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Effect Of Sickle Cell On Hba1c

Sickle Cell Trait Tied To Lower Hba1c

Sickle Cell Trait Tied To Lower Hba1c

Lower HbA1c levels were reported among African Americans with sickle cell trait (SCT), compared with those without the trait, suggesting that HbA1c may "systematically underestimate past glycemia" in black patients with SCT, according to a retrospective cohort study. Significantly lower HbA1c levels were seen among those with SCT (5.72%) versus those without (6.01%), for a mean HbA1c difference of -0.29% (95% CI -0.35% to -0.23%), according to Mary E. (Beth) Lacy, MPH, doctoral candidate at Brown University School of Public Health in Providence, and colleagues. Findings were similar in an adjusted model with significantly lower HbA1c levels among African Americans with SCT (5.35%) versus without SCT (5.65%) for a mean HbA1c difference of -0.30% (-0.39% to -0.21%), they wrote in the Journal of the American Medical Association. Low HbA1c levels reported among African Americans with SCT led to significantly lower rates of prediabetes (29.2% versus 48.6%) and diabetes (3.8% versus 7.3%; P<0.001), when diagnosed with HbA1c criteria, the authors added. "Existing models had been developed in populations with no or few African Americans, so we were focusing on whether or not there were racial differences in the ability of the models to predict individuals who were at-risk for developing diabetes," Lacy told MedPage Today via email. "We found that all models we examined performed better in whites, and that differences were more pronounced when we incorporated hemoglobin A1c. So, we started thinking about what could be impacting A1C in African Americans and that led us to examine the association between A1C and sickle cell trait." The analysis drew data on African American participants (n=4,620) from the Coronary Artery Risk Development in Young Adults (CARDIA) study, as well as Continue reading >>

From The Department Of Medical Laboratory Sciences, Faculty Of Allied Health Sciences, Kuwait University, (al-fadhli) Al-amiri Hospital Medical Laboratory, Ministry Of Health (ahmad And Al-jafer) State Of Kuwait.

From The Department Of Medical Laboratory Sciences, Faculty Of Allied Health Sciences, Kuwait University, (al-fadhli) Al-amiri Hospital Medical Laboratory, Ministry Of Health (ahmad And Al-jafer) State Of Kuwait.

From the Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences, Kuwait University, (Al-Fadhli) Al-Amiri Hospital Medical Laboratory, Ministry of Health (Ahmad and Al-Jafer) State of Kuwait. Address correspondence and reprint request to: Dr. Suad Al-Fadhli, Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences, Kuwait University, PO Box 31470, Sulaibekhat 90805, State of Kuwait. Tel. +965 983 2214. Fax +965 483 3631. E-mail: Sua[email protected] aintenance of appropriate blood glucose level in diabetes mellitus patients is essential to prevent the development of diabetic complications. The Diabetes Control Complications Trial (DCCT) demonstrated that maintaining near-normal blood glucose level significantly lowered a patients risk of developing complications related to diabetes.1,2 Measuring blood glucose on a daily basis is not enough. An index of long-term glycemic control is considered valuable in evaluating the diabetic history of the patient, to monitor the efficacy of dietary M Objective: Glycated hemoglobin determination is being used worldwide to monitor the efficiency of blood glucose control and to plan treatment in diabetes mellitus patients. Several methods are used for measuring glycated hemoglobin, but a possible interference by hemoglobin variants is a major concern. The use of immunoassay methods with glycated hemoglobin-specific antibodies is supposed to overcome this problem. We are evaluating the effect of the most prevalent hemoglobinopathies in the region (sickle trait hemoglobin and ß-Thalassemia) on the immunoassay method used in determining glycated hemoglobin. Method: Eighty-one whole blood sample hemolysates were tested for glycated hemoglobin using Beckman Synchron LX20 system, 37 of these normal adu Continue reading >>

Glucose-hba1c Link Differs In Blacks By Sickle-cell Status

Glucose-hba1c Link Differs In Blacks By Sickle-cell Status

Glucose-HbA1c Link Differs in Blacks by Sickle-Cell Status The relationship between glucose levels and HbA1c in African Americans differs from that of whites, as has been noted previously. Now research suggests blacks with the sickle-cell trait (SCT) have lower HbA1c than African Americans in general, perhaps more akin to that of whites. In a new retrospective analysis of data from two prior cohort studies, published in the February 7, 2017 issue of the Journal of the American Medical Association, epidemiologist Mary E Lacy, MPH, of Brown University, Providence, Rhode Island, and colleagues indicate that the 8% to 10% of African Americans who carry the SCT have lower levels of HbA1c at any given concentration of fasting or 2-hour glucose than do those without the trait. The phenomenon is thought to be due to the fact that red blood cells of people with the SCT contain a lower proportion of hemoglobin A and higher levels of hemoglobin S, resulting in overall shorter red blood cell life-spans and less available time for glycation, thereby throwing off the established glucose-glycated hemoglobin relationship. "As a screening tool, an HbA1c value that systematically underestimates long-term glucose levels may result in a missed opportunity for intervention," the authors write, pointing out that in the current study, using standard HbA1c cutoffs resulted in identifying 40% fewer people with prediabetes and 48% fewer with diabetes among those with the SCT, compared with those without it. At the same time, glucose-based methods resulted in similar prevalences of diabetes and prediabetes regardless of SCT status. "Because black people typically have a higher prevalence of diabetes and experience a number of diabetic complications at higher rates than white people, the cost of Continue reading >>

Genetics Of Hba1c: A Case Study In Clinical Translation

Genetics Of Hba1c: A Case Study In Clinical Translation

Genetics of HbA1c: a case study in clinical translation Author links open overlay panel AaronLeong124 EleanorWheeler34 Glycated hemoglobin (HbA1c) measures the amount of glucose in the blood in the previous 23 months and is used to test whether an individual has diabetes (HbA1c6.5%), or how well they are managing their diabetes. Genome-wide association studies have successfully identified multiple genomic loci influencing HbA1c, through both glycemic (factors that affect the amount blood glucose levels) and erythrocytic (factors that affect the red blood cell) pathways. Inaccuracies in HbA1c, due to non-glycemic variants, could lead to suboptimal care or adverse health consequences. A recently published example is the erythrocytic variant (rs1050828) in G6PD, which leads to the artificial lowering of HbA1c and missed diagnosis of diabetes using current thresholds. In this review we will discuss recent insights into the genetic etiology of HbA1c, and how these can translate to the clinic. Continue reading >>

Sickle Cell Trait & Other Hemoglobinopathies & Diabetes (for Providers)

Sickle Cell Trait & Other Hemoglobinopathies & Diabetes (for Providers)

The hemoglobin A1C (A1C) test can be unreliable for diagnosing or monitoring diabetes and prediabetes in people with inherited hemoglobin variants, also called hemoglobinopathies. Hemoglobins S and E are prevalent variants in people of African, Mediterranean, or Southeast Asian descent. These variants interfere with some A1C tests—both laboratory and point-of-care tests. If A1C tests are at odds with blood glucose testing results, interference should be considered. Reliable A1C tests that do not cause interference with hemoglobin variants are available. More information about appropriate assay methods to use for hemoglobin variants is available from the NGSP at www.ngsp.org . Also, alternative tests may be needed for people with any disorder that affects red blood cells or hemoglobin. When to Suspect that a Patient with Diabetes Has a Hemoglobinopathy Most people who are heterozygous—having one variant gene and one standard hemoglobin gene—for a hemoglobin variant have no symptoms and may not know that they carry this type of hemoglobin. Health care providers should suspect the presence of a hemoglobinopathy when an A1C result is different than expected an A1C result is above 15 percent results of self-monitoring of blood glucose have a low correlation with A1C results a patient’s A1C result is radically different from a previous A1C result following a change in laboratory A1C methods Statistically Speaking Hemoglobins S and C African Americans have an increased risk of inheriting sickle cell trait, the condition in which people have both hemoglobin A (HbA), the usual form of hemoglobin, and hemoglobin S (HbS), a variant. African Americans are also at risk for having hemoglobin C (HbC), another variant. About one in 12 African Americans has sickle cell trait. Ab Continue reading >>

The A1c Blood Sugar Test May Be Less Accurate In African-americans

The A1c Blood Sugar Test May Be Less Accurate In African-americans

A widely used blood test to measure blood-sugar trends can give imprecise results, depending on a person's race and other factors. This test means diabetes can sometimes be misdiagnosed or managed poorly. Doctors have been cautioned before that results from the A1C test don't have pinpoint accuracy. A study published Tuesday underscores that shortcoming as it applies to people who carry the sickle cell trait. Glucose levels in the blood rise and fall all the time, so it can be tricky to look at a single exam to diagnose diabetes or manage the disease in people who have it. But one test gets around this problem. The A1C test measures sugar that binds to hemoglobin molecules in red blood cells. It provides an average of blood sugar over the past three months, "so this has turned out to be an incredibly powerful test, both for the diagnosis and treatment of diabetes," says Dr. Anthony Bleyer, a kidney specialist at the Wake Forest School of Medicine who was not involved in the study. The problem is that the test results can vary, depending on circumstance. For example, people with anemia may get inaccurate readings. So do people who carry unusual types of hemoglobin, the best known being sickle cell trait. Eight to 10 percent of African-Americans carry the sickle cell trait. But only people who inherit two copies of the sickle cell trait, one from each parent, develop the disease. And a few years ago, scientists realized that A1C readings for African-Americans typically don't match those from whites. They are generally higher. "The test was really standardized based on white individuals, and there were just a small number of African-American individuals in that study," Bleyer says. And while the difference isn't large, it can matter a lot, especially for people who are clo Continue reading >>

Glycemic Control And Hemoglobinopathy: When A1c May Not Be Reliable

Glycemic Control And Hemoglobinopathy: When A1c May Not Be Reliable

Background and Clinical Problem The American Diabetes Association (ADA) recommends hemoglobin A1c (A1C) as the standard laboratory assessment of glycemic control and efficacy of treatment for patients with type 1 or type 2 diabetes.1 Large prospective research trials in patients with type 12 and type 2 diabetes3 have demonstrated that A1C levels are directly related to risk of diabetes complications, such as retinopathy, neuropathy, and nephropathy. However, in some clinical situations, laboratory assessment using the A1C test may provide unreliable information. When an A1C result is inconsistent with a patient's clinical situation, conditions that affect red blood cell lifespan and hemoglobinopathies must be considered as possible causes1,4 because normative values for A1C are based on individuals with a normal hematological profile. Hemoglobinopathy Hemoglobin type is inherited. Hemoglobin A (HbA), normal adult hemoglobin, is the most common type. More than 700 forms of hemoglobinopathy or abnormal hemoglobin variants have been reported; sickle cell (HbS) is the most frequently occurring hemoglobin variant in the United States population.5 In sickle cell trait (HbAS), a person inherits a normal HbA gene from one parent and an HbS gene from the other.6 Although its prevalence is highest among African Americans (6–9%),5,7 HbAS may also occur in those of Hispanic, Greek, Italian, and other ethnic groups. In one population, those of non–African-American ethnicity accounted for 11% of people identified as having HbAS.8 It is estimated that more than 2 million people in the United States have HbAS.9 Because of its prevalence and wide ethnic variation, testing for sickle cell and other selected hemoglobinopathies is routinely performed as part of newborn screening progra Continue reading >>

Diagnosing Type 2 Diabetes In African Americans With Sickle Red Blood Cells

Diagnosing Type 2 Diabetes In African Americans With Sickle Red Blood Cells

Diagnosing Type 2 Diabetes in African Americans With Sickle Red Blood Cells Home // ... // Clinical Laboratory News // CLN Articles // Diagnosing Type 2 Diabetes in African Americans With Sickle Red Blood Cells Diagnosing Type 2 Diabetes in African Americans With Sickle Red Blood Cells Author: Chesinta B. Voma, PhD // Date: APR.1.2017 // Source: Clinical Laboratory News Why is it important to focus on African Americans with sickle cell who also have type 2 diabetes? Sickle cell disease (SCD) is an autosomal, recessive hemoglobinopathy that occurs when an individual inherits two copies of the defective beta hemoglobin gene. This is different from sickle cell trait (SCT), in which an individual inherits a single copy of the gene that causes SCD. In the United States, SCD and SCT are extremely rare in white individuals, but 8%10% of African Americans carry the mutated beta hemoglobin gene and 1 in 375 has full-blown SCD. Among non-Hispanic African Americans age 20 or older, 13.2% also have diabetes, compared with only 7.6% of non-Hispanic whites. As a result, there is a greater risk of SCD/SCT interfering with diabetes screening and management in African Americans. How does SCD/SCT impact hemoglobin A1c (HbA1c) testing? HbA1c measurements typically reflect a patients average blood glucose levels over a period of 90120 days, which is the normal lifespan of a red blood cell (RBC). However, the relationship of HbA1c with blood glucose levels may differ between African Americans with and without SCD/SCT. This is because sickle cells have a much shorter lifespan of only 1020 days. Shorter RBC survival results in less time for hemoglobin to be exposed to glycation, reducing HbA1c concentration. In one study, an African American woman with both SCD and type 2 diabetes had blood Continue reading >>

Hba1c May Underestimate Glycemic Control In Blacks With Sickle Cell Trait

Hba1c May Underestimate Glycemic Control In Blacks With Sickle Cell Trait

HbA1c May Underestimate Glycemic Control in Blacks With Sickle Cell Trait HbA1c May Underestimate Glycemic Control in Blacks With Sickle Cell Trait HbA1c levels were significantly lower than in participants without sickle cell trait. Photo Credit: CDC/Sickle Cell Foundation of Georgia: Jackie George, Beverly Sinclair. HealthDay News - Hemoglobin A1c (HbA1c) measurements may be less accurate in black people who have sickle cell trait (SCT), according to a study published online Feb. 7 in the Journal of the American Medical Association. The research included 4,620 patients (average age, 52.3) -- 1,572 from the CARDIA study, and 3,048 from the Jackson Heart Study. Both groups were evaluated to determine the association between SCT and HbA1c for given levels of fasting or two-hour glucose levels. When assessing only HbA1c, the researchers found that 29.2% of blacks with SCT were diagnosed with prediabetes versus 48.6% of blacks without SCT. The corresponding numbers for diabetes were 3.8% and 7.3%. In unadjusted generalized estimating equations analyses, for a given fasting glucose, HbA1c values were lower in those with versus those without SCT (5.72% and 6.01%, respectively). "Findings were similar in models adjusted for key risk factors and in analyses using 2001 concurrent measures of 2-hour glucose and HbA1cconcentration for those with SCT (mean, 5.35%) vs those without SCT (mean, 5.65%) for a mean HbA1cdifference of 0.30% (95% CI, 0.39% to 0.21%)". "These findings suggest that HbA1c may systematically underestimate past glycemia in black patients with SCT and may require further evaluation," the authors conclude. Discharge Blood Glucose Profile Predicts HbA1c With Diabetes Education Lacy ME, Wellenius GA, Summer AE, et al. Association of sickle cell trait with hemoglo Continue reading >>

Sickle Cell Trait In Black Patients Can Skew Diabetes Test Results

Sickle Cell Trait In Black Patients Can Skew Diabetes Test Results

TUESDAY, Feb. 7, 2017 -- A blood test commonly used to diagnose and treat diabetes may be less accurate in black people who have the sickle cell anemia trait, a new study says. The test is called hemoglobin A1C (HbA1C). An A1C reading of 5.7 or more indicates prediabetes or diabetes; below 5.7 is normal, says the American Diabetes Association. But, the current study found that for blacks with a trait for sickle cell anemia, the A1C test may come back lower than it should. This discrepancy could lead to delays in diagnosis and treatment of diabetes, and it might also affect the management of known diabetes. When the researchers compared the results of A1C tests to other measures that check blood sugar levels, they showed that when A1C readings were expected to be 6 percent, they only registered 5.7 percent for blacks with sickle cell trait. "We want to make clinicians aware that things like race and hemoglobin traits can have an effect on A1C. If the A1C numbers don't jibe with blood glucose monitor numbers, this could potentially be a part of that," said Tamara Darsow. Darsow, who wasn't involved in the study, is senior vice president of research and community programs with the American Diabetes Association. The test measures the percentage of red blood cells that have become "glycated" over a two- to three-month period. Glycated essentially means the red blood cells have sugar attached to them. That can happen when blood sugar levels are too high (hyperglycemia). Sickle cell anemia is an inherited disorder that affects the hemoglobin in red blood cells. Hemoglobin is the substance that carries oxygen to the body through the blood. Sickle cell disease causes the hemoglobin to form in a sickle shape instead of the normal rounded disc shape, according to the U.S. National Continue reading >>

Sickle Cell Trait Could Affect Diabetes Diagnosis Results In Hba1c Test

Sickle Cell Trait Could Affect Diabetes Diagnosis Results In Hba1c Test

Sickle cell trait could affect diabetes diagnosis results in HbA1c test Sickle cell trait could affect diabetes diagnosis results in HbA1c test Increased blood sugar levels after eating negatively affects people with diabetes 01 November 2016 A blood test used to diagnose diabetes may not be as accurate as it should be in people with sickle cell disease, research has suggested. Sickle cells disease is the name for a group of genetic conditions that cause people to produce unusually shaped red blood cells. The condition is more common in people of African or Caribbean descent. The HbA1c test provides a measurement of someone's blood glucose control over a three-month period. In the US, a reading of 5.7% or over indicates that a person has prediabetes and a reading of 6.5% or more indicates diabetes . In this new study, a link has been found between the sickle cell trait and lower HbA1c levels, which could indicate that diabetes diagnoses in some people of African descent may be missed. Speaking to Reuters Health, lead author Mary Elizabeth Lacy from the Brown University School of Public Health in Providence, said: "We identified 40 per cent fewer cases of prediabetes and 48 per cent fewer cases of diabetes in individuals with sickle cell trait than in those without sickle cell trait." It is thought around 10 per cent of people with an African or Caribbean background have sickle cell disease, but people from Eastern Mediterranean and Middle Eastern backgrounds can also inherit it. People develop sickle cell trait if one of their parents pass on the gene, which can lead to differences in red blood cells. If both parents pass on the sickle cell trait gene then the person develops sickle cell disease, for which the symptoms are more severe. More than 4,600 African Americans Continue reading >>

Hemoglobinopathies May Distort Hba1c – A Caution To Practitioners

Hemoglobinopathies May Distort Hba1c – A Caution To Practitioners

Measuring glycated hemoglobin (HbA1c) gives us a patient’s long term average blood glucose levels.1 Since HbA1c measures the percentage of patients’ glycosolated hemoglobin, patients who possess variants of hemoglobin can exhibit false readings. Such variants, called hemoglobinopathies, can include inherited hemoglobin variants, elevated fetal hemoglobin, and hemoglobin S and E which are prevalent in people of Southeast Asia, Mediterranean, and African descent. 2 One variant of particular concern is the sickle cell trait. People with this trait have inherited biological differences affecting the formation of their hemoglobin and erythrocytes, which in turn affects their levels of glycated hemoglobin. 5 People who have the sickle cell trait have both normal hemoglobin A and hemoglobin S. In the U.S., African Americans are at a higher risk of having the sickle cell trait, and approximately 18.7 percent of African Americans who are 20 years and older have diabetes. 2 In people who have both the sickle cell trait and diabetes, about 1 million people in the U.S., using HbA1c to measure blood glucose levels can be prone to anomalies. People with these hemoglobin variants can have falsely low or high levels which can lead to improper treatment including: HbA1c readings that are different than expected; HbA1c levels that are extremely different from previous HbA1c readings; or low correlations between HbA1c and self-monitored glucose levels. 2 Normally, for every 25-32mg/dL increase in blood glucose levels, there is a 1% increase in HbA1c in patients without any hematologic variants. 3 But with patients who do have any hematologic disorders, this corresponding increase in HbA1c does not occur. In a published article regarding sickle cell and diabetes, an African American wo Continue reading >>

Factors That Interfere With Hba1c Test Results

Factors That Interfere With Hba1c Test Results

Information for physicians and patients regarding HbS, HbC, HbE and HbD traits More about hemoglobin variants and HbA1c can also be found at the NIDDK web site: Sickle Cell Trait and Other Hemoglobinopathies and Diabetes: Important Information for Physicians For People of African, Mediterranean, or Southeast Asian Heritage: Important Information about Diabetes Blood Tests Factors that Interfere with HbA1c Measurement: Genetic variants (e.g. HbS trait, HbC trait), elevated fetal hemoglobin (HbF) and chemically modified derivatives of hemoglobin (e.g. carbamylated Hb in patients with renal failure) can affect the accuracy of HbA1c measurements. The effects vary depending on the specific Hb variant or derivative and the specific HbA1c method. Table 1 contains information for most of the commonly used current HbA1c methods for the four most common Hb variants, elevated HbF and carbamylated Hb. Interferences from less common Hb variants and derivatives are discussed in Bry, et al [1]. All entries in Table 1 are based on published information. In addition, if a product insert indicates clearly that there is inference from a particular factor, then the interference is entered as “yes” and the product insert is cited. When selecting an assay method, laboratories should take into consideration characteristics of the patient population served, (e.g. high prevalence of hemoglobinopathies or renal failure). Factors that affect interpretation of HbA1c Results: Any condition that shortens erythrocyte survival or decreases mean erythrocyte age (e.g., recovery from acute blood loss, hemolytic anemia) will falsely lower HbA1c test results regardless of the assay method used [2]. HbA1c results from patients with HbSS, HbCC, and HbSC must be interpreted with caution given the patholog Continue reading >>

When Is Hemoglobin A1c Inaccurate In Assessing Glycemic Control?

When Is Hemoglobin A1c Inaccurate In Assessing Glycemic Control?

Faculty Peer Reviewed Hemoglobin A1C (HbA1c) is an invaluable tool for monitoring long-term glycemic control in diabetic patients. However, many clinicians managing diabetics have encountered the problem of HbA1c values that do not agree with fingerstick glucose logs. Before suspecting an improperly calibrated glucometer or poor patient record keeping, it is useful to consider the situations in which HbA1c may be spuriously elevated or depressed. These issues are best understood after reviewing how HbA1c is defined and measured–topics fraught with considerable confusion. Glycosylation is a non-enzymatic, time-dependent chemical reaction in which glucose binds to the amino groups of proteins.[1] Historically, and long before its precise chemistry was discovered, glycosylated Hb was defined as an area of an elution chromatogram containing hemoglobin glycosylation products. This elution peak was labeled as HbA1, in keeping with the existing nomenclature (HbA, HbA2, HbF, etc. had been identified previously). Later it was recognized that the chromatographic HbA1 region is not homogeneous and consists of several component peaks, designated A1a, A1b and A1c, with HbA1c being the dominant one.[1] The HbA1c fraction also turned out to correlate best with mean serum glucose concentrations, ie, to be a better index of long-term glycemia. Relatively recently HbA1c was redefined chemically: now glycohemoglobin refers to hemoglobin glycosylated at any of its amino groups, while HbA1c is defined as glycohemoglobin with glucose bound specifically to the terminal valine of the beta-globin chain. Consequently, the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) has developed a standard reference method for HbA1c in which hemoglobin is cleaved with a specif Continue reading >>

Association Of Sickle Cell Trait With Hemoglobin A1c In African Americans.

Association Of Sickle Cell Trait With Hemoglobin A1c In African Americans.

Association of Sickle Cell Trait With Hemoglobin A1c in African Americans. Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island. Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes, Digestive, and Kidney Diseases and the National Institute of Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland. Department of Medicine, University of Mississippi Medical Center, Jackson. Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Division of Hematology, Oncology & SCT, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois. Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson. Department of Laboratory Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland. Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis. Department of Epidemiology, School of Public Health, University of Alabama at Birmingham. Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island. Department of Epidemiology, University of Washington School of Public Health, Seattle. Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island15Department of Medicine, Alpert Medical School, Brown University, Providence, Rhode Island. Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island13Center for Innovation in Long-Term Services and Support, Providence Veterans Affairs Medical Center, Providence, Rhode Island14Division of Cardiology, Pr Continue reading >>

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