ReSearch Vitals is RGA’s resource dedicated to providing you a collection of key article abstracts and links covering recent medical advances. Our aim is to keep you up-to-date with the latest medical research, curating articles of interest to underwriters, medical officers and claims assessors.

In the current edition, don’t miss articles on hybrid models for genetic testing, polygenic risk scoring, new underwriting rating factors, and the latest research on longevity, mental illness and diabetes.

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Genetic Testing

Emergence of hybrid models of genetic testing beyond direct-to-consumer or traditional labs. JAMA via PubMed, May 30, 2019.

A model of genetic testing that is a cross between direct-to-consumer (DTC) and traditional labs is discussed in this JAMA Viewpoint. This hybrid model of testing is easy for consumers to access, like DTC testing, but requires a clinician (either the individual’s regular physician or one associated with the hybrid lab) to order the tests and interpret the results for clinical decision making. This kind of genetic testing can help satisfy increasing consumer demand for genetic tests while also providing medical-grade results.

Genetic risk score for coronary disease identifies predispositions to cardiovascular and noncardiovascular diseases.  Journal of the American College of Cardiology via PubMed, June 18, 2019. 

Using data from 425,196 UK Biobank participants, researchers derived a genetic risk score based on 300 variants associated with coronary artery disease (CAD). The score was strongly associated with peripheral arterial disease, abdominal aortic aneurysms and stroke, as well as with hypertension and hypercholesterolemia.  The study concludes that a range of cardiovascular conditions may develop consecutively or in parallel with CAD, with the same genetic roots. This genetic risk score could be used to stratify individuals with no or limited genetic overlap with CAD risk.

Significant ‘knowledge gap’ exists in use of genetic testing to decide cancer treatment. EurekAlert, May 30, 2019. 

Finding what they call a “significant knowledge and practice gap,” researchers have determined that, when compared to academic-based oncologists, community-based oncologists use molecular profiling from tumor specimens less frequently and may not fully understand molecular profiling results. The study shows that oncologists need to be educated about this potential therapeutic strategy, especially since the use of molecular profiling to inform targeted therapy in clinical settings is increasing.

Cardiovascular

Determinants of the decline in mortality from acute stroke in England: linked national database study of 795,869 adults. BMJ via PubMed, May 22, 2019. 

From 2001 to 2010, stroke mortality rates decreased by 55%, case fatality decreased by 40%, and stroke event rates decreased by 20%. Mortality and case fatality declined across all age groups, while the stroke event rate decreased in older people but increased by 2% each year in adults aged 35 to 54. The study’s authors found that declines in case fatality contributed more than declines in event rates to this overall decrease in stroke mortality; they further suggest that the reduction in fatality was likely driven by improvements in stroke care.

Association of estimated sleep duration and naps with mortality and cardiovascular events: a study of 116,632 people from 21 countries.  European Heart Journal via PubMed, May 21, 2019. 

A total sleep duration of six to eight hours per day was associated with the lowest risk of deaths and major cardiovascular events. Daytime napping was associated with increased risks of major cardiovascular events and deaths in those with more than six hours of sleep per night. 

Misclassification of myocardial injury as myocardial infarction. JAMA Cardiology via PubMed, March 17, 2019.

Strict adjudication using the Fourth Universal Definition of Myocardial Infarction was applied to patients at Massachusetts General Hospital who had been coded as having type 2 myocardial infarction (T2MI) between October 2017 and May 2018. After the adjudication, it was found that only 56.7% of those patients had T2MI while 41.9% had myocardial injury. Patients with T2MI were found to have a higher prevalence of cardiovascular comorbidities than those with myocardial injury. The authors also discuss potential implications of this miscoding for hospitals.

Apple Heart Study results: notifications are rare, but often coincide with ECG-confirmed a-fib. MobiHealthNews, March 18, 2019.

The results of the Apple Heart Study were announced at the American College of Cardiology’s annual meeting. Of 419,297 participants in the study, 2,161 subjects were alerted to an irregular pulse and 658 of those were sent an ECG patch to wear for subsequent detection of atrial fibrillation episodes. Data from the 450 returned ECG patches showed a 71% positive predictive value. This article also discusses Apple’s wider digital health strategy and other planned studies of its smartwatch, including Heartline, a randomized controlled study of participants aged 65 years and older to be launched later in 2019.

Longevity

Physical activity, multimorbidity, and life expectancy: a UK Biobank longitudinal study.  BMC Medicine via PubMed, June 12, 2019.  

Multimorbidity is an emerging public health priority. Although physical activity (PA) is recommended as a healthy lifestyle behavior, its benefits for multimorbidity are unclear. This study aimed to understand the relationship between PA and all-cause mortality and to also study the effects of PA on life expectancy in people with and without multimorbidity in a large cohort from the UK. The findings reveal an inverse dose-response association between PA and all-cause mortality, indicating that benefits of PA on mortality is still applicable in people with multimorbidity. Based on objective measurement, it was also suggested that even a 10-minute brisk walk per day is associated with longer life expectancy.   

Association of step volume and intensity with all-cause mortality in older women.  JAMA Internal Medicine via PubMed, May 29, 2019.  

Older women with an average of 4,400 steps/day had significantly lower mortality rates in a follow-up of 4.3 years compared to women who took approximately 2,700 steps/day. Mortality rates declined progressively before leveling at 7,500 steps/day.

Period- and cohort-specific trends in life expectancy at different ages: analysis of survival in high-income countries. SSM - Population Health via PubMed, June 8, 2019.

This research investigates changes in survival at older age in high-income countries and shows that having some individuals reach exceptionally old age does not mean that the majority of the population is living longer. Slower survival improvements at ages 65+ indicated that the majority of the population likely may not reach long life expectancies, which can lead to a smaller proportion of adults reaching older ages than projected.

Mental Illness

The depths of despair among U.S. adults entering midlife. American Journal of Public Health via PubMed, May 2019.

Researchers examined four indicators of despair—depressive symptoms, suicidal ideation, marijuana use, and heavy drinking—in a nationally representative U.S. cohort of individuals who were adolescents in 1994. These indicators were measured in five waves between 1994 and 2017. Evidence of rising despair was found in this cohort, which is now reaching midlife, and this pattern of increase is similar across different racial/ethnic, educational, and geographic groups. The authors of the study warn these trends could indicate rising midlife mortality in the next decade. 

The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study. Lancet Psychiatry via PubMed, March 19, 2019. 

Daily cannabis use was associated with increased odds of psychotic disorder compared with those who never used cannabis (adjusted odds ratio [OR] 3·2, 95% CI 2·2–4·1), rising to nearly 5 times increased odds for daily use of high-potency types of cannabis (4·8, 2·5–6·3). Given the increasing availability of high-potency cannabis, this is expected to have serious implications for public health.

Familial aggregation and coaggregation of suicide attempts and comorbid mental disorders in adults. JAMA Psychiatry via PubMed, March 27, 2019.

The study, which included 1,119 adult probands and 5,355 first-degree relatives, showed that suicide attempts were moderately familial and associated with mental disorders, mainly mood disorders. All mood disorder subtypes and substance use disorders were statistically significantly associated with suicide attempts. The familial association between lifetime suicide attempts in probands and relatives was not statistically significant for the combined sample (OR, 1.6; 95% CI, 1.0-2.7). Social anxiety disorder in probands was associated with suicide attempts in relatives (OR, 2.4; 95% CI, 1.7-3.5) after controlling for comorbid mood, anxiety, and substance use disorders.

Burn-out an “occupational phenomenon”: International Classification of Diseases. WHO, May 28, 2019.  

The World Health Organization classified “burn-out” as an occupational phenomenon, but it is not classified as a medical condition in the 11th Revision of the International Classification of Diseases. Burn-out syndrome is conceptualized as chronic workplace stress that has not been managed successfully. It is also characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy.   

Diabetes

New directions in incidence and prevalence of diagnosed diabetes in the USA. BMJ Diabetes Research and Care via PubMed, May 28, 2019.   

From 1990 to 2009, the prevalence and incidence of diagnosed diabetes increased in the U.S. Following that, an eight-year period of stable prevalence and decreasing incidence was observed. While encouraging, the reasons for the plateauing and decrease are not clear. The overall burden of diabetes remains high and warrants continued monitoring and intervention.

Natural history of prediabetes in older adults from a population‐based longitudinal study. Journal of Internal Medicine via PubMed, June 4, 2019.

Researchers examined diabetes‐free participants aged 60 years and older and followed up for 12 years. Of those who had prediabetes (HbA1c ≥5.7%), 22% reverted to normoglycemia, 13% developed diabetes, and 23% died. In examining related factors, obesity was associated with the progression to diabetes, while weight loss, an absence of heart disease, and lower systolic blood pressure aided the reversion from prediabetes to normoglycemia.