Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Social Risk Factors for Medication Nonadherence: Findings from the CARDIA Study

Objectives: Nonadherence to medications has been documented, but the combined effect of social risk factors on medication nonadherence has not been investigated. Methods: We conducted a cross-sectional analysis of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based prospective cohort. The sample (N = 1506) included subjects who at Year 20 (2005-06) were taking prescription medications and completed a 4-item Medication Adherence Scale. Social risk factors were education of high school or less, annual household income \u3c $25,000, high financial strain, high chronic stress, low social support, and high social strain. Results: In a fully adjusted logistic regression model, income \u3c$25,000 (OR = 2.37 [95% CI 1.12-4.98], p \u3c .05) and high chronic stress (OR = 2.07 [95% CI 1.09-3.94], p \u3c .05) were significantly associated with medication nonadherence. Individuals with \u3e /=3 social risk factors had \u3e 3 times higher odds of nonadherence than counterparts with no social risk factors (OR = 3.26 [95% CI 1.72-6.19], p \u3c .001). Conclusion: Low income and chronic stress are associated with medication nonadherence, and the odds of nonadherence increase with the accumulation of social risk factors. Findings may be used to develop risk prediction tools to identify individuals who can benefit from adherence-promoting interventions

Obesity Modifies the Association of Race/Ethnicity with Medication Adherence in the CARDIA Study

Objective: To assess associations between race/ethnicity and medication adherence, and the potential modifying effects of weight category (normal, overweight, obese) in a community-based sample. Study design and setting: We studied 1355 participants from the CARDIA (Coronary Artery Risk Development in Young Adults) study who were taking prescription medications in 2000-1. Medication adherence, as rated on the four-item Morisky medication adherence scale (score of 4 = maximum adherence), was reported for all participants. Results: The mean age ± SD of participants was 40 ± 3.6 years; 45% were African American and 36% were male. Overall, Whites had a higher proportion of maximum adherence than African Americans (59 vs 41%, respectively; p = 0.001). However, this difference was statistically significant only for participants within the normal weight category, of whom 54% of Whites were maximally adherent versus 35% of African Americans (p \u3c 0.05). After adjustment for possible confounding covariates, race/ethnicity was associated with adherence only in those of normal weight: the odds ratio for maximum adherence in Whites versus African Americans of normal weight was 1.98 (95% CI 1.13, 3.47). Within race/ethnicity subgroups, weight category was associated with adherence in Whites but not in African Americans. Conclusion: Weight category modifies the association of race/ethnicity with medication adherence. The high levels of non-adherence observed among African Americans and obese and overweight Whites bodes poorly for treatment of obesity-associated diseases such as cardiovascular disease or diabetes mellitus

Obesity Modifies the Association of Race/Ethnicity with Medication Adherence in the CARDIA Study

Objective: To assess associations between race/ethnicity and medication adherence, and the potential modifying effects of weight category (normal, overweight, obese) in a community-based sample. Study design and setting: We studied 1355 participants from the CARDIA (Coronary Artery Risk Development in Young Adults) study who were taking prescription medications in 2000-1. Medication adherence, as rated on the four-item Morisky medication adherence scale (score of 4 = maximum adherence), was reported for all participants. Results: The mean age +- SD of participants was 40 +- 3.6 years; 45% were African American and 36% were male. Overall, Whites had a higher proportion of maximum adherence than African Americans (59 vs 41%, respectively; p = 0.001). However, this difference was statistically significant only for participants within the normal weight category, of whom 54% of Whites were maximally adherent versus 35% of African Americans (pEthnic-groups, Obesity, Patient-compliance

A group randomized trial to improve safe use of nonsteroidal anti-inflammatory drugs

OBJECTIVE: To determine whether audit/feedback and educational materials improve adherence to recommendations for laboratory monitoring and cytoprotective agents to detect and prevent adverse events caused by nonsteroidal anti-inflammatory agents (NSAIDs). STUDY DESIGN: Controlled, cluster-randomized trial. METHODS: Physicians commonly prescribing NSAIDs were identified within a large managed care organization and randomized to a control or an intervention group (audit/feedback with peer-derived benchmarks and continuing medical education). Medical records were examined 10 months before and after the intervention for clinical data and receipt of complete blood count (CBC), creatinine testing, and cytoprotective agents (process measures). Primary analysis compared intervention versus control physicians among those who initially performed below a peer-derived benchmark. General estimating equations accounted for patient clustering. RESULTS: Of 101 physicians initially randomized, 85 remained eligible (38 internists, 36 family physicians, 11 rheumatologists) postintervention. Mean percent change in performance between intervention and control physicians for CBC monitoring was 16% versus 10%; for creatinine monitoring, 0% versus 17%; and use of cytoprotective agents, -3% versus -1%. None of these changes were significant. Rheumatology specialty, number of NSAID prescriptions and physician visits, and patient risk factors for NSAID-related toxicity were more strongly associated with improved safety practices than the intervention. CONCLUSIONS: Audit/feedback and educational materials had no observed effect on improving NSAID-related safety practices. Potentially contributing factors include high baseline performance (ceiling effect), dilution of the intervention effect by case mix and provider factors, nonreceipt of intervention materials, and diverse indications for lab tests

The effects of physician specialty and patient comorbidities on the use and discontinuation of coxibs

OBJECTIVE: To examine the effects of physician specialty and comorbidities on cyclooxygenase 2-selective nonsteroidal antiinflammatory drugs (NSAIDs; coxibs) utilization. METHODS: Medical records of 452 patients from a regional managed care organization with \u3e/=3 consecutive NSAID prescriptions from June 1998 to April 2001 were abstracted. Multivariable adjusted associations between coxib initiation and discontinuation and patient and provider characteristics were examined. RESULTS: A total of 1,142 NSAID prescriptions were written over 9,398 total patient-months of followup. Compared with patients seeing family or general practitioners, patients seeing rheumatologists (odds ratio [OR] 3.4, 95% confidence interval [95% CI] 2.1-5.7) and internists (OR 2.3, 95% CI 1.5-3.6) were significantly more likely to receive a coxib, as well as patients with a history of osteoarthritis (OR 2.6, 95% CI 1.7-3.8), gastrointestinal disease (OR 2.3, 95% CI 1.2-4.5), and congestive heart failure (OR 4.1, 95% CI 1.0-16.4). Although specialists were more likely than generalists to prescribe coxibs, only family or general practitioners were significantly more likely to selectively use coxibs among their patients with a history of gastrointestinal disease. Fifty-four percent of NSAID prescriptions were discontinued, and coxibs were significantly less likely to be discontinued than were traditional NSAIDs (OR 0.6, 95% CI 0.5-0.8). CONCLUSION: Our findings suggest significantly greater, but perhaps less selective use of coxibs among specialists, even after accounting for important covariates. The initiation and discontinuation of coxibs was influenced by physician specialty and by patient risk factors

Nonsteroidal antiinflammatory drug toxicity monitoring and safety practices

OBJECTIVE: Nonsteroidal antiinflammatory drug (NSAID) related gastrointestinal (GI) and renal adverse events are commonly reported. Although published guidelines recommend periodic laboratory monitoring, NSAID safety practices of physicians have not been investigated at a population level. We examined the associations of physician specialty and patient characteristics with NSAID safety practices. METHODS: Using administrative data and medical record review from a regional managed care organization, we studied a retrospective cohort of 373 frequent NSAID users (\u3e or = 3 consecutive NSAID prescriptions and \u3e or = 1 month of continuous NSAID use and followup). NSAID safety measures included: complete blood count (CBC) testing, creatinine testing, use of GI cytoprotective agents, and lack of simultaneous prescriptions for different NSAID (NSAID overlap). RESULTS: The mean duration of cumulative NSAID use was 14.4 +/- 7.7 months/patient, patient age was 62.0 +/- 11.4 years, and 63% were women. About two-thirds of patients received CBC (238, 63.8%) and creatinine monitoring (263, 70.5%), one-third (120, 32.2%) were prescribed cytoprotective agents, and one-fourth (97, 26%) had at least one NSAID overlap. After multivariable adjustments, concomitant use of disease-modifying antirheumatic drugs (OR 2.5, 95% CI 1.1-5.8), longer NSAID exposure (OR 1.3, 95% CI 1.1-1.4), and a greater number of physician visits/year (OR 1.1, 95% CI 1.0-1.2) were significantly associated with receipt of a CBC. A history of hypertension (OR 2.0, 95% CI 1.2-3.2), longer NSAID exposure (OR 1.3, 95% CI 1.2-1.4), and more physician visits/year (OR 1.1, 95% CI 1.0-1.2) were significantly associated with serum creatinine testing. Rheumatologists, and to a lesser extent internists, trended toward more NSAID toxicity monitoring than family/general practitioners. However, family/general practitioners and internists were more likely to monitor creatinine than rheumatologists among patients with renal risk factors. CONCLUSION: While rheumatologists and internists trended toward more CBC and creatinine testing, visit frequency, duration of NSAID use, and comorbidities were the factors most consistently associated with safety monitoring

Resistência natural da madeira de Corymbia maculata (Hook.) K.D.Hill & L.A.S. Johnson a fungos e cupins xilófagos, em condições de laboratório Wood natural resistance of Corymbia maculata (Hook.) K.D.Hill & L.A.S Johnson to wood destroying fungi and termites, under laboratory tests

A pesquisa teve o objetivo de avaliar a resistência natural da madeira de Corymbia maculata a fungos e a cupins xilófagos, em condições de laboratório. De peças radiais (tábuas) que continham o cerne e o alburno intactos foram retirados corpos-de-prova de 2,00 x 2,00 x 1,00 cm, com a menor dimensão na direção tangencial (ensaio com fungos), e de 2,54 x 2,00 x 0,64 cm, com a maior dimensão na direção das fibras (ensaio com cupins), em quatro posições na direção medula-casca. As amostras foram submetidas à ação dos fungos Postia placenta, Neolentinus lepideus e Polyporus fumosus por 12 semanas, ou à ação de cupins do gênero Nasutitermes por 30 dias. Constatou-se que a resistência da madeira ao apodrecimento foi dependente da posição na direção medula-casca e dos fungos utilizados. As amostras retiradas nas posições mais externas do tronco foram mais deterioradas que as internas. Dentro de cada posição, os fungos causaram deterioração semelhante à madeira, exceto para a posição mais externa (alburno), em que o fungo P. fumosus causou menos deterioração que os demais. De modo geral, a madeira de C. maculata foi altamente resistente (posições internas) ou resistente (posições externas) aos fungos ensaiados. Somente para o fungo N. lepideus a posição mais externa foi moderadamente resistente. Quanto aos cupins, a resistência da madeira não foi afetada pela posição na direção medula-casca e apresentou uma baixa perda de massa para as posições analisadas. Além disto, os cupins causaram somente desgaste superficial à madeira, e morreram durante o ensaio, o que permitiu classificar a madeira de C.maculata como resistente aos cupins ensaiados.<br>This research evaluated the natural resistance of Corymbia maculata wood to wood-destroying fungi and termites, under laboratory tests. Radial pieces (boards), containing intact heartwood and sapwood were transformed into test samples measuring 2.00 x 2.00 x 1.00 cm, with the smallest measure in tangential direction (fungi assay) and measuring 2.45 x 2.00 x 0.64 cm; with the largerst measure fiberwise (termite assay), in four positions from pith to bark. The samples were submitted to fungi Postia placenta, Neolentinus lepideus and Polyporus fumosus action for 12 weeks or to Nasutitermes sp. action for 30 days. Wood decay resistance was found to be dependent on the position pith to bark and on the fungus. The wood samples in the most external positions were more deteriorated. Inside of each position, the fungi caused similar deterioration, except for the most external position (sapwood) where the P. fumosus caused less deterioration than other tested fungi. In general, C. maculata wood was highly resistant (internal positions) or resistant (external positions) to the fungi. Just for the Neolentinus lepideus, the external position was classified as moderately resistante. The tested wood to termite resistance was not affected by position in the pith to bark direction and showed weight loss for allanalyzed positions. Besides, it was affected only superficially and the termites died during the assay. The C. maculata wood was classified as resistant to the termites assayed

A System for Phenotype Harmonization in the NHLBI Trans-Omics for Precision Medicine (TOPMed) Program

Genotype-phenotype association studies often combine phenotype data from multiple studies to increase statistical power. Harmonization of the data usually requires substantial effort due to heterogeneity in phenotype definitions, study design, data collection procedures, and data-set organization. Here we describe a centralized system for phenotype harmonization that includes input from phenotype domain and study experts, quality control, documentation, reproducible results, and data-sharing mechanisms. This system was developed for the National Heart, Lung, and Blood Institute's Trans-Omics for Precision Medicine (TOPMed) program, which is generating genomic and other -omics data for more than 80 studies with extensive phenotype data. To date, 63 phenotypes have been harmonized across thousands of participants (recruited in 1948-2012) from up to 17 studies per phenotype. Here we discuss challenges in this undertaking and how they were addressed. The harmonized phenotype data and associated documentation have been submitted to National Institutes of Health data repositories for controlled access by the scientific community. We also provide materials to facilitate future harmonization efforts by the community, which include 1) the software code used to generate the 63 harmonized phenotypes, enabling others to reproduce, modify, or extend these harmonizations to additional studies, and 2) the results of labeling thousands of phenotype variables with controlled vocabulary terms