Individuals infected with SARS-CoV-2 who also display hyperglycemia suffer from longer hospital stays, higher risk of developing acute respiratory distress syndrome (ARDS), and increased mortality. ...Nevertheless, the pathophysiological mechanism of hyperglycemia in COVID-19 remains poorly characterized. Here, we show that hyperglycemia is similarly prevalent among patients with ARDS independent of COVID-19 status. Yet among patients with ARDS and COVID-19, insulin resistance is the prevalent cause of hyperglycemia, independent of glucocorticoid treatment, which is unlike patients with ARDS but without COVID-19, where pancreatic beta cell failure predominates. A screen of glucoregulatory hormones revealed lower levels of adiponectin in patients with COVID-19. Hamsters infected with SARS-CoV-2 demonstrated a strong antiviral gene expression program in the adipose tissue and diminished expression of adiponectin. Moreover, we show that SARS-CoV-2 can infect adipocytes. Together these data suggest that SARS-CoV-2 may trigger adipose tissue dysfunction to drive insulin resistance and adverse outcomes in acute COVID-19.
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•Hyperglycemia is highly prevalent in acute respiratory distress syndrome ± COVID-19•Insulin resistance is the main cause for hyperglycemia in patients with severe COVID-19•Patients with COVID-19 and hamsters infected with SARS-CoV-2 have decreased adiponectin•SARS-CoV-2 can directly infect human and mouse adipocytes
Here, Reiterer et al. report that hyperglycemia in critically ill patients with COVID-19 is caused mainly by insulin resistance and is associated with decreased circulating adiponectin. SARS-CoV-2 is shown to directly infect human adipocytes, trigger an inflammatory antiviral response in the adipose tissue, and cause its dysfunction.
Historically, women have been less likely than men to receive guideline-recommended statin therapy for the secondary prevention of myocardial infarction (MI).
The authors examined contemporary sex ...differences in prescription fills for high-intensity statin therapy following an MI, overall and across population subgroups, and assessed whether sex differences were attenuated following recent efforts to reduce sex disparities in the use of cardiovascular disease preventive therapies.
The authors studied 16,898 (26% women) U.S. adults <65 years of age with commercial health insurance in the MarketScan database, and 71,358 (49% women) U.S. adults ≥66 years of age with government health insurance through Medicare who filled statin prescriptions within 30 days after hospital discharge for MI in 2014 to 2015. The authors calculated adjusted women-to-men risk ratios and 95% confidence intervals (CIs) for filling a high-intensity statin prescription (i.e., atorvastatin 40 to 80 mg, and rosuvastatin 20 to 40 mg) following hospital discharge for MI.
In 2014 to 2015, 56% of men and 47% of women filled a high-intensity statin following hospital discharge for MI. Adjusted risk ratios for filling a high-intensity statin comparing women with men were 0.91 (95% CI: 0.90 to 0.92) in the total population, 0.91 (95% CI: 0.89 to 0.92) among those with no prior statin use, and 0.87 (95% CI: 0.85 to 0.90) and 0.98 (95% CI: 0.97 to 1.00) for those taking low/moderate-intensity and high-intensity statins prior to their MI, respectively. Women were less likely than men to fill high-intensity statins within all subgroups analyzed, and the disparity was largest in the youngest and oldest adults and for those without prevalent comorbid conditions.
Despite recent efforts to reduce sex differences in guideline-recommended therapy, women continue to be less likely than men to fill a prescription for high-intensity statins following hospitalization for MI.
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•Findings of left and right sided heart disease on the presentation electrocardiogram are associated with death in COVID-19•Right bundle branch block in COVID-19 is likely secondary to acute right ...ventricular distension, and could represent the at-risk right ventricle.•Markers of left ventricular stiffness (atrial premature contractions, prolonged intraventricular conduction, and ischemic repolarization abnormalities) are associated with death.
Coronavirus disease 2019 (COVID-19) is a respiratory syndrome with high rates of mortality, and there is a need for easily obtainable markers to provide prognostic information. We sought to determine whether the electrocardiogram (ECG) on hospital presentation provides prognostic information, specifically related to death.
We performed a retrospective cohort study in patients with COVID-19 who had an ECG at or near hospital admission. Clinical characteristics and ECG variables were manually abstracted from the electronic health record and first ECG. Our primary outcome was death.
756 patients who presented to a large New York City teaching hospital with COVID-19 who underwent an ECG. The mean age was 63.3 ± 16 years, 37% were women, 61% of patients were nonwhite, and 57% had hypertension; 90 (11.9%) died. In a multivariable logistic regression that included age, ECG, and clinical characteristics, the presence of one or more atrial premature contractions (odds ratio OR 2.57, 95% confidence interval CI 1.23–5.36, P = .01), a right bundle branch block or intraventricular block (OR 2.61, 95% CI 1.32–5.18, P = .002), ischemic T-wave inversion (OR 3.49, 95% CI 1.56–7.80, P = .002), and nonspecific repolarization (OR 2.31, 95% CI 1.27–4.21, P = .006) increased the odds of death. ST elevation was rare (n = 5 0.7%).
We found that patients with ECG findings of both left-sided heart disease (atrial premature contractions, intraventricular block, repolarization abnormalities) and right-sided disease (right bundle branch block) have higher odds of death. ST elevation at presentation was rare.
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Background
Diabetes places patients with cancer at an increased risk of infections, hospitalizations, and mortality. The objective of the current study was to characterize diabetes care management ...patterns among patients with cancer in the year before and, separately, after cancer diagnosis. The authors hypothesized that diabetes care declines after a diagnosis of cancer.
Methods
The Surveillance, Epidemiology, and End Results (SEER) cancer registry linked to Medicare claims data was used. The authors included diabetic beneficiaries aged ≥65 years who were diagnosed with incident, nonmetastatic breast, prostate, or colorectal cancer between 2008 and 2013. Controls were diabetic Medicare beneficiaries in SEER regions who did not have cancer. Cases were matched to controls based on age, sex, Charlson Comorbidity Index, and diabetes severity. Primary outcomes were diabetes care received over 12 months: 1) hemoglobin A1c testing; 2) eye examination; and 3) low‐density lipoprotein testing. Using a difference‐in‐difference (DID) approach, the authors examined use differences 12 months before to after diagnosis for patients with cancer and controls. To avoid capturing testing related to diagnosis and not diabetes management, the authors implemented a 90‐day washout period (45 days before and/or after diagnosis).
Results
A total of 32,728 diabetic patients with cancer and 32,728 matched noncancer controls were included. After diagnosis, patients with cancer were found to have modest, but significantly lower, rates of diabetes care use compared with controls. Patients with cancer had greater declines in hemoglobin A1c testing (DID, 2.4%; 95% CI, 1.7%‐3.0%), low‐density lipoprotein testing (DID, 4.3%; 95% CI, 3.6%‐5.0%), and receipt of all diabetes indicators (DID, 2.7%; 95% CI, 1.8%‐3.5%) 12 months before to after diagnosis.
Conclusions
Compared with controls, less diabetes care use was observed among patients with cancer in the year after diagnosis. Understanding and addressing the reasons for this may improve outcomes in this population.
Herein, the authors report less use of diabetes care among patients with cancer in the year after their cancer diagnosis compared with noncancer controls. Understanding and addressing the reasons for this may improve cancer and diabetes outcomes in this population.
Severe acute respiratory coronavirus 2 (SARS-CoV-2) has caused a devastating worldwide pandemic. Hydroxychloroquine (HCQ) has in vitro activity against SARS-CoV-2, but clinical data supporting HCQ ...for coronavirus disease 2019 (COVID-19) are limited.
This was a retrospective cohort study of hospitalized patients with COVID-19 who received ≥1 dose of HCQ at two New York City hospitals. We measured incident Grade 3 or 4 blood count and liver test abnormalities, ventricular arrhythmias, and vomiting and diarrhea within 10 days after HCQ initiation, and the proportion of patients who completed HCQ therapy. We also describe changes in Sequential Organ Failure Assessment hypoxia scores between baseline and day 10 after HCQ initiation and in-hospital mortality.
None of the 153 hospitalized patients with COVID-19 who received HCQ developed a sustained ventricular tachyarrhythmia. Incident blood count and liver test abnormalities occurred in <15% of patients and incident vomiting or diarrhea was rare. Eighty-nine percent of patients completed their HCQ course and three patients discontinued therapy because of QT prolongation. Fifty-two percent of patients had improved hypoxia scores 10 days after starting HCQ. Thirty-one percent of patients who were receiving mechanical ventilation at the time of HCQ initiation died during their hospitalization, compared to 18% of patients who were receiving supplemental oxygen but not requiring mechanical ventilation, and 8% of patients who were not requiring supplemental oxygen. Co-administration of azithromycin was not associated with improved outcomes.
HCQ appears to be reasonably safe and tolerable in most hospitalized patients with COVID-19. However, nearly one-half of patients did not improve with this treatment, highlighting the need to evaluate HCQ and alternate therapies in randomized trials.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
BACKGROUND AND PURPOSE:Social determinants of health (SDOH) have been previously associated with incident stroke. Although SDOH often cluster within individuals, few studies have examined ...associations between incident stroke and multiple SDOH within the same individual. The objective was to determine the individual and cumulative effects of SDOH on incident stroke.
METHODS:This study included 27 813 participants from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study, a national, representative, prospective cohort of black and white adults aged ≥45 years. SDOH was the primary exposure. The main outcome was expert adjudicated incident stroke. Cox proportional hazards models examined associations between incident stroke and SDOH, individually and as a count of SDOH, adjusting for potential confounders.
RESULTS:The mean age was 64.7 years (SD 9.4) at baseline; 55.4% were women and 40.4% were blacks. Over a median follow-up of 9.5 years (IQR, 6.0–11.5), we observed 1470 incident stroke events. Of 10 candidate SDOH, 7 were associated with stroke (P<0.10)race, education, income, zip code poverty, health insurance, social isolation, and residence in one of the 10 lowest ranked states for public health infrastructure. A significant age interaction resulted in stratification at 75 years. In fully adjusted models, among individuals <75 years, risk of stroke rose as the number of SDOH increased (hazard ratio for one SDOH, 1.26 95% CI, 1.02–1.55; 2 SDOH hazard ratio, 1.38 95% CI, 1.12–1.71; and ≥3 SDOH hazard ratio, 1.51 95% CI, 1.21–1.89) compared with those without any SDOH. Among those ≥75 years, none of the observed effects reached statistical significance.
CONCLUSIONS:Incremental increases in the number of SDOH were independently associated with higher incident stroke risk in adults aged <75 years, with no statistically significant effects observed in individuals ≥75 years. Targeting individuals with multiple SDOH may help reduce risk of stroke among vulnerable populations.
BACKGROUND AND PURPOSE—The risk of arterial ischemic events after intracerebral hemorrhage (ICH) is poorly understood given the lack of a control group in prior studies. This study aimed to evaluate ...the risk of acute ischemic stroke and myocardial infarction (MI) among patients with and without ICH.
METHODS—We performed a retrospective cohort study using claims data from Medicare beneficiaries from 2008 to 2014. Our exposure was acute ICH, identified using validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Our primary outcome was a composite of acute ischemic stroke and MI, whereas secondary outcomes were ischemic stroke alone and MI alone. We used Cox regression analysis to compute hazard ratios during 1-month intervals after ICH. Sensitivity analyses entailed exclusion of patients with atrial fibrillation and valvular heart disease.
RESULTS—Among 1 760 439 Medicare beneficiaries, 5924 had ICH. The 1-year cumulative incidence of an arterial ischemic event was 5.7% (95% CI, 4.8–6.8) in patients with ICH and 1.8% (95% CI, 1.7–1.9) in patients without ICH. After adjusting for potential confounders, the risk of an arterial ischemic event remained significantly increased for the first 6 months after ICH and was especially high in the first month (hazard ratio, 6.7 95% CI, 5.0–8.6). In secondary analysis, the risk of ischemic stroke was increased in the first 6 months after ICH (hazard ratio, 6.1 95% CI, 3.5–9.3) but the risk of MI was not (hazard ratio, 1.6 95% CI, 0.3–2.9). In sensitivity analyses excluding patients with atrial fibrillation and valvular heart disease, the association between ICH and arterial ischemic events was similar to that of the primary analysis.
CONCLUSIONS—In a large population-based cohort, we found that elderly patients with ICH had a substantially increased risk of ischemic stroke in the first 6 months after diagnosis. Further exploration of this risk is needed to determine optimal secondary prevention strategies for these patients.
Abstract Background National guidelines recommend use of high-intensity statins after hospitalization for coronary heart disease (CHD) events. Objectives This study sought to estimate the proportion ...of Medicare beneficiaries filling prescriptions for high-intensity statins after hospital discharge for a CHD event and to analyze whether statin intensity before hospitalization is associated with statin intensity after discharge. Methods We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries between 65 and 74 years old. Beneficiaries were included in the analysis if they filled a statin prescription after a CHD event (myocardial infarction or coronary revascularization) in 2007, 2008, or 2009. High-intensity statins included atorvastatin 40 to 80 mg, rosuvastatin 20 to 40 mg, and simvastatin 80 mg. Results Among 8,762 Medicare beneficiaries filling a statin prescription after a CHD event, 27% of first post-discharge fills were for a high-intensity statin. The percent filling a high-intensity statin post-discharge was 23.1%, 9.4%, and 80.7%, for beneficiaries not taking statins pre-hospitalization, taking low/moderate-intensity statins, and taking high-intensity statins before their CHD event, respectively. Compared with beneficiaries not on statin therapy pre-hospitalization, multivariable adjusted risk ratios for filling a high-intensity statin were 4.01 (3.58–4.49) and 0.45 (0.40–0.52) for participants taking high-intensity and low/moderate-intensity statins before their CHD event, respectively. Only 11.5% of beneficiaries whose first post-discharge statin fill was for a low/moderate-intensity statin filled a high-intensity statin within 365 days of discharge. Conclusions The majority of Medicare beneficiaries do not fill high-intensity statins after hospitalization for CHD.
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