Sociodemographic Disparities in Sodium-Glucose Co-Transporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists Prescription Patterns Among Patients With Poorly Controlled Diabetes

Introduction Sodium-glucose co-transporter-2 inhibitors (SGLT2Is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are novel antihyperglycemic agents that reduce cardiovascular mortality through insulin-independent mechanisms. In this cross-sectional study, we investigated prescription patterns of these drugs and identified inequities in antihyperglycemic utilization. Methods Unique encounters for diabetes care between January 1, 2020, and December 31, 2020, were identified through a systematic query of our healthcare system's database. All patients ≥18 years old with a hemoglobin A1C level of ≥8% were included in the sample. Demographic data, SGLT2I or GLP-1RA prescription status, diabetes-related complications, and mortality were abstracted. Results A total of 2,746 patients were included in the sample. Among these individuals, 670 (24.4%) were prescribed either an SGLT2I or a GLP-1RA (users) and 2,076 (75.6%) were not prescribed either agent (non-users). There were significantly more males than females in the cohort, but there was no significant difference in the sex distribution between users and non-users. Compared to non-users, users were younger (mean age of 65.1 ± 9.4 years versus 66.4 ± 9.9 years, p-value = 0.005), more likely to be non-Hispanic (86.3% versus 13.7%), more likely to live in a middle-income zip code, and have private insurance. The mortality rate was lower among users when compared to non-users, but the difference did not reach statistical significance (2.7% versus 5.5%, p-value = 0.62). SGLT2I use was associated with a 60% lower risk of mortality. Conclusion Ethnicity, median household income, and insurance type influence the likelihood of being prescribed an SGLT2I or a GLP-1RA. Individuals prescribed either agent appear to have better mortality outcomes than those prescribed other medications. Further investigation may reveal underlying causes and potential solutions for disparities in prescription patterns.

SVEAT score outperforms HEART score in patients admitted to a chest pain observation unit

BACKGROUND

Timely and accurate identification of subgroup at risk for major adverse cardiovascular events among patients presenting with acute chest pain remains a challenge. Currently available risk stratification scores are suboptimal. Recently, a new scoring system called the Symptoms, history of Vascular disease, Electrocardiography, Age, and Troponin (SVEAT) score has been shown to outperform the History, Electrocardiography, Age, Risk factors and Troponin (HEART) score, one of the most used risk scores in the United States.

AIM

To assess the potential usefulness of the SVEAT score as a risk stratification tool by comparing its performance to HEART score in chest pain patients with low suspicion for acute coronary syndrome and admitted for overnight observation.

METHODS

We retrospectively reviewed medical records of 330 consecutive patients admitted to our clinical decision unit for acute chest pain between January 1^st to April 17^th, 2019. To avoid potential biases, investigators assigned to calculate the SVEAT, and HEART scores were blinded to the results of 30-d combined endpoint of death, acute myocardial infarction or confirmed coronary artery disease requiring revascularization or medical therapy [30-d major adverse cardiovascular event (MACE)]. An area under receiving-operator characteristic curve (AUC) for each score was then calculated. C-statistic and logistic model were used to compare predictive performance of the two scores.

RESULTS

A 30-d MACE was observed in 11 patients (3.33% of the subjects). The AUC of SVEAT score (0.8876, 95%CI: 0.82-0.96) was significantly higher than the AUC of HEART score (0.7962, 95%CI: 0.71-0.88), P = 0.03. Using logistic model, SVEAT score with cut-off of 4 or less significantly predicts 30-d MACE (odd ratio 1.52, 95%CI: 1.19-1.95, P = 0.001) but not the HEART score (odd ratio 1.29, 95%CI: 0.78-2.14, P = 0.32).

CONCLUSION

The SVEAT score is superior to the HEART score as a risk stratification tool for acute chest pain in low to intermediate risk patients.

Association between electrocardiographic features and mortality in COVID-19 patients

BACKGROUND

Cardiovascular events have been reported in the setting of coronavirus disease-19 (COVID-19). It has been hypothesized that systemic inflammation may aggravate arrhythmias or trigger new-onset conduction abnormalities. However, the specific type and distribution of electrocardiographic disturbances in COVID-19 as well as their influence on mortality remain to be fully characterized.

METHODS

Electrocardiograms (ECGs) were obtained from 186 COVID-19-positive patients at a large tertiary care hospital in Northern Nevada. The following arrhythmias were identified by cardiologists: sinus bradycardia, sinus tachycardia, atrial fibrillation (A-Fib), atrial flutter, multifocal atrial tachycardia (MAT), premature atrial contraction (PAC), premature ventricular contraction (PVC), atrioventricular block (AVB), and right bundle branch block (RBBB). The mean PR interval, QRS duration, and corrected QT interval were documented. Fisher's exact test was used to compare the ECG features of patients who died during the hospitalization with those who survived. The influence of ECG features on mortality was assessed with multivariable logistic regression analysis.

RESULTS

A-Fib, atrial flutter, and ST-segment depression were predictive of mortality. In addition, the mean ventricular rate was higher among patients who died as compared to those who survived. The use of therapeutic anticoagulation was associated with reduced odds of death; however, this association did not reach statistical significance.

CONCLUSION

The underlying pathogenesis of COVID-19-associated arrhythmias remains to be established, but we postulate that systemic inflammation and/or hypoxia may induce potentially lethal conduction abnormalities in affected individuals. Longitudinal studies are warranted to evaluate the risk factors, pathogenesis, and management of COVID-19-associated cardiac arrhythmias.

Ponatinib-associated panniculitis: Case report and review of the literature

Ponatinib is a tyrosine kinase inhibitor (TKI) approved for the treatment of Philadelphia chromosome-positive chronic myelogenous leukemia and acute lymphoblastic leukemia. Common adverse effects of ponatinib include neutropenia, arterial thrombosis, and hypertension. We describe a 49-year-old woman who developed panniculitis after brief treatment with ponatinib. In addition, we summarize other studies describing TKI-associated panniculitis.

Sociodemographic Predictors of Outcomes in COVID-19: Examining the Impact of Ethnic Disparities in Northern Nevada

Background 

On March 11, 2020, the World Health Organization declared coronavirus disease-19 (COVID-19) a pandemic. Nearly five million individuals have since been diagnosed with this increasingly common and potentially lethal viral infection. Emerging evidence suggests a disproportionate burden of illness and death among minority communities. We aimed to evaluate the effect of ethnicity on outcomes among patients diagnosed with COVID-19 in Northern Nevada.

Methods 

The electronic health records of 172 patients diagnosed with COVID-19 were obtained from a 946-bed tertiary referral center serving Northern Nevada. Demographic and clinical characteristics were compared by ethnic group (Hispanic versus non-Hispanic). Logistic regression was used to determine predictors of mortality. 

Results 

Among 172 patients who were diagnosed with COVID-19 between March 12 and May 8, 2020, 87 (50.6%) identified as Hispanic and 81 (47.1%) as non-Hispanic. Hispanic individuals were significantly more likely to be uninsured and to live in low-income communities as compared to their non-Hispanic counterparts (27.6% versus 8.2% and 52.9% versus 30.6%, respectively). Hispanic patients were also less likely than non-Hispanics to have a primary care provider (42.5% versus 61.2%). However, mortality was significantly higher among the non-Hispanic population (15.3% versus 5.8%). 

Conclusion 

The COVID-19 pandemic has disproportionately affected Hispanic individuals in Northern Nevada, who account for only 25.7% of the population but over half of the confirmed cases. The underlying causes of ethnic disparities in COVID-19 incidence remain to be established, but further investigation may lead to more effective community- and systems-based interventions.

Atorvastatin-Induced Refractory Thrombocytopenia

Drug-induced thrombocytopenia is rarely associated with statin medications. We describe the case of a 69-year-old woman who developed refractory thrombocytopenia following atorvastatin use. To our knowledge, this is the fourth reported case of atorvastatin-induced thrombocytopenia and the first reported case of atorvastatin-induced refractory thrombocytopenia. Additionally, we summarize the cases of statin-induced thrombocytopenia reported in the medical literature.

Cardiac adverse events of immune checkpoint inhibitors in oncology patients: A systematic review and meta-analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs) are novel therapeutic agents used for various types of cancer. ICIs have revolutionized cancer treatment and improved clinical outcomes among cancer patients. However, immune-related adverse effects of ICI therapy are common. Cardiovascular immune-related adverse events (irAEs) are rare but potentially life-threatening complications.

AIM

To estimate the incidence of cardiovascular irAEs among patients undergoing ICI therapy for various malignancies.

METHODS

We conducted this systematic review and meta-analysis by searching PubMed, Cochrane CENTRAL, Web of Science, and SCOPUS databases for relevant interventional trials reporting cardiovascular irAEs. We performed a single-arm meta-analysis using OpenMeta [Analyst] software of the following outcomes: Myocarditis, pericardial effusion, heart failure, cardiomyopathy, atrial fibrillation, myocardial infarction, and cardiac arrest. We assessed the heterogeneity using the I² test and managed to solve it with Cochrane’s leave-one-out method. The risk of bias was performed with the Cochrane’s risk of bias tool.

RESULTS

A total of 26 studies were included. The incidence of irAEs follows: Myocarditis: 0.5% [95% confidence interval (CI): 0.1%-0.9%]; Pericardial effusion: 0.5% (95%CI: 0.1%-1.0%); Heart failure: 0.3% (95%CI: 0.0%-0.5%); Cardiomyopathy: 0.3% (95%CI: -0.1%-0.6%); atrial fibrillation: 4.6% (95%CI: 1.0%-14.1%); Myocardial infarction: 0.4% (95%CI: 0.0%-0.7%); and Cardiac arrest: 0.4% (95%CI: 0.1%-0.8%).

CONCLUSION

The most common cardiovascular irAEs were atrial fibrillation, myocarditis, and pericardial effusion. Although rare, data from post market surveillance will provide estimates of the long-term prevalence and prognosis in patients with ICI-associated cardiovascular complications.

Methodological issues in designing a multisite trial of risperidone in children and adolescents with autism

OBJECTIVE

To describe the methodological challenges and decisions made in developing a multisite, controlled study of risperidone in children and adolescents with autism.

METHODS

Review the design considerations for clinical trials in children with autistic disorder accompanied by severe tantrums, aggressive and/or self-injurious behaviors. These design considerations include the definition of inclusion criteria that are relevant to clinical practice and matching study design to the goal of evaluating short- and long-term effects. Additional ethical and scientific issues concern the length of trial and sample size.

RESULTS

We undertook a short-term, placebo-controlled study to evaluate the efficacy and safety of risperidone in children and adolescents with autistic disorder. This trial design was followed by an extended open-label maintenance on risperidone to confirm durability of treatment effects and to monitor safety. Finally, a placebo-controlled discontinuation study tested the need for continuous treatment.

CONCLUSIONS

In the absence of standard pharmacological treatment for children with autistic disorder, a placebo-controlled study remains the most appropriate method of testing efficacy and safety. The clinical relevance of this study is enhanced by the addition of an extended maintenance phase followed by a placebo discontinuation.

Structure of tandem RNA recognition motifs from polypyrimidine tract binding protein reveals novel features of the RRM fold

Polypyrimidine tract binding protein (PTB), an RNA binding protein containing four RNA recognition motifs (RRMs), is involved in both pre-mRNA splicing and translation initiation directed by picornaviral internal ribosome entry sites. Sequence comparisons previously indicated that PTB is a non-canonical RRM protein. The solution structure of a PTB fragment containing RRMs 3 and 4 shows that the protein consists of two domains connected by a long, flexible linker. The two domains tumble independently in solution, having no fixed relative orientation. In addition to the betaalphabetabetaalphabeta topology, which is characteristic of RRM domains, the C-terminal extension of PTB RRM-3 incorporates an unanticipated fifth beta-strand, which extends the RNA binding surface. The long, disordered polypeptide connecting beta4 and beta5 in RRM-3 is poised above the RNA binding surface and is likely to contribute to RNA recognition. Mutational analyses show that both RRM-3 and RRM-4 contribute to RNA binding specificity and that, despite its unusual sequence, PTB binds RNA in a manner akin to that of other RRM proteins.

The role of annexin II tetramer in the activation of plasminogen

Annexin II tetramer (AIIt) is a major Ca2+-binding protein of endothelial cells which has been shown to exist on both the intracellular and extracellular surfaces of the plasma membrane. In this report, we demonstrate that AIIt stimulates the activation of plasminogen by facilitating the tissue plasminogen activator (t-PA)-dependent conversion of plasminogen to plasmin. Fluid-phase AIIt stimulated the rate of activation of [Glu]plasminogen about 341-fold compared with an approximate 6-fold stimulation by annexin II. AIIt bound to [Glu]plasminogen(S741C-fluorescein) with a Kd of 1. 26 +/- 0.04 microM (mean +/- S.D., n = 3) and this interaction resulted in a large conformational change in [Glu]plasminogen. Kinetic analysis established that AIIt produces a large increase of about 190-fold in the kcat, app and a small increase in the Km,app which resulted in a 90-fold increase in the catalytic efficiency (kcat/Km) of t-PA for [Glu]plasminogen. AIIt also stimulated the t-PA-dependent activation of [Lys]plasminogen about 28-fold. Furthermore, other annexins such as annexin I, V, or VI did not produce comparable activation of t-PA-dependent conversion of [Glu]plasminogen to plasmin. The stimulation of the activation of [Glu]plasminogen by AIIt was Ca2+-independent and inhibited by epsilon-aminocaproic acid. AIIt bound to human 293 cells potentiated t-PA-dependent plasminogen activation. AIIt that was bound to phospholipid vesicles or heparin also stimulated the activation of [Glu]plasminogen 5- or 11-fold, respectively. Furthermore, immunofluorescence labeling of nonpermeabilized HUVEC revealed a punctated distribution of AIIt subunits on the cell surface. These results therefore identify AIIt as a potent in vitro activator of plasminogen.

Annexin II tetramer inhibits plasmin-dependent fibrinolysis

In this paper, we have characterized the regulation of plasmin activity by annexin II tetramer (AIIt). Plasmin activity was measured by a fibrin lysis assay in which a fibrin polymer was produced from purified components and the extent of polymer lysis was determined by following changes in turbidity. Extrinsic lysis of the fibrin polymer, initiated by addition of tissue plasminogen activator (t-PA), was totally blocked if AIIt was present during fibrin polymer formation. Furthermore, fibrin polymer formed in the presence of AIIt was resistant to extrinsic lysis initiated by addition of plasmin. AIIt bound to fibrin polymer under conditions in which polymer lysis was inhibited. Plasmin-dependent extrinsic lysis of the fibrin polymer was also blocked if AIIt was present in the incubation medium, and under these conditions the amidolytic activity of plasmin, measured with an artificial substrate, was inhibited about 5-fold. In contrast, in the absence of fibrin, and at an AIIt/plasmin molar ratio of 526, the amidolytic activity of plasmin was inhibited by only 22.3% +/- 7.4% (mean +/- SD, n = 5) by AIIt. Plasmin-dependent fibrinolysis was only slightly inhibited if fibrin polymer was formed in the presence of annexins I, II, V, or VI. These results identify AIIt as an in vitro regulator of plasmin activity.