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Huang SP, Su CC, Lin CY, Nethery R, Josey K, Bates B, Robinson D, Gandhi P, Rua M, Parthasarathi A, Setoguchi S, Kao Yang YH. Exposure-Response to High PM 2.5 Levels for Cardiovascular Events in High-risk Older Adults in Taiwan. medRxiv 2024:2024.05.08.24306967. [PMID: 38766145 PMCID: PMC11100932 DOI: 10.1101/2024.05.08.24306967] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background Multiple studies from countries with relatively lower PM 2.5 level demonstrated that acute and chronic exposure even at lower than recommended level, e.g., 9 μg/m 3 in the US increased the risk of cardiovascular (CV) events. However, limited studies using individual level data exist from countries with a wider range of PM levels to illustrate shape of the exposure-response curve throughout the range including > 20 μg/m 3 PM 2·5 concentrations. Taiwan with its policies reduced PM 2.5 over time provide opportunities to illustrate the dose response curves and how reductions of PM 2.5 over time correlated with CV events incidence in a nationwide sample. Methods Using data from the 2009-2019 Taiwan National Health Insurance Database linked to nationwide PM2.5 data. We examined the shape and magnitude of the exposure-response curve between seasonal average PM 2·5 level and CV events-related hospitalizations among older adults at high-risk for CV events. We used history-adjusted marginal structural models including potential confounding by individual demographic factors, baseline comorbidities, and health service measures. To quantify the risk below and above 20 μg/m 3 we conducted stratified Cox regression. We also plotted PM 2.5 and CV events from 2009-2019 as well as average temperature as a comparison. Findings Using the PM 2.5 concentration <15 μg/m 3 (Taiwan regulatory standard) as a reference, the seasonal average PM 2.5 concentration (15-23.5μg/m 3 and > 23.5 μg/m 3 ) were associated with hazard ration of 1.13 (95%CI 1.09-1.18) and 1.19 (95%CI 1.14-1.24), 1.07 (95%CI 1.03-1.11) and 1.14 (95%CI 1.10-1.18), 1.22 (95%CI 1.08-1.38) and 1.31 (95%CI 1.16-1.48), 1.04 (95%CI 0.98-1.10) and 1.10 (95%CI 1.04-1.16) respectively for HF, IS/TIA,PE/DVT and MI/ACS. A nonlinear relationship between PM 2·5 and CV events outcomes was observed at PM 2·5 levels above 20 μg/m 3 . Interpretation A nonlinear exposure-response relationship between PM2·5 concentration and the incidence of cardiovascular events exists when PM2.5 is higher than the levels recommended by WHO Air Quality Guidelines. Further lowering PM2·5 levels beyond current regulatory standards may effectively reduce the incidence of cardiovascular events, particularly HF and DVT, and can lead to tangible health benefits in high-risk elderly population.
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Visaria A, Kang E, Parthasarathi A, Robinson D, Read J, Nethery R, Josey K, Gandhi P, Bates B, Rua M, Ghosh AK, Setoguchi S. Ambient heat exposure patterns and emergency department visits and hospitalizations among medicare beneficiaries 2008-2019. Am J Emerg Med 2024; 81:1-9. [PMID: 38613874 DOI: 10.1016/j.ajem.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/18/2024] [Accepted: 04/05/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVE To assess the association between ambient heat and all-cause and cause-specific emergency department (ED) visits and acute hospitalizations among Medicare beneficiaries in the conterminous United States. DESIGN Retrospective cohort study. SETTING Conterminous US from 2008 and 2019. PARTICIPANTS 2% random sample of all Medicare fee-for-service beneficiaries eligible for Parts A, B, and D. MAIN OUTCOME MEASURES All-cause and cause-specific (cardiovascular, renal, and heat-related) ED visits and unplanned hospitalizations were identified using primary ICD-9 or ICD-10 diagnosis codes. We measured the association between ambient temperature - defined as daily mean temperature percentile of summer (June through September) - and the outcomes. Hazard ratios and their associated 95% confidence intervals were estimated using multivariable Cox proportional hazards regression, adjusting for individual level demographics, comorbidities, healthcare utilization factors and zip-code level social factors. RESULTS Among 809,636 Medicare beneficiaries (58% female, 81% non-Hispanic White, 24% <65), older beneficiaries (aged ≥65) exposed to >95th percentile temperature had a 64% elevated adjusted risk of heat-related ED visits (HR [95% CI], 1.64 [1.46,1.85]) and a 4% higher risk of all-cause acute hospitalization (1.04 [1.01,1.06]) relative to <25th temperature percentile. Younger beneficiaries (aged <65) showed increased risk of heat-related ED visits (2.69 [2.23,3.23]) and all-cause ED visits (1.03 [1.01,1.05]). The associations with heat related events were stronger in males and individuals dually eligible for Medicare and Medicaid. No significant differences were observed by climatic region. We observed no significant relationship between temperature percentile and risk of CV-related ED visits or renal-related ED visits. CONCLUSIONS Among Medicare beneficiaries from 2008 to 2019, exposure to daily mean temperature ≥ 95th percentile was associated with increased risk of heat-related ED visits, with stronger associations seen among beneficiaries <65, males, and patients with low socioeconomic position. Further longitudinal studies are needed to understand the impact of heat duration, intensity, and frequency on cause-specific hospitalization outcomes.
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Affiliation(s)
- Aayush Visaria
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, One Robert Wood Johnson Pl., New Brunswick, NJ 08901, United States of America.
| | - Euntaik Kang
- Rutgers Business School, Rutgers University, New Brunswick, NJ 08901, United States of America.
| | - Ashwaghosha Parthasarathi
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, 112 Paterson St., New Brunswick, NJ 08901, United States of America.
| | - David Robinson
- Department of Geography, Rutgers University, Lucy Stone Hall, 54 Joyce Kilmer Ave., Piscataway, NJ 08854, United States of America.
| | - John Read
- Department of Geography, Rutgers University, Lucy Stone Hall, 54 Joyce Kilmer Ave., Piscataway, NJ 08854, United States of America.
| | - Rachel Nethery
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Ave., Building 1, Boston, MA 02115, United States of America.
| | - Kevin Josey
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Ave., Building 1, Boston, MA 02115, United States of America.
| | - Poonam Gandhi
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, 112 Paterson St., New Brunswick, NJ 08901, United States of America.
| | - Benjamin Bates
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, One Robert Wood Johnson Pl., New Brunswick, NJ 08901, United States of America; Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, 112 Paterson St., New Brunswick, NJ 08901, United States of America.
| | - Melanie Rua
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, 112 Paterson St., New Brunswick, NJ 08901, United States of America.
| | - Arnab K Ghosh
- Department of Medicine, Weill Cornell Medicine, 420 E 70(th) St, NY 10065, United States of America.
| | - Soko Setoguchi
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, One Robert Wood Johnson Pl., New Brunswick, NJ 08901, United States of America; Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, 112 Paterson St., New Brunswick, NJ 08901, United States of America.
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Fayyad R, Josey K, Gandhi P, Rua M, Visaria A, Bates B, Setoguchi S, Nethery RC. Air pollution and serious bleeding events in high-risk older adults. Environ Res 2024; 251:118628. [PMID: 38460663 DOI: 10.1016/j.envres.2024.118628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/18/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
IMPORTANCE Despite biological plausibility, very few epidemiologic studies have investigated the risks of clinically significant bleeding events due to particulate air pollution. OBJECTIVE To measure the independent and synergistic effects of PM2.5 exposure and anticoagulant use on serious bleeding events. DESIGN Retrospective cohort study (2008-2016). SETTING Nationwide Medicare population. PARTICIPANTS A 50% random sample of Medicare Part D-eligible Fee-for-Service beneficiaries at high risk for cardiovascular and thromboembolic events. EXPOSURES Fine particulate matter (PM2.5) and anticoagulant drugs (apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin). MAIN OUTCOMES AND MEASURES The outcomes were acute hospitalizations for gastrointestinal bleeding, intracranial bleeding, or epistaxis. Hazard ratios and 95% CIs for PM2.5 exposure were estimated by fitting inverse probability weighted marginal structural Cox proportional hazards models. The relative excess risk due to interaction was used to assess additive-scale interaction between PM2.5 exposure and anticoagulant use. RESULTS The study cohort included 1.86 million high-risk older adults (mean age 77, 60% male, 87% White, 8% Black, 30% anticoagulant users, mean PM2.5 exposure 8.81 μg/m3). A 10 μg/m3 increase in PM2.5 was associated with a 48% (95% CI: 45%-52%), 58% (95% CI: 49%-68%) and 55% (95% CI: 37%-76%) increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis, respectively. Significant additive interaction between PM2.5 exposure and anticoagulant use was observed for gastrointestinal and intracranial bleeding. CONCLUSIONS Among older adults at high risk for cardiovascular and thromboembolic events, increasing PM2.5 exposure was significantly associated with increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis. In addition, PM2.5 exposure and anticoagulant use may act together to increase risks of severe gastrointestinal and intracranial bleeding. Thus, clinicians may recommend that high-risk individuals limit their outdoor air pollution exposure during periods of increased PM2.5 concentrations. Our findings may inform environmental policies to protect the health of vulnerable populations.
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Affiliation(s)
- Rindala Fayyad
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Building 2, 4th Floor, Boston, MA, 02115, USA
| | - Kevin Josey
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Building 2, 4th Floor, Boston, MA, 02115, USA
| | - Poonam Gandhi
- Rutgers University Institute for Health, Healthcare Policy, and Aging Research, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Melanie Rua
- Rutgers University Institute for Health, Healthcare Policy, and Aging Research, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Aayush Visaria
- Rutgers University Institute for Health, Healthcare Policy, and Aging Research, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, 08901, USA; Department of Medicine, Rutgers Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, NJ, 08901, USA
| | - Benjamin Bates
- Rutgers University Institute for Health, Healthcare Policy, and Aging Research, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, 08901, USA; Department of Medicine, Rutgers Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, NJ, 08901, USA
| | - Soko Setoguchi
- Rutgers University Institute for Health, Healthcare Policy, and Aging Research, The State University of New Jersey, 112 Paterson Street, New Brunswick, NJ, 08901, USA; Department of Medicine, Rutgers Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, NJ, 08901, USA.
| | - Rachel C Nethery
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Building 2, 4th Floor, Boston, MA, 02115, USA.
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Visaria A, Huang SP, Su CC, Robinson D, Read J, Lin CY, Nethery R, Josey K, Gandhi P, Bates B, Rua M, Parthasarathi A, Ghosh AK, Kao Yang YH, Setoguchi S. Ambient Heat and Risk of Serious Hypoglycemia in Older Adults With Diabetes Using Insulin in the U.S. and Taiwan: A Cross-National Case-Crossover Study. Diabetes Care 2024; 47:233-238. [PMID: 38060348 PMCID: PMC10834387 DOI: 10.2337/dc23-1189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/02/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To measure the association between ambient heat and hypoglycemia-related emergency department visit or hospitalization in insulin users. RESEARCH DESIGN AND METHODS We identified cases of serious hypoglycemia among adults using insulin aged ≥65 in the U.S. (via Medicare Part A/B/D-eligible beneficiaries) and Taiwan (via National Health Insurance Database) from June to September, 2016-2019. We then estimated odds of hypoglycemia by heat index (HI) percentile categories using conditional logistic regression with a time-stratified case-crossover design. RESULTS Among ∼2 million insulin users in the U.S. (32,461 hypoglycemia case subjects), odds ratios of hypoglycemia for HI >99th, 95-98th, 85-94th, and 75-84th percentiles compared with the 25-74th percentile were 1.38 (95% CI, 1.28-1.48), 1.14 (1.08-1.20), 1.12 (1.08-1.17), and 1.09 (1.04-1.13) respectively. Overall patterns of associations were similar for insulin users in the Taiwan sample (∼283,000 insulin users, 10,162 hypoglycemia case subjects). CONCLUSIONS In two national samples of older insulin users, higher ambient temperature was associated with increased hypoglycemia risk.
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Affiliation(s)
- Aayush Visaria
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Shu-Ping Huang
- Changhua Christian Hospital Institutional Review Board & Administrative Office, Changhua, Taiwan
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Chou Su
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Clinical Innovation and Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - David Robinson
- Department of Geography, Rutgers University, Piscataway, NJ
| | - John Read
- Department of Geography, Rutgers University, Piscataway, NJ
| | - Chuan-Yao Lin
- Research Center for Environmental Changes, Academia Sinica, Taipei, Taiwan
| | - Rachel Nethery
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Kevin Josey
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Poonam Gandhi
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ
| | - Benjamin Bates
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ
| | - Melanie Rua
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ
| | - Ashwagosha Parthasarathi
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ
| | - Arnab K. Ghosh
- Department of Medicine, Weill Cornell Medical College of Cornell University, New York, NY
| | - Yea-Huei Kao Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Soko Setoguchi
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ
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Pina-Sánchez M, Rua M, Del Pozo JL. Present and future of resistance in Pseudomonas aeruginosa: implications for treatment. Rev Esp Quimioter 2023; 36 Suppl 1:54-58. [PMID: 37997873 PMCID: PMC10793548 DOI: 10.37201/req/s01.13.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
Pseudomonas aeruginosa is a pathogen that has a high propensity to develop antibiotic resistance, and the emergence of multidrug-resistant strains is a major concern for global health. The mortality rate associated with infections caused by this microorganism is significant, especially those caused by multidrug-resistant strains. The antibiotics used to treat these infections include quinolones, aminoglycosides, colistin, and β-lactams. However, novel combinations of β-lactams-β-lactamase inhibitors and cefiderocol offer advantages over other members of their family due to their better activity against certain resistance mechanisms. Selecting the appropriate empiric antibiotic treatment requires consideration of the patient's clinical entity, comorbidities, and risk factors for multidrug-resistant pathogen infections, and local epidemiological data. Optimizing antibiotic pharmacokinetics, controlling the source of infection, and appropriate collection of samples are crucial for successful treatment. In the future, the development of alternative treatments and strategies, such as antimicrobial peptides, new antibiotics, phage therapy, vaccines, and colonization control, holds great promise for the management of P. aeruginosa infections.
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Affiliation(s)
| | | | - J L Del Pozo
- José Luis Del Pozo, Department of Clinical Microbiology, Clínica Universidad de Navarra, Pamplona, Spain.
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Josey K, Nethery R, Visaria A, Bates B, Gandhi P, Parthasarathi A, Rua M, Robinson D, Setoguchi S. Retrospective cohort study investigating synergism of air pollution and corticosteroid exposure in promoting cardiovascular and thromboembolic events in older adults. BMJ Open 2023; 13:e072810. [PMID: 37709308 PMCID: PMC10503335 DOI: 10.1136/bmjopen-2023-072810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE To evaluate the synergistic effects created by fine particulate matter (PM2.5) and corticosteroid use on hospitalisation and mortality in older adults at high risk for cardiovascular thromboembolic events (CTEs). DESIGN AND SETTING A retrospective cohort study using a US nationwide administrative healthcare claims database. PARTICIPANTS A 50% random sample of participants with high-risk conditions for CTE from the 2008-2016 Medicare Fee-for-Service population. EXPOSURES Corticosteroid therapy and seasonal-average PM2.5. MAIN OUTCOME MEASURES Incidences of myocardial infarction or acute coronary syndrome (MI/ACS), ischaemic stroke or transient ischaemic attack, heart failure (HF), venous thromboembolism, atrial fibrillation and all-cause mortality. We assessed additive interactions between PM2.5 and corticosteroids using estimates of the relative excess risk due to interaction (RERI) obtained using marginal structural models for causal inference. RESULTS Among the 1 936 786 individuals in the high CTE risk cohort (mean age 76.8, 40.0% male, 87.4% white), the mean PM2.5 exposure level was 8.3±2.4 µg/m3 and 37.7% had at least one prescription for a systemic corticosteroid during follow-up. For all outcomes, we observed increases in risk associated with corticosteroid use and with increasing PM2.5 exposure. PM2.5 demonstrated a non-linear relationship with some outcomes. We also observed evidence of an interaction existing between corticosteroid use and PM2.5 for some CTEs. For an increase in PM2.5 from 8 μg/m3 to 12 μg/m3 (a policy-relevant change), the RERI of corticosteroid use and PM2.5 was significant for HF (15.6%, 95% CI 4.0%, 27.3%). Increasing PM2.5 from 5 μg/m3 to 10 μg/m3 yielded significant RERIs for incidences of HF (32.4; 95% CI 14.9%, 49.9%) and MI/ACSs (29.8%; 95% CI 5.5%, 54.0%). CONCLUSION PM2.5 and systemic corticosteroid use were independently associated with increases in CTE hospitalisations. We also found evidence of significant additive interactions between the two exposures for HF and MI/ACSs suggesting synergy between these two exposures.
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Affiliation(s)
- Kevin Josey
- Department of Biostatistics, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Rachel Nethery
- Department of Biostatistics, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Aayush Visaria
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Benjamin Bates
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Poonam Gandhi
- Rutgers University Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
| | - Ashwaghosha Parthasarathi
- Rutgers University Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
| | - Melanie Rua
- Rutgers University Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
| | - David Robinson
- Department of Geography, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Soko Setoguchi
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
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Akhabue E, Kuhrt N, Gandhi P, Rua M, Shalmon U, Visaria A, Jackson LR, Setoguchi S. Racial differences in setting of implantable cardioverter-defibrillator placement in older adults with heart failure and association with disparate post-implant outcomes. Front Cardiovasc Med 2023; 10:1197353. [PMID: 37724120 PMCID: PMC10505431 DOI: 10.3389/fcvm.2023.1197353] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Background Implantable cardioverter-defibrillator (ICD) placement in heart failure (HF) patients during or early after (≤90 days) unplanned cardiovascular hospitalizations has been associated with poor outcomes. Racial and ethnic differences in this "peri-hospitalization" ICD placement have not been well described. Methods Using a 20% random sample of Medicare beneficiaries, we identified older (≥66 years) patients with HF who underwent ICD placement for primary prevention from 2008 to 2018. We investigated racial and ethnic differences in frequency of peri-hospitalization ICD placement using modified Poisson regression. We utilized Kaplan-Meier analyses and Cox regression to investigate the association of peri-hospitalization ICD placement with differences in all-cause mortality and hospitalization (HF, cardiovascular and all-cause) within and between race and ethnicity groups for up to 5-year follow-up. Results Among the 61,710 beneficiaries receiving ICDs (35% female, 82% White, 10% Black, 6% Hispanic), 44% were implanted peri-hospitalization. Black [adjusted rate ratio (RR) 95% Confidence Interval (95% CI): 1.16 (1.12, 1.20)] and Hispanic [RR (95% CI): 1.10 (1.06, 1.14)] beneficiaries were more likely than White beneficiaries to have ICD placement peri-hospitalization. Peri-hospitalization ICD placement was associated with an at least 1.5× increased risk of death, 1.5× increased risk of re-hospitalization and 1.7× increased risk of HF hospitalization during 3-year follow-up in fully adjusted models. Although beneficiaries with peri-hospitalization placement had the highest mortality and readmission rates 1- and 3-year post-implant (log-rank p < 0.0001), the magnitude of the associated risk did not differ significantly by race and ethnicity (p = NS for interaction). Conclusions ICD implantation occurring during the peri-hospitalization period was associated with worse prognosis and occurred at higher rates among Black and Hispanic compared to White Medicare beneficiaries with HF during the period under study. The risk associated with peri-hospitalization ICD placement did not differ by race and ethnicity. Future paradigms aimed at enhancing real-world effectiveness of ICD therapy and addressing disparate outcomes should consider timing and setting of ICD placement in HFrEF patients who otherwise meet guideline eligibility.
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Affiliation(s)
- Ehimare Akhabue
- Division of Cardiovascular Diseases and Hypertension, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Nathaniel Kuhrt
- Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Poonam Gandhi
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, United States
| | - Melanie Rua
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, United States
| | - Uri Shalmon
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Aayush Visaria
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Larry R Jackson
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - Soko Setoguchi
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, United States
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Bates BA, Akhabue E, Nahass MM, Mukherjee A, Hiltner E, Rock J, Wilton B, Mittal G, Visaria A, Rua M, Gandhi P, Dave CV, Setoguchi S. Validity of International Classification of Diseases (ICD)-10 Diagnosis Codes for Identification of Acute Heart Failure Hospitalization and Heart Failure with Reduced Versus Preserved Ejection Fraction in a National Medicare Sample. Circ Cardiovasc Qual Outcomes 2023; 16:e009078. [PMID: 36688301 DOI: 10.1161/circoutcomes.122.009078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Heart failure (HF) is a leading cause of hospitalization in older adults. Medicare data have been used to assess HF outcomes. However, the validity of ICD-10 diagnosis codes (used since 2015) to identify acute HF hospitalization or distinguish reduced (heart failure with reduced ejection fraction) versus preserved ejection fraction (HFpEF) is unknown in Medicare data. METHODS Using Medicare data (2015-2017), we randomly sampled 200 HF hospitalizations with ICD-10 diagnosis codes for HF in the first/second claim position in a 1:1:2 ratio for systolic HF (I50.2), diastolic HF (I50.3), and other HF (I50.X). The primary gold standards included recorded HF diagnosis by a treating physician for HF hospitalization, ejection fraction (EF)≤50 for heart failure with reduced ejection fraction, and EF>50 for HFpEF. If the quantitative EF was not present, then qualitative descriptions of EF were used for heart failure with reduced ejection fraction/HFpEF gold standards. Multiple secondary gold standards were also tested. Gold standard data were extracted from medical records using standardized forms and adjudicated by cardiology fellows/staff. We calculated positive predictive values with 95% CIs. RESULTS The 200-chart validation sample included 50 systolic, 50 diastolic, 47 combined dysfunction, and 53 unspecified HF patients. The positive predictive values of acute HF hospitalization was 98% [95% CI, 95-100] for first-position ICD-10 HF diagnosis and 66% [95% CI, 58-74] for first/second-position diagnosis. Quantitative EF was available for ≥80% of patients with systolic, diastolic, or combined dysfunction ICD-10 codes. The positive predictive value of systolic HF codes was 90% [95% CI, 82-98] for EFs≤50% and 72% [95% CI, 60-85] for EFs≤40%. The positive predictive value was 92% [95% CI, 85-100] for HFpEF for EFs>50%. The ICD-10 codes for combined or unspecified HF poorly predicted heart failure with reduced ejection fraction or HFpEF. CONCLUSIONS ICD-10 principal diagnosis identified acute HF hospitalization with a high positive predictive value. Systolic and diastolic ICD-10 diagnoses reliably identified heart failure with reduced ejection fraction and HFpEF when EF 50% was used as the cutoff.
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Affiliation(s)
- Benjamin A Bates
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ (B.A.B., M.R., P.G., C.V.D., S.S.).,Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
| | - Ehimare Akhabue
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
| | - Meghan M Nahass
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
| | - Abhigyan Mukherjee
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
| | - Emily Hiltner
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
| | - Joanna Rock
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
| | - Brandon Wilton
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
| | - Garima Mittal
- Rutgers School of Public Health, Rutgers University, Piscataway, NJ (G.M.)
| | - Aayush Visaria
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
| | - Melanie Rua
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ (B.A.B., M.R., P.G., C.V.D., S.S.)
| | - Poonam Gandhi
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ (B.A.B., M.R., P.G., C.V.D., S.S.)
| | - Chintan V Dave
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ (B.A.B., M.R., P.G., C.V.D., S.S.).,Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ (C.V. D.)
| | - Soko Setoguchi
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ (B.A.B., M.R., P.G., C.V.D., S.S.).,Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (B.A.B., E.A., M.M.N., A.M., E.H., J.R., B.W., A.V., S.S.)
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9
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Akhabue E, Rua M, Gandhi P, Kim JH, Cantor JC, Setoguchi S. Disparate Cardiovascular Hospitalization Trends Among Young and Middle-Aged Adults Within and Across Race and Ethnicity Groups in Four States in the United States. J Am Heart Assoc 2022; 12:e7978. [PMID: 36565205 PMCID: PMC9973609 DOI: 10.1161/jaha.122.027342] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Inpatient hospitalizations for cardiovascular disease (CVD) decreased nationally in the past decade. However, data are lacking on whether national declines represent trends within and across race and ethnicity populations from different US regions. Methods and Results Using State Inpatient Databases, Census Bureau and Behavioral Risk Factor Surveillance System data for Florida, Kentucky, New Jersey, and North Carolina, we identified all CVD hospitalizations and population characteristics for adults aged 18 to 64 years between January 1, 2009 and December 31, 2018. We calculated yearly CVD hospitalization rates for each state for the overall population, by sex, race, and ethnicity. We modeled yearly trends in age-adjusted CVD hospitalization rate in each state using negative binomial regression. State base populations were similar by age (mean age: 40-42 years) and sex (50%-51% female) throughout the study period. There were 314 973 and 288 843 total CVD hospitalizations among the 4 states in 2009 and 2018, respectively. Crude hospitalization rates declined in all states (age 18-44 years NJ: -33.4%; KY: -17.0%; FL: -11.9%; NC: -11.2%; age 45-64 years NJ: -29.8%; KY: -20.3%; FL: -12.2%; NC: -11.6%) over the study period. In age-adjusted models, overall hospitalization rates declined significantly in NJ -2.5%/y (95% CI, -2.9 to -2.1) and in KY -1.6%/y (-1.9 to -1.2) with no significant declining trend in FL and NC. Similar findings were present by sex. Among non-Hispanic White populations, mean yearly decline in hospitalization rate was significant in all states except FL, with the greatest declines in NJ (-3.8%/y [-4.4 to -3.2], P values for state-year interaction <0.0001). By contrast, a significant declining trend was present for non-Hispanic Black and Hispanic populations only in NJ (P values for state-year interaction <0.001). We found similar differences in trend between states in sensitivity analyses incorporating additional demographic and comorbid characteristics. Conclusions Decreases in CVD hospitalization rates in the past decade among nonelderly adults varied considerably by state and appeared largely driven by declines among non-Hispanic White populations. Overall declines did not represent divergent trends between states within non-Hispanic Black and Hispanic populations. Recognition of differences not just between but also within race and ethnicity populations should inform national and local policy initiatives aimed at reducing disparities in CVD outcomes.
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Affiliation(s)
- Ehimare Akhabue
- Division of Cardiovascular Diseases and Hypertension, Department of MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - Melanie Rua
- Institute for Health, Health Care Policy and Aging Research, Rutgers UniversityNew BrunswickNJ
| | - Poonam Gandhi
- Institute for Health, Health Care Policy and Aging Research, Rutgers UniversityNew BrunswickNJ
| | - Jung Hyun Kim
- Department of Preventive MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Joel C. Cantor
- Institute for Health, Health Care Policy and Aging Research, Rutgers UniversityNew BrunswickNJ
| | - Soko Setoguchi
- Institute for Health, Health Care Policy and Aging Research, Rutgers UniversityNew BrunswickNJ,Department of MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
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10
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Jácome C, Marques F, Paixão C, Rebelo P, Oliveira A, Cruz J, Freitas C, Rua M, Loureiro H, Peguinho C, Simões A, Santos M, Valente C, Simão P, Marques A. Embracing digital technology in chronic respiratory care: Surveying patients access and confidence. Pulmonology 2019; 26:56-59. [PMID: 31160235 DOI: 10.1016/j.pulmoe.2019.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- C Jácome
- CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal; Lab 3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal.
| | - F Marques
- ESTGA - Águeda School of Technology and Management, Águeda, Portugal; IEETA - Institute of Electronics and Informatics Engineering of Aveiro, Aveiro, Portugal
| | - C Paixão
- Lab 3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - P Rebelo
- Lab 3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - A Oliveira
- Lab 3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - J Cruz
- Lab 3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; School of Health Sciences (ESSLei), Center for Innovative Care and Health Technology (ciTechCare), Polytechnic Institute of Leiria, Leiria, Portugal
| | - C Freitas
- CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - M Rua
- Research Centre on Didactics and Technology in the Education of Trainers - CIDTFF, Aveiro, Portugal
| | - H Loureiro
- Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - C Peguinho
- Institute of Accounting and Administration, University of Aveiro (ISCA-UA), Aveiro, Portugal
| | - A Simões
- Câmara Municipal de Aveiro, Aveiro, Portugal
| | - M Santos
- Câmara Municipal de Mira, Mira, Portugal
| | - C Valente
- Pulmonology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - P Simão
- Pulmonology Department, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - A Marques
- Lab 3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
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11
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Wulfman CE, Rua M, Lane CD, Shortliffe EH, Fagan LM. Graphical Access to Medical Expert Systems: V. Integration with Continuous-Speech Recognition. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1634892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Abstract:This paper describes three prototypes of computer-based clinical record-keeping tools that use a combination of window-based graphics and continuous speech in their user interfaces. Although many of today’s commercial speech-recognition products achieve high rates of accuracy for large grammars (vocabularies of words or collections of sentences and phrases), they can only “listen for” (and therefore recognize) a limited number of words or phrases at a time. When a speech application requires a grammar whose size exceeds a speech-recognition product’s limits, the application designer must partition the large grammar into several smaller ones and develop control mechanisms that permit users to select the grammar that contains the words or phrases they wish to utter. Furthermore, the user interfaces they design must provide feedback mechanisms that show users the scope of the selected grammars. The three prototypes described were designed to explore the use of window-based graphics as control and feedback mechanisms for continuous-speech recognition in medical applications. Our experiments indicate that window-based graphics can be effectively used to provide control and feedback for certain classes of speech applications, but they suggest that the techniques we describe will not suffice for applications whose grammars are very complex.
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12
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Carmona-Torre F, Rua M, Del Pozo JL. Non-valvular intravascular device and endovascular graft-related infection. Rev Esp Quimioter 2017; 30 Suppl 1:42-47. [PMID: 28882015] [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: 06/07/2023]
Abstract
In the last few years there has been an increase of implantable cardiac electronic device and vascular graft related infections. This is due in part to a higher complexity of some of these procedures and an increase in patient's comorbidities. Despite wide diagnosis methods availability, early stage diagnosis usually constitutes a challenge as often patients only denote insidious symptoms. In most confirmed cases, removal of the infected device is required to resolve the infection. This is mostly explainable because of bacterial ability to grow as biofilms on biomaterial surfaces, conferring them antimicrobial resistance. If removal is not possible, chronic suppressive antimicrobial therapy could be an option.
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Affiliation(s)
| | | | - J L Del Pozo
- José Luis Del Pozo, Division of Infectious Diseases. Clinica Universidad de Navarra. Pamplona, Spain.
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13
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Carmona-Torre F, Rua M, Del Pozo JL. [Directed therapeutic approach to Staphylococcus aureus infections. Clinical aspects of prescription]. Rev Esp Quimioter 2016; 29 Suppl 1:15-20. [PMID: 27608307] [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: 06/06/2023]
Abstract
Infections caused by Staphylococcus aureus have had classically an important impact in morbidity and mortality in the nosocomial and community scene. The description of methicillin resistance among nosocomial isolates of S. aureus and his widespread diffusion has become methicillin-resistant S. aureus (MRSA) in one of the most common causes of bacterial nosocomial infections. In the last years MRSA strains have also emergence in the community. This together with a progressive increase in resistance to antibiotics used classically has become vancomycin in the treatment of choice in most cases according to clinical guidelines. As a result, a progressive rise in the minimum inhibitory concentration (MIC) to vancomycin has been reported. In this context strains with intermediate susceptibility to vancomycin (MIC 8-4 mg/L) and heteroresistance have been noted. These strains are associated with a higher risk of treatment failure when using vancomycin. Among isolates of S. aureus susceptible to vancomycin there has been described stains with elevated MICs (≥1.5 mg/L). It is controversial if the presence of these strains has an impact on clinical outcome if treatment with vancomycin or β-lactams is prescribed. The development of new antibiotics with activity against MRSA and exploring synergies offer a promising alternative to treatment with vancomycin.
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Affiliation(s)
| | | | - J L Del Pozo
- José Luis Del Pozo, Área de Enfermedades Infecciosas y Microbiología Clínica. Clínica Universidad de Navarra. Pamplona. Spain.
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14
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Abstract
Epidemiological and basic science evidence suggest a possible shared pathophysiology between type 2 diabetes mellitus (T2DM) and Alzheimer's disease (AD). It has even been hypothesized that AD might be 'type 3 diabetes'. The present review summarizes some of the evidence for the possible link, putative biochemical pathways and ongoing clinical trials of antidiabetic drugs in AD patients. The primary and review literature were searched for articles published in peer-reviewed sources that were related to a putative connection between T2DM and AD. In addition, public sources of clinical trials were searched for the relevant information regarding the testing of antidiabetic drugs in AD patients. The evidence for a connection between T2DM and AD is based upon a variety of diverse studies, but definitive biochemical mechanisms remain unknown. Additional study is needed to prove the existence or the extent of a link between T2DM and AD, but sufficient evidence exists to warrant further study. Presently, AD patients might benefit from treatment with pharmacotherapy currently used to treat T2DM and clinical trials of such therapy are currently underway.
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Affiliation(s)
- Kawser Akter
- Temple University School of Pharmacy, Philadelphia, PA19140, USA
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15
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16
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Hernáiz MJ, Rua M, Celda B, Medina P, Sinisterra JV, Sánchez-Montero JM. Contribution to the study of the alteration of lipase activity of Candida rugosa by ions and buffers. Appl Biochem Biotechnol 1994; 44:213-29. [PMID: 8198404 DOI: 10.1007/bf02779658] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A semipurified C. rugosa lipase (LS) has been prepared from commercial lipase (LC) using an economical procedure. The presence of sugars and glycopeptides has been detected in LS and LC. Pure lipase only has covalently bonded sugars. The hydrolysis of olive oil catalyzed by LS and commercial lipase (LC) is sensitive to the presence of cations Na(I), Mg(II), Ca(II), and Ba(II) and to the nature of buffer. Highest enzyme activity is obtained with 0.1M Tris/HCl buffers and the combination of NaCl 0.11M and CaCl2 0.11M. Fluorescence spectroscopy analysis of LC, LS, and both pure isoenzymes lipases A and B, was used to analyze the interaction of the lipase with these effectors. Inorganic cations Na or Ca do not interact with pure enzyme LA but do interact with LC and LS and do so slightly with LB. The organic cations (morfolinium or tris) interact with pure lipases. We postulate that the increase in the lipase activity produced by Na(I) or Ca(II) is related with interfacial phenomena, but the increase might be more specific in the hydrolysis of olive oil in the presence of Tris-HCl or morfoline-HCl buffer, owing to enzyme-buffer interaction.
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Affiliation(s)
- M J Hernáiz
- Department of Organic and Pharmaceutical Chemistry, Faculty of Pharmacy, Universidad Complutense, Madrid, Spain
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17
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Wulfman CE, Rua M, Lane CD, Shortliffe EH, Fagan LM. Graphical access to medical expert systems: V. Integration with continuous-speech recognition. Methods Inf Med 1993; 32:33-46. [PMID: 8469159] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This paper describes three prototypes of computer-based clinical record-keeping tools that use a combination of window-based graphics and continuous speech in their user interfaces. Although many of today's commercial speech-recognition products achieve high rates of accuracy for large grammars (vocabularies of words or collections of sentences and phrases), they can only "listen for" (and therefore recognize) a limited number of words or phrases at a time. When a speech application requires a grammar whose size exceeds a speech-recognition product's limits, the application designer must partition the large grammar into several smaller ones and develop control mechanisms that permit users to select the grammar that contains the words or phrases they wish to utter. Furthermore, the user interfaces they design must provide feedback mechanisms that show users the scope of the selected grammars. The three prototypes described were designed to explore the use of window-based graphics as control and feedback mechanisms for continuous-speech recognition in medical applications. Our experiments indicate that window-based graphics can be effectively used to provide control and feedback for certain classes of speech applications, but they suggest that the techniques we describe will not suffice for applications whose grammars are very complex.
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Affiliation(s)
- C E Wulfman
- Department of Medicine, Stanford University School of Medicine, Cal
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