Gender disparity in the use of drug-eluting stents during percutaneous coronary intervention for acute myocardial infarction.

OBJECTIVE: We examined gender disparity in the use of drug-eluting stents (DES) versus bare metal stents (BMS) during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), and gender disparity in all-cause mortality after coronary stent implantation for AMI. BACKGROUND: Gender disparities in AMI managements have been well documented, but it is unclear whether these disparities are seen in the type of coronary stent implantation for AMI and outcomes. METHODS: Hospital discharge data from January 1, 2003 through December 31, 2010 in New Jersey from the Myocardial Infarction Data Acquisition System were used to identify 40,215 patients (12,878 women and 27,337 men) with coronary stent implantation for AMI. The in-hospital, short term (30 days) and long term (1 and 5 year) all-cause mortality rates, unadjusted and adjusted for demographics and comorbidities, were determined. RESULTS: Women were older than men and had a higher prevalence of co-morbidities. Men had higher prevalence of prior coronary revascularizations. After adjustment for co-morbidities, there was no significant gender difference in the use of DES versus BMS for AMI, except in 2003 and 2006 where women were found to be more likely to receive a DES versus a BMS. After adjustment, women had higher odds of in-hospital deaths but no difference in short and long-term all-cause mortality rates. CONCLUSIONS: There was no significant gender difference in the proportion of DES implantation versus BMS for AMI in contemporary years. Women treated with either BMS or DES for AMI had higher in-hospital death than men.

Plasma nitrite is an indicator of acute changes in ambient air pollutant concentrations.

CONTEXT: Endothelial dysfunction has been suggested as a potential mechanism by which ambient air pollution may cause acute cardiovascular events. Recently, plasma nitrite has been developed as a marker of endothelial dysfunction. OBJECTIVES: We examined the changes in plasma nitrite concentration associated with increases in ambient air pollutant concentrations in the previous 7 d. MATERIALS AND METHODS: We linked up to three measurements of plasma nitrite concentrations obtained from 49 students to 24-h average concentrations of five criteria air pollutants [particle mass < 2.5 µm in aerodynamic diameter (PM(2.5)), carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2), and ozone (O3)] measured at two monitoring sites closest to Rutgers University campus (6-15 miles) in New Jersey during the years 2006-2009. We examined the change in plasma nitrite associated with each interquartile-range (IQR) increase in pollutant concentration in the previous 24 h and six preceding 24- h periods, using linear mixed models. RESULTS: IQR increases in mean PM(2.5) (7.0 µg/m³) and CO (161.7 parts per billion) concentrations in the first 24 h before the plasma nitrite measurement were associated with increased plasma nitrite concentrations (PM(2.5): 15.5 nanomolar; 95% confidence interval (CI): 2.4, 28.5; CO: 15.6 nanomolar; 95% CI: 2.4, 28.9). Increased plasma nitrite associated with IQR increases in O3 and SO2 concentrations over longer lags were observed. DISCUSSION AND CONCLUSION: Rapid increases in plasma nitrite following exposure to ambient air pollutants support the hypothesis that ambient air pollution is associated with inducible nitric oxide synthase-mediated systemic inflammation in humans.

Risk of Major Bleeding in Patients With Atrial Fibrillation Taking Dronedarone in Combination With a Direct Acting Oral Anticoagulant (From a U.S. Claims Database).

Dronedarone may increase exposure and the risk of major bleeding when prescribed with a direct oral anticoagulant (DOAC). This retrospective cohort study examined the risk of the first occurrence of major bleeding (hospitalization or emergency room visit for gastrointestinal [GI] bleeding, intracranial hemorrhage [ICH], or bleeding at other sites) among new users of apixaban, dabigatran, and rivaroxaban in patients with AF ≥18 years (January 1, 2007 to September 30, 2017) from the United States Truven Health MarketScan claims, comparing concomitant users of dronedarone to DOAC alone users in patients with atrial fibrillation (AF). No increased risk of major bleeding was associated with use of dronedarone and apixaban (adjusted Hazard Ratio [aHR]: 0.69 [95% confidence interval [CI]: 0.40, 1.17], p = 0.16), a modestly increased risk of GI bleeding but not overall bleeding was associated with use of dronedarone and dabigatran (aHR bleeding: 1.18 [95% CI: 0.89, 1.56], p = 0.26; aHR GI bleeding: 1.40 [95% CI: 1.01, 1.93]; p = 0.04) and an increased risk of overall bleeding, driven by GI bleeding, was associated with use of dronedarone and rivaroxaban (aHR bleeding: 1.31 [95% CI: 1.01, 1.69]; p = 0.04; aHR GI bleeding: 1.39 [95% CI: 0.98, 1.95]; p = 0.06), compared to each DOAC respectively. There was no increased risk of ICH associated with combined use of dronedarone and any DOAC. Prospective analyses, preferably randomized controlled studies, are needed to further explore the risk of major bleeding with concomitant use of DOACs and CYP3A4/P-gp inhibitors such as dronedarone.

Age- and sex-specific incidence of non-traumatic lower limb amputation in patients with type 2 diabetes mellitus in a U.S. claims database.

AIM: To estimate age- and sex-specific incidence rates (IRs) of non-traumatic lower limb amputations (LLA) in patients with type 2 diabetes mellitus (T2DM) using a claims database from the United States (US). METHODS: Patients with T2DM 18 years and older were identified using the Truven Health MarketScan database from January 1, 2007 to September 30, 2018. The overall and age- and sex-specific IRs of all non-traumatic LLA, minor LLA (amputation at or below the ankle), and major LLA (amputation above ankle) were calculated. RESULTS: Among the 6,117,981 patients with T2DM, 14,627 LLA events occurred (minor LLA; 72.8%; major LLA: 27.2%). The IRs (95% CI) of all LLA, minor LLA, and major LLA per 1000 person-years or PY were 0.86 (0.85, 0.88), 0.63 (0.62, 0.64), and 0.23 (0.23, 0.24), respectively. The IR (95% CI) of all LLA per 1000 PY in males was higher compared to females [1.24 (1.22, 1.26) vs. 0.46 (0.45, 0.48)]. The incidence of all LLA increased with an increasing age (highest IR in age-group of ≥80 years). CONCLUSIONS: This study identified males and older patients with T2DM at higher risk of developing LLA in the US, warranting further exploration of risk factors of LLA in these subgroups.

Cardiovascular outcomes after preeclampsia or eclampsia complicated by myocardial infarction or stroke.

OBJECTIVE: To assess the relationship between preeclampsia or eclampsia and stroke, myocardial infarction (MI), subsequent cardiovascular outcomes, and long-term survival. METHODS: Using the Myocardial Infarction Data Acquisition System in New Jersey (1994-2009), we analyzed cardiovascular outcomes in women with and without preeclampsia or eclampsia and a first MI or stroke but with a hospitalization for a first MI or stroke (analysis 1: MI case group, n=57; MI control group, n=155; stroke case group, n=132; stroke control group, n=379). We also compared these outcomes in women with preeclampsia or eclampsia and a first MI or stroke during pregnancy with women with preeclampsia or eclampsia without MI or stroke during pregnancy (analysis 2: MI case group, n=23; MI control group, n=67; stroke case group, n=90; stroke control group, n=263). A subsequent occurrence of MI, stroke, and cardiovascular death, as well as a combined cardiovascular outcome, was ascertained. RESULTS: In analysis 1, women with preeclampsia or eclampsia were at significantly lower risk for combined cardiovascular outcome with all deaths (frequency of outcome 16.7%) and with cardiovascular deaths (10.6%) compared with women without preeclampsia or eclampsia after a first stroke (33.8% and 23.5%, respectively). In analysis 2, women with preeclampsia or eclampsia and a first stroke during admission were at significantly higher risk of all death (11.1%) and the combined cardiovascular outcome with all deaths (11.1%) compared with women with preeclampsia or eclampsia without a stroke (1.9% and 2.7%, respectively) during that admission. CONCLUSION: Our study indicates that preeclampsia or eclampsia not complicated by MI or stroke during pregnancy may not confer a very high risk for subsequent MI and stroke in up to 16 years of follow-up. Our data suggest that other known risk factors put women at greater risk for stroke than preeclampsia or eclampsia complicated by a stroke. LEVEL OF EVIDENCE: II.

Organizational factors and office workers' health after the World Trade Center terrorist attacks: long-term physical symptoms, psychological distress, and work productivity.

OBJECTIVE: To assess if organizational factors are predictors of workers' health and productivity after the World Trade Center attacks. METHODS: We conducted a survey of 750 workers and compared those who had direct exposures to the World Trade Center attacks (south of Canal Street workers; primary victims) with those less directly exposed (north of Canal Street workers; other victims and non-victims). RESULTS: South of Canal Street workers reported headache more frequently than north of Canal Street workers did (P = 0.0202). Primary victims reported headache and cough more frequently than did other victims and non-victims (P = 0.0086 and 0.0043, respectively). Defensive organizational culture was an independent predictor of cough and job stress, and job stress was an independent predictor of on-the-job productivity losses. CONCLUSION: Organizational variables may modify health and productivity outcomes after a large-scale traumatic event in the workplace.

Use of adjuvant systemic therapy for early breast cancer among women 65 years of age and older.

BACKGROUND: The National Institutes of Health (NIH) consensus statement recommends adjuvant therapy for early breast cancer irrespective of age. However, the actual use of such therapy is not well documented among women over 65 years of age. METHODS: We studied the frequency of use of adjuvant therapy and report the receipt of this therapy among 200 women aged > or = 65 years diagnosed with early breast cancer who were identified from the New Jersey State Cancer Registry. RESULTS: In this population, 28% of patients received chemotherapy alone or in combination with hormonal therapy, whereas 42% received hormonal therapy alone. Less than half of the women with estrogen receptor-negative tumors received chemotherapy alone or in combination with hormonal treatment. Adjuvant therapy was not prescribed in 30% of patients. CONCLUSIONS: Despite NIH recommendations, the frequency of use of adjuvant therapy in New Jersey is low among women over 65 years of age, regardless of their receptor status.