight. One hundred millilitres of microbial feed additive or 100 g fermented feed was fed to the animals of group 2 (curd containing lactic acid bacteria at 10(8) cfu x ml(-1)), group 3 (Saccharomyces cerevisiae NCDC-49 at 10(6) cfu x ml(-1)) and group 4 (Lactobacillus acidophilus-15 at 10(8) cfu x ml(-1)). Group 1 served as control. The incidence and duration of diarrhoea was lower in the animals of probiotic fed groups as compared to control group. Out of three microbial feed additives, yeast feeding showed maximum suppression of diarrhoea followed by Lactobacillus and curd. CONCLUSIONS, SIGNIFICANCE AND IMPACT OF THE STUDY There was no effect of probiotic feeding on the log number of cells of lactic acid bacteria, yeast and coliform bacteria in the faeces and rumen liquor at any age. The activities of carboxymethylcellulase, xylanase, beta-glucosidase, alpha-glucosidase, alpha-amylase, protease, urease and pH of the rumen liquor remained unaffected by probiotic feeding at all ages tested in this experiment.
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Affiliation(s)
- N Agarwal
- Microbiology Section, Centre of Advanced Studies in Animal Nutrition, Indian Veterinary Research Institute, Izatnagar-243122, India
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Abstract
We report pyknodysostosis presenting as extramedullary haematopoiesis in one of two siblings and as obstructive airway disease in the other. Visceral manifestations are rare and have been reported in only two cases in the Indian literature. They have often been mistaken for osteopetrosis, haemolytic anaemia and other osteochondrodystrophies. The cases we report illustrate that, though the physical characteristics may be similar, it is the radiological features that are typical and help establish the diagnosis.
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Affiliation(s)
- I Agarwal
- Department of Child Health, Christian Medical College and Hospital, Vellore, India
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Todd DW, Shoemaker CT, Agarwal I, Browdie DA. Temporary banding of the gastroesophageal juncture in a very small neonate with esophageal atresia and tracheoesophageal fistula. Minn Med 1990; 73:30-2. [PMID: 2366719] [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: 12/31/2022]
Abstract
A 700 gm, small-for-gestational-age infant with severe respiratory distress, esophageal atresia, and Type C tracheoesophageal fistula was treated with initial banding of the gastroesophageal juncture followed by a gastrostomy. Primary repair was completed later, when the infant had stabilized and grown. Continuous air pressure had distended the fistula, thus dilating the distal esophagus and facilitating repair. In very small, high-risk infants with Type C esophageal atresia and tracheoesophageal fistula, banding of the distal esophagus enables enteral feeding and time for growth while protecting the lungs from repetitive aspiration and pneumonia and facilitates subsequent repair. The patient described here is one of the smallest infants reported to survive this problem. It is also the first time the enlargement of the distal pouch and removal of the band from above have been described.
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Affiliation(s)
- D W Todd
- Division of Pediatric Surgery, University of North Dakota School of Medicine, Fargo
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Affiliation(s)
- C M Lathers
- Medical College of Pennsylvania/EPPI, Department of Pharmacology, Philadelphia 19129
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