Publications by authors named "Shivani Patel"

212 Publications

The Impact of COVID-19 Pandemic on Cancer Care in a Tertiary Care Facility.

South Asian J Cancer 2021 Jan 2;10(1):32-35. Epub 2021 Sep 2.

Department of Medical Oncology, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India.

 Coronavirus disease 2019 (COVID-19) pandemic had an overwhelming impact on health care worldwide. Cancer patients represent a subgroup that is vulnerable and is under high risk. It is, therefore, necessary to analyze factors that predict outcomes in these patients so that they can be triaged accordingly to mitigate the effects of COVID-19 on cancer management. To date, the impact of COVID-19 on cancer patients remain largely unknown.  Data of 291 cancer patients undergoing active treatment from March 23 to August 15, 2020 were retrospectively reviewed; the incidence, demographic and clinical characteristics, treatment, and outcomes of cancer patients infected by COVID-19 were included in the analysis.  During the index period (March 23-August 15, 2020), 4,494 confirmed cases of COVID-19 were admitted at our institute. In the department of medical oncology out of 578 patients presented to outpatient department, 291 patients were admitted for active treatment. Considering the cancer patients, infection rate was 7.9% (23/291) and mortality 13% (3/23). Median age was 40 years and the majority of patients were male (60%). The most common cancer type was acute lymphoblastic leukemia presented at various stages of treatment. Twenty patients (86.9%) were discharged after full clinical recovery and negative real-time polymerase chain reaction on a nasopharyngeal swab. Anticancer treatment was modified according to the type of cancer under intensive surveillance.  Although mortality rate in COVID-19 cancer patients is elevated, our results support the feasibility and safety of continuing anticancer treatment during pandemic by endorsing consistent preventive measures, but however should be modified based on the type and prognosis of cancer.
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http://dx.doi.org/10.1055/s-0041-1731577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8413016PMC
January 2021

Tension pneumomediastinum and diffuse subcutaneous emphysema with severe acute respiratory syndrome coronavirus 2 infection requiring operative management for impending airway collapse: A case report.

Clin Case Rep 2021 Aug 15;9(8):e04656. Epub 2021 Aug 15.

Indiana University School of Medicine South Bend Campus Notre Dame IN USA.

Tension pneumomediastinum is a rare complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that has increased in incidence with the novel coronavirus disease 2019 pandemic. Although traditionally managed with conservative measures, we present the indications and methods for the first operative management of tension pneumomediastinum with concomitant SARS-CoV-2 infection.
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http://dx.doi.org/10.1002/ccr3.4656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8364998PMC
August 2021

A giant spleen with multiple cysts: a rare case of isolated splenic hemangiomatosis.

Pan Afr Med J 2021 17;39:42. Epub 2021 May 17.

Department of General Surgery, Baroda Medical College, Vadodara, India.

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http://dx.doi.org/10.11604/pamj.2021.39.42.29712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356921PMC
September 2021

The Phenotypic Profile Associated With the Premutation in Women: An Investigation of Clinical-Behavioral, Social-Cognitive, and Executive Abilities.

Front Psychiatry 2021 6;12:718485. Epub 2021 Aug 6.

Roxelyn and Richard Pepper Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL, United States.

The gene in its premutation (PM) state has been linked to a range of clinical and subclinical phenotypes among PM carriers, including some subclinical traits associated with autism spectrum disorder (ASD). This study attempted to further characterize the phenotypic profile associated with the PM by studying a battery of assessments examining clinical-behavioral traits, social-cognitive, and executive abilities in women carrying the PM, and associations with -related variability. Participants included 152 female PM carriers and 75 female controls who were similar in age and IQ, and screened for neuromotor impairments or signs of fragile X-associated tremor/ataxia syndrome. The phenotypic battery included assessments of ASD-related personality and language (i.e., pragmatic) traits, symptoms of anxiety and depression, four different social-cognitive tasks that tapped the ability to read internal states and emotions based on different cues (e.g., facial expressions, biological motion, and complex social scenes), and a measure of executive function. Results revealed a complex phenotypic profile among the PM carrier group, where subtle differences were observed in pragmatic language, executive function, and social-cognitive tasks that involved evaluating basic emotions and trustworthiness. The PM carrier group also showed elevated rates of ASD-related personality traits. In contrast, PM carriers performed similarly to controls on social-cognitive tasks that involved reliance on faces and biological motion. The PM group did not differ from controls on self-reported depression or anxiety symptoms. Using latent profile analysis, we observed three distinct subgroups of PM carriers who varied considerably in their performance across tasks. Among PM carriers, CGG repeat length was a significant predictor of pragmatic language violations. Results suggest a nuanced phenotypic profile characterized by subtle differences in select clinical-behavioral, social-cognitive, and executive abilities associated with the PM in women.
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http://dx.doi.org/10.3389/fpsyt.2021.718485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8377357PMC
August 2021

Locus Coeruleus Pathology Indicates a Continuum of Lewy Body Dementia.

J Parkinsons Dis 2021 Jul 30. Epub 2021 Jul 30.

Neuropathology Unit, Department of Brain Sciences, Imperial College London, London, UK.

Background: Lewy body dementia (LBD) has two main phenotypes of LBD, Parkinson's disease dementia (PDD) and dementia with Lewy bodies (DLB), separated by the 'one-year-rule'. They also show different symptom profiles: core DLB features include fluctuating cognition, REM-sleep behaviur disorder, and visual hallucinations. These symptoms are sometimes present in PDD, representing an intermediate 'PDD-DLB' phenotype.

Objective: DLB-like features may reflect deficits in the functions of the noradrenergic nucleus locus coeruleus (LC). Therefore, we compared the LC in the LBD phenotypes, PD, and controls.

Methods: 38 PD, 56 PDD, 22 DLB, and 11 age-matched control cases from the Parkinson's UK tissue bank were included. LC tissue sections were immunostained for tyrosine-hydroxylase (TH), α-synuclein, tau, and amyloid-β. TH-neurons were quantified and pathologic burden calculated by %-coverage method.

Results: The LC shows a stepwise reduction in neuron count from controls, PD, PDD, to DLB. PDD-DLB cases showed an intermediate clinical phenotype that was reflected pathologically. Cell counts were significantly reduced in DLB compared to PDD after correction for demographic factors. LC degeneration contributed significantly to the onset of all DLB symptoms. While α-synuclein was not significantly different between PDD and DLB cases, DLB exhibited significantly less tau pathology.

Conclusion: DLB and DLB-like symptoms represent noradrenergic deficits resulting from neuronal loss in the LC. PDD and DLB are likely to represent a clinical continuum based on the presence or absence of DLB-like symptoms mirrored by a pathological continuum in the LC.
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http://dx.doi.org/10.3233/JPD-212748DOI Listing
July 2021

Temporal trends in the association of social vulnerability and race/ethnicity with county-level COVID-19 incidence and outcomes in the USA: an ecological analysis.

BMJ Open 2021 07 22;11(7):e048086. Epub 2021 Jul 22.

Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA

Background: The COVID-19 pandemic adversely affected the socially vulnerable and minority communities in the USA initially, but the temporal trends during the year-long pandemic remain unknown.

Objective: We examined the temporal association of county-level Social Vulnerability Index (SVI), a percentile-based measure of social vulnerability to disasters, its subcomponents and race/ethnic composition with COVID-19 incidence and mortality in the USA in the year starting in March 2020.

Methods: Counties (n=3091) with ≥50 COVID-19 cases by 6 March 2021 were included in the study. Associations between SVI (and its subcomponents) and county-level racial composition with incidence and death per capita were assessed by fitting a negative-binomial mixed-effects model. This model was also used to examine potential time-varying associations between weekly number of cases/deaths and SVI or racial composition. Data were adjusted for percentage of population aged ≥65 years, state-level testing rate, comorbidities using the average Hierarchical Condition Category score, and environmental factors including average fine particulate matter of diameter ≥2.5 μm, temperature and precipitation.

Results: Higher SVI, indicative of greater social vulnerability, was independently associated with higher COVID-19 incidence (adjusted incidence rate ratio per 10 percentile increase: 1.02, 95% CI 1.02 to 1.03, p<0.001) and death per capita (1.04, 95% CI 1.04 to 1.05, p<0.001). SVI became an independent predictor of incidence starting from March 2020, but this association became weak or insignificant by the winter, a period that coincided with a sharp increase in infection rates and mortality, and when counties with higher proportion of white residents were disproportionately represented ('third wave'). By spring of 2021, SVI was again a predictor of COVID-19 outcomes. Counties with greater proportion of black residents also observed similar temporal trends in COVID-19-related adverse outcomes. Counties with greater proportion of Hispanic residents had worse outcomes throughout the duration of the analysis.

Conclusion: Except for the winter 'third wave', when majority of the white communities had the highest incidence of cases, counties with greater social vulnerability and proportionately higher minority populations experienced worse COVID-19 outcomes.
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http://dx.doi.org/10.1136/bmjopen-2020-048086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8300549PMC
July 2021

Demographic Benchmarks for Equitable Coverage of COVID-19 Vaccination.

Am J Prev Med 2021 08 28;61(2):291-293. Epub 2021 Apr 28.

Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia. Electronic address:

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http://dx.doi.org/10.1016/j.amepre.2021.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080160PMC
August 2021

A modular protein subunit vaccine candidate produced in yeast confers protection against SARS-CoV-2 in non-human primates.

bioRxiv 2021 Jul 14. Epub 2021 Jul 14.

Vaccines against SARS-CoV-2 have been distributed at massive scale in developed countries, and have been effective at preventing COVID-19. Access to vaccines is limited, however, in low- and middle-income countries (LMICs) due to insufficient supply, high costs, and cold storage requirements. New vaccines that can be produced in existing manufacturing facilities in LMICs, can be manufactured at low cost, and use widely available, proven, safe adjuvants like alum, would improve global immunity against SARS-CoV-2. One such protein subunit vaccine is produced by the Serum Institute of India Pvt. Ltd. and is currently in clinical testing. Two protein components, the SARS-CoV-2 receptor binding domain (RBD) and hepatitis B surface antigen virus-like particles (VLPs), are each produced in yeast, which would enable a low-cost, high-volume manufacturing process. Here, we describe the design and preclinical testing of the RBD-VLP vaccine in cynomolgus macaques. We observed titers of neutralizing antibodies (>10 ) above the range of protection for other licensed vaccines in non-human primates. Interestingly, addition of a second adjuvant (CpG1018) appeared to improve the cellular response while reducing the humoral response. We challenged animals with SARS-CoV-2, and observed a ~3.4 and ~2.9 log reduction in median viral loads in bronchoalveolar lavage and nasal mucosa, respectively, compared to sham controls. These results inform the design and formulation of current clinical COVID-19 vaccine candidates like the one described here, and future designs of RBD-based vaccines against variants of SARS-CoV-2 or other betacoronaviruses.
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http://dx.doi.org/10.1101/2021.07.13.452251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8288147PMC
July 2021

A Quick Review on the Multisystem Effects of Prone Position in Acute Respiratory Distress Syndrome (ARDS) Including COVID-19.

Clin Med Insights Circ Respir Pulm Med 2021 1;15:11795484211028526. Epub 2021 Jul 1.

Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, Newark, NJ, USA.

Objective: The purpose of this review is to highlight the multisystem effects of prone position in ARDS patients with a focus on current findings regarding its use in COVID-19 patients.

Methods: Two reviewers comprehensively searched PubMed database for literature regarding pathophysiology and efficacy of prone position in ARDS patients as well as specific data regarding this approach in COVID-19 patients.

Conclusion: Prone positioning is well-documented to improve oxygenation and cardiac function in ARDS patients and might confer increased survival, with benefits that outweigh risks such as facial edema, endotracheal tube displacement, and intraabdominal organ dysfunction in obese patients. Severe COVID-19 pneumonia, while meeting ARDS criteria, differs from typical ARDS in several ways. Data would suggest that advantages of prone position would become limited after significant disease progression and fibrosis. The use of this technique in COVID-19 requires prolonged sessions that are unprecedented in the treatment of ARDS patients. New data regarding COVID-19 pathophysiology and patients continues to evolve daily. More frequently, patients are proned while maintaining spontaneous breathing-the results of this intervention are an area for future studies. There is more to learn about the appropriate use of prone position in COVID-19 patients. The multisystem risks and benefits require clinicians to adopt a patient centered decision-making algorithm when employing this technique in COVID-19 patients.

Level Of Evidence: NA.
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http://dx.doi.org/10.1177/11795484211028526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255560PMC
July 2021

Durable Humoral and Cellular Immune Responses Following Ad26.COV2.S Vaccination for COVID-19.

medRxiv 2021 Jul 7. Epub 2021 Jul 7.

Janssen Vaccines & Prevention, Leiden, The Netherlands.

Interim immunogenicity and efficacy data for the Ad26.COV2.S vaccine for COVID-19 have recently been reported . We describe here the 8-month durability of humoral and cellular immune responses in 20 individuals who received one or two doses of 5Ã-10 vp or 10 vp Ad26.COV2.S and in 5 participants who received placebo . We evaluated antibody and T cell responses on day 239, which was 8 months after the single-shot vaccine regimen (N=10) or 6 months after the two-shot vaccine regimen (N=10), although the present study was not powered to compare these regimens . We also report neutralizing antibody responses against the parental SARS-CoV-2 WA1/2020 strain as well as against the SARS-CoV-2 variants D614G, B.1.1.7 (alpha), B.1.617.1 (kappa), B.1.617.2 (delta), P.1 (gamma), B.1.429 (epsilon), and B.1.351 (beta).
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http://dx.doi.org/10.1101/2021.07.05.21259918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8282116PMC
July 2021

Relative and absolute wealth mobility since birth in relation to health and human capital in middle adulthood: An analysis of a Guatemalan birth cohort.

SSM Popul Health 2021 Sep 19;15:100852. Epub 2021 Jun 19.

Hubert Department of Global Health, Emory University, Atlanta GA, USA.

Background: Wealth mobility, as both relative (positional) and absolute (material) wealth acquisition, may counteract negative consequences of early life adversities on adult health.

Methods: We use longitudinal data (1967-2018) from the INCAP birth cohort, Guatemala (n = 1386). Using wealth as a measure of socio-economic position, we assess the association of life course relative mobility using latent class analysis and absolute material gains using conditional wealth measures. We estimate associations of wealth mobility with indicators of human capital, specifically height, weight status (BMI in kg/m), psychological distress (WHO SRQ-20 score) and fluid intelligence (Ravens Progressive Matrices score; RPM) in middle adulthood.

Results: We identified four latent classes of relative mobility - Stable Low (n = 498), Stable High (n = 223), Downwardly Mobile (n = 201) and Upwardly Mobile (n = 464). Attained schooling (years) was positively associated with membership in Upwardly Mobile (odds ratio; 1.50, 95%CI: 1.31, 1.71) vs Stable Low, and inversely with membership in Downwardly Mobile (0.65, 95%CI: 0.54, 0.79) vs Stable High. Being Upwardly Mobile (vs Stable Low) was positively associated with height (1.88 cm, 95%CI: 1.04, 2.72), relative weight (1.32 kg/m, 95%CI: 0.57, 2.07), lower psychological distress (-0.82 units, 95%CI: 1.34, -0.29) and fluid intelligence (0.94 units, 95%CI: 0.28, 1.59). Being Downwardly Mobile (vs Stable High) was associated with lower fluid intelligence (-2.69 units, 95%CI: 3.69, -1.68), and higher psychological distress (1.15 units, 95%CI: 0.34, 1.95). Absolute wealth gains (z-scores) from early to middle adulthood were positively associated with relative weight (0.62 kg/m, 95%CI: 0.28, 0.96), lower psychological distress (-0.37 units, 95%CI: 0.60, -0.14) and fluid intelligence (0.50 units, 95%CI: 0.21, 0.79).

Conclusions: Higher attained schooling provided a pathway for upward relative mobility and higher absolute wealth gains as well as protection against downward relative mobility. Upward mobility was associated with lower psychological distress and higher fluid intelligence but also higher weight status.
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http://dx.doi.org/10.1016/j.ssmph.2021.100852DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8242036PMC
September 2021

Protective efficacy of Ad26.COV2.S against SARS-CoV-2 B.1.351 in macaques.

Nature 2021 08 23;596(7872):423-427. Epub 2021 Jun 23.

Bioqual, Rockville, MD, USA.

The emergence of SARS-CoV-2 variants that partially evade neutralizing antibodies poses a threat to the efficacy of current COVID-19 vaccines. The Ad26.COV2.S vaccine expresses a stabilized spike protein from the WA1/2020 strain of SARS-CoV-2, and has recently demonstrated protective efficacy against symptomatic COVID-19 in humans in several geographical regions-including in South Africa, where 95% of sequenced viruses in cases of COVID-19 were the B.1.351 variant. Here we show that Ad26.COV2.S elicits humoral and cellular immune responses that cross-react with the B.1.351 variant and protects against B.1.351 challenge in rhesus macaques. Ad26.COV2.S induced lower binding and neutralizing antibodies against B.1.351 as compared to WA1/2020, but elicited comparable CD8 and CD4 T cell responses against the WA1/2020, B.1.351, B.1.1.7, P.1 and CAL.20C variants. B.1.351 infection of control rhesus macaques resulted in higher levels of virus replication in bronchoalveolar lavage and nasal swabs than did WA1/2020 infection. Ad26.COV2.S provided robust protection against both WA1/2020 and B.1.351, although we observed higher levels of virus in vaccinated macaques after B.1.351 challenge. These data demonstrate that Ad26.COV2.S provided robust protection against B.1.351 challenge in rhesus macaques. Our findings have important implications for vaccine control of SARS-CoV-2 variants of concern.
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http://dx.doi.org/10.1038/s41586-021-03732-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373608PMC
August 2021

Cardiovascular disease risk and pathophysiology in South Asians: can longitudinal multi-omics shed light?

Wellcome Open Res 2020 20;5:255. Epub 2021 May 20.

Institute of Genomics and Integrative Biology, Council of Scientific and Industrial Research, New Delhi, India.

Cardiovascular disease (CVD) is the leading cause of mortality in South Asia, with rapidly increasing prevalence of hypertension, type 2 diabetes (T2DM) and hyperlipidemia over the last two decades. Atherosclerotic CVD (ASCVD) affects South Asians earlier in life and at lower body weights, which is not fully explained by differential burden of conventional risk factors. Heart failure (HF) is a complex clinical syndrome of heterogeneous structural phenotypes including two major clinical subtypes, HF with preserved (HFpEF) and reduced ejection fraction (HFrEF). The prevalence of HF in South Asians is also rising with other metabolic diseases, and HFpEF develops at younger age and leaner body mass index in South Asians than in Whites. Recent genome-wide association studies, epigenome-wide association studies and metabolomic studies of ASCVD and HF have identified genes, metabolites and pathways associated with CVD traits. However, these findings were mostly driven by samples of European ancestry, which may not accurately represent the CVD risk at the molecular level, and the unique risk profile of CVD in South Asians. Such bias, while formulating hypothesis-driven research studies, risks missing important causal or predictive factors unique to South Asians. Importantly, a longitudinal design of multi-omic markers can capture the life-course risk and natural history related to CVD, and partially disentangle putative causal relationship between risk factors, multi-omic markers and subclinical and clinical ASCVD and HF. In conclusion, combining high-resolution untargeted metabolomics with epigenomics of rigorous, longitudinal design will provide comprehensive unbiased molecular characterization of subclinical and clinical CVD among South Asians. A thorough understanding of CVD-associated metabolomic profiles, together with advances in epigenomics and genomics, will lead to more accurate estimates of CVD progression and stimulate new strategies for improving cardiovascular health.
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http://dx.doi.org/10.12688/wellcomeopenres.16336.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176264PMC
May 2021

Low-dose Ad26.COV2.S protection against SARS-CoV-2 challenge in rhesus macaques.

Cell 2021 06 1;184(13):3467-3473.e11. Epub 2021 Jun 1.

Bioqual, Rockville, MD 20852, USA.

We previously reported that a single immunization with an adenovirus serotype 26 (Ad26)-vector-based vaccine expressing an optimized SARS-CoV-2 spike (Ad26.COV2.S) protected rhesus macaques against SARS-CoV-2 challenge. To evaluate reduced doses of Ad26.COV2.S, 30 rhesus macaques were immunized once with 1 × 10, 5 × 10, 1.125 × 10, or 2 × 10 viral particles (vp) Ad26.COV2.S or sham and were challenged with SARS-CoV-2. Vaccine doses as low as 2 × 10 vp provided robust protection in bronchoalveolar lavage, whereas doses of 1.125 × 10 vp were required for protection in nasal swabs. Activated memory B cells and binding or neutralizing antibody titers following vaccination correlated with protective efficacy. At suboptimal vaccine doses, viral breakthrough was observed but did not show enhancement of disease. These data demonstrate that a single immunization with relatively low dose of Ad26.COV2.S effectively protected against SARS-CoV-2 challenge in rhesus macaques, although a higher vaccine dose may be required for protection in the upper respiratory tract.
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http://dx.doi.org/10.1016/j.cell.2021.05.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166510PMC
June 2021

Structure- and ligand-based drug design methods for the modeling of antimalarial agents: a review of updates from 2012 onwards.

J Biomol Struct Dyn 2021 Jun 15:1-26. Epub 2021 Jun 15.

Department of Pharmaceutical Chemistry, Institute of Pharmacy, Nirma University, Ahmedabad, India.

Malaria still persists as one of the deadliest infectious disease having a huge morbidity and mortality affecting the higher population of the world. Structure and ligand-based drug design methods like molecular docking and MD simulations, pharmacophore modeling, QSAR and virtual screening are widely used to perceive the accordant correlation between the antimalarial activity and property of the compounds to design novel dominant and discriminant molecules. These modeling methods will speed-up antimalarial drug discovery, selection of better drug candidates for synthesis and to achieve potent and safer drugs. In this work, we have extensively reviewed the literature pertaining to the use and applications of various ligand and structure-based computational methods for the design of antimalarial agents. Different classes of molecules are discussed along with their target interactions pattern, which is responsible for antimalarial activity. Communicated by Ramaswamy H. Sarma.
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http://dx.doi.org/10.1080/07391102.2021.1932598DOI Listing
June 2021

Ecological Analysis of the Temporal Trends in the Association of Social Vulnerability and Race/Ethnicity with County-Level COVID-19 Incidence and Outcomes in the United States.

medRxiv 2021 Jun 7. Epub 2021 Jun 7.

Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA.

Background: The COVID-19 pandemic adversely affected the socially vulnerable and minority communities in the U.S. initially, but the temporal trends during the year-long pandemic remain unknown.

Objective: We examined the temporal association between the county-level Social Vulnerability Index (SVI), a percentile-based measure of social vulnerability to disasters, its subcomponents and race/ethnic composition with COVID-19 incidence and mortality in the U.S. in the year starting in March 2020.

Methods: Counties (n=3091) with ≥ 50 COVID-19 cases by March 6 , 2021 were included in the study. Associations between SVI (and its subcomponents) and county level racial composition with the incidence and death per capita were assessed by fitting a negative-binomial mixed-effects model. This model was also used to examine potential time varying associations between weekly number of cases/deaths and SVI or racial composition. Data was adjusted for percentage of population aged ≥65 years, state level testing rate, comorbidities using the average Hierarchical Condition Category (HCC) score, and environmental factors including average fine particulate matter (PM ), temperature and precipitation.

Results: Higher SVI, indicative of greater social vulnerability, was independently associated with higher COVID-19 incidence (adjusted incidence rate ratio [IRR] per-10 percentile increase:1.02, (95% CI 1.02, 1.03, p<0.001), and death per capita (1.04, (95% CI 1.04, 1.05, p<0.001). SVI became an independent predictor of incidence starting from March 2020, but this association became weak or insignificant by the winter, a period that coincided with a sharp increase in infection rates and mortality, and when counties with higher proportion of White residents were disproportionately represented ("third wave"). By Spring of 2021, SVI was again a predictor of COVID-19 outcomes. Counties with greater proportion of Black residents also observed similar temporal trends COVID-19-related adverse outcomes. Counties with greater proportion of Hispanic residents had worse outcomes throughout the duration of the analysis.

Conclusion: Except for the winter "third wave" when majority White communities had the highest incidence of cases, counties with greater social vulnerability and proportionately higher minority populations, experienced worse COVID-19 outcomes.

Article Summary/strengths & Limitations: Examined full 12 months of county-level data in the US delineating the temporal trends in the association between social vulnerability index and COVID-19 outcomesInvestigated COVID-19 outcomes in predominantly Black and Hispanic communities in comparison to White communities in the USAnalysis is ecological, descriptive, and on the county-level rather than on an individual levelAnalysis adjusted for confounders including county level age ≥ 65, comorbidities, and environmental factorsAnalysis limited to the US.
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http://dx.doi.org/10.1101/2021.06.04.21258355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202439PMC
June 2021

Assessment of Studies of Quality Improvement Strategies to Enhance Outcomes in Patients With Cardiovascular Disease.

JAMA Netw Open 2021 Jun 1;4(6):e2113375. Epub 2021 Jun 1.

Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Importance: Clinical care quality improvement (QI) strategies are critical to prevent and control cardiovascular disease (CVD). However, there is limited evidence regarding which components of the health system-, clinician-, and patient-based QI strategies contribute to their impact on CVD.

Objectives: To identify, map, and organize evidence on the effectiveness and implementation of cardiovascular QI strategies that seek to improve outcomes in patients with CVD.

Evidence Review: Eight electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library, ProQuest, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform) were searched for studies published between January 1, 2009, and October 25, 2019. Eligible study designs included randomized trials and preintervention and postintervention evaluations. Descriptive findings of included studies were reported using several frameworks to map the intervention components stratified by target population, setting, outcomes, and overall results.

Findings: From 8066 screened titles and abstracts, 456 unique studies with 150 148 unique patients (38.1% women and 61.9% men; mean [SD] age, 64.6 [7.1] years) were identified, including 427 randomized trials, 21 quasi-randomized studies, and 8 preintervention and postintervention studies. Of 336 studies from 45 countries that were classified, 255 (75.9%) were from high-income countries; 68 (20.2%), upper-middle-income countries; 13 (3.9%), lower-middle-income countries; and 0, low-income countries, with diverse clinical settings and target patient populations (post-myocardial infarction, stroke, heart failure). Patient support (311 studies), information communication technology (ICT) for health (78 studies), community support (18 studies), supervision (15 studies), and high-intensity training (14 studies) were the most commonly evaluated QI strategies. Other strategies were group problem-solving (7 studies), printed information (5 studies), strengthening infrastructure (4 studies), and financial incentives (3 studies). Patient support, ICT for health, training, and community support were strategies that had been evaluated the most for clinical end points and showed modest associations with several clinical outcomes. The other strategies did not have outcome-driven evaluations reported. Group problem-solving was associated with improved patient self-care and quality of life. Strengthening infrastructure was associated with improved treatment satisfaction. Printed information and financial incentives showed no meaningful effect.

Conclusions And Relevance: This systematic review found that substantial variations exist in the types, effectiveness, and implementation of QI strategies for patients with CVD. A comprehensive map of QI strategies created by this study would be useful for researchers to identify where new knowledge is needed to improve cardiovascular outcomes. Outcome-driven evaluations and long-term studies are needed, particularly in low-income settings, to better understand the effects of QI strategies on prevention and control of CVD.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.13375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8204210PMC
June 2021

Emerging role of Tissue Resident Memory T cells in vitiligo: From pathogenesis to therapeutics.

Autoimmun Rev 2021 Aug 10;20(8):102868. Epub 2021 Jun 10.

C. G. Bhakta Institute of Biotechnology, Uka Tarsadia University, Tarsadi, Surat 394350, Gujarat, India. Electronic address:

Vitiligo is an acquired depigmenting disorder which affects both skin and mucous membranes and autoimmunity has been strongly suggested to play a role in loss of melanocytes. The recurrence of skin macules at the same sites where they were observed prior to the treatment, suggests the existence of Tissue Resident Memory T cells (TRMs) that persist within the skin or peripheral tissues with a longer survivability. Emerging studies have shown that reactivation of these skin TRMs results into autoreactive TRM cells in various autoimmune diseases including vitiligo. This review focuses on different subsets (CD8 TRMs and CD4 TRMs) of TRM cells, their retention and survivability in the skin along with their pathomechanisms leading to melanocyte death and progression of vitiligo. In addition, the review describes the TRM cells as potential targets for developing effective therapeutics of vitiligo.
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http://dx.doi.org/10.1016/j.autrev.2021.102868DOI Listing
August 2021

Comparing traditional, immersive simulation with Rapid Cycle Deliberate Practice in postgraduate year 2 anesthesiology residents.

Adv Simul (Lond) 2021 May 26;6(1):20. Epub 2021 May 26.

Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 625 19th Street South, QT 334, Birmingham, AL, 35249-5980, USA.

Background: Rapid Cycle Deliberate Practice (RCDP) is an increasingly popular simulation technique that allows learners to achieve mastery of skills through repetition, feedback, and increasing difficulty. This manuscript describes the implementation and assessment of RCDP in an anesthesia residency curriculum.

Methods: Researchers describe the comparison of RCDP with traditional instructional methods for anesthesiology residents' application of Emergency Cardiovascular Care (ECC) and communication principles in a simulated environment. Residents (n = 21) were randomly assigned to either Traditional or RCDP education groups, with each resident attending 2 days of bootcamp. On their first day, the Traditional group received a lecture, then participated in a group, immersive simulation with reflective debriefing. The RCDP group received education through an RCDP simulation session. On their second bootcamp day, all participants individually engaged in an immersive simulation, then completed the "Satisfaction and Self-Confidence in Learning" survey. Application of ECC and communication principles during the simulation was scored by a blinded reviewer through video review. Participants ended the bootcamp by ranking the experiences they found most valuable.

Results: No significant differences were found in the different group members' individual performances during the immersive simulation, nor in the experiences they deemed most valuable. However, the Traditional education group reported higher levels of satisfaction and self-confidence in learning in 5 areas (p = 0.004-0.04).

Conclusions: Regardless of RCDP or Traditional education grouping, anesthesia residents demonstrated no difference in ECC skill level or perceived value of interventions. However, members of the Traditional education group reported higher levels of satisfaction and self-confidence in numerous areas. Additional RCDP opportunities in the anesthesia residency program should be considered prior to excluding it as an educational method in our program.
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http://dx.doi.org/10.1186/s41077-021-00174-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157720PMC
May 2021

Developments in Photoredox-Mediated Alkylation for DNA-Encoded Libraries.

Trends Chem 2021 Mar 29;3(3):161-175. Epub 2020 Dec 29.

Roy and Diana Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, Philadelphia, PA 19104-6323, USA.

Recently, DNA-encoded library (DEL) technology has emerged as an innovative screening modality for the rapid discovery of therapeutic candidates in pharmaceutical settings. This platform enables a cost-effective, time-efficient, and large-scale assembly and interrogation of billions of small organic ligands against a biological target in a single experiment. An outstanding challenge in DEL synthesis is the necessity for water-compatible transformations under ambient conditions. To access uncharted chemical space, the adoption of photoredox catalysis in DELs, including Ni-catalyzed manifolds and radical/polar crossover reactions, has enabled the construction of novel structural scaffolds through regulated odd-electron intermediates. Herein, a critical discussion of the validation of photoredox-mediated alkylation in DEL environments is presented. Current synthetic gaps are highlighted and opportunities for further development are speculated upon.
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http://dx.doi.org/10.1016/j.trechm.2020.11.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112611PMC
March 2021

Immunogenicity of COVID-19 mRNA Vaccines in Pregnant and Lactating Women.

JAMA 2021 06;325(23):2370-2380

Harvard Medical School, Boston, Massachusetts.

Importance: Pregnant women are at increased risk of morbidity and mortality from COVID-19 but have been excluded from the phase 3 COVID-19 vaccine trials. Data on vaccine safety and immunogenicity in these populations are therefore limited.

Objective: To evaluate the immunogenicity of COVID-19 messenger RNA (mRNA) vaccines in pregnant and lactating women, including against emerging SARS-CoV-2 variants of concern.

Design, Setting, And Participants: An exploratory, descriptive, prospective cohort study enrolled 103 women who received a COVID-19 vaccine from December 2020 through March 2021 and 28 women who had confirmed SARS-CoV-2 infection from April 2020 through March 2021 (the last follow-up date was March 26, 2021). This study enrolled 30 pregnant, 16 lactating, and 57 neither pregnant nor lactating women who received either the mRNA-1273 (Moderna) or BNT162b2 (Pfizer-BioNTech) COVID-19 vaccines and 22 pregnant and 6 nonpregnant unvaccinated women with SARS-CoV-2 infection.

Main Outcomes And Measures: SARS-CoV-2 receptor binding domain binding, neutralizing, and functional nonneutralizing antibody responses from pregnant, lactating, and nonpregnant women were assessed following vaccination. Spike-specific T-cell responses were evaluated using IFN-γ enzyme-linked immunospot and multiparameter intracellular cytokine-staining assays. Humoral and cellular immune responses were determined against the original SARS-CoV-2 USA-WA1/2020 strain as well as against the B.1.1.7 and B.1.351 variants.

Results: This study enrolled 103 women aged 18 to 45 years (66% non-Hispanic White) who received a COVID-19 mRNA vaccine. After the second vaccine dose, fever was reported in 4 pregnant women (14%; SD, 6%), 7 lactating women (44%; SD, 12%), and 27 nonpregnant women (52%; SD, 7%). Binding, neutralizing, and functional nonneutralizing antibody responses as well as CD4 and CD8 T-cell responses were present in pregnant, lactating, and nonpregnant women following vaccination. Binding and neutralizing antibodies were also observed in infant cord blood and breast milk. Binding and neutralizing antibody titers against the SARS-CoV-2 B.1.1.7 and B.1.351 variants of concern were reduced, but T-cell responses were preserved against viral variants.

Conclusion And Relevance: In this exploratory analysis of a convenience sample, receipt of a COVID-19 mRNA vaccine was immunogenic in pregnant women, and vaccine-elicited antibodies were transported to infant cord blood and breast milk. Pregnant and nonpregnant women who were vaccinated developed cross-reactive antibody responses and T-cell responses against SARS-CoV-2 variants of concern.
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http://dx.doi.org/10.1001/jama.2021.7563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8120446PMC
June 2021

RANKL and RANK in extracellular vesicles: surprising new players in bone remodeling.

Extracell Vesicles Circ Nucl Acids 2021 30;2:18-28. Epub 2021 Mar 30.

Department of Orthodontics and Pediatric Dentistry, Stony Brook School of Dental Medicine, Stony Brook, NY 11794, USA.

Receptor activator of nuclear factor kappa B-ligand (RANKL), its receptor RANK, and osteoprotegerin which binds RANKL and acts as a soluble decoy receptor, are essential controllers of bone remodeling. They also play important roles in establishing immune tolerance and in the development of the lymphatic system and mammary glands. In bone, RANKL stimulates osteoclast formation by binding RANK on osteoclast precursors and osteoclasts. This is required for bone resorption. Recently, RANKL and RANK have been shown to be functional components of extracellular vesicles (EVs). Data linking RANKL and RANK in EVs to biological regulatory roles are reviewed, and crucial unanswered questions are examined. RANKL and RANK are transmembrane proteins and their presence in EVs allows them to act at a distance from their cell of origin. Because RANKL-bearing osteocytes and osteoblasts are often spatially distant from RANK-containing osteoclasts in vivo, this may be crucial for the stimulation of osteoclast formation and bone resorption. RANK in EVs from osteoclasts has the capacity to stimulate a RANKL reverse signaling pathway in osteoblasts that promotes bone formation. This serves to couple bone resorption with bone formation and has inspired novel bifunctional therapeutic agents. RANKL- and RANK- containing EVs in serum may serve as biomarkers for bone and immune pathologies. In summary, EVs containing RANKL and RANK have been identified as intercellular regulators in bone biology. They add complexity to the central signaling network responsible for maintaining bone. RANKL- and RANK-containing EVs are attractive as drug targets and as biomarkers.
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http://dx.doi.org/10.20517/evcna.2020.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112638PMC
March 2021

Development and implementation of a clinician report to reduce unnecessary urine drug screen testing in the ED: a quality improvement initiative.

Emerg Med J 2021 May 12. Epub 2021 May 12.

Emergency Medicine, Saskatchewan Health Authority, Regina, Saskatchewan, Canada.

Background: Unnecessary testing is a problem-facing healthcare systems around the world striving to achieve sustainable care. Despite knowing this problem exists, clinicians continue to order tests that do not contribute to patient care. Using behavioural and implementation science can help address this problem. Locally, audit and feedback are used to provide information to clinicians about their performance on relevant metrics. However, this is often done without evidence-based methods to optimise uptake. Our objective was to improve the appropriate use of laboratory tests in the ED using evidence-based audit and feedback and behaviour change techniques.

Methods: Using the behaviour change wheel, we implemented an audit and feedback tool that provided information to ED physicians about their use of laboratory tests; specifically, we focused on education and review of the appropriate use of urine drug screen tests. The report was designed in collaboration with end users to help maximise engagement. Following development of the report, audit and feedback sessions were delivered over an 18-month period.

Results: Data on urine drug screen testing were collected continually throughout the intervention period and showed a sustained decrease among ED physicians. Test use dropped from a monthly departmental average of 26 urine drug screen tests per 1000 patient visits to only eight tests per 1000 patient visits following the initiation of the audit and feedback intervention.

Conclusion: Audit and feedback reduced unnecessary urine drug screen testing in the ED. Regular feedback sessions continuously engaged physicians in the audit and feedback intervention and allowed the implementation team to react to changing priorities and feedback from the clinical group. It was important to include the end users in the design of audit and feedback tools to maximise physician engagement. Inclusion in this process can help ensure physicians adopt a sense of ownership regarding which metrics to review and provides a key component for the motivation aspect of behaviour change. Departmental leadership is also critical to the process of implementing a successful audit and feedback initiative and achieving sustained behaviour change.
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http://dx.doi.org/10.1136/emermed-2020-210009DOI Listing
May 2021

Primer on Epidemiology 2: The elements of study validity and key issues in interpretation.

Natl Med J India 2020 May-Jun;33(3):160-165

Centre for Chronic Disease Control, New Delhi, India.

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http://dx.doi.org/10.4103/0970-258X.314011DOI Listing
April 2021

Spouse's Diabetes Status and Incidence of Depression and Anxiety: An 18-Year Prospective Study.

Diabetes Care 2021 Apr 16. Epub 2021 Apr 16.

Emory Global Diabetes Research Center, Hubert Department of Global Health, Rollins School of Global Health, Emory University, Atlanta, GA.

Objective: We investigated the risk of depression and anxiety in people whose spouse did or did not have diabetes. We also examined associations between depression and anxiety and severity of spouse's diabetes.

Research Design And Methods: We analyzed prospective self-reported data about diagnosed depression/anxiety and diabetes in cohabiting couples in the national Panel Study of Income Dynamics (PSID) during 1999-2017 ( = 13,500, 128,833 person-years of follow-up, median follow-up 8.1 years). We used Poisson models to estimate incidence and incidence rate ratios (IRRs) of depression/anxiety, according to spouse's diabetes status overall and by severity of diabetes.

Results: Age-, sex-, and race-adjusted incidence of depression/anxiety was 8.0/1,000 person-years (95% CI 6.5, 9.6) among those whose spouse had diabetes and 6.5/1,000 person-years (95% CI 6.0, 6.9) among those whose spouse did not have diabetes. Those whose spouse had diabetes had higher risk of depression/anxiety (IRR 1.24 [95% CI 1.01, 1.53]). Those whose spouse had diabetes-related limitations in daily activities (IRR 1.89 [95% CI 1.35, 2.67]) and diabetes combined with other chronic conditions (IRR 2.34 [95% CI 1.78, 3.09]) were more likely to develop depression/anxiety, while those whose spouse had diabetes with no limitations or additional chronic conditions had incidence of depression/anxiety similar to that of subjects whose spouses did not have diabetes.

Conclusions: People living with a spouse with diabetes are at higher risk of developing depression/anxiety than people whose spouse does not have diabetes; this risk is driven by the severity of the spouse's diabetes. Strategies to address the impacts of diabetes on families need to be devised and tested.
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http://dx.doi.org/10.2337/dc20-2652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8247506PMC
April 2021

The use of a metacognition and contemplation intervention in improving student abilities to recognize order entry errors.

Curr Pharm Teach Learn 2021 May 22;13(5):544-549. Epub 2021 Jan 22.

Pharmacy Resident University of California Davis Medical Center, 2467 Mojave Dr, Brentwood, CA 94513, United States. Electronic address:

Background And Purpose: To describe a pilot study testing a metacognition and contemplative pedagogy intervention designed to improve student abilities to identify errors on orders entered into a computerized provider order entry (CPOE) system. Educational activity and setting: Student teams worked up five patient cases and entered new orders into a CPOE system. All orders entered by teams were analyzed for errors and faculty members identified fifteen orders representing the top errors and selected these for the pre-exercise, in-class contemplation activity, and post-exercise. Course instructors instructed students to identify all errors on these orders. Students completed a pre/post-survey rating their ability to enter new orders. Two weeks later, students worked up a new patient case and entered orders into the CPOE. These orders were graded and scores were compared to the 2017 cohort to determine any differences in error rates.

Findings: Study participants included 205 students The average score of correctly identified errors increased from 22% on the pre-exercise to 62.8% on the post-exercise. On the survey of their skills, students rated their ability to "accurately enter medication orders into the [electronic health record] EHR" more highly after the intervention. The 2017 cohort made 73 errors on 170 orders compared to 45 errors on 165 orders by the 2018 cohort.

Summary: Based on improvements in student ability to identify order entry errors and overall positive student feedback, this strategy may be adopted by other educators looking to improve student identification of errors on orders entered into a CPOE system.
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http://dx.doi.org/10.1016/j.cptl.2021.01.015DOI Listing
May 2021

Correction: Opportunities and Challenges for Digital Social Prescribing in Mental Health: Questionnaire Study.

J Med Internet Res 2021 03 29;23(3):e29041. Epub 2021 Mar 29.

Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom.

[This corrects the article DOI: .].
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http://dx.doi.org/10.2196/29041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8042537PMC
March 2021

Incidence of diabetes in South Asian young adults compared to Pima Indians.

BMJ Open Diabetes Res Care 2021 03;9(1)

Diabetology, Dr Mohan's Diabetes Specialities Centre Gopalapuram, Chennai, India.

Introduction: South Asians (SA) and Pima Indians have high prevalence of diabetes but differ markedly in body size. We hypothesize that young SA will have higher diabetes incidence than Pima Indians at comparable body mass index (BMI) levels.

Research Design And Methods: We used prospective cohort data to estimate age-specific, sex, and BMI-specific diabetes incidence in SA aged 20-44 years living in India and Pakistan from the Center for Cardiometabolic Risk Reduction in South Asia Study (n=6676), and compared with Pima Indians, from Pima Indian Study (n=1852).

Results: At baseline, SA were considerably less obese than Pima Indians (BMI (kg/m): 24.4 vs 33.8; waist circumference (cm): 82.5 vs 107.0). Age-standardized diabetes incidence (cases/1000 person-years, 95% CI) was lower in SA than in Pima Indians (men: 14.2, 12.2-16.2 vs 37.3, 31.8-42.8; women: 14.8, 13.0-16.5 vs 46.1, 41.2-51.1). Risk of incident diabetes among 20-24-year-old Pima men and women was six times (relative risk (RR), 95% CI: 6.04, 3.30 to 12.0) and seven times (RR, 95% CI: 7.64, 3.73 to 18.2) higher as compared with SA men and women, respectively. In those with BMI <25 kg/m, however, the risk of diabetes was over five times in SA men than in Pima Indian men. Among those with BMI ≥30 kg/m, diabetes incidence in SA men was nearly as high as in Pima men. SA and Pima Indians had similar magnitude of association between age, sex, BMI, and insulin secretion with diabetes. The effect of family history was larger in SA, whereas that of insulin resistance was larger in Pima Indians CONCLUSIONS: In the background of relatively low insulin resistance, higher diabetes incidence in SA is driven by poor insulin secretion in SA men. The findings call for research to improve insulin secretion in early natural history of diabetes.
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http://dx.doi.org/10.1136/bmjdrc-2020-001988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006824PMC
March 2021

Incidence and pathophysiology of diabetes in South Asian adults living in India and Pakistan compared with US blacks and whites.

BMJ Open Diabetes Res Care 2021 03;9(1)

All India Institute of Medical Sciences, New Delhi, Delhi, India.

Introduction: We compared diabetes incidence in South Asians aged ≥45 years in urban India (Chennai and Delhi) and Pakistan (Karachi), two low-income and middle-income countries undergoing rapid transition, with blacks and whites in the US, a high-income country.

Research Design And Methods: We computed age-specific, sex-specific and body mass index (BMI)-specific diabetes incidence from the prospective Center for Cardiometabolic Risk Reduction in South Asia Study (n=3136) and the Atherosclerosis Risk in Communities Study (blacks, n=3059; whites, n=9924). We assessed factors associated with incident diabetes using Cox proportional hazards regression.

Results: South Asians have lower BMI and waist circumference than blacks and whites (median BMI, kg/m: 24.9 vs 28.2 vs 26.0; median waist circumference, cm 87.5 vs 96.0 vs 95.0). South Asians were less insulin resistant than blacks and whites (age-BMI-adjusted homeostatic model assessment of insulin resistance, µIU/mL/mmol/L: 2.30 vs 3.45 vs 2.59), and more insulin deficient than blacks but not whites (age-BMI-adjusted homeostasis model assessment of β-cell dysfunction, µIU/mL/mmol/L: 103.7 vs 140.6 vs 103.9). Age-standardized diabetes incidence (cases/1000 person-years (95% CI)) in South Asian men was similar to black men and 1.6 times higher (1.37 to 1.92) than white men (26.0 (22.2 to 29.8) vs 26.2 (22.7 to 29.7) vs 16.1 (14.8 to 17.4)). In South Asian women, incidence was slightly higher than black women and 3 times (2.61 to 3.66) the rate in white women (31.9 (27.5 to 36.2) vs 28.6 (25.7 to 31.6) vs 11.3 (10.2 to 12.3)). In normal weight (BMI <25 kg/m), diabetes incidence adjusted for age was 2.9 times higher (2.09 to 4.28) in South Asian men, and 5.3 times (3.64 to 7.54) in South Asian women than in white women.

Conclusions: South Asian adults have lower BMI and are less insulin resistant than US blacks and whites, but have higher diabetes incidence than US whites, especially in subgroups without obesity. Factors other than insulin resistance (ie, insulin secretion) may play an important role in the natural history of diabetes in South Asians.
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http://dx.doi.org/10.1136/bmjdrc-2020-001927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006839PMC
March 2021
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