Accumulation of metabolic cardiovascular risk factors in black and white young adults over 20 years

BACKGROUND: Cross-sectional clustering of metabolic risk factors for cardiovascular disease in middle-aged adults is well described, but less is known regarding the order in which risk factors develop through young adulthood and their relation to subclinical atherosclerosis. METHOD AND RESULTS: A total of 3178 black and white women and men in the Coronary Artery Risk Development in Young Adults study were assessed to identify the order in which cardiovascular disease risk factors including diabetes, hypertension, dyslipidemia (low high-density lipoprotein cholesterol or high triglyceride levels), hypercholesterolemia (high total or low-density lipoprotein cholesterol), and obesity develop. Observed patterns of risk factor development were compared with those expected if risk factors accumulated randomly, given their overall distribution in the population. Over the 20 years of follow-up, 80% of participants developed at least 1 risk factor. The first factor to occur was dyslipidemia in 39% of participants, obesity in 20%, hypercholesterolemia in 11%, hypertension in 7%, and diabetes in 1%. Dyslipidemia was the only risk factor both to occur first and to be followed by additional risk factors more often than expected (P \u3c 0.001 for both). Order of risk factor accrual did not affect subclinical atherosclerosis at year 20. Results were similar by sex, race, and smoking status. CONCLUSIONS: Multiple patterns of cardiovascular risk factor development were observed from young adulthood to middle age. Dyslipidemia, a potentially modifiable condition, often preceded the development of other risk factors and may be a useful target for intervention and monitoring

Acute Care Surgery Patterns in the Current Era: Results of a Qualitative Study

Introduction: Since Acute Care Surgery (ACS) was first conceptualized as a specialty a decade ago, ACS teams have been widely adopted. Little is known about the structure and function of these teams. Methods: We conducted 18 open-ended interviews with ACS leaders (1 interview/center representing geographic [New England, Northeast, Mid-Atlantic, South, West, Midwest] and practice [Public/Charity, Community, University] variations). Two independent reviewers analyzed transcribed interviews using an inductive approach to determine major themes in practice variation (NVivo qualitative analysis software). Results: All respondents described ACS as a specialty treating time sensitive surgical disease including trauma, emergency general surgery (EGS), and surgical critical care (SCC). 11/18 combined trauma and EGS into a single clinical team; 6/18 included elective general surgery. Emergency orthopedics, neurosurgery, and triage for all surgical services were rare (1/18 each). 11/18 had blocked OR time. All had a core group of trauma and SCC surgeons; 8/18 shared EGS due to volume, manpower, or competition for EGS call. Many (12/18) had formal morning signout rounds; few (2/18) had prospective EGS data registries. Streamlined access to EGS, evidence-based EGS protocols, and improved communication were considered strengths of ACS. ACS was described as the last great surgical service reinvigorated to provide timely, cost-effective EGS by experts in resuscitation and critical care and to attract young, talented, eager surgeons to trauma and SCC; however, there was concern that it might become the waste basket for everything that happens at inconvenient times. Conclusion: Despite rapid adoption of ACS, its implementation varies widely. Standardization of scope of practice, continuity of care, and registry development may improve EGS outcomes and allow the specialty to thrive

The relationship between neighborhood poverty and alcohol use: estimation by marginal structural models.

BACKGROUND: Previous studies on the relationship of neighborhood disadvantage with alcohol use or misuse have often controlled for individual characteristics on the causal pathway, such as income-thus potentially underestimating the relationship between disadvantage and alcohol consumption. METHODS: We used data from the Coronary Artery Risk Development in Young Adults study of 5115 adults aged 18-30 years at baseline and interviewed 7 times between 1985 and 2006. We estimated marginal structural models using inverse probability-of-treatment and censoring weights to assess the association between point-in-time/cumulative exposure to neighborhood poverty (proportion of census tract residents living in poverty) and alcohol use/binging, after accounting for time-dependent confounders including income, education, and occupation. RESULTS: The log-normal model was used to estimate treatment weights while accounting for highly-skewed continuous neighborhood poverty data. In the weighted model, a one-unit increase in neighborhood poverty at the prior examination was associated with a 86% increase in the odds of binging (OR = 1.86 [95% confidence interval = 1.14-3.03]); the estimate from a standard generalized-estimating-equations model controlling for baseline and time-varying covariates was 1.47 (0.96-2.25). The inverse probability-of-treatment and censoring weighted estimate of the relative increase in the number of weekly drinks in the past year associated with cumulative neighborhood poverty was 1.53 (1.02-2.27); the estimate from a standard model was 1.16 (0.83-1.62). CONCLUSIONS: Cumulative and point-in-time measures of neighborhood poverty are important predictors of alcohol consumption. Estimators that more closely approximate a causal effect of neighborhood poverty on alcohol provided a stronger estimate than estimators from traditional regression models.http://deepblue.lib.umich.edu/bitstream/2027.42/78334/1/CerdaDiezRoux2010_Epidemiology.pd

Area characteristics, individual-level socioeconomic indicators, and smoking in young adults: the coronary artery disease risk development in young adults study

The 10-year follow-up examination in 1995-1996 to the population-based Coronary Artery Disease Risk Development in Young Adults Study was used to compare the strength with which socioeconomic indicators at the individual and area levels are related to smoking prevalence and to investigate contextual effects of area characteristics. When categories based on similar percentile cutoffs were compared, differences across area categories in the odds of smoking were smaller than differences across categories based on individual-level indicators. In Whites, there was evidence of a significant contextual effect of area characteristics on smoking: Living in the most disadvantaged area quartiles was associated with 50-110% higher odds of smoking, even after controlling for individual-level socioeconomic indicators. Clear contextual effects of area characteristics were not present in Blacks, but there was evidence that contextual effects may emerge at higher levels of individual-level socioeconomic position. Similar results were obtained for census tracts and block groups. Even in the presence of contextual effects, area measures may underestimate associations of individual-level variables with health outcomes. On the other hand, as illustrated by the presence of contextual effects, area- and individual-level measures are likely to tap into different constructs.http://deepblue.lib.umich.edu/bitstream/2027.42/78991/1/DiezRouxMerkin2003_AJE.pd

Area characteristics, individual-level socioeconomic indicators, and smoking in young adults: the coronary artery disease risk development in young adults study

The 10-year follow-up examination in 1995-1996 to the population-based Coronary Artery Disease Risk Development in Young Adults Study was used to compare the strength with which socioeconomic indicators at the individual and area levels are related to smoking prevalence and to investigate contextual effects of area characteristics. When categories based on similar percentile cutoffs were compared, differences across area categories in the odds of smoking were smaller than differences across categories based on individual-level indicators. In Whites, there was evidence of a significant contextual effect of area characteristics on smoking: Living in the most disadvantaged area quartiles was associated with 50-110% higher odds of smoking, even after controlling for individual-level socioeconomic indicators. Clear contextual effects of area characteristics were not present in Blacks, but there was evidence that contextual effects may emerge at higher levels of individual-level socioeconomic position. Similar results were obtained for census tracts and block groups. Even in the presence of contextual effects, area measures may underestimate associations of individual-level variables with health outcomes. On the other hand, as illustrated by the presence of contextual effects, area- and individual-level measures are likely to tap into different constructs.http://deepblue.lib.umich.edu/bitstream/2027.42/78991/1/DiezRouxMerkin2003_AJE.pd

Self-reported health, perceived racial discrimination, and skin color in african americans in the CARDIA study

http://deepblue.lib.umich.edu/bitstream/2027.42/61518/1/Borrell_Self-reported-health,-perceived-racial-discrimination,-and-skin-color-in-African-Americans-in-the-CARDIA-study_2006.pd

Association of Changes in Neighborhood-Level Racial Residential Segregation With Changes in Blood Pressure Among Black Adults: The CARDIA Study

Importance: Despite cross-sectional evidence linking racial residential segregation to hypertension prevalence among non-Hispanic blacks, it remains unclear how changes in exposure to neighborhood segregation may be associated with changes in blood pressure. Objective: To examine the association of changes in neighborhood-level racial residential segregation with changes in systolic and diastolic blood pressure over a 25-year period. Design, Setting, and Participants: This observational study examined longitudinal data of 2280 black participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective investigation of adults aged 18 to 30 years who underwent baseline examinations in field centers in 4 US locations from March 25, 1985, to June 7, 1986, and then were re-examined for the next 25 years. Racial residential segregation was assessed using the Getis-Ord Gi* statistic, a measure of SD between the neighborhood\u27s racial composition (ie, percentage of black residents) and the surrounding area\u27s racial composition. Segregation was categorized as high (Gi* \u3e 1.96), medium (Gi* 0-1.96), and low (Gi* \u3c 0). Fixed-effects linear regression modeling was used to estimate the associations of within-person change in exposure to segregation and within-person change in blood pressure while tightly controlling for time-invariant confounders. Data analyses were performed between August 4, 2016, and February 9, 2017. Main Outcomes and Measures: Within-person changes in systolic and diastolic blood pressure across 6 examinations over 25 years. Results: Of the 2280 participants at baseline, 974 (42.7%) were men and 1306 (57.3%) were women. Of these, 1861 (81.6%) were living in a high-segregation neighborhood; 278 (12.2%), a medium-segregation neighborhood; and 141 (6.2%), a low-segregation neighborhood. Systolic blood pressure increased by a mean of 0.16 (95% CI, 0.06-0.26) mm Hg with each 1-SD increase in segregation score after adjusting for interactions of time with age, sex, and field center. Of the 1861 participants (81.6%) who lived in high-segregation neighborhoods at baseline, reductions in exposure to segregation were associated with reductions in systolic blood pressure. Mean differences in systolic blood pressure were -1.33 (95% CI, -2.26 to -0.40) mm Hg when comparing high-segregation with medium-segregation neighborhoods and -1.19 (95% CI, -2.08 to -0.31) mm Hg when comparing high-segregation with low-segregation neighborhoods after adjustment for time and interactions of time with baseline age, sex, and field center. Changes in segregation were not associated with changes in diastolic blood pressure. Conclusions and Relevance: Decreases in exposure to racial residential segregation are associated with reductions in systolic blood pressure. This study adds to the small but growing body of evidence that policies that reduce segregation may have meaningful health benefits

Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation

BACKGROUND: Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF. METHODS: Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either excellent/very good , good , and fair/poor . Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty. RESULTS: Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], \u3e /= 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status. CONCLUSIONS: Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF

Multiple Chronic Conditions and Psychosocial Limitations in a Contemporary Cohort of Patients Hospitalized with an Acute Coronary Syndrome

Background: As adults live longer, multiple chronic conditions have become more prevalent over the past several decades. We describe the prevalence of, and patient characteristics associated with, cardiac and non-cardiac-related multimorbidities in patients discharged from the hospital after an acute coronary syndrome (ACS). Methods: We studied 2,174 patients discharged from the hospital after an ACS at 6 medical centers in Massachusetts and Georgia between April, 2011 and May, 2013. Hospital medical records yielded clinical information including presence of 8 cardiac-related and 8 non-cardiac-related morbidities on admission. We assessed multiple psychosocial characteristics during the index hospitalization using standardized in-person instruments. Results: The mean age of the study sample was 61 years, 67% were men, and 81% were non-Hispanic whites. The most common cardiac-related morbidities were hypertension, hyperlipidemia, and diabetes (76%, 69%, and 31%, respectively). Arthritis, chronic pulmonary disease, and depression (20%, 18%, and 13%, respectively) were the most common non-cardiac morbidities. Patients with ≥4 morbidities (37% of the population) were slightly older and more frequently female than those with 0-1 morbidity; they were also heavier and more likely to be cognitively impaired (26% vs. 12%), have symptoms of moderate/severe depression (31% vs. 15%), high perceived stress (48% vs. 32%), a limited social network (22% vs. 15%), low health literacy (42% vs. 31%), and low health numeracy (54% vs. 42%). Conclusions: Multimorbidity, highly prevalent in patients hospitalized with an ACS, is strongly associated with indices of psychosocial deprivation. This emphasizes the challenge of caring for these patients, which extends well beyond ACS management

Culturally adaptive storytelling intervention versus didactic intervention to improve hypertension control in Vietnam- 12 month follow up results: A cluster randomized controlled feasibility trial

INTRODUCTION: Vietnam is experiencing an epidemiologic transition with an increased prevalence of non-communicable diseases. The country needs novel, large-scale, and sustainable interventions to improve hypertension control. We report the 12 month follow-up results of a cluster randomized feasibility trial in Hung Yen province, Vietnam, which evaluated the feasibility and acceptability of two community-based interventions to improve hypertension control: a storytelling and a didactic intervention. METHODS: The storytelling intervention included stories in the patients\u27 own words about coping with hypertension and didactic content about the importance of healthy lifestyle behaviors in controlling elevated blood pressure levels. The didactic intervention included only didactic content, which were general recommendations for managing several important risk factors for hypertension and other non-communicable diseases. The storytelling intervention was delivered by two DVDs three months apart; the didactic intervention included only one DVD. The trial was conducted in patients with poorly controlled hypertension from 4 communes (communities), which were equally randomized to the two interventions. RESULTS: The mean age of the 160 patients was 66 years and 54% were men. Between baseline enrollment and the 12 month follow-up, mean systolic blood pressure declined by 10.8 mmHg (95% CI: 6.5-14.9) in the storytelling group and by 5.8 mmHg (95% CI: 1.6-10.0) in the didactic content group. The storytelling group also experienced more improvement in several health behaviors, including increased levels of physical activity and reduced consumption of salt and alcohol. CONCLUSIONS: We observed considerable long-term beneficial effects of both interventions, especially of our storytelling intervention, among patients with inadequately controlled hypertension. A large scale randomized trial should more systematically compare the short and long-term effectiveness of the two interventions in controlling hypertension. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02483780