Community-Level Cardiovascular Risk Factors Impact Geographic Variation in Cardiovascular Disease Hospitalizations for Women

Prior work has shown significant geographic variation in cardiovascular (CV) risk factors including metabolic syndrome, obesity, and hypercholesterolemia. However, little is known about how variations in CV risk impact cardiovascular disease (CVD)-related hospitalizations. Community-level CV risk factors (hypertension, dyslipidemia, hyperglycemia, and elevated waist circumference) were assessed from community-wide health screenings sponsored by Sister to Sister (STS) from 2008 to 2009 in 17 major US cities. Using data from the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (HCUP-NIS), CVD hospitalizations were identified based on ICD-9 codes for acute myocardial infarction (AMI), congestive heart failure (CHF), and stroke. We linked STS data with HCUP-NIS hospitalizations based on common cities and restricted the analysis to women discharged from hospitals inside the STS cities. Using hierarchical models with city as the random intercept, we assessed the impact of city-specific CV risk factors on between-city variance of AMI, CHF, and stroke. Analyses were also adjusted for patient age and clinical comorbidities. Our analysis yielded a total of 742,445 all-cause discharges across 70 hospitals inside of 13 linked cities. The overall city-specific range proportion of AMI, CHF, and stroke hospitalizations were 1.13 % (0.75–1.59 %), 2.57 % (1.44–3.92 %), and 1.24 % (0.66–1.84 %), respectively. After adjusting for city-specific CV risk factors, between-city variation was no longer statistically significant for all CVD conditions explored. In conclusion, we found that geographic variations in AMI, CHF, and stroke hospitalizations for women may be partially explained by community-level CV risk factors. This finding suggests that interventions to reduce CVD should be tailored to the unique risk profile and needs of high-risk communities.     

Latent tuberculosis: mechanisms of host and bacillus that contribute to persistent infection

Most people infected with Mycobacterium tuberculosis contain the initial infection and develop latent tuberculosis. This state is characterised by evidence of an immune response against the bacterium (a positive tuberculin skin test) but no signs of active infection. It can be maintained for the lifetime of the infected person. However, reactivation of latent infection occurs in about 10% of infected individuals, leading to active and contagious tuberculosis. An estimated 2 billion people worldwide are infected with M tuberculosis--an enormous reservoir of potential tuberculosis cases. The establishment and reactivation of latent infection depend on several factors, related to both host and bacterium. Elucidation of the host immune mechanisms that control the initial infection and prevent reactivation has begun. The bacillus is well adapted to the human host and has a range of evasion mechanisms that contribute to its ability to avoid elimination by the immune system and establish a persistent infection. We discuss here current understanding of both host and bacterial factors that contribute to latent and reactivation tuberculosis.     

The SWAL–QOL and SWAL–CARE Outcomes Tool for Oropharyngeal Dysphagia in Adults: III. Documentation of Reliability and Validity

Advances in the measurement of swallowing physiologic parameters have been clinician-driven, as has the development of intervention techniques to modify swallowing pathophysiology. However, a critical element to determining the success of such efforts will be established by the patients themselves. We conceptualized, developed, and validated the SWAL–QOL, a 93-item quality-of-life and quality-of-care outcomes tool for dysphagia researchers and clinicians. With 93 items, the SWAL–QOL was too long for practical and routine use in clinical research and practice. We used an array of psychometric techniques to reduce the 93-item instrument into two patient-centered outcomes tools: (1) the SWAL–QOL, a 44-item tool that assesses ten quality-of-life concepts, and (2) the SWAL–CARE, a 15-item tool that assesses quality of care and patient satisfaction. All scales exhibit excellent internal-consistency reliability and short-term reproducibility. The scales differentiate normal swallowers from patients with oropharyngeal dysphagia and are sensitive to differences in the severity of dysphagia as clinically defined. It is intended that the standardization and publication of the SWAL–QOL and the SWAL–CARE will facilitate their use in clinical research and clinical practice to better understand treatment effectiveness as a critical step toward improving patients' quality of life and quality of care.     

Predictors of cardiologist care for older patients hospitalized for heart failure

Background

Studies have suggested that cardiologists may provide higher quality heart failure care than generalists. However, national rates of specialty care during hospitalization for heart failure and factors associated with care by a cardiologist are unknown.

Methods

We assessed specialty care in a sample of Medicare patients hospitalized nationwide with heart failure between 1998 and 1999 (n = 25,869). Multivariable hierarchical logistic regression models were used to identify factors independently associated with treatment by a cardiologist.

Results

One-quarter (25.5%) of patients had a cardiologist as their attending physician, 31.3% of patients received a cardiology consult, and 43.2% of patients were not treated by a cardiologist during hospitalization. Older patients (age <75 years: referent; age 75-84 years: risk ratio [RR], 0.92; 95% CI, 0.86-0.98; age ≥85 years: RR, 0.81; 95% CI, 0.74-0.88) and women (RR, 0.87; 95% CI, 0.83-0.93) were less likely to have an attending cardiologist. Patients with a history of heart failure (RR, 1.13; 95% CI, 1.06-1.20), coronary disease (RR, 1.23; 95% CI, 1.14-1.32), coronary artery bypass grafting (RR, 1.42; 95% CI, 1.32-1.42), or percutaneous transluminal coronary angioplasty (RR, 1.30; 95% CI, 1.19-1.42) were more likely to be treated by a cardiologist, whereas patients with chronic obstructive pulmonary disease (RR, 0.74; 95% CI, 0.70-0.79) and dementia (RR, 0.61; 95% CI, 0.54-0.70) were less likely to be treated by a cardiologist. Patient race was not associated with treatment by a cardiologist. The strongest predictors of attending cardiology care were hospital factors, including large volume (>300 beds; RR, 1.45; 95% CI, 1.32-1.42) and geographic location (RR, 1.00 Northeast (referent) vs RR, 0.55; 95% CI 0.46-0.65 Midwest).

Conclusions

Slightly more than half of older patients with heart failure received care from a cardiologist. Several patient characteristics, including age and sex, were associated with the use of specialty care, suggesting that factors other than clinical presentation may independently influence the use of specialty care.     

Wild-type tumor repressor protein 53 (Trp53) promotes ovarian cancer cell survival

Loss of Pten in the Kras(G12D);Amhr2-Cre mutant mice leads to the transformation of ovarian surface epithelial (OSE) cells and rapid development of low-grade, invasive serous adenocarcinomas. Tumors occur with 100% penetrance and express elevated levels of wild-type tumor repressor protein 53 (TRP53). To test the functions of TRP53 in the Pten;Kras (Trp53+) mice, we disrupted the Trp53 gene yielding Pten;Kras(Trp53-) mice. By comparing morphology and gene expression profiles in the Trp53+ and Trp53- OSE cells from these mice, we document that wild-type TRP53 acts as a major promoter of OSE cell survival and differentiation: cells lacking Trp53 are transformed yet are less adherent, migratory, and invasive and exhibit a gene expression profile more like normal OSE cells. These results provide a new paradigm: wild-type TRP53 does not preferentially induce apoptotic or senescent related genes in the Pten;Kras(Trp53+) cancer cells but rather increases genes regulating DNA repair, cell cycle progression, and proliferation and decreases putative tumor suppressor genes. However, if TRP53 activity is forced higher by exposure to nutlin-3a (a mouse double minute-2 antagonist), TRP53 suppresses DNA repair genes and induces the expression of genes that control cell cycle arrest and apoptosis. Thus, in the Pten;Kras(Trp53+) mutant mouse OSE cells and likely in human TP53+ low-grade ovarian cancer cells, wild-type TRP53 controls global molecular changes that are dependent on its activation status. These results suggest that activation of TP53 may provide a promising new therapy for managing low-grade ovarian cancer and other cancers in humans in which wild-type TP53 is expressed.     

Barriers and Facilitators to Engagement and Retention in Care among Transgender Women Living with Human Immunodeficiency Virus

Background

Transgender women have 49 times the odds of human immunodeficiency virus (HIV) infection compared to other groups, yet they are disproportionately underserved by current treatment efforts.

Purpose

This study aimed to examine culturally unique barriers and facilitators to engagement and retention in HIV care and strengthen efforts to mitigate health disparities, guided by the Models of Gender Affirmation and Health Care Empowerment.

Methods

Through 20 interviews and five focus groups (n?=?38), transgender women living with HIV discussed their experiences and life contexts of engagement in and adherence to HIV care and treatment.

Results

Our participants faced substantial challenges to adhering to HIV care and treatment, including avoidance of healthcare due to stigma and past negative experiences, prioritization of hormone therapy, and concerns about adverse interactions between antiretroviral treatment for HIV and hormone therapy. Receiving culturally competent, transgender-sensitive healthcare was a powerful facilitator of healthcare empowerment.

Conclusions

Recommendations are offered to inform intervention research and guide providers, emphasizing gender affirming HIV care that integrates transition-related healthcare needs.     

Review of side-effect profile of combination ezetimibe and statin therapy in randomized clinical trials

Effective treatment to achieve target lipid parameters in high-risk patients may require combination drug therapies. Concerns regarding risks associated with such combination therapies may limit their use. A systematic overview of randomized controlled trials to assess risks associated with combination statin and ezetimibe therapy was performed. Eighteen trials were identified, including 14,471 patients. Follow-up ranged from 6 to 48 weeks. Compared with statin monotherapy, combination therapy did not result in significant absolute increases in risks of myalgias (risk difference -0.033, 95% confidence interval [CI] -0.06 to -0.01), creatine kinase increases (risk difference 0.011, 95% CI -0.02 to 0.04), rhabdomyolysis (risk difference -0.003, 95% CI -0.01 to 0.004), transaminase increases (risk difference -0.003, 95% CI -0.01 to 0.005), gastrointestinal adverse events (risk difference 0.005, 95% CI -0.03 to 0.04), or discontinuations because of an adverse event (risk difference -0.005, 95% CI -0.03 to 0.02). In conclusion, based on available randomized trials, the addition of ezetimibe to statin therapy did not increase the risk of myalgias, creatine kinase increases, rhabdomyolysis, transaminase increases, gastrointestinal adverse events, or discontinuations because of an adverse event. Additional trials are necessary to ensure that results of clinical trials are consistent with routine clinical practice, particularly in older patients with more co-morbid conditions and patients on higher statin doses.     

The Frequency and Functional Impact of Overlapping Hypertension on Hypertrophic Cardiomyopathy: A Single-Center Experience

J Clin Hypertens (Greenwich) Between 1995 and 2005, 196 adults with hypertrophic cardiomyopathy (HCM) were evaluated. Among these, 122 (62%, group 1) patients also had systemic hypertension. The clinical presentation, management, outcome, and echocardiographic findings of these patients were compared with 74 (38%, group 2) patients without systemic hypertension. Patients in group 1 were older at the time of HCM diagnosis and had a higher prevalence of diabetes (28% vs 9%; P=.02) and coronary artery disease (40% vs 25%; P=.03). In addition, echocardiography showed a significantly higher prevalence of systolic anterior motion of the anterior mitral valve in association with dynamic left ventricular outflow obstruction (52% vs 19%; P=.02) and mitral annular calcification (27% vs 13%; P=.03) in group 1 patients. Left ventricular wall thickness (17 mm vs 19 mm), end-diastolic diameter (42 mm vs 42 mm), resting outflow tract gradient >30 mm Hg (17% vs 16%), and ejection fraction (65% vs 64%) were similar in the two groups. HCM frequently coexists with systemic hypertension in the adult population. Presence of systemic hypertension in HCM patients is associated with older age and higher risk of diabetes, coronary artery disease, and noncardiac death.