Ticagrelor versus Genotype-Driven Antiplatelet Therapy for Secondary Prevention after Acute Coronary Syndrome: A Cost-Effectiveness Analysis

Clopidogrel’s effectiveness is likely reduced significantly for prevention of thrombotic events after acute coronary syndrome (ACS) in patients exhibiting a decreased ability to metabolize clopidogrel into its active form. A genetic mutation responsible for this reduced effectiveness is detectable by genotyping. Ticagrelor is not dependent on gene-based metabolic activation and demonstrated greater clinical efficacy than clopidogrel in a recent secondary prevention trial. In 2011, clopidogrel will lose its patent protection and likely will be substantially less expensive than ticagrelor

Stress Imaging Use and Repeat Revascularization Among Medicare Patients With High-Risk Coronary Artery Disease

The optimal use of stress testing after coronary revascularization remains unclear, and over-utilization of stress testing may increase rates of repeat revascularization. We analyzed the relationship at both the patient and regional level between the use of stress testing and repeat revascularization for a cohort of Medicare beneficiaries receiving revascularization within 30 days of an admission for symptomatic coronary artery disease (CAD).The sample consisted of 219,748 Medicare beneficiaries older than 65 years who received percutaneous coronary intervention (PCI) or cardiac bypass surgery (CABG) following hospital admission for symptomatic CAD in 2003–2004. Medicare claims data through 2008 identified the use of stress testing and repeat revascularization. Associations between the cumulative incidence of stress testing and repeat revascularization were analyzed using linear regressions. Within six years of initial revascularization, the cumulative incidence of events was 0.61 for stress testing and 0.23 for repeat revascularization. Most (53.1%) repeat revascularizations were preceded by a stress test. Only 10.3% of repeat revascularization procedures were preceded by myocardial infarction. Four-year cumulative incidence of repeat revascularization and stress testing varied between the Hospital Referral Regions represented by the sample, and the positive correlation between the rates by HRR accounted for only a small portion of the total HRR variation in revascularization rates. Stress testing is commonly performed among Medicare patients after initial revascularization, and the majority of repeat procedures are performed for stable CAD. Variation in stress testing patterns only explains a modest fraction of regional variation in repeat revascularization rates

Evaluating the effectiveness of a rapidly adopted cardiovascular technology with administrative data: The case of drug-eluting stents for acute coronary syndromes

Instrumental variable (IV) methods can correct for unmeasured confounding when using administrative (claims) data for cardiovascular outcomes research, but difficulties identifying valid IVs have limited their use. We evaluated the safety and efficacy of drug-eluting coronary stents (DES) compared to bare metal stents (BMS) for Medicare beneficiaries with acute coronary syndromes (ACS) using the rapid uptake of DES in clinical practice as an instrument. We compared results from IV to those from propensity score matching (PSM) and multivariable regression models

Resource Use Trajectories for Aged Medicare Beneficiaries with Complex Coronary Conditions

To use coronary revascularization choice to illustrate the application of a method simulating a treatment's effect on subsequent resource use

Membrane vesicles, current state-of-the-art: emerging role of extracellular vesicles

Release of membrane vesicles, a process conserved in both prokaryotes and eukaryotes, represents an evolutionary link, and suggests essential functions of a dynamic extracellular vesicular compartment (including exosomes, microparticles or microvesicles and apoptotic bodies). Compelling evidence supports the significance of this compartment in a broad range of physiological and pathological processes. However, classification of membrane vesicles, protocols of their isolation and detection, molecular details of vesicular release, clearance and biological functions are still under intense investigation. Here, we give a comprehensive overview of extracellular vesicles. After discussing the technical pitfalls and potential artifacts of the rapidly emerging field, we compare results from meta-analyses of published proteomic studies on membrane vesicles. We also summarize clinical implications of membrane vesicles. Lessons from this compartment challenge current paradigms concerning the mechanisms of intercellular communication and immune regulation. Furthermore, its clinical implementation may open new perspectives in translational medicine both in diagnostics and therapy

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

Effects of Integrative Medicine on Pain and Anxiety Among Oncology Inpatients

BACKGROUND: Few studies have investigated the effectiveness of integrative medicine (IM) therapies on pain and anxiety among oncology inpatients. METHODS: Retrospective data obtained from electronic medical records identified patients with an oncology International Classification of Diseases-9 code who were admitted to a large Midwestern hospital between July 1, 2009 and December 31, 2012. Outcomes were change in patient-reported pain and anxiety, rated before and after individual IM treatment sessions, using a numeric scale (0–10). RESULTS: Of 10948 hospital admissions over the study period, 1833 (17%) included IM therapy. Older patients had reduced odds of receiving any IM therapy (odds ratio [OR]: 0.97, 95% confidence interval [95% CI] = 0.96 to 0.98) and females had 63% (OR: 1.63, 95% CI = 1.38 to 1.92) higher odds of receiving any IM therapy compared with males. Moderate (OR: 1.97, 95% CI = 1.61 to 2.41), major (OR: 3.54, 95% CI = 2.88 to 4.35), and extreme (OR: 5.96, 95% CI = 4.71 to 7.56) illness severity were significantly associated with higher odds of receiving IM therapy compared with admissions of minor illness severity. After receiving IM therapy, patients averaged a 46.9% (95% CI = 45.1% to 48.6%, P <.001) reduction in pain and a 56.1% (95% CI = 54.3% to 58.0%, P <.001) reduction in anxiety. Bodywork and traditional Chinese Medicine therapies were most effective for reducing pain, while no significant differences among therapies for reducing anxiety were observed. CONCLUSIONS: IM services to oncology inpatients resulted in substantial decreases in pain and anxiety. Observational studies using electronic medical records provide unique information about real-world utilization of IM. Future studies are warranted and should explore potential synergy of opioid analgesics and IM therapy for pain control

Stress Imaging Use and Repeat Revascularization Among Medicare Patients With High-Risk Coronary Artery Disease

The optimal use of stress testing after coronary revascularization remains unclear, and over-utilization of stress testing may increase rates of repeat revascularization. We analyzed the relationship at both the patient and regional level between the use of stress testing and repeat revascularization for a cohort of Medicare beneficiaries receiving revascularization within 30 days of an admission for symptomatic coronary artery disease (CAD).The sample consisted of 219,748 Medicare beneficiaries older than 65 years who received percutaneous coronary intervention (PCI) or cardiac bypass surgery (CABG) following hospital admission for symptomatic CAD in 2003–2004. Medicare claims data through 2008 identified the use of stress testing and repeat revascularization. Associations between the cumulative incidence of stress testing and repeat revascularization were analyzed using linear regressions. Within six years of initial revascularization, the cumulative incidence of events was 0.61 for stress testing and 0.23 for repeat revascularization. Most (53.1%) repeat revascularizations were preceded by a stress test. Only 10.3% of repeat revascularization procedures were preceded by myocardial infarction. Four-year cumulative incidence of repeat revascularization and stress testing varied between the Hospital Referral Regions represented by the sample, and the positive correlation between the rates by HRR accounted for only a small portion of the total HRR variation in revascularization rates. Stress testing is commonly performed among Medicare patients after initial revascularization, and the majority of repeat procedures are performed for stable CAD. Variation in stress testing patterns only explains a modest fraction of regional variation in repeat revascularization rates