Publications by authors named "Ana Palacio"

82 Publications

A Systematic Review and Meta-analysis of Ligation Versus Repair of Inferior Vena Cava Injuries.

Ann Vasc Surg 2021 Apr 4. Epub 2021 Apr 4.

Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA. Electronic address:

Objective: Inferior vena cava (IVC) injuries have a high mortality rate that may be related to the location of injury and type of repair. Previous studies have been either single center series or database studies lacking granular detail. These have reported conflicting results. We aimed to perform a systematic review and meta-analysis of published literature evaluating ligation versus repair.

Methods: Studies published in English on MEDLINE or EMBASE from 1946 through October 2018 were examined to evaluate mortality among patients treated with ligation versus repair of IVC injuries. Studies were included if they provided mortality associated with ligation versus repair and reported IVC injury by level. Risk of bias was assessed regarding incomplete and selective outcome reporting with Newcastle-Ottawa score of 7 or higher to evaluate study quality. We used a random-effects model with restricted maximum likelihood estimation method in R using the Metafor package to evaluate outcomes.

Results: Our systematic review identified 26 studies, of which 14 studies, including 855 patients, met our inclusion criteria for meta-analysis. IVC ligation was associated with higher mortality than IVC repair (OR: 3.12, p<0.01, I=49%). Ligation of infrarenal IVC injuries was not statistically associated with mortality (OR: 3.13, p=0.09). Suprarenal injury location compared to infrarenal (OR 3.11, p<0.01, I=28%) and blunt mechanism compared to penetrating (OR: 1.91, p=0.02, I=0%) were also associated with higher mortality.

Conclusions: In this meta-analysis, ligation of IVC injuries was associated with increased mortality compared to repair, but not specifically for infrarenal IVC injuries. Suprarenal IVC injury, and blunt mechanism was associated with increased mortality compared to infrarenal IVC injury and penetrating mechanism, respectively. Data are limited regarding acute renal injury and venous thromboembolic events after IVC ligation and may warrant multicenter studies. Standardized reporting of IVC injury data has not been well established and is needed in order to enable comparison of outcomes across institutions. In particular, reporting of injury location, severity, and repair type should be standardized. A contemporary prospective, multicenter study is needed in order to definitively compare surgical technique.
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http://dx.doi.org/10.1016/j.avsg.2021.02.032DOI Listing
April 2021

Metformin is associated with lower hospitalizations, mortality and severe coronavirus infection among elderly medicare minority patients in 8 states in USA.

Diabetes Metab Syndr 2021 Mar-Apr;15(2):513-518. Epub 2021 Feb 18.

Department of Medicine, Miller School of Medicine at the University of Miami, Miami, FL, USA; Department of Medicine, Veterans Affairs Medical Center, Miami, FL, USA. Electronic address:

Background And Aims: Metformin has antiviral and anti-inflammatory effects and several cohort studies have shown that metformin lower mortality in the COVID population in a majority white population. There is no data documenting the effect of metformin taken as an outpatient on COVID-19 related hospitalizations. Our aim was to evaluate if metformin decreases hospitalization and severe COVID-19 among minority Medicare patients who acquired the SARS-CoV2 virus.

Methods: We conducted a retrospective cohort study including elderly minority Medicare COVID-19 patients across eight states. We collected data from the inpatient and outpatient electronic health records, demographic data, as well as clinical and echocardiographic data. We classified those using metformin as those patients who had a pharmacy claim for metformin and non-metformin users as those who were diabetics and did not use metformin as well as non-diabetic patients. Our primary outcome was hospitalization. Our secondary outcomes were mortality and acute respiratory distress syndrome (ARDS).

Results: We identified 1139 COVID-19 positive patients of whom 392 were metformin users. Metformin users had a higher comorbidity score than non-metformin users (p < 0.01). The adjusted relative hazard (RH) of those hospitalized for metformin users was 0.71; 95% CI 0.52-0.86. The RH of death for metformin users was 0.34; 95% CI 0.19-0.59. The RH of ARDS for metformin users was 0.32; 95% CI 0.22-0.45. Metformin users on 1000 mg daily had lower mortality, but similar hospitalization and ARDS rates when compared to those on 500-850 mg of metformin daily.

Conclusions: Metformin is associated with lower hospitalization, mortality and ARDS among a minority COVID-19 population. Future randomized trials should confirm this finding and evaluate for a causative effect of the drug preventing disease.
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http://dx.doi.org/10.1016/j.dsx.2021.02.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891082PMC
April 2021

Outpatient metformin use is associated with reduced severity of COVID-19 disease in adults with overweight or obesity.

J Med Virol 2021 Feb 12. Epub 2021 Feb 12.

Department of Medicine, Division of Pulmonary Medicine, University of Minnesota, Minneapolis, Minnesota, USA.

Observational studies suggest outpatient metformin use is associated with reduced mortality from coronavirus disease-2019 (COVID-19). Metformin is known to decrease interleukin-6 and tumor-necrosis factor-α, which appear to contribute to morbidity in COVID-19. We sought to understand whether outpatient metformin use was associated with reduced odds of severe COVID-19 disease in a large US healthcare data set. Retrospective cohort analysis of electronic health record (EHR) data that was pooled across multiple EHR systems from 12 hospitals and 60 primary care clinics in the Midwest between March 4, 2020 and December 4, 2020. Inclusion criteria: data for body mass index (BMI) > 25 kg/m and a positive SARS-CoV-2 polymerase chain reaction test; age ≥ 30 and ≤85 years. Exclusion criteria: patient opt-out of research. Metformin is the exposure of interest, and death, admission, and intensive care unit admission are the outcomes of interest. Metformin was associated with a decrease in mortality from COVID-19, OR 0.32 (0.15, 0.66; p = .002), and in the propensity-matched cohorts, OR 0.38 (0.16, 0.91; p = .030). Metformin was associated with a nonsignificant decrease in hospital admission for COVID-19 in the overall cohort, OR 0.78 (0.58-1.04, p = .087). Among the subgroup with a hemoglobin HbA1c available (n = 1193), the adjusted odds of hospitalization (including adjustment for HbA1c) for metformin users was OR 0.75 (0.53-1.06, p = .105). Outpatient metformin use was associated with lower mortality and a trend towards decreased admission for COVID-19. Given metformin's low cost, established safety, and the mounting evidence of reduced severity of COVID-19 disease, metformin should be prospectively assessed for outpatient treatment of COVID-19.
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http://dx.doi.org/10.1002/jmv.26873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013587PMC
February 2021

Social Determinants of Health Mediate COVID-19 Disparities in South Florida.

J Gen Intern Med 2021 02 18;36(2):472-477. Epub 2020 Nov 18.

GRECC, Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Miami, FL, USA.

Background: There are several reports of health disparities related to COVID-19. Understanding social determinants of health (SDoH) could help develop mitigation strategies to prevent further COVID-19 spread. Our aim is to evaluate self-reported and census-based SDoH as a mediator of health disparities in COVID-19.

Methods: We conducted a cross-sectional ecological study and included all COVID-19 cases report by the COVID-19 Florida dashboard as the dependent variable. The independent variables were census-based median household income, population and household size, and self-reported SDoH using a validated survey. We calculated the incidence rate ratio (IRR) of COVID-19 by zip code using Poisson regression and structured equation modelling to evaluate the mediation effect of income and SDoH on COVID-19 cases.

Results: We included 97,594 COVID-19 positive cases across 79 Miami-Dade ZIP codes with a median age of 43 years; females represented 50.7% of the cases. The highest IRR (4.44) were for ZIP code 33125 (income $21,106, 6% Black, 93% Hispanic), while the lowest IRR (0.86) was for ZIP code 33146 (median household incomes $96,609, 3% Black and 53% Hispanic). In structured equation models, the indirect coefficient of income in the relationship between race/ethnicity and COVID-19 were only significant for Blacks and not Hispanics.

Conclusions: This ecological analysis using ZIP code and aggregate individual-level SDoH shows that in Miami-Dade county, COVID infection is associated with economic disadvantage in a particular geographical area and not with racial/ethnic distribution.
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http://dx.doi.org/10.1007/s11606-020-06341-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673244PMC
February 2021

Social determinants of health score: does it help identify those at higher cardiovascular risk?

Am J Manag Care 2020 10 1;26(10):e312-e318. Epub 2020 Oct 1.

University of Miami, 1120 NW 14th St, Ste 967, Miami, FL 33136. Email:

Objectives: Cardiovascular disease (CVD) continues to disproportionately affect disadvantaged populations, leading to calls to address social determinants of health (SDOH) as a preventive strategy. Our aim is to create a weighed SDOH score and to test the impact of each SDOH factor on the Framingham risk score (FRS) and on individual traditional CVD risk factors.

Study Design: We conducted a retrospective cohort study.

Methods: We included patients seen at a primary care clinic at UHealth/University of Miami Health System who answered a SDOH survey between September 16, 2016, and September 10, 2017. The survey included SDOH domains recommended by the American Heart Association position statement and by the National Academy of Medicine. We selected the FRS as well as all traditional CVD risk factors as our outcome metrics.

Results: We included 2876 patients. The mean (SD) age of our cohort was 53.8 (15.8) years, 61% were female, 9% were Black, 38% were Hispanic, and 87% reported speaking English. The statistically significant β coefficients in the FRS model corresponded to being born outside of the United States, being a racial minority, living alone, having a high social isolation score, and having a low geocoded median household income (P < .01). Increasing quartile of SDOH score was significantly associated with higher systolic blood pressure, FRS, glycated hemoglobin, and smoking pack-years (P < .05). It was also associated with fewer minutes spent exercising weekly (P < .01).

Conclusions: The addition of self-reported SDOH data has a dose effect on CVD risk factors. Future studies should address how to intervene to address social factors.
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http://dx.doi.org/10.37765/ajmc.2020.88504DOI Listing
October 2020

Prior cardiovascular risk and screening echocardiograms predict hospitalization and severity of coronavirus infection among elderly medicare patients.

Am J Prev Cardiol 2020 Sep 1;3:100090. Epub 2020 Oct 1.

Department of Medicine, Miller School of Medicine at the University of Miami, Miami, FL, USA.

Background: The COVID-19 pandemic has disproportionally impacted the elderly. In the United States and Europe the mortality rate of elderly patients with COVID-19 is greater than 30%. Our aim is to determine predictors of COVID-19 related hospitalization and severity of disease among elderly Medicare patients in the United States.

Methods: We conducted a retrospective cohort study including elderly Medicare COVID-19 patients across eight states. We collected data from the inpatient and outpatient electronic health record, demographic, clinical and echocardiographic predictors. Our primary outcomes were hospitalization and adult respiratory distress syndrome (ARDS). Our secondary outcome was mortality.

Results: We identified 400 COVID-19 positive patients (incidence 5.2; (95% CI 4.7-5.7) per 1000 patients). The mean age of our patients was 72 ​± ​8, 60% were female, 82% were minorities and had a mean Charlson score of 2.9 ​± ​1.4. Two-hundred and forty-four patients were hospitalized due to COVID-19 (63%) and the mortality rate was 18%; 95% CI 14-22 with 1 patient still in the hospital. Age, socioeconomic status, Charlson score, systolic blood pressure, body mass index, grade 2 or 3 diastolic dysfunction, moderate or severe left ventricular hypertrophy were significant predictors of hospitalization and ARDS (p ​< ​0.05).

Conclusions: Our study reports a lower incidence on a COVID-19 cohort than previously reported. Predictors of poor outcomes included socio-economic, cardiovascular risk and echocardiographic measures. High touch care with early cardiovascular risk factor modification could explain the low risk of events in our population.
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http://dx.doi.org/10.1016/j.ajpc.2020.100090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528840PMC
September 2020

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

Performance of Multiparametric MRI of the Prostate in Biopsy Naïve Men: A Meta-analysis of Prospective Studies.

Urology 2020 Dec 2;146:189-195. Epub 2020 Sep 2.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL. Electronic address:

Objective: To assess the outcomes through systematic review and meta-analysis of multi-parametric magnetic resonance imaging (mpMRI) of the prostate in biopsy naïve men.

Methods: Systemic review and meta-analysis was performed to assess the performance of mpMRI on prostate cancer (PCa) detection at the time of biopsy. We used standard methods for performing a meta-analysis evaluating a diagnostic test and reported the pooled sensitivity and specificity, and the positive and negative likelihood ratios (LR) for mpMRI in the detection of any and clinically significant prostate cancer (csPCa).

Results: A total of 10 studies comprising 2486 patients were analyzed. Overall, if biopsies would have been performed only in men with an mpMRI suspicious for malignancy between 7.4% and 58.5% of the biopsies could have been avoided, but 2.3%-36% of any PCa and 0%-30.8% of csPCa would have been missed. The sensitivity, specificity, positive LR, and negative LR of mpMRI for any PCa detection were 0.86 (95% confidence interval [CI], 0.78-0.91), 0.67 (95% CI, 0.40-0.86), 2.6 (95% CI, 1.2-5.5), and 0.2 (95% CI, 0.12-0.32), respectively. The AUC for any PCa detection was 0.84 (95% CI, 0.75-0.90). The pooled sensitivity, specificity, positive LR, and negative LR of mpMRI for csPCa detection was 0.94 (95% CI, 0.83-0.98), 0.54 (95% CI, 0.42-0.65), 2 (95% CI, 1.5-2.7), and 0.1 (95% CI, 0.02-0.35), respectively. The AUC for csPCa detection was 0.94 (95% CI, 0.65-1).

Conclusion: This study provides summary estimates indicating that mpMRI can accurately detect prostate cancer and help avoid unnecessary biopsies in this population.
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http://dx.doi.org/10.1016/j.urology.2020.06.102DOI Listing
December 2020

Excess mortality risk from sepsis in patients with HIV - A meta-analysis.

J Crit Care 2020 10 5;59:101-107. Epub 2020 Jun 5.

Department of Medicine, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL 33136, United States of America; Department of Medicine, Miami VA Medical Center, 1201 NW 16th Street, Miami, FL 33136, United States of America.

Purpose: Differences in HIV prevalence, access to antiretrovirals and ICU resources may result in wide variation in sepsis mortality in HIV patients. The aim of this study was to perform a meta-analysis to quantify the excess risk of sepsis mortality in HIV patients.

Materials And Methods: A systematic review was performed using three databases. The systemic inflammatory response syndrome criteria was used for the presumptive diagnosis of sepsis. We only included studies that stratified sepsis mortality by HIV serostatus. A meta-analysis was performed using random effects models, with subgroup analyses performed using country income, sepsis severity, and time periods.

Results: 17 studies were included, containing 82,905 patients. Sepsis mortality was found to be 28% higher in the HIV positive patients (95% CI 1.13-1.46, p < .01). Relative risk of mortality was higher in patients treated in low-income countries (RR 1.43 in low-income vs. 1.29 in high-income countries). Mortality was more pronounced in HIV patients with severe sepsis (RR 1.32 in severe sepsis vs. RR 1.15 in sepsis).

Conclusions: HIV increases the risk of sepsis mortality compared to seronegative individuals across all time periods and geographic areas. We note that this effect is more pronounced in patients with organ dysfunction.
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http://dx.doi.org/10.1016/j.jcrc.2020.05.018DOI Listing
October 2020

Patients with elevated blood pressure or stage 1 hypertension have structural heart disease.

Blood Press Monit 2020 Aug;25(4):178-183

Population Health and Computational Medicine, Miller School of Medicine, University of Miami.

Background: The 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) recommendations lower the hypertension threshold to 130/80 mmHg and recommends treatment for high-risk patients. Our aim is to determine whether the new blood pressure categories are associated with left ventricular (LV) structural changes and whether echocardiograms can provide risk stratification and help treatment initiation.

Methods: We conducted a cross-sectional study and performed screening echocardiograms to consecutive primary care patients. We calculated the Framingham score to identify patients with a low or intermediate score who had structural heart disease.We classified everyone as having normal, elevated blood pressure, stage 1 or stage 2 hypertension according to the 2017 ACC/AHA guidelines. We defined structural heart disease as having LV hypertrophy and an abnormal LV mass index.

Results: We included 16 650 patients who underwent a screening echocardiogram and had recorded blood pressure. Out of the 16 650 patients, 1465 patients had a normal blood pressure, 1382 had elevated blood pressure, 1333 had stage 1 hypertension, and the remainder had stage 2 hypertension. The adjusted odds ratios of having structural heart disease for elevated blood pressure and stage 1 hypertension were 1.30; 95% CI, 1.112-1.64; P < 0.01 and 1.69; 95% CI, 1.25-2.30; P < 0.01, respectively. We identified 542 patients with stage 1 hypertension who had a low or intermediate Framingham score and 19% (95% CI, 16-23%) had structural heart disease.

Conclusion: A quarter of patients identified as having elevated blood pressure or stage 1 hypertension have structural heart disease. Screening echocardiograms may help to risk stratify those patients deemed ineligible for treatment.
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http://dx.doi.org/10.1097/MBP.0000000000000447DOI Listing
August 2020

Asymptomatic Patients Without Known Heart Disease Have Markers of Occult Heart Disease.

Am J Cardiol 2020 05 4;125(9):1449-1450. Epub 2020 Feb 4.

Division of Cardiology, University of Miami, Miami, Florida.

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http://dx.doi.org/10.1016/j.amjcard.2020.01.032DOI Listing
May 2020

Effect of blood pressure control on sudden death risk score in the SPRINT trial.

Int J Cardiol 2020 05 25;307:166-170. Epub 2020 Jan 25.

Department of Medicine Division of Cardiology, United States of America.

Background: Recent data suggest that population screening for risk of sudden cardiac death (SCD) may be feasible with risk scores that can be implemented in the electronic health record. But, there are no established therapeutic strategies to target lowering risk for SCD in the general population. Our aim was to evaluate the effect of the Systolic Blood Pressure Intervention Trial (SPRINT) intensive blood pressure intervention on SCD risk and cardiovascular (CV) outcomes.

Methods: We conducted a prospective cohort study within the SPRINT trial including all participants who had information required to calculate a SCD score. We classified SPRINT participants at baseline by randomized arm into high, intermediate and low SCD risk and followed them for a period of 12 months. We determined changes in SCD risk by comparing the baseline SCD risk score with the 12-month recalculated SCD risk score and determined the incidence of the primary SPRINT outcome and all-cause mortality. We used both linear regression and Cox proportional models to evaluate outcomes adjusted for CV risk, prevalent CV diseases, and randomization site.

Results: We included 8052 SPRINT participants who met our inclusion criteria. The median baseline SCD score was 2.7% SCD per 10 years; 95% CI 1.6 to 4.7 for both randomized arms. At 12-month follow-up, the median SCD score for the intensive group was 5.5 (2.0-20) while the standard group was 6.8 (2.4-26) p<0.01. Over a follow-up period of 3.8 years, in the intensive arm, the HR for those who had a reduction in SCD risk score was 0.80; 95% CI 0.62-0.98 for the primary event while the HR for the standard arm was 1.01; 95% CI 0.81-1.26. The changes in SCD risk were mediated by decreases in blood pressure and an increase in diabetes incidence as well as age.

Conclusions: SCD risk changed in SPRINT because of intensive blood pressure control and those who changed their score had fewer cardiovascular events. Future studies should target comprehensive interventions targeting all modifiable risk factors.
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http://dx.doi.org/10.1016/j.ijcard.2020.01.060DOI Listing
May 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

Usefulness of Single Nucleotide Polymorphisms as Predictors of Sudden Cardiac Death.

Am J Cardiol 2019 06 20;123(12):1900-1905. Epub 2019 Mar 20.

Division of Cardiology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida.

The pathophysiology of sudden cardiac death (SCD) remains incompletely understood. Genetic mutations can create a favorable substrate for SCD. Our aim is to evaluate the evidence of single nucleotide polymorphisms (SNPs) as predictors of SCD. We searched the Medline database (2000 to 2017) and selected all case-control or cohort studies that reported associations between SNPs and SCD. Our search terms included "polymorphisms" and "sudden death." We collected the study design, population ethnic background, gene testing strategy, the association between the SNP and SCD, and the cardiovascular comorbidities of the population. Our search yielded 723 studies, of which we included 24 based upon our inclusion criteria. The studies had a total population of 78,165 participants, with a median age of 62.5 years (IQR 56 to 66) and 35% (IQR 13 to 32) were female. Almost all studies were conducted in white patients of European descent and the most commonly used genetic strategy was candidate gene panels. Fifteen of the studies had a case-control design that included SCD patients without known heart disease as the comparison group and the other 9 studies included patients with heart failure and coronary artery disease. The studies evaluated 53 SNPs and the most common genetic loci were SCN5A, RyR2, CASQ2, NOSA1P, and AGTR. SNPs with the 3 strongest statistically significant ORs >1 were: rs6684209 of CASQ2 (odds ratio [OR] 19), rs3814843 of CALM1 (OR 5.5), and rs35594137 of GJA5 (OR 3.6). In Conclusion, many SNPs are associated with SCD, with the strongest associations seen in SNPs of genes related to intracellular calcium handling. These findings were generated primarily using a candidate gene strategy in white patients with European descent.
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http://dx.doi.org/10.1016/j.amjcard.2019.02.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175955PMC
June 2019

[Changes in body composition in patients following bariatric surgery: gastric bypass and sleeve gastrectomy].

Nutr Hosp 2019 Apr;36(2):334-349

Facultad de Medicina. Universidad del Desarrollo.

Introduction: Introduction: among the surgical techniques that promote greater weight loss are Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). These procedures generate changes in muscle mass (MM) and fat mass (FM). Objective: the aim of this study was to determine changes in body composition in patients undergoing RYGB and SG in a period of one-year after surgery. Methods: a cross-sectional retrospective study was conducted in three clinical centers of bariatric surgery in the Metropolitan Region, Chile. Information on MM and FM was obtained through bioimpedance analysis of 96 women and 32 men, operated between 2013 and 2017. Results: RYGB operated subjects presented higher MM content preoperatively and at the end of the first year compared to SG. In the first six months, the loss for MM, FM and % total fat (%FM) was similar in both techniques. Men with RYGB present greater loss of MM and FM in the first trimester post-surgery than those who submitted to SG (p = 0.0453). Subjects submitted to RYGB presented higher weight and body mass index (BMI) in the preoperative (p = 0.0109); the BMI at the end was similar in both surgical techniques (p = 0.6936). The lost kilos of MM were greater in the subjects submitted to RYGB (p = 0.0042), however, the % loss of MM exceeds the recommended (up to 22%) in both techniques. Conclusion: the nutritional approach is necessary to increase protein intake pre- and post-surgery as well as physical activity in order to preserve this compartment.
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http://dx.doi.org/10.20960/nh.2255DOI Listing
April 2019

Febuxostat and Cardiovascular Events: A Systematic Review and Meta-Analysis.

Int J Rheumatol 2019 3;2019:1076189. Epub 2019 Feb 3.

Division of Population Health and Computational Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA.

Background: Febuxostat is approved in the United States for the management of hyperuricemia in patients with gout. In November 2017 the FDA released a warning alert on a possible link between febuxostat and cardiovascular disease (CVD) reported in a single clinical trial.

Objective: To conduct a systematic review and meta-analysis and assess the risk of major adverse cardiovascular events (MACE) in patients receiving febuxostat compared to a control group.

Methods: We searched the MEDLINE and EMBASE database for studies published up until March 2018. We included randomized clinical trials (RCTs) that compared febuxostat to control groups including placebo and allopurinol. We calculated the pooled relative risk (RR) of MACE and cardiovascular disease (CVD) mortality with the corresponding 95% confidence intervals (CI).

Results: Our search yielded 374 potentially relevant studies. Among the 25 RCTs included in the systematic review, 10 qualified for the meta-analysis. Among the 14,402 subjects included, the median age was 54 years (IQR 52-67) and 90% were male (IQR 82-96); 8602 received febuxostat, 5118 allopurinol, and 643 placebo. The pooled RR of MACE for febuxostat was 0.9; 95% CI 0.6-1.5 (p= 0.96) compared to the control. The RR of CV-related death for febuxostat was 1.29; 95% CI 1.01-1.66 (p=0.03).

Conclusions: Compared with other SU-lowering treatments, febuxostat does not increase or decrease the risk of cardiovascular disease but may increase the risk of CVD death. More RCTs measuring cardiovascular safety as a primary outcome are needed to adequately evaluate the risk of CVD with febuxostat.
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http://dx.doi.org/10.1155/2019/1076189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378016PMC
February 2019

The additive role of echocardiography in the screening for sudden death.

Echocardiography 2019 03 3;36(3):451-457. Epub 2019 Feb 3.

Department of Medicine, Chen Neighborhood Medical Centers, Miami, Florida.

Background: A clinically based sudden cardiac death (SCD) risk score has predictive value. Echocardiographic parameters predict SCD. Our aim was to evaluate the effect of adding echocardiographic parameters to the clinical SCD risk score for the prediction of all-cause mortality.

Methods: We conducted a retrospective cohort of screening echocardiograms performed on primary care patients. We calculated the SCD risk score and added the left ventricular (LV) mass index, LV hypertrophy, diastolic dysfunction, and LV ejection fraction (EF). We calculated the c-statistic, net reclassification index (NRI), and Hosmer-Lemeshow chi-square for the SCD score alone or combined with each echocardiographic parameter in predicting all-cause mortality.

Results: We included 6447 primary care patients who underwent a screening echocardiogram and had a SCD score. The c-statistic of the SCD score for mortality was 0.61; 95% CI 0.58-0.62 and the c-statistic for the score combined with LV mass index increased to 0.64; 95% CI 0.63-0.65 and for the score combined with LVEF, the c-statistic was 0.64;95% CI 0.63-0.67. When diastolic dysfunction and LV hypertrophy were added to the SCD score, the c-statistic did not significantly change (P > 0.05). The NRI for the addition of LV mass index and LVEF was 0.52 ± 0.02, and the Hosmer-Lemeshow statistic was nonsignificant (P > 0.05).

Conclusions: Adding LV mass index or LVEF to the SCD risk score improves the ability to predict mortality, but in the primary care setting, the improvement is small and underscores the challenge of SCD prediction and prevention in the community.
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http://dx.doi.org/10.1111/echo.14256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219534PMC
March 2019

Diabetes Is Associated with Cognitive Decline in Middle-Aged Patients.

Metab Syndr Relat Disord 2018 Oct 11. Epub 2018 Oct 11.

1 Escuela de Medicina, Universidad Catolica Santiago de Guayaquil , Guayaquil, Ecuador .

Background: Diabetes is a major contributor to dementia in the elderly. Identifying mild cognitive decline in younger individuals with diabetes could aid in preventing the progression of the disease. The aim of our study is to compare whether patients with diabetes experience greater cognitive decline than those without diabetes.

Methods: We conducted a cross-sectional study using population-based recruitment to identify a cohort of individuals with diabetes and corresponding control group without diabetes of 55-65 years of age. We defined diabetes according to the American Diabetes Association and conducted a battery of standardized neuropsychological tests consisting of nine verbal and nonverbal tasks assessing three cognitive domains. We defined cognitive decline as an abnormal test in one or more of the domains. We used hierarchical regression to predict abnormal cognitive function by diabetes status, adjusting for gender, education, hypertension, and depression.

Results: We included 142 patients with diabetes and 167 control group patients. Those with diabetes had a mean age of 59 ± 4 years, 54% were women, the mean education level was 11 ± 4.5 years of schooling, and their hemoglobin A1c was 8.6 ± 2.5. They had an overall lower mean of all five executive function measures, all seven attention measures, and all five memory measures (P < 0.05). In multivariate analyses, all executive function beta coefficients for diabetes were significant, whereas attention had four out of seven and memory had four out of five.

Conclusions: Diabetes is associated with cognitive decline in younger patients with diabetes. Preventive strategies should be developed for the prevention of dementia in younger populations.
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http://dx.doi.org/10.1089/met.2018.0014DOI Listing
October 2018

High-touch care leads to better outcomes and lower costs in a senior population.

Am J Manag Care 2018 09 1;24(9):e300-e304. Epub 2018 Sep 1.

University of Miami, 1120 NW 14th St, Ste 1124, Miami, FL 33136. Email:

Objectives: There are several models of primary care. A form of high-intensity care is a high-touch model that uses a high frequency of encounters to deliver preventive services. The aim of this study is to compare the healthcare utilization of patients receiving 2 models of primary care, ​1 with high-touch care and 1 without.

Study Design: Retrospective cohort study.

Methods: We conducted a retrospective cohort study of 2 models of care used among Medicare Advantage populations. Model 1 is a high-touch care model, and model 2 is a standard care model. Compared with model 2, model 1 has smaller panel sizes and a higher frequency of encounters. We compared patients' healthcare utilization and hospitalizations between both models using a propensity score-matched analysis, matching by Charlson Comorbidity Index (CCI) score, age, and gender.

Results: We included 17,711 unmatched Medicare Advantage primary care patients and matched 5695 patients from both models of care. CCI scores, age, and gender were similar between both matched groups (P >.05). The median total per member per month healthcare costs in model 1 were $87 (95% CI, $26-$278) compared with $121 (95% CI, $52-$284) in model 2 (P <.01). The mean number of hospital admissions was lower in model 1 (0.10 ± 0.40) compared with model 2 (0.20 ± 0.58). The number of primary care physician visits and preventive medication use were higher in model 1 (P <.05 for both).

Conclusions: In a propensity-matched sample of Medicare Advantage patients, those receiving high-touch care had lower healthcare costs and fewer hospitalizations. Potential explanations are higher preventive medication use and more frequent visits.
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September 2018

Increasing myocardial infarction mortality trends in a middle-income country.

Cardiovasc Diagn Ther 2018 Aug;8(4):493-499

Division of Population Health and Computational Medicine, University of Miami, Miami, USA.

Background: Developed countries continue to show a decrease in cardiovascular disease (CVD) mortality. Little is known about CVD mortality trends in low and middle-income countries. The aim of our study is to describe myocardial infarction (MI) mortality trends and evaluate if differences between ethnic groups and geographic regions are present among the Ecuadorians with acute MI.

Methods: We conducted a cross sectional analysis mortality national registry and included deaths related to MI between 2012 and 2016 that had complete demographic data. To describe the general population, we used the 2010 census and applied estimates as population projections. We calculated age and sex standardized MI mortality rates per 100,000. We compared trends in MI mortality rate for every ethnic group and geographic region and used linear regression to estimate predictors of the changing mortality rates.

Results: We included 18,277 MI deaths between the years 2012 and 2016. The mean age of death was 73.6±19.5, 59% were male and 33% were illiterate. From 2012 to 2016, the standardized MI mortality rate increased from 51 to 157 deaths per 100,000. The most significant predictors of the increasing mortality rate were living in the coast (β=0.10), belonging to a mixed race (β=-0.033) and the year of death (β=0.013).

Conclusions: Our study found a worrisome increase in MI mortality between 2012-2016 in Ecuador, a middle-income country in South America. This rapid increase seems to be driven by geographic and racial differences. A thorough evaluation of the causes of this increase has to be undertaken by the Ecuadorian health authorities.
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http://dx.doi.org/10.21037/cdt.2018.07.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129823PMC
August 2018

Hispanics Coming to the US Adopt US Cultural Behaviors and Eat Less Healthy: Implications for Development of Inflammatory Bowel Disease.

Dig Dis Sci 2018 11 7;63(11):3058-3066. Epub 2018 Jul 7.

Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, USA.

Introduction: The incidence of inflammatory bowel disease (IBD) among US Hispanics is rising. Adoption of an American diet and/or US acculturation may help explain this rise.

Aims: To measure changes in diet occurring with immigration to the USA in IBD patients and controls, and to compare US acculturation between Hispanics with versus without IBD. Last, we examine the current diet of Hispanics with IBD compared to the diet of Hispanic controls.

Methods: This was a cross-sectional study of Hispanic immigrants with and without IBD. Participants were recruited from a university-based GI clinic. All participants completed an abbreviated version of the Stephenson Multi-Group Acculturation Scale and a 24-h diet recall (the ASA-24). Diet quality was calculated using the Healthy Eating Index (HEI-2010).

Results: We included 58 participants: 29 controls and 29 IBD patients. Most participants were Cuban or Colombian. Most participants, particularly those with IBD, reported changing their diet after immigration (72% of IBD and 57% of controls). IBD participants and controls scored similarly on US and Hispanic acculturation measures. IBD patients and controls scored equally poorly on the HEI-2010, although they differed on specific measures of poor intake. IBD patients reported a higher intake of refined grains and lower consumption of fruits, whereas controls reported higher intake of empty calories (derived from fat and alcohol).

Conclusion: The majority of Hispanics change their diet upon immigration to the USA and eat poorly irrespective of the presence of IBD. Future studies should examine gene-diet interactions to better understand underlying causes of IBD in Hispanics.
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http://dx.doi.org/10.1007/s10620-018-5185-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6182439PMC
November 2018

Informed consent comprehension among vulnerable populations in Ecuador: video-delivered vs. in-person standard method.

Account Res 2018 15;25(5):259-272. Epub 2018 May 15.

b Miller School of Medicine , University of Miami , Miami , Florida , USA.

The informed consent comprehension process is key to engaging potential research subject participation. The aim of this study is to compare informed consent comprehension between two methods: standard and video-delivered. We compared the in-person and video-delivered informed consent process in the Familias Unidas intervention. We evaluated comprehension using a 7-item true/false questionnaire. There were a total of 152 participants in the control group and 87 in the experimental. General characteristics were similar between both groups (p > 0.05). First-attempt informed consent comprehension was higher in the intervention group but was not statistically significant (80% and 78% respectively p = 0.44). A video-delivered informed consent process did not differ from the standard method of informed consent in a low educational and socioeconomic environment.
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http://dx.doi.org/10.1080/08989621.2018.1470931DOI Listing
October 2019

Mobile Technologies for Managing Heart Failure: A Systematic Review and Meta-analysis.

Telemed J E Health 2018 Apr 2. Epub 2018 Apr 2.

1 Division of Internal Medicine, GRECC, Veterans Affairs Medical Center , Miami, Florida.

Background: Randomized clinical trials (RCTs) conducted among heart failure (HF) patients have reported that mobile technologies can improve HF-related outcomes. Our aim was to conduct a meta-analysis to evaluate m-Health's impact on healthcare services utilization, mortality, and cost.

Methods: We searched MEDLINE, Cochrane, CINAHL, and EMBASE for studies published between 1966 and May-2017. We included studies that compared the use of m-Health in HF patients to usual care. m-Health is defined as the use of mobile computing and communication technologies to record and transmit data. The outcomes were HF-related and all-cause hospital days, cost, admissions, and mortality.

Results: Our search strategy resulted in 1,494 articles. We included 10 RCTs and 1 quasi-experimental study, which represented 3,109 patients in North America and Europe. Patient average age range was 53-80 years, New York Heart Association (NYHA) class III, and Left Ventricular Ejection Fraction <50%. Patients were mostly monitored daily and followed for an average of 6 months. A reduction was seen in HF-related hospital days. Nonsignificant reductions were seen in HF-related cost, admissions, and mortality and total mortality. We found no significant differences for all-cause hospital days and admissions, and an increase in total cost.

Conclusions: m-Health reduced HF-related hospital days, showed reduction trends in total mortality and HF-related admissions, mortality and cost, and increased total costs related to more clinic visits and implementation of new technologies. More studies reporting consistent quality outcomes are warranted to give conclusive information about the effectiveness and cost-effectiveness of m-Health interventions for HF.
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http://dx.doi.org/10.1089/tmj.2017.0269DOI Listing
April 2018

Provider Perspectives on the Collection of Social Determinants of Health.

Popul Health Manag 2018 12 29;21(6):501-508. Epub 2018 Mar 29.

1 Division of Population Health and Computational Medicine, Miller School of Medicine, University of Miami , Miami, Florida.

Social determinants of health (SDH) impact health outcomes. Medical centers have begun to collect SDH data, urged by government and scientific entities. Provider perspectives on collecting SDH are unknown. The aim is to understand differences in views and preferences according to provider characteristics. A cross-sectional survey of University of Miami clinical faculty was conducted in late 2016. The survey contained 11 questions: 8 demographic and departmental responsibilities questions and 3 Likert scale questions to capture collection and use of SDH perspectives. The main outcome was whether providers thought the benefit of collecting SDH outweighs the burden and risks. In all, 240 faculty members were included. The majority were men (64%), with a mean age of 51 years. Among participants, 53.5% were non-Hispanic white, 32% were Hispanic, 5% were Black/African American, and 5% were Asian. The majority agreed that SDH are important predictors of health outcomes and quality of care (83%). When comparing minority to nonminority faculty, 25% believed that SDH should only be available to PCPs, compared to 8% of nonminorities (P < 0.01). In a multivariate model, belonging to a racial ethnic minority was the only characteristic associated with believing that benefits of collecting SDH outweigh the risks (odds ratio 1.87, 95% confidence interval 1.02- 3.5) after adjusting for age, sex, minority status, health care provider type, type of responsibilities, and department. This study reveals that although most providers of a health system believe social risks impact health outcomes and quality metrics, the buy-in to collect SDH varies according to the racial/ethnic composition of the faculty.
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http://dx.doi.org/10.1089/pop.2017.0166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425987PMC
December 2018

Minority Veterans Are More Willing to Participate in Complex Studies Compared to Non-minorities.

J Bioeth Inq 2018 03 19;15(1):155-161. Epub 2017 Dec 19.

Department of Medicine, Miller School of Medicine at the University of Miami, Miami, FL, USA.

Background: Minorities are an underrepresented population in clinical trials. A potential explanation for this underrepresentation could be lack of willingness to participate. The aim of our study was to evaluate willingness to participate in different hypothetical clinical research scenarios and to evaluate the role that predictors (e.g. health literacy) could have on the willingness of minorities to participate in clinical research studies.

Methods: We conducted a mixed-methods study at the Miami VA Healthcare system and included primary care patients with hypertension. We measured willingness to participate as a survey of four clinical research scenarios that evaluated common study designs encountered in clinical research and that differed in degree of complexity. Our qualitative portion included comments about the scenarios.

Results: We included 123 patients with hypertension in our study. Of the entire sample, ninety-three patients were minorities. Seventy per cent of the minorities were willing to participate, compared to 60 per cent of the non-minorities. The odds ratio (OR) of willingness to participate in simple studies was 0.58; 95 per cent CI 0.18-1.88 p=0.37 and the OR of willingness to participate in complex studies was 5.8; 95 per cent CI 1.10-1.31 p=0.03. In complex studies, minorities with low health literacy cited obtaining benefits (47 per cent) as the most common reason to be willing to participate. Minorities who were not willing to participate, cited fear of unintended outcomes as the main reason.

Conclusions: Minorities were more likely to be willing to participate in complex studies compared to non-minorities. Low health literacy and therapeutic misconception are important mediators when considering willingness to participate in clinical research.
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http://dx.doi.org/10.1007/s11673-017-9829-2DOI Listing
March 2018

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

Racial Disparities in the Presentation and Treatment of Colorectal Cancer: A Statewide Cross-sectional Study.

J Clin Gastroenterol 2018 10;52(9):817-820

Departments of Internal Medicine, Division of Gastroenterology.

Background: Non-Hispanic blacks (NHB) and Hispanics often present with advanced colorectal cancer (CRC). The aim of the study was to characterize CRC differences among Hispanics, NHB, and non-Hispanic whites (NHW).

Methods: A cross-sectional analysis and logistic regression of 2009 Florida Agency for Healthcare Administration Hospital Admission Database data for CRC using the International Classification of Diseases, 9th Revision, Clinical Modification codes was performed. Outcomes included CRC location, frequency of metastasis and colectomy rates. Each minority group was compared with NHW.

Results: A total of 34,577 patients were NHW, 5190 were NHB, and 5033 were Hispanic. NHB had more proximal CRC [odds ratio (OR), 1.17; 95% confidence interval (CI), 1.09-1.25; P<0.0001]; Hispanics had more distal CRC (OR, 0.90; 95% CI, 0.83-0.96; P=0.0024). Hispanics had increased metastases (OR, 1.11; 95% CI, 1.02-1.22; P=0.04). NHB and Hispanics underwent fewer colectomies [(OR, 0.93; 95% CI, 0.86-0.99; P=0.03) and (OR, 0.9; 95% CI, 0.84-0.97; P=0.001), respectively].

Conclusions: Disparities in CRC metastases and colectomy rates exist among these racial groups in Florida. This work should serve as a foundation to study potential causes and to design culture-specific interventions.
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http://dx.doi.org/10.1097/MCG.0000000000000951DOI Listing
October 2018

The Forgotten Need of Disaster Relief.

Disaster Med Public Health Prep 2018 06 18;12(3):284-286. Epub 2017 Sep 18.

Department of Medicine, Miller School of Medicine at the University of Miami, and the Department of Medicine and Surgery, Veterans Affairs Medical Center, Miami, Florida.

Disasters in countries with limited resources can put the emergency preparedness of the country to the test. The first major task after a disaster is to take care of the wounded. In countries where the epidemiological transition has occurred, chronic disease can place a major strain on public health preparedness after a disaster. The purpose of this field report is to alert public health practitioners of an infrequently reported public health problem: the impact of natural disasters on adherence to chronic medications. In our experience, the most common complaint in the weeks that followed the 2016 earthquake was not having access to their chronic medications. (Disaster Med Public Health Preparedness. 2018; 12: 291-295).
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http://dx.doi.org/10.1017/dmp.2017.67DOI Listing
June 2018