Author Interviews / 21.06.2016
Nearly Half of All Heart Attacks are ‘Silent’ or Lack Classic Symptoms
MedicalResearch.com Interview with:
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Dr. Zhu-Ming Zhang[/caption]
Zhu-Ming Zhang, MD, MPH, FAHA
Associate Professor
Epidemiological Cardiology Research Center (EPICARE)
Wake Forest School of Medicine
Medical Center Blvd, Winston Salem, NC 27157
MedicalResearch.com: What is the background for this study?
Response: Heart disease still is the leading cause of death globally. About 635,000 new cases of coronary heart disease occur annually in the United States, with an additional 155,000 incidentally discovered asymptomatic silent myocardial infarctions (SMI). Silent myocardial infarctions, defined as the presence of pathological Q waves in the absence of a history of typical cardiac symptoms, is one of the important cardiac abnormalities, and given them medical attention could prevent subsequent adverse outcomes or even their lives.
Dr. Zhu-Ming Zhang[/caption]
Zhu-Ming Zhang, MD, MPH, FAHA
Associate Professor
Epidemiological Cardiology Research Center (EPICARE)
Wake Forest School of Medicine
Medical Center Blvd, Winston Salem, NC 27157
MedicalResearch.com: What is the background for this study?
Response: Heart disease still is the leading cause of death globally. About 635,000 new cases of coronary heart disease occur annually in the United States, with an additional 155,000 incidentally discovered asymptomatic silent myocardial infarctions (SMI). Silent myocardial infarctions, defined as the presence of pathological Q waves in the absence of a history of typical cardiac symptoms, is one of the important cardiac abnormalities, and given them medical attention could prevent subsequent adverse outcomes or even their lives.
Ghenet Besera[/caption]
MedicalResearch.com Interview with:
Ghenet Besera, MPH
National Center for Chronic Disease Prevention and Health Promotion
CDC
MedicalResearch.com: What is the background for this study?
Response: The Title X program, established in 1970, offers confidential family planning and related preventive services to both men and women. While most clients are women, Title X also promotes use of services by men through delivery of male-focused services. Men’s family planning needs include services not only related to contraception, but also related to preconception care, infertility, and STD/ HIV services, which affect their reproductive health and overall health.
Dr. Gregoire Boulouis[/caption]
Dr. Gregoire Boulouis MD MS
Research Fellow at Massachusetts General Hospital / Harvard Med. School
Boston, Massachusetts
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Boulouis: Hemorrhagic Stroke or Intracerebral hemorrhage (ICH) still has a poor prognosis. A substantial proportion of patients will experience ongoing intracranial bleeding and their hematomas will grow in size in the first hours following presentation, a phenomenon called 'hemorrhage epxansion'. Patients with hemorrhage expansion have been shown to have significantly worse clinical outcome. If all baseline ICH characteristics (location, initial hemorrhage volume, ..) are non modifiable at the time of diagnosis, hemorrhage expansion, however, represents one of the few potential targets to improve outcome in ICH patients. An accurate selection of patients at high risk of expansion is needed to optimize patients' selection in expansion targetted trials and, eventually, to help stratifying the level of care at the acute phase.
In this study, we investigated whether the presence of non-contrast Computed Tomography hypodensities within the baseline hematoma, a very easily and reliably assessed imaging marker, was associated with more hemorrhage expansion.
A total of 1029 acute phase ICH patients were included ; approximately a third of them demonstrated CT hypodensities at baseline. In this population, CT hypodensities were independently associated with hemorrhage expansion with an odds ratio of 3.42 (95% CI 2.21-5.31) for expansion in fully adjusted multivariable model.
Dr. Alan Fayaz[/caption]
Dr Alan Fayaz
MA MBBS MRCP FRCA FFPMRCA
Consultant in Anaesthesia and Pain Medicine
University College London Hospital NHS Foundation Trust
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Fayaz: Despite fairly well established negative consequences of chronic pain (social, psychological, biological) very little is known about the burden of chronic pain in the United Kingdom. For example healthcare costs relating to chronic pain in the USA outstrip those of Cancer and Cardiovascular disease, and yet the profile of chronic pain (as disease in its own right) is not nearly as well established as either of those conditions. Surprisingly, prior to our study, there was little consensus regarding the prevalence of chronic pain in the UK. The purpose of our review was to synthesise existing data on the prevalence of various chronic pain phenotypes, in the United Kingdom, in order to produce accurate and contemporary national estimates.
Dr. John Mafi[/caption]
John N. Mafi, MD, MPH
Assistant Professor of Medicine
Division of General Internal Medicine and Health Services Research
UCLA David Geffen School of Medicine
Los Angeles, CA 90024
Affiliated Adjunct in Health Policy
RAND Corporation
Santa Monica, CA 90401
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Mafi: The U.S. healthcare system faces a looming shortage of primary care physicians, with some estimates as high as 20,000 physicians by the year 2020. In addition, fewer and fewer trainees enter primary care careers because of the harder work and lower salaries. Combine this with the passage of the Affordable Care Act and the millions of newly insured patients looking for a primary care provider, and you have created a perfect storm where timely access to primary care becomes essentially unachievable.
Many advocate for expanding the role of nurse practitioners and physician assistants to mitigate the physician shortage. But this is controversial as most doctors believe nurse practitioners provide inferior care to doctors and many feel that expanding their role would worsen the value and efficiency of the U.S. healthcare system.
While studies suggest they provide similar quality of care to physicians, few have actually evaluated whether they provide greater amounts of inefficient or low value care. Low value care is important because it can harm patients (antibiotics for colds don’t help patients and have harmful side effects) and they can raise healthcare costs. In this context, we used a large national database on ambulatory visits to compare the quality and efficiency of care among nurse practitioners, physician assistants, and physicians in the U.S. primary care setting.
In our 15 year analysis of nearly 29,000 patients who saw either a nurse practitioner, physician assistant, or a physician, we found similar rates of inappropriate antibiotic use for colds, unnecessary imaging (such as x-rays, CT scans, and MRI scans) for back pain and headache, and potentially necessary referrals to specialists for these same three conditions.
Dr. Andrea M. Kriska PhD MS
Professor, Department of Epidemiology
Graduate School of Public Health
Pittsburgh, PA 15261
MedicalResearch.com: What is the background for this study?
Dr. Kriska: The Diabetes Prevention Program (DPP) was a well administered national research study primarily supported by the National Institutes of Health (NIDDK) that demonstrated that lifestyle intervention with weight loss and physical activity goals can prevent type 2 diabetes in diverse, high risk US adults. The importance of physical activity in preventing diabetes development in the DPP until now was thought to be due to its role in achieving weight loss and weight maintenance but activity was not considered a strong key factor alone.
The lifestyle group had a significantly greater increase in physical activity and decrease in weight than the other two groups. They also had a 58% decrease in diabetes incidence compared to the control group. The successful decrease in T2D held across all age, sex, baseline BMI and ethnicity/race subgroups.
Despite the fact that the lifestyle intervention was then offered to all participants, in the follow-up years, the lifestyle participants still maintained a lower cumulative diabetes incidence that could not be explained by differences in weight loss.
Dr. Orit Markowitz[/caption]
Orit Markowitz, MD
Director of Pigmented Lesions and Skin Cancer
The Mount Sinai Hospital and
Assistant Professor of Dermatology
Icahn School of Medicine at Mount Sinai
Director of Pigmented lesions clinic
Brooklyn VA,
Adjunct Professor, Dermatology
SUNY Downstate Medical Center, Brooklyn, NY
Chief of Dermatology
Queens General Hospital, Jamaica, NY
MedicalResearch.com Editors’ Note: As part of an ongoing series of occasional article on cancer prevention, Dr. Markowitz from The Mount Sinai Hospital discusses skin cancer and the use Optical Coherence Tomography in skin cancer diagnosis and treatment.
MedicalResearch.com: How common is the problem of non-melanoma skin cancer? Are they difficult to detect and treat?
Dr. Markowitz: Skin cancer is the most commonly diagnosed cancer in the United States. Non melanoma skin cancers, including basal cell carcinomas and squamous cell carcinomas, are the most common malignancies of the skin, constituting around 80 percent of all skin cancers. The annual cost of treating skin cancers in the U.S. is estimated at $8.1 billion, with $3.3 billion for melanoma.
Dr. Morgan Freiman[/caption]
J. Morgan Freiman, MD
Infectious disease research fellow
Boston Medical Center
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Freiman: There are 130-150 million persons infected with chronic HCV with 75% of all cases occurring in low- and middle- income countries (LMICs). Diagnosis is a 2-step process that starts with screening for exposure with an assay that detects antibodies to HCV (anti-HCV), followed by nucleic acid testing (NAT) for persons with reactive anti-HCV to measure HCV ribonucleic acid (RNA) and confirm active viremia.
In LMICs diagnostic capacity is low, and fewer than 1% of patients are aware of their infection. Additionally, a significant proportion of patients who test positive for anti-HCV are lost to follow-up before nucleic acid testing. The 2-step diagnostic process is thus a major bottleneck to the HCV cascade of care. Testing for hepatitis C virus core antigen (HCVcAg) is a potential replacement for NAT.
Our systematic review evaluated the accuracy of diagnosis of active HCV infection among adults and children for 5 commercially available HCVcAg tests compared with NAT. We found that HCVcAg assays with signal amplification have high sensitivity, high specificity, and have the potential to replace NAT in settings with high HCV prevalence.
Dr. Renuka Tipirneni[/caption]
Renuka Tipirneni, MD, MSc
Clinical Lecturer in Internal Medicine
University of Michigan Department of Internal Medicine, Division of General Medicine
North Campus Research Complex, Bldg 16, Rm 472C
Ann Arbor, MI
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Tipirneni: One year after Medicaid expansion in Michigan, 600,000 individuals had enrolled in the program and there was concern that new enrollees would crowd doctor’s offices and new patients would not be able to get an appointment. We found that the opposite occurred – primary care appointment availability for new Medicaid patients increased.
This study builds on a previous study looking at what happened in the first four months after Medicaid expansion. In the earlier study, we found that appointment availability for new Medicaid patients had increased in the first few months after expansion. Even though the number of enrollees in the Medicaid expansion program doubled since then, the new study found that appointment availability remained increased for new Medicaid patients one year after expansion.
Dr. Mike Allan[/caption]
Michael Allan, MD CCFP
Professor of Family Medicine and
Director of Evidence Based Medicine
Faculty of Medicine & Dentistry
University of Alberta
MedicalResearch.com: What is the background for this study?
Dr. Allan: A large volume of observational (lower-level) research links lower Vitamin D levels with a long list of health concerns. Other non-clinical studies show the biochemical and physiological actions of Vitamin D could impact many health states. These factors have led many clinicians and scientists to advocate strongly for Vitamin D supplementation. However, this type of research can draw false connections. Therefore, we must examine high-quality randomized studies to determine if Vitamin D supplement can help people live longer, have improved health or avoid negative health outcomes.
Dr. Luca Passamonti[/caption]
MedicalResearch.com Interview with:
Dr. Luca Passamonti MD
Department of Clinical Neurosciences
University of Cambridge
MedicalResearch.com: What is the background for this study?
Dr. Passamonti: We wanted to study if the brain of young people with two different forms of conduct disorder (CD) (https://en.wikipedia.org/wiki/Conduct_disorder), a neuropsychiatric disease associated with severe and persistent antisocial behaviors (weapon use, aggression, fire-setting, stealing, fraudulent behavior), was different from that of young peers with no such abnormal behaviors.
There is already evidence that conduct disorder may have a biological basis (i.e., reduced levels of cortisol under stress) and brain alterations but a whole “map” of the brain in conduct disorder studying cortical thickness was never been done before.
Dr. Steven Woloshin[/caption]
Steven Woloshin, MD
Professor of The Dartmouth Institute
Professor of Medicine
Professor of Community and Family Medicine
New Hamphsire
MedicalResearch.com: What is the background for this study?
Dr. Woloshin: Drug companies are required by law to post results of trials used to support drug applications to the FDA on the clinicaltrials.gov website - but it is not clear whether posted results are complete and accurate. Recent studies attempting to validate posted results by comparing them to corresponding peer reviewed medical journal publications suggest that discrepancies are relatively common. But it is which source is more likely to be correct. We tried to validate posted results against an arguably better gold standard, the drug approval packages from the FDA (ie, the medical and statistical reviews posted on the drugs@fda.gov website). FDA reviews have an advantage over peer reviewed publications: unlike medical journal editors and peer reviewers, FDA has access to the individual participant data from the trials. This means FDA can see all the trials and all the outcomes (avoiding sleective publication) and it means FDA can independently reanalyze according to what they believe to be the best statistical practices (data can be analyzed in many ways - and different decisions, for example, how to account for missing data, can yield very different results).
Dr. Luisa Borrell[/caption]
Luisa N. Borrell, DDS, PhD
Professor
Department of Epidemiology & Biostatistics
Graduate School of Public Health & Health Policy
City University of New York
MedicalResearch.com: What is the background for this study?
Dr. Borrell: Racial/ethnic disparities in birth outcomes in the United States are well documented, with non-Hispanic Black women exhibiting the worst outcomes. Several hypotheses have been proposed as explanation to this finding such as the weathering hypothesis and cumulative or chronic experiences of social inequality and racism. However, these hypotheses have only accounted for the stress burden associated with the mother’s race/ethnicity, as her race/ethnicity has been the sole information used to determine the child’s race/ethnicity, ignoring the possible stress associated with the father’s race/ethnicity. We used NYC birth- and death-linked data from 2000 to 2010 to examine the added effect of paternal race/ethnicity on adverse birth outcomes (low birth weight [LBW], small for gestational age [SGA], preterm births, and infant mortality [IM]) among NYC women.
Dr. James Freeman[/caption]
Dr. James V. Freeman MD
Assistant professor of cardiology and
Assistant Clinical Professor of Nursing
Internal Medicine
Yale School of Medicine
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Freeman: Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost-effectiveness compared to anticoagulation has not been evaluated using all available contemporary trial data.
We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost-effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of PROTECT AF and PREVAIL randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios (ICER) compared to warfarin and dabigatran were $20,486 and $23,422 per quality adjusted life year (QALY), respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 QALYs, respectively) and more costly.
Dr. Sahil Agrawal[/caption]
Sahil Agrawal MD, MD
Heart and Vascular Center
St. Luke’s University Health Network
Bethlehem, PA 18015
MedicalResearch.com: What is the background for this study?
Dr. Agrawal: Patients admitted on a weekend have previously been known to have poorer outcomes compared to patients admitted on weekdays for various acute illnesses. With the advent of early fibrinolytic therapy and subsequently, emergent primary percutaneous coronary interventions (PCI), such discrepancies in outcomes have been largely resolved for ST-segment elevation myocardial infarctions (STEMI). In contrast, treatment of non-ST segment elevation myocardial infarction (NSTEMI) has remained less stringent such that invasive coronary angiography and potential intervention is often delayed for those presenting on a weekend rather than a week day. According to current ACC/AHA guidelines for NSTEMI, an early invasive strategy (EIS) is the preferred method of management unless barred by presence of contraindications (comorbid conditions) or patients’ preference. We were interested in investigating differences in utilization of EIS between patients admitted on a weekend versus those admitted on a weekday for an NSTEMI, and to evaluate the impact of such differences on in-hospital mortality in such patients.
Dr. Ian Kronish[/caption]
Ian Kronish, MD, MPH
Florence Irving Assistant Professor of Medicine
Center for Behavioral Cardiovascular Health
Columbia University Medical Center
MedicalResearch.com: What is the background for this study?
Dr. Kronish: Prior studies have shown that adherence to statins is suboptimal both in patients prescribed statins for primary prevention and in high-risk patients who are prescribed statins to prevent recurrent events. But, to our knowledge, prior studies had not examined the impact of a hospitalization for a myocardial infarction (MI) on subsequent adherence to statins. We wondered whether the hospitalization would serve as a wake-up call that led patients to become more adherent after the MI. At the same time, we were concerned that the physical and psychological distress that arises after a hospitalization for an MI may lead to a decline in statin adherence.
Prof. David Halon[/caption]
Prof. David A. Halon MB ChB, FACC, FESC
Associate Professor of Clinical Medicine
Technion, Israel Institute of Technology.
Director, Interventional Cardiology
Lady Davis Carmel Medical Center
Haifa, Israel
MedicalResearch.com: What is the background for this study?
Prof. Halon: Type 2 diabetics are well known to have more cardiovascular events than non-diabetics but even among diabetics this risk is heterogeneous and some remain at very low risk. It remains uncertain if additional diagnostic modalities over and above clinical risk scores may be helpful in defining which diabetics are at high risk for an adverse event. We performed a study using cardiac CT angiography (CCTA) in 630 type 2 diabetics 55-74 years of age with no history of coronary artery disease to examine if CTA findings would have additional prognostic value over traditional risk scores for cardiovascular or microvascular based events over 7.5 years of follow-up.
Dr. Mari Videman[/caption]
Mari Videman
Senior Consultant in Child Neurology
BABA Center
Children’s Hospital, Helsinki University Hospital
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Depression and anxiety are common during pregnancy, and up to 5% of all pregnant women are treated with serotonin uptake inhibitors (SRI). It is now known that SRIs do not cause major malformations in humans, however recent animal studies have suggested that fetal early SRI exposure may cause changes in brain microstructure and neuronal signaling. Prior human studies have shown that fetal SRI exposure leads to transient postnatal adaptation syndrome, as well as to an increased risk of developing childhood depression.
We used electroencephalography (EEG) and advanced computational methods to assess both the local and global cortical function of the newborn brain. We found that several aspects of newborn brain activity are affected by exposuse to SRI during pregnancy. Most importantly, the communication between brain hemispheres, and the synchronization between cortical rhythms were weaker in the SRI-exposed newborns. These changes were most likely related to SRI exposure, because they did not correlate with the psychiatric symptoms of the mothers.
Dr. Kelli Komro[/caption]
Kelli A. Komro, MPH, PhD, Professor
Director of Graduate Studies
Behavioral Sciences and Health Education
Jointly Appointed, Epidemiology
Rollins School of Public Health
Emory University
Atlanta, GA 30322
MedicalResearch.com: What is the background for this study?
Dr. Komro: Epidemiologists have done a thorough job describing the income-health gradient, which shows a clear association between income and health. That is, as income increases, exposure to health risks and premature mortality decreases. Each step down on the income ladder decreases one’s health for many reasons related to material resources, physical environment exposures and social circumstances.
The income to health association begins at birth, and more than one in four women giving birth in the U.S. are below the poverty level, putting nearly 1 million babies at risk each year. Low-income mothers are more likely to give birth prematurely, to have low birth weight babies, and to suffer the death of their infant during the post-neonatal period (28 to 364 days old).
Given the importance of the income-health gradient, we set out to test the health effects of policies that are designed to increase economic security among low-income families. Our main question is: Do policies designed to reduce poverty and improve family economic security also improve health?
One relevant policy is minimum wage laws. A federal minimum wage was first enacted in 1938. The real value (in 2015 dollars) of the federal minimum wage reached a high of $10.85 in 1968. The current federal rate is $7.25. Many cities and states have passed minimum wage laws that are higher than the federal rate, and currently there is a range of minimum wage increases under active public and policymaker discussion.
Given that some states pass minimum wage standards and others do not, and that laws within states change over time, we took advantage of all the changes that have occurred to design a natural experiment. Our natural experiment examined the effects of state minimum wage laws on infant health.
Dr. Kathleen Fischer[/caption]
Kathleen Fischer, PhD
Department of Biology
UAB | University of Alabama Birmingham
Birmingham, AL
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Fischer: Aging is by far the greatest risk factor for most of the chronic, non-communicable diseases (e.g. cardiovascular disease, cancer, diabetes). By discovering the basic mechanisms responsible for aging we can find ways to extend healthy and productive life and reduce the burdens of chronic disease and disability experienced by individuals and society. Sex differences in longevity can provide novel insights into the basic biology of aging; however this aspect of aging has been largely ignored.
Demographic data show that women outlive men in every society during every historical period and in every geographic area. In spite of this robust survival advantage, women suffer far greater morbidity late in life—a phenomenon described as the morbidity-mortality paradox. It is not clear whether this is a general mammalian pattern or something unique to humans. Research on sex differences in aging and age-related diseases in humans and a range of species will be crucial if we are going to identify the basic mechanisms responsible for the patterns we observe.
Dr. Kate Merritt[/caption]
Kate Merritt PhD
Post-Doctoral Research Worker
NOC Study (Nitric Oxide in Cognition)
Institute of Psychiatry
De Crespigny Park
London
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Merritt: Research has indicated that levels of one of the main chemicals in the brain, glutamate, may be abnormal in schizophrenia. Almost sixty studies have measured glutamate levels in schizophrenia, however the findings are inconsistent, and it is thought that changes in glutamate levels may vary with the length or the severity of illness. This study therefore analysed all the published reports of glutamate in schizophrenia.
The main findings are that, overall, schizophrenia is associated with elevated glutamate in several brain regions; namely the medial temporal cortex, the basal ganglia and the thalamus. These changes also differed with the stage of illness; in the medial frontal cortex, glutamate was increased in people at risk for developing schizophrenia, but not in people who had been diagnosed with schizophrenia for several years, whereas in the medial temporal lobe the opposite pattern was detected.
Dr. Celeste Torio[/caption]
Celeste M. Torio, Ph.D., M.P.H
Scientific Review Officer
AHRQ
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Torio: Hospital care expenditures constitute the largest single component of health care spending. These expenses are of significant concern to policymakers because of their impact on governments, consumers and insurers.
MedicalResearch.com: What are the main findings?
• Aggregate hospital costs for 35.6 million hospital stays totaled $381.4 billion in 2013.
• Septicemia, osteoarthritis, newborn infants, complication of device, and acute myocardial infarction are the five most expensive conditions, and account for 1/5 of the total aggregate costs for hospitalizations.
• Sixty-three percent of aggregate hospital costs were covered by Medicare and Medicaid, while 28 percent were covered by private insurance and 5 percent were covered by the uninsured.
Dr. Leland McClure[/caption]
Leland McClure, PhD
Director in Medical Affairs for Quest Diagnostics
Fellow of the American Board of Forensic Toxicology
MedicalResearch.com: What is the background for this study?
Dr. McClure: Quest Diagnostics is the leading provider of diagnostic information services, providing clinical lab testing to about one in three American adults each year. As a result, we've amassed the largest private clinical laboratory database in the United States, based on 20 billion data points from lab testing. Quest uses this data (in de-identified, HIPAA compliant form) to perform research -- called Quest Diagnostics Health Trends(TM) -- to reveal insights on important health issues to inform clinical patient management and health policy. Other Health Trends reports have focused on diabetes, pregnancy and influenza, among others.