Fellowship directors endorse the need for increasing diversity in cardiology

Underrepresented minorities remain few in number among practicing cardiologists and across cardiology fellowship training programs in the United States, with fellowship directors agreeing that increased diversity is needed in the field and is particularly necessary within graduate medical education cardiology fellowship training programs.

Underrepresented minorities, specifically African American, Native American, Hispanic and/or Pacific Island physicians comprise only about 12% of the cardiology workforce. There are cardiology fellowship programs in the U.S. that have never trained an underrepresented minority fellow until recently, said study author Arif Musa, a fourth-year medical student at the Wayne State University School of Medicine.

Cardiovascular disease is a leading contributor to morbidity and mortality throughout the United States. Minority communities are often disproportionately affected and not able to access care until the disease has progressed greatly. Moreover, cardiology remains one of the least diverse specialties with regard to representation of African American, Native American, Hispanic and/or Pacific Islander cardiologists. Given the role of cardiology fellowship training program directors in selecting and ranking applicants to their programs, our study sought to identify which strategies program directors preferred to increase underrepresented minority representation in cardiology."

Arif Musa, a fourth-year medical student, Wayne State University School of Medicine

The study, "Increasing Diversity in Cardiology: A Fellowship Director's Perspective," was published this month in Cureus Journal of Medical Science by a team that included Musa's Class of 2022 classmates Amman Bhasin and Louis Massoud; Class of 2021 graduate and WSU Family Medicine resident Azar Razikeen, M.D.; Cedars-Sinai Medical Center attending cardiologist Arshia Noori, M.D.; Henry Ford Health Internal Medicine residents and School of Medicine alumni Ali Ghandour, M.D. '20, and David Gelovani, M.D. '20; WSU Professor of Medicine and Division of Cardiology Chief Luis Afonso, M.D., and WSU Professor of Medicine Randy Lieberman, M.D., both attending cardiologists at Detroit Medical Center; and Ajay Vaidya, M.D., attending cardiologist and association program director of the Cardiology Fellowship program at the University of California Keck School of Medicine.

The findings were presented at the 70th American College of Cardiology annual meeting in May.

A 15-item survey was submitted to all American College of Graduate Medical Education- accredited cardiology fellowship programs via email to compile the study data. The cross-sectional study was performed to identify which strategies were supported and implemented by cardiology fellowship program directors to increase representation, to determine which entities hold the responsibility to increase diversity according to program directors, and to quantify representation in cardiology fellowship programs.

According to the study, program directors endorsed several avenues that would alleviate the gap. They included increasing the number of underrepresented faculty (73.2%), mentorship by underrepresented faculty (69%), holistic application review (67.6%), opportunities for applicants to connect with other minority fellows (54.9%), increased involvement of underrepresented minority faculty in the application selection process (54.9%) and recruitment by current fellows (54.9%) were endorsed by program directors.

Program directors allocated the most responsibility to increase diversity to fellowship programs (71.8%), but most also allocated responsibility to internal medicine residency programs (63.3%) and medical schools (53.5%).

Source:

Wayne State University

Journal reference:

Bhasin, A., et al. (2021) Increasing Diversity in Cardiology: A Fellowship Director’s Perspective. Cureus Journal of Medical Science. doi.org/10.7759/cureus.16344.

Posted in: Medical Research News | Healthcare News

Tags: Cardiology, Cardiovascular Disease, Education, Medicine, Mortality

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Delta Variant as Contagious as Chicken Pox: CDC Documents

Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.

Internal Centers for Disease Control and Prevention (CDC) documents support the high transmission rate of the delta variant and put the risk in easier to understand terms. The documents also show that breakthrough infections in the vaccinated make people about as contagious as those who are unvaccinated.

In addition to being more transmissible, the delta variant likely causes more severe COVID-19 illness.

Given these recent findings, the document advises that the CDC should “acknowledge the war has changed.”

The internal CDC slide presentation also puts the new transmission risk in simple terms. Saying the delta variant is about as contagious as chicken pox, for example, immediately brings back vivid memories for some of staying indoors and away from friends during childhood or teenage outbreaks.

This also means each person infected with the delta variant could infect an average eight or nine others.

In contrast, the original strain of the SARS-CoV-2 virus was about as infectious as the common cold. In other words, someone was likely to infect about two other people on average.

In addition to the cold, the CDC notes that the delta variant is now more contagious than Ebola, the seasonal flu, or smallpox.

These delta variant comparisons are one tangible way of explaining why the CDC on Tuesday recommended a return to masking in schools and other indoor spaces for people – vaccinated and unvaccinated – in about 70% of the counties across the United States.

The delta variant is so different that the CDC considers it almost acting like a new virus altogether.

The CDC internal documents were first released by The Washington Post on Thursday. The slides cite communication challenges for the agency to continue promoting vaccination while also acknowledging that breakthrough cases are occurring and therefore the fully vaccinated, in some instances, are likely infecting others.

 

Trust but Verify

In announcing the new mask guidance on Tuesday, CDC Director Rochelle Walensky, MD, MPH, referred to new science that supports the move. Many experts asked to see the full research for themselves. As a result the CDC is expected to release the full study details today.

One novel finding is expected to be the evidence for more severe disease associated with the delta variant.  

Novel evidence also came out this week answering a long unanswered question. The CDC explained that the fully vaccinated can be COVID transmitters because people with “breakthrough infections” walk around with the same amount of virus in their noses as the unvaccinated do.

Moving back to science talk, the CDC used a recent outbreak in Barnstable County, Massachusetts, as an example. The cycle threshold or Ct values, a measure of viral load, were about the same between 80 people linked to the Provincetown Fourth of July outbreak, who had a mean Ct value of 21.9, compared to 65 other unvaccinated people with a Ct of 21.5.

Many experts are quick to note that vaccination remains essential, in part, because a vaccinated person also walks around with a much lower risk for severe outcomes, hospitalization, and death. In the internal slide show, the CDC points out that vaccination reduces the risk of infection threefold.

The agency notes next steps for the agency include consideration of prevention measures including vaccine mandates for healthcare professionals to protect vulnerable populations, universal masking for source control and prevention, and reconsidering other community mitigation strategies.

Damian McNamara is a staff journalist based in Miami. He covers a wide range of medical specialties, including infectious diseases, gastroenterology and critical care. Follow Damian on Twitter: @MedReporter.

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Dual-drug therapy shows promise for treating alcohol use disorder

alcohol

UCSF researchers have leveraged two new molecules, one of which is currently in clinical oncology trials, to devise a dual-drug therapy for alcohol use disorder (AUD), without the side effects or complications associated with current treatment regimens. The approach had highly successful results in mice and may be applicable to other drugs that are often abused. 

At the root of the team’s thinking is the idea that AUD and other substance abuse disorders are the result of reinforced pathways in the brain, and that those pathways can be blocked or redirected, ending cravings and habitual behavior. 

“Alcohol use disorder is really a process of maladapted learning and memory,” said Dorit Ron, Ph.D., a professor of neurology and senior author on the study, published July 27 in Nature Communications. “Alcohol is rewarding, and we learn to associate alcohol, and even the environment in which we drink the alcohol, with that reward.”

Current pharmaceutical options for AUD attempt to change behavior by making alcohol consumption an unpleasant experience and some require patients to abstain for several days before beginning treatment. 

Since 2010, Ron, who is also faculty in the Weill Institute for Neurosciences, has taken a different approach, studying the role of the enzyme mTORC1 in the creation of those memories and associations, with the goal of creating an effective drug that can treat the neurological causes of AUD. 

Ordinarily, mTORC1 is involved in brain plasticity, helping to create connections between neurons that reinforce memory. In previous work, Ron showed that consuming alcohol activates the enzyme in the brain. 

Ron has also shown that blocking the activity of mTORC1 with the FDA-approved compound rapamycin, used to treat some types of cancer and suppress immune response in transplant patients, can halt cravings in mice engineered for alcohol use disorder. But mTORC1 contributes to a bevy of other bodily tasks related to metabolism and liver function, and people taking it for an extended period often develop liver toxicity, glucose intolerance, and other side effects. 

For some of her previous work, Ron had teamed up with Kevan Shokat, Ph.D., a professor of Cellular Molecular Pharmacology, who had created RapaLink-1, a molecule similar to rapamycin, which he designed specifically to keep a tight grip on mTORC1 and completely subdue it. A version of the drug is now being tested in oncology clinical trials. 

Shokat’s thought was that, since Ron is concerned only with the activity of mTORC1 in the brain, that’s the only place where RapaLink-1 or rapamycin needs to be effective. So Ziyang Zhang, Ph.D., a postdoctoral researcher in Shokat’s lab, designed a second molecule that would latch onto RapaLink-1 or rapamycin—essentially negating its effect—while at the same time being too big to cross the blood-brain barrier. 

In other words, Shokat reasoned that RapaLink-1 or rapamycin could administered and allowed to circulate throughout the body. Once it had a chance to reach the brain, Rapablock could be given, halting the activity of Rapalink-1 everywhere except in that targeted area. 

The tactic worked like a charm when it was tested on the mice by Yann Ehinger, Ph.D., a postdoctoral researcher in Ron’s lab. “We could see these side effects in mice who are taking rapamycin or RapaLink-1, and then when you give Rapablock, it’s like magic, the side effects are gone,” said Ron. 

Shokat said a similar strategy is being explored in treating other conditions, such as Parkinson’s disease. Those trials involve different drugs, but the underlying principle is the same: one drug results in the desired effect in the brain, while its activity is blocked by a molecule that isn’t able to cross the blood-brain barrier. 

Ron believes that tackling addiction from this neurological perspective has potential for broad applications. She notes that while we see addiction with a wide chemical array of molecules—alcohol, nicotine, cocaine, opiates, and the like—the addictive behavior that results from each is the same. 

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Family Doctors Omit Tests for Kidney Disease in Type 2 Diabetes

U.S. primary care physicians are not properly checking patients with type 2 diabetes for chronic kidney disease (CKD) nearly as often as they should, meaning many of these patients miss getting a timely diagnosis.

Inadequate measurement of urinary albumin-to-creatinine ratio (uACR) is the issue.

Review of data from more than half a million U.S. primary care patients with type 2 diabetes seen at any of 1,164 practice sites run by any of 24 health care organizations during 2016-2019 showed that barely more than half, 52%, had both their uACR and estimated glomerular filtration rate (eGFR) checked annually as recommended by several U.S. medical societies, and just 73% had both values checked during a 3-year period, Nikita Stempniewicz, MSc, and associates reported in Diabetes Care.

More detailed data showed that measurement of eGFR was reasonably robust, measured at a 90% rate annually and in 97% of patients at least once every 3 years. But recording uACR values lagged, with a 53% annual rate and a 74% rate of measurement at least once every 3 years, reported Stempniewicz, director of research and analytics for the American Medical Group Association, a trade association based in Alexandria, Va. The 24 health care organizations that supplied the study’s data are all members of this association.

Prevailing recommendations from various medical societies call for annual monitoring of urinary albumin in patients with type 2 diabetes and specify the uACR, such as in the Standards of Medical Care in Diabetes from the American Diabetes Association, as well as in recommendations promoted by the National Kidney Foundation.

Missing Half the CKD Patients With eGFR Only

“Half the patients with type 2 diabetes and chronic kidney disease have elevated albuminuria without decreased eGFR and would not be detected with eGFR testing alone,” Stempniewicz noted in an interview.

“Many patients who present for nephrology care are incompletely assessed with only low eGFR but no urine testing. Missing albuminuria testing and uACR values means patients with high levels of albuminuria but normal kidney function go undetected and thus are not able to benefit from evidenced-based interventions, including nephrology services,” said Joseph A. Vassalotti, MD, a nephrologist, chief medical officer for the National Kidney Foundation, and a coauthor of the report.

Not testing patients with type 2 diabetes regularly for their uACR “is a missed opportunity to identify the highest-risk patients and treat them,” added Josef Coresh, MD, PhD, a professor of clinical epidemiology at Johns Hopkins University, Baltimore, and senior author on the study. Measurement of albuminuria is especially important for these patients because medications from the sodium-glucose cotransporter 2 inhibitor class have been proven to slow progression of CKD in patients with type 2 diabetes, but these drugs are expensive, and in some cases have labeling that specifies the presence of albuminuria.

“I have no doubt that improving albuminuria testing is a critical step to identify patients with diabetes at highest risk who should get the best treatment possible, including SGLT2 inhibitors,” Coresh said in an interview.

The new report is not the first to document inadequate assessment of albuminuria and uACR among primary care physicians (PCPs), but it came from the largest reported U.S. study to date. “eGFR is commonly collected in a routine laboratory blood panel, but collecting urine requires additional work flow,” noted Cara B. Litvin, MD, a general internal medicine researcher at the Medical University of South Carolina, Charleston, who has tested interventions aimed at boosting CKD assessment by PCPs and was not involved in the new study.

“There have also been conflicting guidelines,” such as a “now-inactive guideline from the American College of Physicians that recommended against routine urine albumin screening in patients with diabetes and already on treatment with an angiotensin converting enzyme inhibitor or an angiotensin receptor blocker,” she said.

New Renal Drugs Change the Stakes

The availability of newer drugs for slowing CKD progression such as the SGLT2 inhibitors will help trigger greater support for routine albuminuria testing, Litvin predicted in an interview. “Now that we have more medications that can reduce albuminuria and improve outcomes, I see screening for albuminuria increasing.” Finerenone (Kerendia) is another new agent from a new class that recently received Food and Drug Administration approval for treating CKD in patients with type 2 diabetes.

Other drivers of increased uACR testing she expects include revised clinical practice guidelines, and new quality measures of clinical care.

“Undertesting of albuminuria means that [nephrologists] have incomplete data to detect and completely risk stratify the CKD population. That in turn results in a reduced ability to match population health interventions to the severity of the condition or the risk stratification based on eGFR and uACR,” Vassalotti said in an interview.

“We are missing opportunities to prevent or delay kidney failure and reduce the risk of cardiovascular events and cardiovascular death in these patients, particularly now that we have a number of medications that offer kidney and cardiovascular protection such as SGLT2 inhibitors,” he added. “Leaders in nephrology are beginning to understand the consequences of undertesting, and are working to innovate to improve risk stratification, CKD detection, and apply interventions to give Americans living with CKD better outcomes.”

Strategies Proven to Boost Albuminuria Testing

Stempniewicz and coauthors cited in their report potential strategies for improving albuminuria testing, including benchmarking to identify best-performing sites for albumin testing within a health system and encouraging replication of identified best practices at lower-performing sites, and implementation of clinical-decision support tools in the EHR such as pop-up test reminders.

These were among the tools tested in two studies led by Litvin. One study, with results reported in 2016, involved 12 small U.S. primary care practices with a total of more than 30,000 patients and compared performance in a series of clinical quality measures at baseline with performance after 2 years of receiving various interventions designed to boost awareness for albuminuria testing.

The second study, with findings reported in 2019, involved 21 U.S. primary care practices that collectively cared for more than 100,000 patients and randomized the practices to either undergo interventions aimed at boosting testing awareness or to serve as controls.

Results from both studies showed significant and substantial increases in serial testing for albuminuria in patients with diabetes or hypertension when practices received the interventions.

“We showed that [using a] clinical-decision support tool, along with standing orders to automatically collect urine specimens, dramatically increased screening for urinary albumin in primary care practices,” Litvin said. “However, perhaps because of conflicting guidelines and clinical inertia there hasn’t been a major impetus for primary care practices in general to improve screening.” She hopes that will quickly change.

“As we have shown, adoption of EHR-based reminders along with standing orders can very quickly improve screening for albuminuria in primary care.”

Variation in Testing Rates Among Sites ‘Tremendous

One finding of the new study gives Stempniewicz hope for greater future testing: The large variance that the researchers saw in albuminuria testing rates within individual health systems.

“The paper shows that higher rates of testing are completely achievable within each system. Some clinics do very well, and the other units can learn from these local successes,” he said. At least half the organizations in the study had individual sites that fell into the top 10% for testing rates across all the greater than 1,000 sites included, and those same organizations also had at least one site that fell into the bottom 10% for testing.

“The variation is tremendous, and highlights an opportunity for improvement,” declared Stempniewicz.

“For routine testing, you need systems that help people. Clinicians shouldn’t have to think about doing routine testing. It should just happen,” said Coresh.

The study was funded in part by Janssen. Stempniewicz and Litvin had no disclosures. Coresh is an adviser to Healthy.io, a company that markets a home albuminuria testing kit to patients. Vassalotti has received personal fees from Renalytix.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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India’s vaccine rollout is ignoring the many inequities in its society

India's vaccine rollout is ignoring the many inequities in its society

Some six months after India began what is said to be the largest COVID-19 vaccination drive in the world, equitable distribution has been a challenge.

A recent instance from a remote area in one of India’s hill states is illustrative. According to news reports, over 90% of vaccination slots meant for locals were booked by people from other areas.

Residents lost out because the area had no internet connectivity. To address the digital divide, local authorities had to appeal to the outsiders to cancel their bookings.

This access issue is just one of many ways India’s prioritization strategy for COVID-19 vaccination has fallen short.

Who gets the shot first: what did experts agree on?

The World Health Organization (WHO) had foreseen vaccine shortages and consequently, inequitable distribution. In 2020, it advocated a nuanced approach to ensure those who most needed the vaccine got it.

The WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) designed a document called the “Values Framework”. This document listed over 20 vulnerable groups such as homeless peoples, those living in informal settlements, and those in urban slums.

They underscored that countries ensure access to priority populations and take action to ensure equal access to everyone who qualifies under a priority group, particularly socially disadvantaged populations.

How did India prioritize vaccines?

The first phase of India’s rollout began in January, covering an estimated 30 million healthcare and front-line workers.

On March 1, the second phase began which incorporated people over 45 with chronic illnesses, and the over-60s. On April 1, this was expanded to everyone over 45.

From May 1, it was decided all adults over 18 would be included.

Now, despite all adults being eligible, only 10% are fully protected with two doses. Despite the overall pace of vaccination increasing, the target of 135 million doses administered in July may be missed, and things look unlikely to improve in August.

With the threat of a third wave fuelled by variants, relaxing of lockdown restrictions, and the constant uptick in cases in two of the larger Indian states (Kerala and Maharashtra) as well as most of the North Eastern states, there’s an urgent need to increase vaccine coverage.

How should India prioritize vaccines?

India’s prioritization strategy was limited to age, and to front-line workers specifically linked to COVID management—police and armed forces personnel, disaster management volunteers and municipal workers. It did not address the real-world diverse spectrum of vulnerabilities.

The Values Framework points to a range of vulnerabilities and priorities and includes people unable to physically distance such as those in geographically remote and clustered populations (detention facilities, dormitories, refugee camps and dense urban neighborhoods).

Levels of COVID-19 among prison populations and high levels of antibodies (suggesting prior infection) among slum residents shows this is a legitimate concern.

Then there are those who are at high risk of transmitting infection such as youth who are mobile but largely asymptomatic, and school-going children. Vaccinating them early would minimize disruption of their education and socio-emotional development. The union health minister has announced vaccination of children is likely to begin in August.

Workers in non-essential but economically critical sectors, particularly in occupations that do not permit remote work such as construction and food services, should also be vaccinated early.

While only health workers were included in the category of essential workers, teachers, childcare providers, agriculture and food workers, and transport workers should have been added to this category.

Finally, to ensure equity, the needs of those who, at no fault of their own, are at risk of experiencing greater burdens from the COVID-19 pandemic, must be addressed.

This would include those living in extreme poverty, low-income migrant workers, nomadic populations, refugees or internally displaced persons, populations in conflict settings, those affected by humanitarian emergencies, and hard-to-reach groups.

At least one Indian state—Chhattisgarh—tried to reach out to its poorest, by proposing those under the state’s food scheme be vaccinated first in the 18–44 years category. However, after the intervention of the courts, the state had to reverse the order and allow vaccination for all adults.

What’s the fallout?

Rural-urban and gender inequities in the vaccine rollout have emerged as significant concerns.

By late May, 114 of India’s least developed districts had administered just 23 million doses to its 176 million residents. India’s nine major cities received the same number of doses, despite having half as many people.

During the same period, 17% more men were immunized than women.

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Report: The Unvaccinated Infected With Delta Remain Contagious

Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.

The CDC is expected to announce this week that new data shows people vaccinated against COVID-19 who become infected with the Delta variant can spread it and infect others, The New York Times reported late Thursday.

The revelation is one reason the agency reversed course this week and said fully vaccinated people should go back to wearing masks in many cases.

The new findings also are a reversal from what scientists had believed to be true about other variants of the virus, the Times said.

The bottom line is that the CDC data shows people with so-called breakthrough cases of the Delta variant may be just as contagious as unvaccinated people, even if they do not show symptoms.

ABC News reported earlier Thursday that the CDC’s updated mask guidance followed an outbreak on Cape Cod, where crowds gathered for the Fourth of July.

As of Thursday, 882 people were tied to the outbreak centered in Provincetown, Massachusetts. Of those who live in Massachusetts, 74% were unvaccinated. ABC said the majority were showing symptoms of COVID-19.

Aaron Gould Sheinin is executive editor of WebMD and Medscape.

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ACC Issues Decision Pathway for Hypertriglyceridemia Management

A new decision pathway for the management of hypertriglyceridemia, prompted by a large and growing body of evidence that elevated triglycerides to a targetable risk factor for atherosclerotic cardiovascular disease (ASCVD), has been issued by the American College of Cardiology.

According to the chairman of the writing committee, Salim S. Virani, MD, PhD, the recommendations amplify and update more than alter the hypertriglyceridemia treatment recommendations in the 2018 joint multisociety blood cholesterol guidelines issued in 2018.

This decision pathway, however, is focused on triglycerides alone.

“The previous guidelines included a section on strategies for addressing hypertriglyceridemia to reduce ASCVD risk, but this new decision pathway builds on the recommendations with more details and with additional information,” explained Virani, professor of medicine in the section of cardiovascular research, Baylor College of Medicine, Houston.

Within this newly published document, the definitions of hypertriglyceridemia and rationale for treatment are followed by detailed algorithms for four specific patient groups with varying triglyceride levels:

  • Adults with ASCVD.

  • Adults at least 40 years of age with diabetes but no ASCVD.

  • Adults at least 20 years of age with no ASCVD or diabetes.

  • Adults at least 20 years of age with severe hypertriglyceridemia.

“In the design of these algorithms, we made an active effort to make them suitable for use by primary care physicians as well as specialists,” said Virani. Despite “lots of boxes and arrows,” the flowcharts for each of these patient groups permit clinicians to follow the decision pathway without having to reread the text.

The common emphasis in all four algorithms is to begin by evaluating patients for secondary causes of hypertriglyceridemia, such as multifactorial chylomicronemia syndrome and other diseases associated with elevated triglycerides. The next steps, also common to all algorithms, are to optimize diet and lifestyle changes that lower triglycerides, optimize glycemic control, and optimize statin therapy.

“Although commonly recognized for their impact on LDL-C, statins also provide a 10%-30% dose-dependent reduction in triglycerides in patients with elevated levels,” the guidelines state. Statins are considered a fundamental step to secondary prevention of ASCVD regardless of triglyceride levels.

Once treatable causes or contributors to hypertriglyceridemia have been addressed, lifestyle interventions and statin therapy have been optimized, pharmacologic therapy directed specifically at control of hypertriglyceridemia “can be considered” in those at highest risk of ASCVD events, but Virani explained that this is never an early or first step in control of elevated triglycerides.

“The entire working group agreed that lifestyle interventions should be highlighted front and center before considering any other intervention,” Virani explained.

Pharmacologic therapy for hypertriglyceridemia is not ignored. Prescription omega-3 fatty acid products are preferred over nonprescription dietary supplements, which may vary in quality and purity. But these products, rather than a standalone solution, are best applied within the context of efforts to improve diet, lower body weight, and increase physical activity.

Several trials have associated ethyl ester and carboxylic acid preparations with meaningful reductions in triglycerides, but these drugs, including icosapent ethyl (IPE), are not without adverse events. In the pivotal REDUCE-IT trial, IPE was linked with an increased risk of atrial fibrillation relative to placebo.

IPE is “the best option” and the only therapy with an indication for reduction in ASCVD risk, according to Virani, but he explained that safety concerns led the authors of the new decision pathway to employ cautious language in regard to its use, suggesting that it be “considered” in high-risk patients after other methods of lowering triglycerides have been optimized.

In the algorithm for the four different risk groups, the decision pathways follow stratifications for different levels of hypertriglyceridemia (defined under fasting and nonfasting conditions) and also for specific levels of LDL cholesterol. ASCVD risk assessment is also a factor in determining the next steps along the decision pathway.

According to Michael Davidson, MD, director of the lipid clinic at the University of Chicago, the emphasis on lifestyle changes for hypertriglyceridemia and the prudent language in regard to pharmacologic therapy is appropriate.

“In light of the controversies regarding the REDUCE-IT trial, the writing committee has done a nice job with providing useful guidance regarding the utilization of icosapent ethyl in higher risk patients,” Davidson said.

Calling the ACC decision pathway “a welcome enhancement of the 2018 ACC/AHA cholesterol guidelines,” Davidson praised the way in which the limitations of the evidence regarding pharmacologic therapies were explained.

“Most importantly, this decision pathway helps clinicians appreciate that hypertriglyceridemia can be best managed with lifestyle changes and addressing potential secondary causes,” Davidson said.

Virani reports no potential conflicts of interest. Davidson reports financial relationships with multiple pharmaceutical companies including those making or pursuing therapies for control of hypertriglyceridemia.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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NIST's Privacy Framework can help orgs find their 'sweet spot'

In January 2020, the National Institute of Standards and Technology released Version 1.0 of its Privacy Framework: a voluntary tool aimed at helping organizations manage risk arising from their products and services.  

Since then, said Dylan Gilbert, privacy policy advisor at NIST, “many multinational organizations have used the framework to create a foundational program that they can then tailor to different jurisdictions within which they operate.”  

As a voluntary tool, Gilbert says, the framework is intended to help innovators build new products while still protecting individuals’ privacy.

“This tool is the result of NIST collaboration with a diverse set of stakeholders from around the world representing private industry, the public sector, academia, and civil society over a yearlong open and transparent development process,” explained Gilbert, who will be presenting at HIMSS21 in a few weeks alongside HITRUST Chief Privacy Officer Nikole Davenport.  

Gilbert noted that the Privacy Framework can assist with supporting ethical decision-making in design of products and services that optimize beneficial uses of data while minimizing adverse consequences.  

“This is the benefit of the framework’s flexible, risk-based approach to privacy,” he told Healthcare IT News. “Privacy risk assessments can help organizations understand in a given context the values to protect, the methods to employ, and how to balance the implementation of measures to find that ‘sweet spot’ between maximizing data utility and minimizing problems or harms to individuals.”  

In addition, Gilbert said, the framework can help with compliance, especially amid a changing policy and technological environment, by identifying outcomes and activities that map to current obligations.  

“This helps them establish traceability with their products and services and answer the important question of how they’re meeting their compliance requirements,” he said.   

Finally, the framework also contains numerous outcomes and activities that organizations can prioritize in order to ensure they’re identifying, reflecting and maintaining customer privacy preferences.   

“Privacy risk management requires organizations to monitor how changes to laws and regulations, data processing activities, and organizational priorities may affect privacy risks so they may adjust accordingly,” he said.  

In the year and a half since Version 1.0’s release, Gilbert said the agency has heard good feedback about the way implementers have used the framework to identify gaps in their requirements or better integrate their security programs.  

“Others have used the Framework simply to facilitate high-level conversations that resulted in an ‘aha’ moment with leadership about how the organization’s privacy program is organized and where they need to go to meet their goals,” he said.

Ultimately, he said he hopes attendees leave the session with the knowledge that privacy goes beyond compliance alone.  

“Healthcare is a great example of a sector that offers numerous current and future benefits to individuals and society thanks to data processing and its associated technologies,” he said. “That said, there are very real and important privacy risks associated with health data processing. Laws and regulations often struggle to keep up with the pace of innovation and social norms.  

“The Privacy Framework can help organizations go beyond mere compliance and take a forward-looking privacy risk management approach to reap the benefits of health data while protecting the privacy of individuals and groups,” he continued.  

Gilbert and Davenport will explain more during their HIMSS21 session, “The Trust Factor: Privacy Framework Adoption in Healthcare.” It’s scheduled for Tuesday, August 10, from 2:30-3:30 p.m., in Caesars Forum 123.

 

Kat Jercich is senior editor of Healthcare IT News.
Twitter: @kjercich
Email: [email protected]
Healthcare IT News is a HIMSS Media publication.

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Rare disorder offers roadmap for understanding roots of inflammatory disease

Inflammatory Bowel Disease

Yale researchers have discovered the underlying genetic cause of a rare childhood disorder that mimics inflammatory bowel disease, a finding that may help researchers uncover the roots of a host of other inflammatory and autoimmune disorders.

For the study, a team of Yale researchers investigated a mysterious case of a young boy who was treated at Yale New Haven Hospital for abdominal pain, intermittent bouts of fever, and diarrhea over multiple days, and canker sores in his mouth. Using genome sequencing of the child and his healthy parents, they revealed that the boy had a genetic defect that blocked ELF4, a transcription factor on the X chromosome that regulates expression of a large number of other genes.

Then, after reaching out to colleagues in the field of rare diseases, the research team identified two other male children with similar symptoms who also had ELF4 gene variants. This disorder is now termed “Deficiency in ELF4, X-linked,” or DEX for short. And an increasing number of cases are being identified.

“It is very exciting to start with patients who are sick and discover an unexpected new gene with a fundamental role in regulating inflammation,” said Carrie Lucas, an assistant professor of immunobiology at Yale School of Medicine and senior author of the paper published July 29 in the journal Nature Immunology.

The study was headed by Paul Tyler, Molly Bucklin, and Mengting Zhao, all of whom are members of Lucas’s lab.

Inflammatory diseases caused by a single gene mutation affect about 1 out of every 5,000 children.

According to the researchers, the symptoms experienced by the children in the study were similar to those associated with other inflammatory bowel diseases, including ulcerative colitis and Crohn’s Disease, thought to be caused by an overactive immune system response that damages tissues of the host.

After identifying the ELF4 variant, Lucas’s lab then studied its effects in cultured cells from patients, as well as in mice using CRISPR gene-editing to introduce patient-derived ELF4 mutations. They confirmed that the variant disrupted ELF4 function, and resulted in elevated inflammatory responses of a variety of immune cell types.

The widespread effects of the variant suggest ELF4 and its target genes likely play a role in regulating inflammation in multiple diseases, Lucas said.

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Heart Failure Diagnoses Often Missed in Primary Care Setting

(Reuters Health) – Many patients with heart failure are not diagnosed until they seek care in an acute setting, particularly female and Black patients, a U.S. study suggests.

Researchers examined commercial insurance claims data and Medicare Advantage data for 959,438 patients with a new heart failure diagnosis between 2003 and 2019. Overall, 38% of patients were diagnosed in acute care settings, and 46% of those diagnosed in acute care had potential heart failure symptoms in the previous six months.

Women were significantly more likely than men to be diagnosed in acute settings rather than primary care (adjusted odds ratio 1.11). And Black patients were significantly more likely than white patients to be diagnosed in acute care settings (aOR 1.18).

“Unfortunately, this is not a surprising finding given the disparities that are present throughout the healthcare system for women and racial minorities,” said lead study author Dr. Alex Sandhu, an instructor of medicine at Stanford University in California.

The study findings suggest that clinicians may need a lower threshold for evaluating patients for heart failure, Dr. Sandhu said by email.

“This may be increasing the use of natriuretic peptide testing among patients with unexplained symptoms given its high sensitivity for identifying heart failure, or arranging for faster follow-up for symptomatic patients diagnosed with alternate conditions to ensure they improve with initial treatment,” Dr. Sandhu said.

Beyond this, primary care clinicians likely need more time with complex symptomatic medical patients to improve diagnosis, and, in many locations, need better access to specialists like cardiologists and testing such as echocardiography, Dr. Sandhu added.

During the study period, the odds of heart failure diagnosis happening in an acute care setting increased by 3.2% annually, the analysis found.

Among patients not diagnosed with heart failure until a hospital admission or emergency department visit, 15% had edema in the previous six months. Many also had other potential heart failure symptoms in the previous six months including cough (12%), shortness of breath (11%), and chest pain (11%), the study team reports in Circulation: Heart Failure.

Patients with the lowest net worth, less than $25,000, were significantly more likely to be diagnosed in acute care settings than patients with the highest net worth, above $500,000 (aOR 1.39).

In addition, patients who identified their occupation as “retired” or “homemaker” were significantly more likely to be diagnosed in acute care settings (aOR 1.04) than those categorized in professional jobs.

Like all claims-based studies, one limitation of the analysis is that researchers only had limited insight into the clinical characteristics and comorbidities of each heart failure case, the authors note.

Even so, the results suggest that heart failure diagnoses are commonly missing in the outpatient setting, said Dr. Gregg Fonarow, co-director of the preventive cardiology program at the David Geffen School of Medicine at the University of California, Los Angeles.

“As other studies have shown less diagnostic testing and lower quality of care for women and minority populations presenting with cardiovascular disease, including heart failure, these results for heart failure diagnosis timing suggest there may be explanations in common,” Dr. Fonarow, who wasn’t involved in the study, said by email.

“Initiatives are needed to improve the timeliness and accuracy of heart failure diagnoses and reduce the gaps and disparities observed in this important study,” Dr. Fonarow said.

SOURCE: https://bit.ly/3zJX53N Circulation: Heart Failure, online July 27, 2021.

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