Publications by authors named "Ana M Palacio"

11 Publications

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Correction to: Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus.

Drugs Aging 2020 Oct;37(10):777

Geriatrics Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, 1201 NW 16th St., 11 GRC, CLC 207 A2, Miami, FL, 33125, USA.

The article Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus, written by Willy M. Valencia, Hermes J. Florez and Ana M. Palacio was originally published Online First without open access.
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http://dx.doi.org/10.1007/s40266-020-00795-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525277PMC
October 2020

Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus.

Drugs Aging 2019 12;36(12):1083-1096

Geriatrics Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, 1201 NW 16th St., 11 GRC, CLC 207 A2, Miami, FL, 33125, USA.

The management of type 2 diabetes mellitus in older adults requires a comprehensive understanding of the relationship between the disease (medical) and the functional, psychological/cognitive, and social geriatric domains, to individualize both glycemic targets and therapeutic approaches. Prevention of hypoglycemia is a major priority that should be addressed as soon as its presence or risk is detected, adjusting the target and therapeutics accordingly. Nonetheless, treatment intensification should not be neglected when applicable, consistent with recommendations from organizations such as the American Geriatrics Society and the American Diabetes Association, to reduce not only long-term macrovascular and microvascular complications (individualization), but also short-term complications from hyperglycemia (polyuria, volume depletion, urinary incontinence). Such complications can negatively impact the physical and cognitive function of older adults, worsen their quality of life, and additionally affect their families and society. We emphasize individualization, utilizing the multiple classes of antihyperglycemic agents available. Metformin remains as first-line therapy, and additional agents offer advantages and disadvantages that ought to be considered when developing a patient-centric plan of care. For selected cases, injectable therapies such as long-acting basal insulin analogs and glucagon-like peptide-1 receptor agonists can offer advantages to counter hypoglycemia risk, patient-related barriers, and clinical inertia. Furthermore, some injectable agents could potentially simplify regimens while providing safe and effective glycemic control. In this review, we discuss the use of injectable therapies for selected community-dwelling older adults, barriers to transition to injectable therapy, and measures aimed at removing these barriers and assisting physicians and their teams to transition older patients to injectable therapies when appropriate.
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http://dx.doi.org/10.1007/s40266-019-00706-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481154PMC
December 2019

Prevalence of Hypertension (HTN) and Cardiovascular Risk Factors in a Hospitalized Pediatric Hemophilia Population.

J Pediatr Hematol Oncol 2018 04;40(3):196-199

Division of Pediatric Hematology-Oncology.

Improved life expectancy in hemophilia has led to a greater interest in age-related disorders. Hypertension (HTN) as well as cardiovascular disease have been increasingly reported in hemophilic adults but there is currently very limited data in the pediatric population. We conducted a cross-sectional study using data from the 2012 National Health Cost and Utilization Project database to determine the prevalence of HTN and associated cardiovascular risk factors in a hospitalized pediatric hemophilia population, between the ages of 0 to 21 years, in comparison with the general pediatric population. The prevalence of HTN was significantly higher in children with hemophilia (CWH) in comparison with the general pediatric population (1.71% vs. 1.02%, P-value=0.005). When adjusting the analysis for sex, the prevalence of HTN in the hemophilia cohort remained higher, although not statistically significant (1.52% vs. 1.22%, P-value=0.2568). When examining the concomitant presence of ≥1 cardiovascular risk factors in the hypertensive subgroups, CWH had a higher prevalence of obesity (2.64% vs. 1.32%, P-value <0.0001). Interestingly, diabetes mellitus was more prevalent in nonhemophilic children (1.47% vs. 0.56%, P-value=0.0015). These data suggest that cardiovascular risk factors need to be closely monitored in CWH, and a better preventive strategy is likely needed to identify those hemophilic patients at higher risk of developing cardiovascular disease in adulthood.
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http://dx.doi.org/10.1097/MPH.0000000000001036DOI Listing
April 2018

Can We Identify Minority Patients at Risk of Nonadherence to Antiplatelet Medication at the Time of Coronary Stent Placement?

J Cardiovasc Nurs 2017 Nov/Dec;32(6):522-529

Ana M. Palacio, MD, MPH Associate Professor, School of Medicine, Departments of Medicine and Public Health Sciences and Veterans Affairs Medical Center, University of Miami Miller, Florida. Denise C. Vidot, PhD Assistant Professor, School of Nursing and Health Studies, University of Miami, Florida. Leonardo J. Tamariz, MD, MPH Associate Professor, School of Medicine, Departments of Medicine and Public Health Sciences, and Veterans Affairs Medical Center, University of Miami Miller, Florida. Claudia Uribe, MD, MHA Research Manager, Comprehensive Health Insights, Miami, Florida. Leslie Hazel-Fernandez, PhD Researcher, Comprehensive Health Insights, Miami, Florida. Hua Li, MD, PhD Biostatistician, School of Medicine, Departments of Medicine and Public Health Sciences, and Veterans Affairs Medical Center, University of Miami Miller, Florida. Sylvia D. Garay, MD Assistant Scientist/Motivational Interviewing Coach, School of Medicine, Department of Medicine, University of Miami Miller, Florida. Olveen Carrasquillo, MD, MPH Professor, School of Medicine, Departments of Medicine and Public Health Sciences, University of Miami Miller, Florida.

Background: Lack of medication adherence is associated with significant morbidity and mortality, particularly among minorities. We aim to identify predictors of nonadherence to antiplatelet medications at the time of percutaneous coronary intervention (PCI) with stent among African American and Hispanic patients.

Methods: We used data collected for a randomized clinical trial that recruited 452 minority patients from a large US health insurance organization in 2010 post-PCI to compare telephone-based motivational interviewing by trained nurses with an educational video. The primary outcome was 12-month adherence to antiplatelet medications measured by the claims-based medication possession ratio (MPR). Adequate adherence was defined as an MPR of 0.80 or higher.

Results: More than half of the sample (age, 69.52 ± 8.8 years) was male (57%) and Hispanic (57%). Most (78%) had a median income below $30 000 and 22% completed high school or higher. Univariate analyses revealed that symptoms of depression (<.01) and not having a spouse (P = .03) were associated with inadequate adherence. In multivariate analysis, baseline self-reported adherence (1.4; 95% confidence interval [CI], 1.05-1.89), depressive symptoms (0.49; 95% CI, 0.7-0.90), comorbidity (0.89; 95% CI, 0.80-0.98), and telephone-based motivational interviewing by trained nurses (3.5; 95% CI, 1.9-2.70) were associated with adherence.

Conclusions: Having multiple comorbidities, depression, suboptimal adherence to medications, and low English proficiency at the time of PCI increase the risk of poor 12-month adherence to antiplatelets among minorities. Identifying these risk factors can guide PCI therapy and the use of evidence-based strategies to improve long-term adherence.
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http://dx.doi.org/10.1097/JCN.0000000000000387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5830119PMC
June 2018

Improving HCV cure rates in HIV-coinfected patients - a real-world perspective.

Am J Manag Care 2016 May;22(6 Spec No.):SP198-204

Jackson Medical Towers, Ste 1101, Miami, FL. E-mail:

Objectives: To study rates and predictors of hepatitis C virus (HCV) cure among human immunodeficiency virus (HIV)/HCV-coinfected patients, and then to evaluate the effect of attendance at clinic visits on HCV cure.

Methods: Retrospective cohort study of adult HIV/HCV-coinfected patients who initiated and completed treatment for HCV with direct-acting antivirals (DAAs) between January 1, 2014, and June 30, 2015.

Results: Eighty-four participants reported completing treatment. The median age was 58 years (interquartile ratio, 50-66); 88% were male and 50% were black. One-third were cirrhotic and half were HCV-treatment-experienced. The most commonly used regimen was sofosbuvir/ledipasvir (40%) followed by simeprevir/sofosbuvir (30%). Cure was achieved in 83.3%, 11.9% relapsed, and 2.3% experienced virological breakthrough. Two patients (2.3%) did not complete treatment based on pill counts and follow-up visit documentation. In multivariable analysis, cure was associated with attendance at follow-up clinic visits (odds ratio [OR], 9.0; 95% CI, 2.91-163) and with use of an integrase-based HIV regimen versus other non-integrase regimens, such as non-nucleoside analogues or protease inhibitors (OR, 6.22; 95% CI 1.81-141). Age, race, genotype, presence of cirrhosis, prior HCV treatment, HCV regimen, and pre-treatment CD4 counts were not associated with cure.

Conclusions: Real-world HCV cure rates with DAAs in HCV/HIV coinfection are lower than those seen in clinical trials. Cure is associated with attendance at follow-up clinic visits and with use of an integrase-based HIV regimen. Future studies should evaluate best antiretroviral regimens, predictors of attendance at follow-up visits, impact of different monitoring protocols on medication adherence, and interventions to ensure adequate models of HIV/HCV care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5942559PMC
May 2016

Patient values and preferences when choosing anticoagulants.

Patient Prefer Adherence 2015 22;9:133-8. Epub 2015 Jan 22.

The Department of Medicine, Miller School of Medicine, University of Miami, FL, USA ; The Veterans Affairs Medical Center, Miami, FL, USA ; Division of Public Health Sciences, University of Miami, Miami, Florida, USA.

Background: New oral anticoagulants have similar efficacy and lower bleeding rates compared with warfarin. However, in case of bleeding there is no specific antidote to reverse their effects. We evaluated the preferences and values of anticoagulants of patients at risk of atrial fibrillation and those who have already made a decision regarding anticoagulation.

Methods: We conducted a cross-sectional study of Veterans in the primary care clinics and the international normalized ratio (INR) laboratory. We developed an instrument with patient and physician input to measure patient values and preferences. The survey contained a hypothetical scenario of the risk of atrial fibrillation and the attributes of each anticoagulant. After the scenario, we asked participants to choose the option that best fits their preferences. The options were: 1) has better efficacy at reducing risk of stroke; 2) has been in the market for a long period of time; 3) has an antidote to reverse the rare case of bleeding; 4) has better quality of life profile with no required frequent laboratory tests; or 5) I want to follow physician recommendations. We stratified our results by those patients who are currently exposed to anticoagulants and those who are not exposed but are at risk of atrial fibrillation.

Results: We approached 173 Veterans and completed 137 surveys (79% response rate). Ninety subjects were not exposed to anticoagulants, 46 reported being on warfarin, and one reported being on dabigatran at the time of the survey. Ninety-eight percent of subjects stated they would like to participate in the decision-making process of selecting an anticoagulant. Thirty-six percent of those exposed and 37% of those unexposed to anticoagulants reported that they would select a medication that has an antidote even if the risk of bleeding was very small. Twenty-three percent of the unexposed and 22% of the exposed groups reported that they would prefer the medication that gives the best quality of life.

Conclusion: Our study found that patients who may be exposed to an anticoagulation decision prefer to actively participate in the decision-making process, and have individual values for making a decision that cannot be predicted or assumed by anyone in the health care system.
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http://dx.doi.org/10.2147/PPA.S64295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4309777PMC
February 2015

Can phone-based motivational interviewing improve medication adherence to antiplatelet medications after a coronary stent among racial minorities? A randomized trial.

J Gen Intern Med 2015 Apr 13;30(4):469-75. Epub 2014 Dec 13.

Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA,

Background: Minorities have lower adherence to cardiovascular medications and have worst cardiovascular outcomes post coronary stent placement

Objective: The aim of this study is to compare the efficacy of phone-delivered Motivational Interviewing (MINT) to an educational video at improving adherence to antiplatelet medications among insured minorities.

Design: This was a randomized study.

Participants: We identified minorities with a recently placed coronary stent from an administrative data set by using a previously validated algorithm.

Interventions: MINT subjects received quarterly phone calls and the DVD group received a one-time mailed video.

Main Measures: Outcome variables were collected at baseline and at 12-month post-stent, using surveys and administrative data. The primary outcome was antiplatelet (clopidogrel and prasugrel) adherence measured by Medication Possession Ratio (MPR) and self- reported adherence (Morisky score). We also measured appropriate adherence defined as an MPR ≥ 0.80.

Key Results: We recruited 452 minority subjects with a new coronary stent (44 % Hispanics and 56 % Black). The patients had a mean age of 69.5 ± 8.8, 58 % were males, 78 % had an income lower than $30,000 per year and only 22 % had achieved high school education or higher. The MPR for antiplatelet medications was 0.77 for the MINT group compared to 0.70 for the DVD group (p < 0.05). The percentage of subjects with adequate adherence to their antiplatelet medication was 64 % in the MINT group and 50 % in the DVD group (p < 0.01). Self-reported adherence at 12 months was higher in the MINT group compared to the DVD group (p < 0.01). Results were similar among drug-eluting stent (DES) recipients.

Conclusions: Among racial minorities, a phone-based motivational interview is effective at improving adherence to antiplatelet medications post coronary stent placement. Phone-based MINT seems to be a promising and cost-effective strategy to modify risk behaviors among minority populations at high cardiovascular risk.
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http://dx.doi.org/10.1007/s11606-014-3139-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4370989PMC
April 2015

Can claims-based data be used to recruit black and Hispanic subjects into clinical trials?

Health Serv Res 2012 Apr 30;47(2):770-82. Epub 2011 Aug 30.

Division of General Medicine, Department of Medicine, The University of Miami Miller School of Medicine, The Miami VA Medical Center, Miami, FL 33136, USA.

Objective: Evaluate the accuracy of an algorithm at identifying ethnic minorities from administrative claims for enrollment into a clinical trial.

Data Sources/study Setting: Claims data from a health benefits company.

Study Design: We compared results of a three-step algorithm to self-reported race/ethnicity.

Data Collection/extraction Methods: Using the algorithm, we identified subjects with high probability of being minority and ascertained self-reported race/ethnicity.

Principal Findings: We identified 164 subjects as likely minority based on our algorithm. Of these, 94 completed the survey and 87 identified themselves as black or Hispanic. The positive predictive value of the algorithm was 93 percent (CI: 85-97).

Conclusions: Claims data can be used to efficiently identify minorities for participation in clinical trials.
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http://dx.doi.org/10.1111/j.1475-6773.2011.01316.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3419888PMC
April 2012

Results of the 2003-2004 GEP-ISFG collaborative study on mitochondrial DNA: focus on the mtDNA profile of a mixed semen-saliva stain.

Forensic Sci Int 2006 Jul 21;160(2-3):157-67. Epub 2005 Oct 21.

Instituto Nacional de Toxicología y Ciencias Forenses, Servicio de Biología, Barcelona, Spain.

We report here a review of the seventh mitochondrial DNA (mtDNA) exercise undertaken by the Spanish and Portuguese working group (GEP) of the International Society for Forensic Genetics (ISFG) corresponding to the period 2003-2004. Five reference bloodstains from five donors (M1-M5), a mixed stain of saliva and semen (M6), and a hair sample (M7) were submitted to each participating laboratory for nuclear DNA (nDNA; autosomal STR and Y-STR) and mtDNA analysis. Laboratories were asked to investigate the contributors of samples M6 and M7 among the reference donors (M1-M5). A total of 34 laboratories reported total or partial mtDNA sequence data from both, the reference bloodstains (M1-M5) and the hair sample (M7) concluding a match between mtDNA profiles of M5 and M7. Autosomal STR and Y-STR profiling was the preferred strategy to investigate the contributors of the semen/saliva mixture (M6). Nuclear DNA profiles were consistent with a mixture of saliva from the donor (female) of M4 and semen from donor M5, being the semen (XY) profile the dominant component of the mixture. Strikingly, and in contradiction to the nuclear DNA analysis, mtDNA sequencing results yield a more simple result: only the saliva contribution (M4) was detected, either after preferential lysis or after complete DNA digestion. Some labs provided with several explanations for this finding and carried out additional experiments to explain this apparent contradictory result. The results pointed to the existence of different relative amounts of nuclear and mtDNAs in saliva and semen. We conclude that this circumstance could strongly influence the interpretation of the mtDNA evidence in unbalanced mixtures and in consequence lead to false exclusions. During the GEP-ISFG annual conference a validation study was planned to progress in the interpretation of mtDNA from different mixtures.
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http://dx.doi.org/10.1016/j.forsciint.2005.09.005DOI Listing
July 2006