Multiple uncontrolled conditions and blood pressure medication intensification: an observational study

Abstract Background Multiple uncontrolled medical conditions may act as competing demands for clinical decision making. We hypothesized that multiple uncontrolled cardiovascular risk factors would decrease blood pressure (BP) medication intensification among uncontrolled hypertensive patients. Methods We observed 946 encounters at two VA primary care clinics from May through August 2006. After each encounter, clinicians recorded BP medication intensification (BP medication was added or titrated). Demographic, clinical, and laboratory information were collected from the medical record. We examined BP medication intensification by presence and control of diabetes and/or hyperlipidemia. 'Uncontrolled' was defined as hemoglobin A1c ≥ for diabetes, BP ≥ 140/90 mmHg (≥ 130/80 mmHg if diabetes present) for hypertension, and low density lipoprotein cholesterol (LDL-c) ≥ 130 mg/dl (≥ 100 mg/dl if diabetes present) for hyperlipidemia. Hierarchical regression models accounted for patient clustering and adjusted medication intensification for age, systolic BP, and number of medications. Results Among 387 patients with uncontrolled hypertension, 51.4% had diabetes (25.3% were uncontrolled) and 73.4% had hyperlipidemia (22.7% were uncontrolled). The BP medication intensification rate was 34.9% overall, but higher in individuals with uncontrolled diabetes and uncontrolled hyperlipidemia: 52.8% overall and 70.6% if systolic BP ≥ 10 mmHg above goal. Intensification rates were lowest if diabetes or hyperlipidemia were controlled, lower than if diabetes or hyperlipidemia were not present. Multivariable adjustment yielded similar results. Conclusions The presence of uncontrolled diabetes and hyperlipidemia was associated with more guideline-concordant hypertension care, particularly if BP was far from goal. Efforts to understand and improve BP medication intensification in patients with controlled diabetes and/or hyperlipidemia are warranted.http://deepblue.lib.umich.edu/bitstream/2027.42/78266/1/1748-5908-5-55.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78266/2/1748-5908-5-55.pdfPeer Reviewe

Depressive Symptoms and Cardiovascular Health by the American Heart Association’s Definition in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Background Depressive symptoms are associated with increased incident and recurrent cardiovascular events. In 2010, the American Heart Association published the Life’s Simple 7, a metric for assessing cardiovascular health as measured by 4 health behaviors (smoking, physical activity, body mass index, diet) and 3 biological measures (cholesterol, blood pressure, glucose). The association between depressive symptoms and the Life’s Simple 7 has not yet been explored. Methods Data from 20,093 participants ≥45 years of age who enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study between 2003 and 2007 and who had complete data available on Life’s Simple 7 components were used for these analyses. The prevalence of ideal, intermediate, and poor health on each Life’s Simple 7 component and total Life’s Simple 7 scores were compared between participants with and without depressive symptoms. Depressive symptoms were measured using the 4-item Centers for Epidemiologic Studies of Depression scale. Results Participants with depressive symptoms were more likely to have poor levels on each of the Life’s Simple 7 components other than cholesterol [adjusted prevalence ratios (95% CI): smoking 1.41 (1.29–1.55); physical activity 1.38 (1.31–1.46); body mass index 1.09 (1.04–1.15); diet 1.08 (1.06–1.10); blood pressure 1.11 (1.02–1.21); glucose 1.24 (1.09–1.41)]. There was a graded association between increasing depressive symptoms and lower total Life’s Simple 7 score. Conclusion Depressive symptoms are associated with worse cardiovascular health on the overall Life’s Simple 7 and on individual components representing both health behaviors and biological factors

Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults: A National Cohort Study

Background: Excessive sedentary time is ubiquitous in Western societies. Previous studies have relied on self-reporting to evaluate the total volume of sedentary time as a prognostic risk factor for mortality and have not examined whether the manner in which sedentary time is accrued (in short or long bouts) carries prognostic relevance. Objective: To examine the association between objectively measured sedentary behavior (its total volume and accrual in prolonged, uninterrupted bouts) and all-cause mortality. Design: Prospective cohort study. Setting: Contiguous United States. Participants: 7985 black and white adults aged 45 years or older. Measurements: Sedentary time was measured using a hip-mounted accelerometer. Prolonged, uninterrupted sedentariness was expressed as mean sedentary bout length. Hazard ratios (HRs) were calculated comparing quartiles 2 through 4 to quartile 1 for each exposure (quartile cut points: 689.7, 746.5, and 799.4 min/d for total sedentary time; 7.7, 9.6, and 12.4 min/bout for sedentary bout duration) in models that included moderate to vigorous physical activity. Results: Over a median follow-up of 4.0 years, 340 participants died. In multivariable-adjusted models, greater total sedentary time (HR, 1.22 [95% CI, 0.74 to 2.02]; HR, 1.61 [CI, 0.99 to 2.63]; and HR, 2.63 [CI, 1.60 to 4.30]; P for trend < 0.001) and longer sedentary bout duration (HR, 1.03 [CI, 0.67 to 1.60]; HR, 1.22 [CI, 0.80 to 1.85]; and HR, 1.96 [CI, 1.31 to 2.93]; P for trend < 0.001) were both associated with a higher risk for all-cause mortality. Evaluation of their joint association showed that participants classified as high for both sedentary characteristics (high sedentary time [≥12.5 h/d] and high bout duration [≥10 min/bout]) had the greatest risk for death. Limitation: Participants may not be representative of the general U.S. population. Conclusion: Both the total volume of sedentary time and its accrual in prolonged, uninterrupted bouts are associated with all-cause mortality, suggesting that physical activity guidelines should target reducing and interrupting sedentary time to reduce risk for death

Flood realities, perceptions, and the depth of divisions on climate

Research has led to broad agreement among scientists that anthropogenic climate change is happening now and likely to worsen. In contrast to scientific agreement, US public views remain deeply divided, largely along ideological lines. Science communication has been neutralised in some arenas by intense counter-messaging, but as adverse climate impacts become manifest they might intervene more persuasively in local perceptions. We look for evidence of this occurring with regard to realities and perceptions of flooding in the northeastern US state of New Hampshire. Although precipitation and flood damage have increased, with ample news coverage, most residents do not see a trend. Nor do perceptions about past and future local flooding correlate with regional impacts or vulnerability. Instead, such perceptions follow ideological patterns resembling those of global climate change. That information about the physical world can be substantially filtered by ideology is a common finding from sociological environment/society research

Recommendations for Providers on Person-Centered Approaches to Assess and Improve Medication Adherence

Medication non-adherence is a significant clinical challenge that adversely affects psychosocial factors, costs, and outcomes that are shared by patients, family members, providers, healthcare systems, payers, and society. Patient-centered care (i.e., involving patients and their families in planning their health care) is increasingly emphasized as a promising approach for improving medication adherence, but clinician education around what this might look like in a busy primary care environment is lacking. We use a case study to demonstrate key skills such as motivational interviewing, counseling, and shared decision-making for clinicians interested in providing patient-centered care in efforts to improve medication adherence. Such patient-centered approaches hold considerable promise for addressing the high rates of non-adherence to medications for chronic conditions

‘Give courage to the ladies’: expansive apprenticeship for women in rural Malawi

Apprenticeship in developed and industrialised nations is increasingly understood as a theory of learning which connects workplace activity and formal study. The concept of ‘expansive apprenticeship’ defines frameworks for workforce development where participants acquire knowledge and skills which will help them in the future as well as in their current roles, whilst ‘restrictive’ apprenticeships limit opportunities for wider, lifelong learning. In developing nations apprenticeship is a traditional route to learning and employment, but apprenticeships in these contexts tend to reflect a restrictive approach characterized by narrowly defined roles and weak educational outcomes. This paper examines a project in Malawi which uses concepts of expansive apprenticeship to address barriers to female continuing education and chronic teacher shortages. The Malawi Access to Teaching Scholarship recruited one thousand women to follow a year-long combined programme of academic distance study and practical work experience in rural primary schools. The aim is to increase the numbers of women teachers in Malawi, especially in rural areas. The Scholarship materials and support structures are designed to move participants from restrictive to expansive contexts for learning so that Scholars develop hybrid roles as students, community workers and apprentice pedagogues. The programme’s resources and approach offer an innovative model of expansive apprenticeship in Sub Saharan Africa

Association of Prediabetes and Diabetes With Stroke Symptoms The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

OBJECTIVE Stroke symptoms among individuals reporting no physician diagnosis of stroke are associated with an increased risk of future stroke. Few studies have assessed whether individuals with diabetes or prediabetes, but no physician diagnosis of stroke, have an increased prevalence of stroke symptoms. RESEARCH DESIGN AND METHODS This study included 25,696 individuals aged ≥45 years from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who reported no history of stroke or transient ischemic attack at baseline (2003–2007). Glucose measurements, medication use, and self-reported physician diagnosis were used to categorize participants into diabetes, prediabetes, or normal glycemia groups. The presence of six stroke symptoms was assessed using a validated questionnaire. RESULTS The prevalence of any stroke symptom was higher among participants with diabetes (22.7%) compared with those with prediabetes (15.6%) or normal glycemia (14.9%). In multivariable models, diabetes was associated with any stroke symptom (prevalence odds ratio [POR] 1.28 [95% CI 1.18–1.39]) and two or more stroke symptoms (1.26 [1.12–1.43]) compared with normal glycemia. In analyses of individual stroke symptoms, diabetes was associated with numbness (1.15 [1.03–1.29]), vision loss (1.52 [1.31–1.76]), half-vision loss (1.54 [1.30–1.84]), and lost ability to understand people (1.34 [1.12–1.61]) after multivariable adjustment. No association was present between prediabetes and stroke symptoms. CONCLUSIONS In this population-based study, almost one in four individuals with diabetes reported stroke symptoms, which suggests that screening for stroke symptoms in diabetes may be warranted

N-Terminal Pro-B-Type Natriuretic Peptide and Microsize Myocardial Infarction Risk in the Reasons for Geographic and Racial Differences in Stroke Study

Background: N-terminal pro B-type peptide (NT-proBNP) has been associated with risk of myocardial infarction (MI), but less is known about the relationship between NT-proBNP and very small non ST-elevation MI, also known as microsize MI. These events are now routinely detectable with modern troponin assays and are emerging as a large proportion of all MI. Here, we sought to compare the association of NT-proBNP with risk of incident typical MI and microsize MI in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Methods: The REGARDS Study is a national cohort of 30,239 US community-dwelling black and white adults aged ≥ 45 years recruited from 2003 to 2007. Expert-adjudicated outcomes included incident typical MI (definite/probable MI with peak troponin ≥ 0.5 μg/L), incident microsize MI (definite/probable MI with peak troponin \u3c 0.5 μg/L), and incident fatal CHD. Using a case-cohort design, we estimated the hazard ratio of the outcomes as a function of baseline NT-proBNP. Competing risk analyses tested whether the associations of NT-proBNP differed between the risk of incident microsize MI and incident typical MI as well as if the association of NT-proBNP differed between incident non-fatal microsize MI and incident non-fatal typical MI, while accounting for incident fatal coronary heart disease (CHD) as well as heart failure (HF). Results: Over a median of 5 years of follow-up, there were 315 typical MI, 139 microsize MI, and 195 incident fatal CHD. NT-proBNP was independently and strongly associated with all CHD endpoints, with significantly greater risk observed for incident microsize MI, even after removing individuals with suspected HF prior to or coincident with their incident CHD event. Conclusion: NT-proBNP is associated with all MIs, but is a more powerful risk factor for microsize than typical MI

The species diversity&nbsp;×&nbsp;fire severity relationship is hump-shaped in semiarid yellow pine and mixed conifer forests

The combination of direct human influences and the effects of climate change are resulting in altered ecological disturbance regimes, and this is especially the case for wildfires. Many regions that historically experienced low–moderate severity fire regimes are seeing increased area burned at high severity as a result of interactions between high fuel loads and climate warming with a number of negative ecological effects. While ecosystem impacts of altered fire regimes have been examined in the literature, little is known of the effects of changing fire regimes on forest understory plant diversity even though understory taxa comprise the vast majority of forest plant species and play vital roles in overall ecosystem function. We examined understory plant diversity across gradients of wildfire severity in eight large wildfires in yellow pine and mixed conifer temperate forests of the Sierra Nevada, California, USA. We found a generally unimodal hump-shaped relationship between local (alpha) plant diversity and fire severity. High-severity burning resulted in lower local diversity as well as some homogenization of the flora at the regional scale. Fire severity class, post-fire litter cover, and annual precipitation were the best predictors of understory species diversity. Our research suggests that increases in fire severity in systems historically characterized by low and moderate severity fire may lead to plant diversity losses. These findings indicate that global patterns of increasing fire size and severity may have important implications for biodiversity