Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke

Importance: Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective: To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants: This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures: Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results: Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance: Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible

Anxiety and depression in Nepal: prevalence, comorbidity and associations

BACKGROUND: Anxiety and depression are two important contributors to the global burden of disease. In many developing countries, including Nepal, their prevalences are yet to be assessed. METHODS: A nationwide cross-sectional study was conducted among a representative sample of Nepalese adults aged 18–65 years (N = 2100), selected by multistage random cluster sampling and interviewed at home during unannounced visits. The validated questionnaires included the Hospital Anxiety and Depression Scale (HADS), to detect cases of anxiety (HADS-A), depression (HADS-D) and comorbid anxiety and depression (HADS-cAD), the Eysenck Personality Questionnaire Revised Short Form-Neuroticism (EPQRS-N), and the World Health Organization Quality of Life 8-question scale (WHOQOL-8). Logistic regression analyses were used to explore associations of caseness with four groups of variables: demographic, domicile, substance use, and behavioural and health. RESULTS: Age- and gender-adjusted point prevalences of HADS-A, HADS-D and HADS-cAD were 16.1, 4.2 and 5.9 % respectively. In a multivariate model, HADS-A was positively associated with urban residence (AOR = 1.82; p < 0.001) and neuroticism (AOR = 1.32; p < 0.001), and negatively with alcohol consumption (AOR = 0.71; p = 0.041). HADS-D was positively associated with marijuana use (AOR = 3.61; p = 0.017) and negatively with quality of life (QoL) (AOR = 0.86; p < 0.001). HADS-cAD was positively associated with widowhood (AOR = 2.71; p = 0.002), urban residence (AOR = 2.37; p = 0.001), living at altitude ≥2000 m (AOR = 2.32; p = 0.002) and neuroticism (AOR = 1.26; p < 0.001), and negatively with alcohol use (AOR = 0.56; p = 0.026) and QoL (AOR = 0.79; p < 0.001). CONCLUSION: Depression and anxiety are important mental health conditions in Nepal, and major contributors to public ill health, being very highly prevalent, comorbid and associated with psychosocial burden. They are also linked to the unique topography, habitation and social structure of the country. High prevalence coupled with the disabling nature of these disorders establishes their health-care priority and their importance in national health policy

Prevalence and Associated Factors of Hypertension Among Civil Servants Working in Arba Minch Town, South Ethiopia

Despite Hypertension is a global public health challenge and a leading modifiable risk factor for cardiovascular disease and death attention was not given in developing countries. Therefore measuring the prevalence and identifying predictors of Hypertension is very important. Institution based cross sectional study design was employed from March–April, 2016 by taking 319 randomly selected civil servants working in in Arba Minch town. Data was collected using structured questionnaire and standardized instruments for physical examination by 5 trained nurses. SPSS version 20 was used for data analysis. Bi-variable and Multivariate logistic regression was employed for analysis of risk factors. The mean SBP and DBP of study participants were 120.87 + 14.15 mmHg and 80.28 + 8.8 mmHg, respectively. The prevalence of hypertension was found to be 27.8% (95% CI = 22.9-32.7%). Civil servants of age 50 years and above [AOR = 13.3], age 40-49 years [AOR = 5], age 30-39 years [AOR = 3.5], abdominal obesity [AOR=12.2], general obesity [AOR = 4.2], stress status [AOR = 12.3], current alcohol drink [AOR = 3.3], ex-drinker [AOR = 8.9] and family history of hypertension [AOR = 5.6] were found to be significantly associated with hypertension. The prevalence indicates that it is hidden epidemic in this population; therefore for screening and risk reduction program are needed

The impact of peripheral arterial disease on patients with mechanical circulatory support.

Background: Left ventricular assist devices (LVAD) are indicated as bridging or destination therapy for patients with advanced (Stage D) heart failure and reduced ejection fraction (HFrEF). Due to the clustering of the mutual risk factors, HFrEF patients have a high prevalence of peripheral arterial disease (PAD). This, along with the fact that continuous flow LVAD influence shear stress on the vasculature, can further deteriorate the PAD. Methods: We queried the National Inpatient Sample (NIS) database (2002-2014) to identify the burden of pre-existing PAD cases, its association with LVAD, in-hospital mortality, and other complications of LVAD. The adjusted odds ratio (aOR) and 95% confidence interval (CI) were calculated using the Cochran-Mantel-Haenszel test. Results: A total of 20,817 LVAD patients, comprising of 1,625 (7.8%) PAD and 19,192 (91.2%) non-PAD patients were included in the study. The odds of in-hospital mortality in PAD patients were significantly higher compared to non-PAD group (OR 1.29, CI, 1.07-1.55, P = 0.007). The PAD group had significantly higher adjusted odds as compared to non-PAD group for acute myocardial infarction (aOR 1.29; 95% CI, 1.07-1.55, P = 0.007), major bleeding requiring transfusion (aOR, 1.286; 95% CI, 1.136-1.456, P \u3c 0.001), vascular complications (aOR, 2.360; 95% CI, 1.781-3.126, P \u3c 0.001), surgical wound infections (aOR, 1.50; 95% CI, 1.17-1.94, P = 0.002), thromboembolic complications (aOR, 1.69; 95% CI, 1.36-2.10, P \u3c 0.001), implant-related complications (aOR, 1.47; 95% CI, 1.19-1.80, P \u3c 0.001), and acute renal failure (aOR, 1.26; 95% CI, 1.12-1.43, P \u3c 0.001). Conclusion: PAD patients can have high LVAD associated mortality as compared to non-PAD

Intestinal helminth infections and dietary diversity score predict nutritional status of urban schoolchildren from southern Ethiopia

BACKGROUND: Undernutrition is a major public health problem in developing countries like Ethiopia where schoolchildren are among the vulnerable groups. However, limited attention has been given for the nutritional status of schoolchildren including the lack of available evidence on the magnitude and modifiable risk factors in different parts of the country. Thus, we aimed at determining the magnitude and predictors of undernutrition among schoolchildren in Arba Minch town, southern Ethiopia. METHODS: A school-based cross-sectional study was conducted in March and April, 2014 involving 532 schoolchildren aged 7 to 14 years. A two-stage probability sampling procedure was applied to select study schools and subjects. Anthropometry measurements were taken using standardized techniques and calibrated equipment. Intestinal parasite infections were determined from stool samples using direct saline method and formal ether concentration technique; whereas data on demographic and relevant risk factors were gathered through structured interview of caretakers. Bivariate and multivariable logistic regressions were used to identify predictors of stunting and wasting in the study population. RESULTS: The prevalence of stunting and wasting were 26.0% (95% CI: 22.3, 30.1%) and 11.7% (95% CI: 9.1, 14.9%), respectively. In multivariable model, poor household wealth [AOR (95% CI) = 3.2 (1.2, 8.5)], living in large family [AOR (95% CI) = 2.3 (1.0, 5.1)], lack of maternal formal education [AOR (95% CI) = 4.1 (1.8, 9.4)], low Dietary Diversity Score [AOR (95% CI) = 2.3 (1.2, 4.7)], A. lumbricoides [AOR (95% CI) = 5.0 (2.7, 9.4)], hookworm [AOR (95% CI) = 8.0 (4.0, 15.8)] and T. trichuria [AOR (95% CI) = 6.3 (2.8, 14.1)] infections were associated with stunting. Wasting status was independently associated with not living with both parents [AOR (95% CI) = 2.0 (1.0, 4.1)], poor household wealth [AOR (95% CI) = 8.9 (2.0, 39.2)], and recent illnesses [AOR (95% CI) = 6.3 (3.1, 12.6)]. CONCLUSIONS: Both acute and chronic malnutrition are prevalent among schoolchildren in the study area where intestinal parasite infections, poor dietary quality and common illnesses are important modifiable risk factors. A comprehensive school-based health and nutrition intervention involving parents may help to alleviate the problem including regular deworming and promotion of personal hygiene and balanced diet

Co-Occurrence of Multiple Risk Factors and Intimate Partner Violence in an Urban Emergency Department

Introduction: Urban emergency departments (ED) provide care to populations with multiple health-related and overlapping risk factors, many of which are associated with intimate partner violence (IPV). We examine the 12-month rate of physical IPV and its association with multiple joint risk factors in an urban ED.Methods: Research assistants surveyed patients regarding IPV exposure, associated risk factors, and other sociodemographic features. The joint occurrence of seven risk factors was measured by a variable scored 0–7 with the following risk factors: depression; adverse childhood experiences; drug use; impulsivity; post-traumatic stress disorder; at-risk drinking; and partner’s score on the Alcohol Use Disorders Identification Test. The survey (N = 1037) achieved an 87.5% participation rate.Results: About 23% of the sample reported an IPV event in the prior 12 months. Logistic regression showed that IPV risk increased in a stepwise fashion with the number of present risk factors, as follows: one risk factor (adjusted odds ratio [AOR] [3.09]; 95% confidence interval [CI], 1.47-6.50; p&lt;.01); two risk factors (AOR [6.26]; 95% CI, 3.04-12.87; p&lt;.01); three risk factors (AOR = 9.44; 95% CI, 4.44-20.08; p&lt;.001); four to seven risk factors (AOR [18.62]; 95% CI, 9.00-38.52; p&lt;001). Ordered logistic regression showed that IPV severity increased in a similar way, as follows: one risk factor (AOR [3.17]; 95% CI, 1.39-7.20; p&lt;.01); two risk factors (AOR [6.73]; 95% CI, 3.04-14.90; p&lt;.001); three risk factors (AOR [10.36]; 95%CI, 4.52-23.76; p&lt;.001); four to seven risk factors (AOR [20.61]; 95% CI, 9.11-46.64; p&lt;001).Conclusion: Among patients in an urban ED, IPV likelihood and IPV severity increase with the number of reported risk factors. The best approach to identify IPV and avoid false negatives is, therefore, multi-risk assessment

Associations of suicidal ideation with opioid/prescription drug use, violence, food insecurity, and community factors among New Hampshire high school students

Purpose: Suicide is the second leading cause of death for New Hampshire (NH) youth. Evidence-based public health emphasizes the use of data for translating research into practice/policy. We utilized data from the Youth Risk Behavior Survey (YRBS) to support community-academic partnerships and inform suicide prevention interventions. Methods: Data from the 2011 NH YRBS, a cross-sectional survey of 9th-12th grade students, were analyzed. Gender-stratified, adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression models (SAS 9.4, ProcSuveylogistic) to evaluate associations between suicidal ideation (seriously considering attempting suicide within the past 12 months), violence (e.g., physical bullying, cyber-bullying, forced sexual activity), opioid/prescription drug use, food insecurity, and perceptions of being valued by one’s community. Results: Overall, the prevalence of suicidal ideation was 14.3% (females 16.8%; males 12.2%). For both genders, higher prevalence of suicidal ideation was observed among students in grades 9 (15.6%) and 10 (17.8%) compared to grades 11 (11.6%) and 12 (11.3%). In adjusted models, among girls, suicidal ideation was positively associated with the use of opioid/prescription drugs (aOR: 1.38; CI: 1.13-1.67)), violence (being forced to have sex (aOR 2.32 (CI 1.12-4.81)); being bullied on school property (aOR 2.28 (CI 1.31-3.97)), and food insecurity ((aOR 1.36 (CI 1.02-1.81)). Among boys, suicidal ideation was positively associated with opioid/drug use (aOR 1.25 (CI 1.04-1.49)), cyberbullying (aOR 2.69(CI 1.17-6.18)), and food insecurity ((aOR 1.44 (CI 1.14-1.83). Youth who perceived that they did not matter to their community were more likely to report suicidal ideation (Girls: aOR: 1.62; CI: 1.27-2.08; Boys: aOR: 1.37; (CI: 1.10-1.71)), compared to those who felt that they mattered to their community. Conclusions: Drug use, violence, and food insecurity emerged as significant risk factors for suicidal ideation among NH youth. Interventions that make youth feel that they matter to their communities may protect against suicidal ideation

Integration of HIV Care with Primary Health Care Services: Effect on Patient Satisfaction and Stigma in Rural Kenya.

HIV departments within Kenyan health facilities are usually better staffed and equipped than departments offering non-HIV services. Integration of HIV services into primary care may address this issue of skewed resource allocation. Between 2008 and 2010, we piloted a system of integrating HIV services into primary care in rural Kenya. Before integration, we conducted a survey among returning adults ≥18-year old attending the HIV clinic. We then integrated HIV and primary care services. Three and twelve months after integration, we administered the same questionnaires to a sample of returning adults attending the integrated clinic. Changes in patient responses were assessed using truncated linear regression and logistic regression. At 12 months after integration, respondents were more likely to be satisfied with reception services (adjusted odds ratio, aOR 2.71, 95% CI 1.32-5.56), HIV education (aOR 3.28, 95% CI 1.92-6.83), and wait time (aOR 1.97 95% CI 1.03-3.76). Men's comfort with receiving care at an integrated clinic did not change (aOR = 0.46 95% CI 0.06-3.86). Women were more likely to express discomfort after integration (aOR 3.37 95% CI 1.33-8.52). Integration of HIV services into primary care services was associated with significant increases in patient satisfaction in certain domains, with no negative effect on satisfaction

'The difference in determinants of Chlamydia trachomatis and Mycoplasma genitalium in a sample of young Australian women.'

BACKGROUND Differences in the determinants of Chlamydia trachomatis ('chlamydia') and Mycoplasma genitalium (MG) genital infection in women are not well understood. METHODS A cohort study of 16 to 25 year old Australian women recruited from primary health care clinics, aimed to determine chlamydia and MG prevalence and incidence. Vaginal swabs collected at recruitment were used to measure chlamydia and MG prevalence, organism-load and chlamydia-serovar a cross-sectional analysis undertaken on the baseline results is presented here. RESULTS Of 1116 participants, chlamydia prevalence was 4.9% (95% CI: 2.9, 7.0) (n = 55) and MG prevalence was 2.4% (95% CI: 1.5, 3.3) (n = 27). Differences in the determinants were found - chlamydia not MG, was associated with younger age [AOR:0.9 (95% CI: 0.8, 1.0)] and recent antibiotic use [AOR:0.4 (95% CI: 0.2, 1.0)], and MG not chlamydia was associated with symptoms [AOR:2.1 (95% CI: 1.1, 4.0)]. Having two or more partners in last 12 months was more strongly associated with chlamydia [AOR:6.4 (95% CI: 3.6, 11.3)] than MG [AOR:2.2 (95% CI: 1.0, 4.6)] but unprotected sex with three or more partners was less strongly associated with chlamydia [AOR:3.1 (95%CI: 1.0, 9.5)] than MG [AOR:16.6 (95%CI: 2.0, 138.0)]. Median organism load for MG was 100 times lower (5.7 × 104/swab) than chlamydia (5.6 × 10⁶/swab) (p < 0.01) and not associated with age or symptoms for chlamydia or MG. CONCLUSIONS These results demonstrate significant chlamydia and MG prevalence in Australian women, and suggest that the differences in strengths of association between numbers of sexual partners and unprotected sex and chlamydia and MG might be due to differences in the transmission dynamics between these infections.This project was funded by the Commonwealth of Australia, as part of a National Chlamydia Pilot program that is currently running to test the effectiveness of a number of models for chlamydia testing in Australia. This project will assist in developing possible recommendations for a National Chlamydia Program. The analysis of MG was funded by the National Health and Research Council (research grant number 509144)

Factors Associated with Immunization Opinion Leadership among Men Who Have Sex with Men in Los Angeles, California

We sought to identify the characteristics of men who have sex with men (MSM) who are opinion leaders on immunization issues and to identify potential opportunities to leverage their influence for vaccine promotion within MSM communities. Using venue-based sampling, we recruited and enrolled MSM living in Los Angeles (N = 520) from December 2016 to February 2017 and evaluated characteristic differences in sociodemographic characteristics, health behaviors, and technology use among those classified as opinion leaders versus those who were not. We also asked respondents about their past receipt of meningococcal serogroups A, C, W, and Y (MenACWY) and meningococcal B (MenB) vaccines, as well as their opinions on the importance of 13 additional vaccines. Multivariable results revealed that non-Hispanic black (aOR = 2.64; 95% CI: 1.17–5.95) and other race/ethnicity (aOR = 2.98; 95% CI: 1.41–6.29) respondents, as well as those with a history of an STI other than HIV (aOR = 1.95; 95% CI: 1.10–3.48), were more likely to be opinion leaders. MenACWY (aOR = 1.92; 95% CI: 1.13–3.25) and MenB (aOR = 3.09; 95% CI: 1.77–5.41) vaccine uptake, and perceived importance for these and seven additional vaccines, were also associated with being an opinion leader. The results suggest that the co-promotion of vaccination and other health promotion initiatives via opinion leaders could be a useful strategy for increasing vaccination among MSM