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Crude prices rise after positive news from China

Oil prices rose early Tuesday, after Monday declines, possibly helped by some positive news from China -- but doubts remain as to whether that direction will hold.




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Cancer patients on Medicaid might not benefit from experimental treatments, study finds

Cancer patients on Medicaid or who don't have insurance benefit less from experimental treatments, even if they get into clinical trials, a study published Thursday by JAMA Network Open has found.




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Exploring New Legal Migration Pathways: Lessons from Pilot Projects

As European countries launch ambitious new legal migration partnerships with several origin and transit countries in Africa, this report takes stock of the long and mixed history of such projects. To make the most of their potential to encourage skills development and fill pressing labor gaps, policymakers will need to think carefully about the partners and sectors they choose, among other key considerations.




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Social Innovation for Refugee Inclusion: From Bright Spots to System Change

In the three years since the European migration and refugee crisis vividly captured public attention, a wave of innovative initiatives has emerged to help newcomers settle into receiving societies. Now, as the sense of crisis abates, this report explores what these initiatives will need to do to outlast the hype and produce lasting change on key integration issues such as housing, economic inclusion, and community building.




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Renal and Cardiovascular Outcomes After Weight Loss From Gastric Bypass Surgery in Type 2 Diabetes: Cardiorenal Risk Reductions Exceed Atherosclerotic Benefits

OBJECTIVE

We examined detailed renal and cardiovascular (CV) outcomes after gastric bypass (GBP) surgery in people with obesity and type 2 diabetes mellitus (T2DM), across several renal function categories, in a nationwide cohort study.

RESEARCH DESIGN AND METHODS

We linked data from the National Diabetes Register and the Scandinavian Obesity Surgery Register with four national databases holding information on socioeconomic variables, medications, hospitalizations, and causes of death and matched 5,321 individuals with T2DM who had undergone GBP with 5,321 who had not (age 18–65 years, mean BMI >40 kg/m2, mean follow-up >4.5 years). The risks of postoperative outcomes were assessed with Cox regression models.

RESULTS

During the first years postsurgery, there were small reductions in creatinine and albuminuria and stable estimated glomerular filtration rate (eGFR) in the GBP group. The incidence rates of most outcomes relating to renal function, CV disease, and mortality were lower after GBP, being particularly marked for heart failure (hazard ratio [HR] 0.33 [95% CI 0.24, 0.46]) and CV mortality (HR 0.36 [(95% CI 0.22, 0.58]). The risk of a composite of severe renal disease or halved eGFR was 0.56 (95% CI 0.44, 0.71), whereas nonfatal CV risk was lowered less (HR 0.82 [95% CI 0.70, 0.97]) after GBP. Risks for key outcomes were generally lower after GBP in all eGFR strata, including in individuals with eGFR <30 mL/min/1.73 m2.

CONCLUSIONS

Our data suggest robust benefits for renal outcomes, heart failure, and CV mortality after GBP in individuals with obesity and T2DM. These results suggest that marked weight loss yields important benefits, particularly on the cardiorenal axis (including slowing progression to end-stage renal disease), whatever the baseline renal function status.




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Obstructive Sleep Apnea, a Risk Factor for Cardiovascular and Microvascular Disease in Patients With Type 2 Diabetes: Findings From a Population-Based Cohort Study

OBJECTIVE

To determine the risk of cardiovascular disease (CVD), microvascular complications, and mortality in patients with type 2 diabetes who subsequently develop obstructive sleep apnea (OSA) compared with patients with type 2 diabetes without a diagnosis of OSA.

RESEARCH DESIGN AND METHODS

This age-, sex-, BMI-, and diabetes duration–matched cohort study used data from a U.K. primary care database from 1 January 2005 to 17 January 2018. Participants aged ≥16 years with type 2 diabetes were included. Exposed participants were those who developed OSA after their diabetes diagnosis; unexposed participants were those without diagnosed OSA. Outcomes were composite CVD (ischemic heart disease [IHD], stroke/transient ischemic attack [TIA], heart failure [HF]), peripheral vascular disease (PVD), atrial fibrillation (AF), peripheral neuropathy (PN), diabetes-related foot disease (DFD), referable retinopathy, chronic kidney disease (CKD), and all-cause mortality. The same outcomes were explored in patients with preexisting OSA before a diagnosis of type 2 diabetes versus diabetes without diagnosed OSA.

RESULTS

A total of 3,667 exposed participants and 10,450 matched control participants were included. Adjusted hazard ratios for the outcomes were as follows: composite CVD 1.54 (95% CI 1.32, 1.79), IHD 1.55 (1.26, 1.90), HF 1.67 (1.35, 2.06), stroke/TIA 1.57 (1.27, 1.94), PVD 1.10 (0.91, 1.32), AF 1.53 (1.28, 1.83), PN 1.32 (1.14, 1.51), DFD 1.42 (1.16, 1.74), referable retinopathy 0.99 (0.82, 1.21), CKD (stage 3–5) 1.18 (1.02, 1.36), albuminuria 1.11 (1.01, 1.22), and all-cause mortality 1.24 (1.10, 1.40). In the prevalent OSA cohort, the results were similar, but some associations were not observed.

CONCLUSIONS

Patients with type 2 diabetes who develop OSA are at increased risk of CVD, AF, PN, DFD, CKD, and all-cause mortality compared with patients without diagnosed OSA. Patients with type 2 diabetes who develop OSA are a high-risk population, and strategies to detect OSA and prevent cardiovascular and microvascular complications should be implemented.




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Dietary Manganese, Plasma Markers of Inflammation, and the Development of Type 2 Diabetes in Postmenopausal Women: Findings From the Womens Health Initiative

OBJECTIVE

To examine the association between manganese intake and the risk of type 2 diabetes in postmenopausal women and determine whether this association is mediated by circulating markers of inflammation.

RESEARCH DESIGN AND METHODS

We included 84,285 postmenopausal women without a history of diabetes from the national Women’s Health Initiative Observational Study (WHI-OS). Replication analysis was then conducted among 62,338 women who participated in the WHI-Clinical Trial (WHI-CT). Additionally, data from a case-control study of 3,749 women nested in the WHI-OS with information on biomarkers of inflammation and endothelial dysfunction were examined using mediation analysis to determine the relative contributions of these known biomarkers by which manganese affects type 2 diabetes risk.

RESULTS

Compared with the lowest quintile of energy-adjusted dietary manganese, WHI-OS participants in the highest quintile had a 30% lower risk of type 2 diabetes (hazard ratio [HR] 0.70 [95% CI 0.65, 0.76]). A consistent association was also confirmed in the WHI-CT (HR 0.79 [95% CI 0.73, 0.85]). In the nested case-control study, higher energy-adjusted dietary manganese was associated with lower circulating levels of inflammatory biomarkers that significantly mediated the association between dietary manganese and type 2 diabetes risk. Specifically, 19% and 12% of type 2 diabetes risk due to manganese were mediated through interleukin 6 and hs-CRP, respectively.

CONCLUSIONS

Higher intake of manganese was directly associated with a lower type 2 diabetes risk independent of known risk factors. This association may be partially mediated by inflammatory biomarkers.




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microRNA-21/PDCD4 Proapoptotic Signaling From Circulating CD34+ Cells to Vascular Endothelial Cells: A Potential Contributor to Adverse Cardiovascular Outcomes in Patients With Critical Limb Ischemia

OBJECTIVE

In patients with type 2 diabetes (T2D) and critical limb ischemia (CLI), migration of circulating CD34+ cells predicted cardiovascular mortality at 18 months after revascularization. This study aimed to provide long-term validation and mechanistic understanding of the biomarker.

RESEARCH DESIGN AND METHODS

The association between CD34+ cell migration and cardiovascular mortality was reassessed at 6 years after revascularization. In a new series of T2D-CLI and control subjects, immuno-sorted bone marrow CD34+ cells were profiled for miRNA expression and assessed for apoptosis and angiogenesis activity. The differentially regulated miRNA-21 and its proapoptotic target, PDCD4, were titrated to verify their contribution in transferring damaging signals from CD34+ cells to endothelial cells.

RESULTS

Multivariable regression analysis confirmed that CD34+ cell migration forecasts long-term cardiovascular mortality. CD34+ cells from T2D-CLI patients were more apoptotic and less proangiogenic than control subjects and featured miRNA-21 downregulation, modulation of several long noncoding RNAs acting as miRNA-21 sponges, and upregulation of the miRNA-21 proapoptotic target PDCD4. Silencing miR-21 in control subject CD34+ cells phenocopied the T2D-CLI cell behavior. In coculture, T2D-CLI CD34+ cells imprinted naïve endothelial cells, increasing apoptosis, reducing network formation, and modulating the TUG1 sponge/miRNA-21/PDCD4 axis. Silencing PDCD4 or scavenging reactive oxygen species protected endothelial cells from the negative influence of T2D-CLI CD34+ cells.

CONCLUSIONS

Migration of CD34+ cells predicts long-term cardiovascular mortality in T2D-CLI patients. An altered paracrine signaling conveys antiangiogenic and proapoptotic features from CD34+ cells to the endothelium. This damaging interaction may increase the risk for life-threatening complications.




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Top 5 Questions about ADHD- From Everyday Health

Everyday Health is gathering the responses of several professionals of the top 5 questions they get regarding ADHD. They asked me to participate. The following are the questions and my answers. Check in with Everyday Health next week to see the compilation of responses.

1. Why are there so many theories about the causes of ADHD? What are the most common?

Any disorder that does not have a known cause is open to a number of theories. People naturally want to know why or want to feel as if it can be prevented in the future. Heredity is believed to be the most commonly accepted cause.

2. How can you explain the value of treatment to resistant parents? For example, “I survived my childhood with ADHD --and I was never diagnosed or treated. Why does my child need ADHD treatment?”

Often children with ADHD have gaps in their education. As they are in and out of focus each day, they miss key points in instruction. As new skills build upon old skills, it can be more and more difficult to learn new tasks where there are gaps in the foundation. This difficulty can make focusing even more difficult, further compounding the problem. Treatment can help reduce or prevent this cycle.

3. What role does a child’s school have in helping him or her with ADHD?

The school can help by providing support and accommodations specific to the particular needs of your child IF it can be determined that the symptoms of ADHD are significantly impacting his or her education. Of course, each school has different criteria for determining if there is a significant impact.

4. Are the medications recommended for ADHD safe for children? What are the potential dangers?

There is not a lot of solid research yet on this topic. While the medications are believed to be safe, they have not been around long enough to fully study long term effects. There are also side effects that may make the medications not worth the benefits in some children. All of that being said, I've seen kids who are finally able to focus after starting medication. Taking the medication improves learning, grades, and self esteem, which has numerous positive long term benefits. Medication is not something to take lightly. Parents must think very carefully weigh the unknown risks of taking the medications verses the possible risks of refusing the medications. There is not one answer that fits all children.

5. What are the most common side effects of ADHD meds?

Weight loss, behavioral changes, and headaches are possible side effects.




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House probe: Trump admin failed to adequately screen travelers from South Korea, Italy for COVID-19

The Trump administration failed to conduct effective screening of passengers from South Korea and Italy for the coronavirus when those countries were experiencing rapid expansion in COVID-19 cases.




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Astronauts anticipate first crewed launch from U.S. soil in nine years

The two astronauts who are to begin a new era of human spaceflight from U.S. soil this month said Friday they hope to inspire generations of Americans.




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Astronomers find black hole just 1,000 light-years from Earth

Scientists have discovered the closest black hole to Earth, located just 1,000 light-years away.




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Televangelist Jim Bakker recovering from stroke

Televangelist Jim Bakker is recovering at his North Carolina home after having a stroke, his wife said Friday.




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Watch: Gwyneth Paltrow, Ben Schwartz read texts from their moms on 'Kimmel'

Gwyneth Paltrow, Ben Schwartz and other celebrities read text messages from their mothers on "Jimmy Kimmel Live" in honor of Mother's Day.




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Princess Love files for divorce from Ray J

Princess Love filed for divorce from Ray J, her husband and "Love & Hip Hop: Hollywood" co-star, after nearly four years of marriage.





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How to Stay Sane While Staying Home: Advice from an Introvert

For loners, recluses, and other solitary types such as myself, sheltering-in-place feels natural and normal. However scary other aspects of this pandemic might be, for us, this aspect isn’t. Working...




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[ Credit ] Open Question : I'm 23 with a 536 credit score because I was stupid from ages 18-20. Is there any way to make it higher? ?

I have 2500 worth of debt and most of it has been turned over into collections 




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[ Religion & Spirituality ] Open Question : My mother keeps turning water into wine, walking on water and resurrecting from the dead. Is she a witch?




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[ Politics ] Open Question : IF Cons rewrote the Constitution of the United States would it have less laws, more liberty, & move power from DC to the State Capitals?

Oh would that 'less laws/more liberty/more state capital power' look anything like Mike Pence's Religious Freedom Restoration Act or in other words the 'we Conservative Republican Christians are such oppressed persecuted victims WAAAAA WAAAA' Bill. https://www.youtube.com/watch?v=KIikqPmbgvI 




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From Emigration to Asylum Destination, Italy Navigates Shifting Migration Tides

Long a country of emigration—13 million Italians went abroad between 1880 and 1915—Italy has also experienced significant inflows of Middle Eastern and sub-Saharan African workers in recent decades. Italy has also been on the frontlines of Europe's refugee crisis. This country profile examines Italy's shifting migration patterns, policy responses over time, and debates.




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Under Lockdown Amid COVID-19 Pandemic, Europe Feels the Pinch from Slowed Intra-EU Labor Mobility

Border closures and lockdowns amid the COVID-19 pandemic have put a chill on intra-EU labor mobility, most immediately with the difficulty for European farmers to gain access to much-needed seasonal workers and for health-care institutions to get care workers. This article explores how these workers, who often face difficult situations, may be more vulnerable now. It also takes on implications for intra-EU labor mobility post-pandemic.




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Tapping the Talents of Highly Skilled Immigrants in the United States: Takeaways from Experts Summit

Economists project a shortage of 5 million U.S. workers with postsecondary education and training by 2020. Yet 2 million immigrant college graduates in the United States are either unemployed or work in jobs that require no more than a high school degree. How can this skill underutilization, known as "brain waste," be remedied? MPI asked the experts, and this report summarizes their discussion and recommendations.




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'Attraction Effect' Helps Voters Pick From the Pack

Some years ago, a political scientist conducted an interesting experiment that speaks to the fractured race for the Republican presidential nomination, which now has six candidates, five issues, and four potential front-runners.




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What Obama Might Learn From Emily Dickinson

Tell all the Truth but tell it slant/Success in Circuit lies/Too bright for our infirm Delight/The Truth's superb surprise . . .





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After the Storm: Learning from the EU Response to the Migration Crisis

As maritime arrivals climbed in 2015, EU policymakers struggled to mount a coordinated response. A range of ad hoc crisis-response tools emerged, but many officials worry that if another migration emergency were to hit Europe, the European Union may still be unprepared. This report traces the evolution of the EU response to the 2015–16 crisis and lays out recommendations to lock in progress and shore up weaknesses.




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Supporting DLLs in Superdiverse PreK-3 Programs: Findings from Two Studies

Marking the release of two research reports that highlight promising, effective approaches to teaching and learning for Dual Language Learners in multilingual, multicultural classrooms, report authors present their findings on this webinar and discuss key implications for policy and practice.




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Reducing Integration Barriers Facing Foreign-Trained Immigrants: Policy and Practice Lessons from Across the United States

Marking the release of an MPI report, researchers and practitioners on this webinar discuss brain waste among college-educated immigrants and initiatives that ease the barriers foreign-educated newcomers confront with regards to credential recognition, employment, and relicensure, as well as recent policy developments and ongoing challenges in the field.




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Reducing Integration Barriers Facing Foreign-Trained Immigrants: Policy and Practice Lessons from Across the United States

Marking the release of a report on the barriers foreign-trained high-skilled immigrants face in the United States, this webinar examines programs and initiatives that assist with credential recognition, employment, and relicensure, as well as recent policy developments. Discussants review recommendations for community-based organizations, employers, and policymakers to expand successful efforts aimed at preventing brain waste. 




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As Millions Are Pushed from Jobs amid Pandemic, the Loss of Employer Health Coverage &amp; Limited Access to Public Coverage for Many Immigrants Hold Major Implications for Them – and U.S. Overall

WASHINGTON – As more than 33 million U.S. workers have lost their jobs since March amid the pandemic-induced economic crisis, immigrants are among the most vulnerable: They are more likely than the U.S. born to be laid off and to live in communities with high COVID-19 infection rates, and less likely to have health insurance coverage and access to a doctor or other usual source of health care.




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As More Migrants from Africa and Asia Arrive in Latin America, Governments Seek Orderly and Controlled Pathways

Growing numbers of African and Asian migrants are moving through Latin America, many hoping to reach the United States or Canada after expensive, arduous, and often dangerous journeys that can take months or even years. As more extracontinental migrants transit through South and Central America, Colombia, Panama, and Costa Rica have developed the most comprehensive policies to manage these flows, sometimes working in coordination with the U.S. government.




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Efficacy and Safety of Dapagliflozin in the Elderly: Analysis From the DECLARE-TIMI 58 Study

OBJECTIVE

Data regarding the effects of sodium–glucose cotransporter 2 inhibitors in the elderly (age ≥65 years) and very elderly (age ≥75 years) are limited.

RESEARCH DESIGN AND METHODS

The Dapagliflozin Effect on Cardiovascular Events (DECLARE)–TIMI 58 assessed cardiac and renal outcomes of dapagliflozin versus placebo in patients with type 2 diabetes. Efficacy and safety outcomes were studied within age subgroups for treatment effect and age-based treatment interaction.

RESULTS

Of the 17,160 patients, 9,253 were <65 years of age, 6,811 ≥65 to <75 years, and 1,096 ≥75 years. Dapagliflozin reduced the composite of cardiovascular death or hospitalization for heart failure consistently, with a hazard ratio (HR) of 0.88 (95% CI 0.72, 1.07), 0.77 (0.63, 0.94), and 0.94 (0.65, 1.36) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.5277). Overall, dapagliflozin did not significantly decrease the rates of major adverse cardiovascular events, with HR 0.93 (95% CI 0.81, 1.08), 0.97 (0.83, 1.13), and 0.84 (0.61, 1.15) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.7352). The relative risk reduction for the secondary prespecified cardiorenal composite outcome ranged from 18% to 28% in the different age-groups with no heterogeneity. Major hypoglycemia was less frequent with dapagliflozin versus placebo, with HR 0.97 (95% CI 0.58, 1.64), 0.50 (0.29, 0.84), and 0.68 (0.29, 1.57) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.2107). Safety outcomes, including fractures, volume depletion, cancer, urinary tract infections, and amputations were balanced with dapagliflozin versus placebo, and acute kidney injury was reduced, all regardless of age. Genital infections that were serious or led to discontinuation of the study drug and diabetic ketoacidosis were uncommon, yet more frequent with dapagliflozin versus placebo, without heterogeneity (interaction P values 0.1058 and 0.8433, respectively).

CONCLUSIONS

The overall efficacy and safety of dapagliflozin are consistent regardless of age.




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Myocardial Ischemic Burden and Differences in Prognosis Among Patients With and Without Diabetes: Results From the Multicenter International REFINE SPECT Registry

OBJECTIVE

Prevalence and prognostic impact of cardiovascular disease differ between patients with or without diabetes. We aimed to explore differences in the prevalence and prognosis of myocardial ischemia by automated quantification of total perfusion deficit (TPD) among patients with and without diabetes.

RESEARCH DESIGN AND METHODS

Of 20,418 individuals who underwent single-photon emission computed tomography myocardial perfusion imaging, 2,951 patients with diabetes were matched to 2,951 patients without diabetes based on risk factors using propensity score. TPD was categorized as TPD = 0%, 0% < TPD < 1%, 1% ≤ TPD < 5%, 5% ≤ TPD ≤ 10%, and TPD >10%. Major adverse cardiovascular events (MACE) were defined as a composite of all-cause mortality, myocardial infarction, unstable angina, or late revascularization.

RESULTS

MACE risk was increased in patients with diabetes compared with patients without diabetes at each level of TPD above 0 (P < 0.001 for interaction). In patients with TPD >10%, patients with diabetes had greater than twice the MACE risk compared with patients without diabetes (annualized MACE rate 9.4 [95% CI 6.7–11.6] and 3.9 [95% CI 2.8–5.6], respectively, P < 0.001). Patients with diabetes with even very minimal TPD (0% < TPD < 1%) experienced a higher risk for MACE than those with 0% TPD (hazard ratio 2.05 [95% CI 1.21–3.47], P = 0.007). Patients with diabetes with a TPD of 0.5% had a similar MACE risk as patients without diabetes with a TPD of 8%.

CONCLUSIONS

For every level of TPD >0%, even a very minimal deficit of 0% < TPD < 1%, the MACE risk was higher in the patients with diabetes compared with patients without diabetes. Patients with diabetes with minimal ischemia had comparable MACE risk as patients without diabetes with significant ischemia.




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Microvascular and Cardiovascular Outcomes According to Renal Function in Patients Treated With Once-Weekly Exenatide: Insights From the EXSCEL Trial

OBJECTIVE

To evaluate the impact of once-weekly exenatide (EQW) on microvascular and cardiovascular (CV) outcomes by baseline renal function in the Exenatide Study of Cardiovascular Event Lowering (EXSCEL).

RESEARCH DESIGN AND METHODS

Least squares mean difference (LSMD) in estimated glomerular filtration rate (eGFR) from baseline between the EQW and placebo groups was calculated for 13,844 participants. Cox regression models were used to estimate effects by group on incident macroalbuminuria, retinopathy, and major adverse CV events (MACE). Interval-censored time-to-event models estimated effects on renal composite 1 (40% eGFR decline, renal replacement, or renal death) and renal composite 2 (composite 1 variables plus macroalbuminuria).

RESULTS

EQW did not change eGFR significantly (LSMD 0.21 mL/min/1.73 m2 [95% CI –0.27 to 0.70]). Macroalbuminuria occurred in 2.2% of patients in the EQW group and in 2.5% of those in the placebo group (hazard ratio [HR] 0.87 [95% CI 0.70–1.07]). Neither renal composite was reduced with EQW in unadjusted analyses, but renal composite 2 was reduced after adjustment (HR 0.85 [95% CI 0.74–0.98]). Retinopathy rates did not differ by treatment group or in the HbA1c-lowering or prior retinopathy subgroups. CV outcomes in those with eGFR <60 mL/min/1.73 m2 did not differ by group. Those with eGFR ≥60 mL/min/1.73 m2 had nominal risk reductions for MACE, all-cause mortality, and CV death, but interactions by renal function group were significant for only stroke (HR 0.74 [95% CI 0.58–0.93]; P for interaction = 0.035) and CV death (HR 1.08 [95% CI 0.85–1.38]; P for interaction = 0.031).

CONCLUSIONS

EQW had no impact on unadjusted retinopathy or renal outcomes. CV risk was modestly reduced only in those with eGFR ≥60 mL/min/1.73 m2 in analyses unadjusted for multiplicity.




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Glycated Hemoglobin, Prediabetes, and the Links to Cardiovascular Disease: Data From UK Biobank

OBJECTIVE

HbA1c levels are increasingly measured in screening for diabetes; we investigated whether HbA1c may simultaneously improve cardiovascular disease (CVD) risk assessment, using QRISK3, American College of Cardiology/American Heart Association (ACC/AHA), and Systematic COronary Risk Evaluation (SCORE) scoring systems.

RESEARCH DESIGN AND METHODS

UK Biobank participants without baseline CVD or known diabetes (n = 357,833) were included. Associations of HbA1c with CVD was assessed using Cox models adjusting for classical risk factors. Predictive utility was determined by the C-index and net reclassification index (NRI). A separate analysis was conducted in 16,596 participants with known baseline diabetes.

RESULTS

Incident fatal or nonfatal CVD, as defined in the QRISK3 prediction model, occurred in 12,877 participants over 8.9 years. Of participants, 3.3% (n = 11,665) had prediabetes (42.0–47.9 mmol/mol [6.0–6.4%]) and 0.7% (n = 2,573) had undiagnosed diabetes (≥48.0 mmol/mol [≥6.5%]). In unadjusted models, compared with the reference group (<42.0 mmol/mol [<6.0%]), those with prediabetes and undiagnosed diabetes were at higher CVD risk: hazard ratio (HR) 1.83 (95% CI 1.69–1.97) and 2.26 (95% CI 1.96–2.60), respectively. After adjustment for classical risk factors, these attenuated to HR 1.11 (95% CI 1.03–1.20) and 1.20 (1.04–1.38), respectively. Adding HbA1c to the QRISK3 CVD risk prediction model (C-index 0.7392) yielded a small improvement in discrimination (C-index increase of 0.0004 [95% CI 0.0001–0.0007]). The NRI showed no improvement. Results were similar for models based on the ACC/AHA and SCORE risk models.

CONCLUSIONS

The near twofold higher unadjusted risk for CVD in people with prediabetes is driven mainly by abnormal levels of conventional CVD risk factors. While HbA1c adds minimally to cardiovascular risk prediction, those with prediabetes should have their conventional cardiovascular risk factors appropriately measured and managed.




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Confirming the Bidirectional Nature of the Association Between Severe Hypoglycemic and Cardiovascular Events in Type 2 Diabetes: Insights From EXSCEL

OBJECTIVE

We sought to confirm a bidirectional association between severe hypoglycemic events (SHEs) and cardiovascular (CV) event risk and to characterize individuals at dual risk.

RESEARCH DESIGN AND METHODS

In a post hoc analysis of 14,752 Exenatide Study of Cardiovascular Event Lowering (EXSCEL) participants, we examined time-dependent associations between SHEs and subsequent major adverse cardiac events (CV death, nonfatal myocardial infarction [MI] or stroke), fatal/nonfatal MI, fatal/nonfatal stroke, hospitalization for acute coronary syndrome (hACS), hospitalization for heart failure (hHF), and all-cause mortality (ACM), as well as time-dependent associations between nonfatal CV events and subsequent SHEs.

RESULTS

SHEs were uncommon and not associated with once-weekly exenatide therapy (hazard ratio 1.13 [95% CI 0.94–1.36], P = 0.179). In fully adjusted models, SHEs were associated with an increased risk of subsequent ACM (1.83 [1.38–2.42], P < 0.001), CV death (1.60 [1.11–2.30], P = 0.012), and hHF (2.09 [1.37–3.17], P = 0.001), while nonfatal MI (2.02 [1.35–3.01], P = 0.001), nonfatal stroke (2.30 [1.25–4.23], P = 0.007), hACS (2.00 [1.39–2.90], P < 0.001), and hHF (3.24 [1.98–5.30], P < 0.001) were all associated with a subsequent increased risk of SHEs. The elevated bidirectional time-dependent hazards linking SHEs and a composite of all CV events were approximately constant over time, with those individuals at dual risk showing higher comorbidity scores compared with those without.

CONCLUSIONS

These findings, showing greater risk of SHEs after CV events as well as greater risk of CV events after SHEs, validate a bidirectional relationship between CV events and SHEs in patients with high comorbidity scores.




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Can a Company be pro-regulation and pro-commerce? Gregg Renfrew from Beautycounter thinks so

It’s the middle of an election year and, according to the Pew Research Center, the country hasn’t been this polarized since the Civil War. In such a climate, it would seem to be an oxymoron for a company to push for both financial growth and tighter regulations. Gregg Renfrew, CEO & Founder of Beautycounter, wouldn’t […]




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Thinking with AND: Insights from KIND’s story

“I’m a confused Mexican Jew.” So says Daniel Lubetzky, Founder and CEO of KIND Snack, in his very personal interview with Columbia faculty member David Rogers at BRITE ’16. Their discussion touched on the many ideas behind KIND Snacks, from the beginnings of the company, to the strategic thinking that forces Lubetzky to stay away […]




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10 Examples of Heroism Arising From the COVID-19 Pandemic

By Scott T. Allison In any tragedy or crisis, you will see many people standing out and stepping up to save lives and make the world a better place. These heroic individuals can range from leaders of nations to ordinary citizens who rise to the occasion to help others in need. During this COVID-19 pandemic, … Continue reading 10 Examples of Heroism Arising From the COVID-19 Pandemic




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No-Failure Design and Disaster Recovery: Lessons from Fukushima

One of the striking aspects of the early stages of the nuclear accident at Fukushima-Daiichi last March was the nearly total absence of disaster recovery capability. For instance, while Japan is a super-power of robotic technology, the nuclear authorities had to import robots from France for probing the damaged nuclear plants. Fukushima can teach us an important lesson about technology.

The failure of critical technologies can be disastrous. The crash of a civilian airliner can cause hundreds of deaths. The meltdown of a nuclear reactor can release highly toxic isotopes. Failure of flood protection systems can result in vast death and damage. Society therefore insists that critical technologies be designed, operated and maintained to extremely high levels of reliability. We benefit from technology, but we also insist that the designers and operators "do their best" to protect us from their dangers.

Industries and government agencies who provide critical technologies almost invariably act in good faith for a range of reasons. Morality dictates responsible behavior, liability legislation establishes sanctions for irresponsible behavior, and economic or political self-interest makes continuous safe operation desirable.

The language of performance-optimization  not only doing our best, but also achieving the best  may tend to undermine the successful management of technological danger. A probability of severe failure of one in a million per device per year is exceedingly  and very reassuringly  small. When we honestly believe that we have designed and implemented a technology to have vanishingly small probability of catastrophe, we can honestly ignore the need for disaster recovery.

Or can we?

Let's contrast this with an ethos that is consistent with a thorough awareness of the potential for adverse surprise. We now acknowledge that our predictions are uncertain, perhaps highly uncertain on some specific points. We attempt to achieve very demanding outcomes  for instance vanishingly small probabilities of catastrophe  but we recognize that our ability to reliably calculate such small probabilities is compromised by the deficiency of our knowledge and understanding. We robustify ourselves against those deficiencies by choosing a design which would be acceptable over a wide range of deviations from our current best understanding. (This is called "robust-satisficing".) Not only does "vanishingly small probability of failure" still entail the possibility of failure, but our predictions of that probability may err.

Acknowledging the need for disaster recovery capability (DRC) is awkward and uncomfortable for designers and advocates of a technology. We would much rather believe that DRC is not needed, that we have in fact made catastrophe negligible. But let's not conflate good-faith attempts to deal with complex uncertainties, with guaranteed outcomes based on full knowledge. Our best models are in part wrong, so we robustify against the designer's bounded rationality. But robustness cannot guarantee success. The design and implementation of DRC is a necessary part of the design of any critical technology, and is consistent with the strategy of robust satisficing.

One final point: moral hazard and its dilemma. The design of any critical technology entails two distinct and essential elements: failure prevention and disaster recovery. What economists call a `moral hazard' exists since the failure prevention team might rely on the disaster-recovery team, and vice versa. Each team might, at least implicitly, depend on the capabilities of the other team, and thereby relinquish some of its own responsibility. Institutional provisions are needed to manage this conflict.

The alleviation of this moral hazard entails a dilemma. Considerations of failure prevention and disaster recovery must be combined in the design process. The design teams must be aware of each other, and even collaborate, because a single coherent system must emerge. But we don't want either team to relinquish any responsibility. On the one hand we want the failure prevention team to work as though there is no disaster recovery, and the disaster recovery team should presume that failures will occur. On the other hand, we want these teams to collaborate on the design.

This moral hazard and its dilemma do not obviate the need for both elements of the design. Fukushima has taught us an important lesson by highlighting the special challenge of high-risk critical technologies: design so failure cannot occur, and prepare to respond to the unanticipated.





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