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• Heavy metals and metalloids stress is a major threat to agricultural productivity and sustainability. • Chromium stress significantly decreased the growth, physio-biochemical, and osmolyte status in spinach. • Induced chromium stress improved electrolyte leakage and enzymatic antioxidants in spinach leaves. • Soil applied biochar and foliage applied selenium promotes a biostimulant effect by increasing spinach plant biomass. • Combined application of biochar and selenium helped in the adaptation of spinach to mild chromium stress. The contamination of agricultural soils with metals and metalloids significantly affects crop productivity. The objective of the present study was to investigate how the combined application of biochar and selenium (Se) could mitigate the adverse effects of chromium (Cr) stress on spinach. The effects of selenium (Na 2 SeO 4) (1 mg L −1) and biochar (5 %, w/w) application both individually and in combination were evaluated on the basis of growth, physio-biochemical and antioxidant potential of spinach grown under Cr stress (100 µM [29.40 mg] using K 2 Cr 2 O 7 of soil) and without Cr stress as control (0 µM). The results indicated that Cr stress decreased the root length (34.62 %), shoot length (35.32 %), number of leaves (23.18 %), root dry weight (12.00 %), and leaf dry weight (24.36 %) under Cr stress by lowering relative water content (RWC) and chlorophyll concentrations due to increased electrolyte leakage (64.03 %) and the Cr accumulation in leaves. However, the combined application of biochar and Se significantly enhanced the fresh and dry biomass under Cr stress and control conditions. The synergistic effect of Se and biochar partly alleviates the effects of Cr stress in spinach by up-regulating the antioxidant system, reducing lipid peroxidation (60.00 %), increasing leaf soluble sugars (25.22 %), and simultaneously decreasing electrolyte leakage. The combined effect of Se and biochar proved better results as compared to the sole application in minimizing Cr uptake in leaves (52.08 %) and limiting the health risk assessment values. Overall, this study highlights that the combined application of biochar and Se is an innovative and eco-friendly approach to improving the physio-biochemical defense responses against Cr stress in spinach plants. [ABSTRACT FROM AUTHOR]

The mean mass concentrations of black carbon (BC), biomass burning (BC)bb, and fossil fuel combustion (BC)ff have been estimated during March–May 2020 (during the COVID-19 outbreak) and March–May 2019 at a semiarid region of Agra over the Indo-Gangetic basin region. The daily mean mass concentration of BC in 2020 and 2019 was 3.9 and 6.9 µg m−3, respectively. The high monthly mean mass concentration of BC was found to be 4.7, 3.4 and 3.3 µg m−3 in Mar-2020, Apr-2020, and May-2020, respectively, whereas in Mar-2019, Apr-2019, and May-2019 was 7.7, 7.5 and 5.4 µg m−3, respectively. The absorption coefficient (babs) and absorption angstrom exponent (AAE) of black carbon were calculated. The highest mean AAE was 1.6 in the year 2020 (Mar–May 2020) indicating the dominance of biomass burning. The mean mass concentration of fossil fuel (BC)ff and biomass burning (BC)bb is 3.4 and 0.51 µg m−3, respectively, in 2020 whereas 6.4 and 0.73 µg m−3, respectively, in 2019. The mean fraction contribution of BC with fossil fuel (BC)ff was 82.1 ± 13.5% and biomass burning (BC)bb was 17.9 ± 4.3% in 2020, while in 2019, fossil fuel (BC)ff was 86.7 ± 13.5% and biomass burning (BC)bb was 13.3 ± 6.7%. The population-weighted mean concentration of BC, fossil fuel (BC)ff, and biomass burning (BC)bb has been calculated. The health risk assessment of BC has been analyzed in the form of attributable relative risk factors and attributed relative risk during the COVID-19 outbreak using AirQ + v.2.0 model. The attributable relative risk factors of BC were 20.6% in 2020 and 29.4% in 2019. The mean attributed relative risk per 10,000,000 populations at 95% confidence interval (CI) due to BC was 184.06 (142.6–225.2) in 2020 and 609.06 (418.3–714.6) in 2019. The low attributed factor and attributed relative risk in 2020 may be attributed to improvements in air quality and a fall in the emission of BC. In 2020, due to the COVID-19 pandemic, the whole country faced the biggest lockdown, ban of the transportation of private vehicles, trains, aircraft, and construction activities, and shut down of the industry leading to a fall in the impact of BC on human health. Overall, this was like a blessing in disguise. This study will help in future planning of mitigation and emission control of air pollutants in large and BC in particular. It only needs a multipronged approach. This study may be like torch bearing to set path for mitigation of impacts of air pollution and improvement of air quality. [ABSTRACT FROM AUTHOR]

The goal of this research paper is to provide a case study of two ACA initiatives focused specifically on Medicare cost reduction: Readmissions Reduction Program (RRP) and Value-Based Purchasing (VBP). The paper discusses generally how the ACA reforms are aimed to reduce Medicare costs through these two cost reduction programs and how hospitals are impacted by the financial penalties associated with these reforms. Through a case study of a Midwestern regional acute care hospital, detailed solutions will be provided on ways to limit financial losses. Additionally, consideration will be given to how much a hospital should weigh its investment in improving program metrics versus the net overall benefit. [ABSTRACT FROM AUTHOR]

This study enhances the understanding of the particulate matters (PM2.5 and PM10) and their physical and chemical behavior over the Taj Mahal, Agra, in North-Central India. The mass concentration was determined, and the shape and size of the particles and chemical characterizations have been carried out using SEM–EDX. The high level and significant variation of PM10 (162.2 µg m−3) and PM2.5 (83.9 µg m−3) were observed. The exceedance factor of the present study region is in critical and moderate condition. Morphological characterization reveals the particles of different shapes and sizes, while elemental analysis shows the presence of Si, Al, Fe, Ca, K, Cl, Mg, Na, Cu, and Zn. The dominance of Si indicated the contribution of natural sources, i.e., soil over this region. Three significant sources, viz. soil/road paved dust/vegetative emissions, vehicular/industrial emissions, and intermingling of dust and combustion particles, have been identified using principal component analysis over North-Central India. Health risk analysis of particulate matter identified carcinogenic and non-carcinogenic metals in the present study, which comes in contact with human beings during inhalation. The non-carcinogenic risk was much higher than the acceptable level. The high carcinogenic risks were found in Zn in PM10 and Cu in PM2.5 for both children and adults. [ABSTRACT FROM AUTHOR]

Copyright of Journal of Agro-Environment Science is the property of Journal of Agro-Environment Science Editorial Board and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Health risk analyses (HRA) indicate whether, and to which extent of severity, a given chemical substance may constitute a threat for health, e.g., the accidental ingestion of water during recreational use with direct contact. Objectives of this paper are to estimate the risk from an accidental ingestion of water carrying agrichemicals (á y ä HCH, Aldrine, ã – Chlordane, Glyphosate, and Imazethapyr) while bathing in the Azul River bathing resort by making use of HRA, and to discuss the potential use of such a tool for water resources management. It is based on the USEPA model, and, with the exception of the concentration of the substance in water, all other variables (ingestion rate, weight of individuals, frequency and duration of the exposition) are treated probabilistically and fit a recreational scenario with direct contact. The aggregated risk is estimated with an additive model of the particular risk of each substance. Results show that the risk, non carcinogenetic effects, may be disregarded because its value is always less than 1 (Aldrine is the principal contributor). Regarding the carcinogenetic effects, although the value is slightly greater than the limiting value of 10-5, the conservative approach of this study makes it to be minimized (its principal contributor is á –HCH). The Buenos Aires Province does not count with regulations referred to the quality of natural waters used for bathing. For that reason, the HRA stand out as an option for decision-makers given the absence of alternative management strategies.

Particulate-bound poly-aromatic hydrocarbons (PAHs) are of great concern due to their mutagenicity and carcinogenicity effect on human health. In this context, identification, quantification and inhalation cancer risk (ICR) assessment due to PM10- and PM2.5-bound PAHs has been carried out at six monitoring stations in a critically polluted Jharia coalfield/Dhanbad City. Identification of pollution sources at study area has been performed by using PCA statistical methods. Air quality index (AQI) and air quality health index (AQHI) were calculated based on the concentration levels of PM10. Location-wise direct comparison between AQI, AQHI and ICR was performed to analyse the risk levels. Consequently, maximum concentration levels of particulate (PM2.5 and PM10)-bound total PAHs (400 and 482 ng/m3) were recorded at the monitoring station Lodna Thana, followed by Bank More and Sijua Stadium, respectively. It was also observed that mine fire-affected station Lodna Thana was exaggerated with presence of PAHs due to wood and open coal burning activities. Moreover, about 1000 and 889 cases of inhalation cancer risk were estimated due to direct exposure of PM10- and PM2.5-bound PAHs in the study area, respectively. Active mine fire-affected station Lodna Thana was recorded with maximum probability of lung tumour due to inhalation cancer risk. This study has reported higher AQHI at station Dugdha Basti, Lodna Thana and Bank More, which results increased number of tumours due to ICR. This result concludes that Jharia coalfield/Dhanbad City are not only critically polluted area but it is also an inhalation cancer prone area due to direct exposure of active mine fire. [ABSTRACT FROM AUTHOR]

Copyright of Kesmas: National Public Health Journal is the property of Universitas Indonesia, Faculty of Public Health and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Increasing anthropogenic alteration has resulted in increased exposure to both point and nonpoint source pollution. These exposures are increasingly studied for their role in human diseases, including diseases with known genetic or lifestyle risk factors. This study analyzed associations between a variety of human diseases and trace metals, PCBs, and PAHs in soil, groundwater, sediment, and fish. Contaminant spatial data at the county level from Virginia were used in ArcGIS to identify these associations among socially vulnerable populations. The neurologic and psychiatric disorders and cognitive markers were associated with numerous metals in groundwater/soil and/or aquatic system contaminants. Cancer death rates, fetal deaths, and infant deaths were also related to multiple environmental exposures from both categories of exposure. In contrast, many of the chronic diseases which are primarily attributed to lifestyle showed little association with these exposures with the exception of COPD which did appear to be associated with multiple metal exposures. Asthma showed similar associations compared to COPD. Our data suggest that within the context of socially vulnerable populations, where disease burden is often highest, exposures to metals, PAHs, and PCBs may play a role in the development or exacerbation of several highly prevalent categories of disease. These environmental exposures likely act through a variety of pathways all generally leading to increased oxidative stress, inflammation, or interference with biological systems and a subsequent role in disease development. [ABSTRACT FROM AUTHOR]

Landfills are sources of fugitive volatile organic carbon (VOC) emissions, including halocarbons. The objective of this study was to evaluate the contribution of halogenated VOCs to the health risks associated with the exposure of workers operating in landfills, gathering information on the role of endogenous/exogenous sources present in anthropized areas. A hazardous waste landfill located in Turin, Italy was used as a case study. Ambient concentrations of 10 pollutants (BTEX, styrene, 1,3,5-trimethylbenzene, 1,2,4-trimethylbenzene, 1,2-dichloroethane, and 1,2-dichloropropane), measured in 10 points of the landfill area, were considered and analyzed. The data had a monthly frequency and covered two years. A cumulative health risk analysis was conducted by applying a Monte-Carlo method. The results showed that the contribution of 1,2-dichloroethane and 1,2-dichloropropane was 17.9% and 19.4% for the total risk and hazard index respectively. Benzene and ethylbenzene gave the highest contribution to the total risk (56.8% and 24.8%, respectively). In the second phase of the study, waste typologies that are possibly responsible for halocarbon emissions were investigated. Halocarbon concentration trends and waste disposal records were compared. Although further investigation is needed, some waste typologies were not excluded to contribute to halocarbon emissions, in particular sludge coming from wastewater treatment plants.

This paper estimates the cost-effectiveness of a 20% price discount on healthy food and beverages with and without consumer nutrition education, as trialled in remote Northern Australia. Changes in actual store sales, from the pre-discount baseline period, were analysed for population impact on consumption of fruit and vegetables, water and artificially sweetened soft drinks, in addition with total dietary weight (grams), energy (Mega Joules), and sodium (milligrams). Disability Adjusted Life Years (DALYs), arising from changes in dietary risk factor prevalence in the population, were estimated as the primary health outcome in a multi health-state Markov model. The costs of the strategies were sourced from paid invoices and time estimates of staff providing store-based discount promotion and consumer education. The incremental cost-effectiveness ratio adopted a partial societal perspective, (including health and retail sector costs), as cost per DALY averted and was presented in 2011 Australian dollars. The price discount, helped address a gap in food price equity for residents of remote communities. However, the discount strategy, with or without consumer education led to a net loss of population health –36 95%CI (-47,-25) or -21(-28, -15) DALYs respectively, at increased cost to the retail and health sectors, of AUD860000 95%CI (710000, 1million) or AUD500000 (410000, 590000). The strategies trialled were thereby categorised as dominated by current practice while acknowledging considerable uncertainty surrounding the health outcome estimates. The 20% discount on limited targeted products appeared to need to be considered in conjunction with other marketing strategies to support healthy food choices, if remote Australian Indigenous population health is to be improved. [ABSTRACT FROM AUTHOR]

Background: Non-communicable diseases (NCDs) have become a global public health problem, which threatens Sub-Sahara Africa (SSA) including Nigeria. Civil servants are at risk of NCDs because of the stressful and sedentary nature of their work. The study aimed to determine the prevalence and associated factors of the major risk factors of NCDs among civil servants in Ibadan, Nigeria. Methods: A cross-sectional study was conducted among 606 civil servants in Oyo State using a two-stage cluster sampling technique. The WHO Stepwise approach was used to assess the behavioural and metabolic risk factors. Anthropometric (weight, height, waist and hip circumferences), blood pressure and biochemical measurements (fasting blood sugar) were obtained. Prevalence rates and 95% confidence intervals were calculated. Multivariate logistic models with adjusted odds ratios and their 95% confidence intervals were used to assess the associated factors of NCD risk factors. Multiple Poisson regression was also performed to determine the effects of certain socio-demographic factors on the clustering of NCD risk factors. Results: The mean age of the civil servants was 43.0±10.3 and 53.8% were males. The prevalence estimates and 95% confidence intervals of the risk factors were 6.5% (95% CI:4.5–8.5) for current smoking, 7.8% (95% CI:5.1–10.5) for harmful use of alcohol, 62.2% (95% CI:58.2–66.2) for low physical activity, 69.7% (95% CI:66.0–73.4) for insufficient fruit and vegetable intake, 37.1% (95% CI:33.2–41.0) for abdominal obesity, 57.3% (95% CI:53.3–61.3) for overweight and obesity, 33.1% (95% CI:29.3–36.8) for raised blood pressure and 7.1% (95% CI:5.0–9.1) for raised blood sugar. Over 75% of the population had at least two NCD risk factors and the study participants had an average of 3 NCD risk factors 3.01 (95% CI: 2.88–3.14) The female gender was significantly associated with an increased risk for abdominal obesity (AOR 27.9; 95% CI: 12.09–64.6) and being overweight or obese (AOR 6.78; 95% CI: 3.53–13.01), but was protective of smoking (AOR 0.21; 95% CI: 0.07–0.61) and binge drinking (AOR 0.04; 95% CI: 0.01–0.45). Also, the risk of hypertension increased with age– 30–39 years (AOR 12.29; 95% CI: 1.06–141.8), 40–49 years (AOR 14.28; 95% CI: 1.10–181.4) and 50 years and above (AOR 32.43; 95% CI: 2.44–413.7). Raised blood pressure was a strong correlate for having raised blood sugar (AOR 5.63; 95% CI: 1.48–21.3). Increasing age (IRR 1.02; 95% CI: 1.01–1.02) and being female (IRR 1.36; 95% CI: 1.23–1.49) were also important predictors of the clustering of risk factors. Conclusion: The feminization (i.e. the preponderance of risk factors among the females) and clustering of non-communicable disease risk factors were observed among Oyo State civil servants. Our findings highlight the high prevalence of cardio-metabolic risk factors among the working class. Hence the need for targeted preventive and therapeutic interventions among this population. [ABSTRACT FROM AUTHOR]

Study question: The Cardiovascular Health Awareness Program (CHAP) cardiovascular risk reduction program consisted of sessions run by local volunteers in local pharmacies during which cardiovascular risk was assessed, healthy lifestyle and preventive care was promoted, and the participants were oriented to local resources to support changes in modifiable risk factors. A clustered randomized trial implemented in September 2006 across 39 communities targeting community-dwelling individuals 65 years and older showed a significant reduction in hospitalization one year after its implementation (rate ratio of 91 [95% confidence interval (CI): 86%-97%]). This study explores the impact of CHAP in the first five years. Methods: Using health administrative data housed at the Institute for Clinical Evaluative Sciences, we established a closed cohort consisting of all individuals eligible in these communities at the study onset whom we followed over time. We assessed hospitalizations and survival using a negative binomial model for count data and Cox regression to assess time to first event, accounting for the clustered design. The primary outcome was the rate of cardiovascular-related hospitalizations defined as congestive heart failure, stroke or acute myocardial infarction. Results: Most estimates pointed to an advantage for the intervention arm, but only all-cause mortality reached statistical significance (hazard ratio [95% CI] = 0.955 [0.914–0.999]). The hospitalization cardiovascular-related hospitalization rate ratio was (0.958, 95% CI: 0.898–1.022) in favour of the intervention communities, translating to an estimated 408 averted hospitalizations over the five-year period. There was no evidence of the effect of time from start of intervention. Conclusions: The consistent direction of the outcomes in favour of the intervention arms suggests that CHAP likely had a meaningful impact on reducing cardiovascular-related morbidity and mortality. Given the low cost of the intervention, further development of CHAP should be pursued. [ABSTRACT FROM AUTHOR]

Cases of exertional heat stroke have been reported every year during basic training for Royal Thai Army (RTA) conscripts. Prevention is an important strategy to reduce the incidence of heat-related illnesses. We conducted a study to identify potential indicators for the prevention and monitoring of heat-related illnesses among military conscripts undergoing basic training in Thailand. All newly inducted RTA conscripts in 5 basic training units in 5 regions in Thailand were invited to participate in a prospective cohort study from May 1 to July 9, 2013. The incidence rate of heat-related illnesses and the incidence rate ratio (IRR) based on a Poisson regression model were used to identify the independent factors associated with heat-related illnesses, daily tympanic (body) temperatures higher than 37.5°C, >3% decreases in body weight in one day, and the production of dark brown urine. Eight hundred and nine men aged 21.4 (±1.13) years were enrolled in this study. The prevalence of a body mass index (BMI) ≥30 kg/m2 was 5.5%. During the study period, 53 subjects (6.6%) representing 3.41/100 person-months (95% confidence interval (CI), 2.55–4.23) developed heat-related illnesses (excluding heat rash), and no subjects experienced heat stroke. The incidence rates of a daily tympanic temperature >37.5°C at least once, body weight loss of >3% per day, and the production of dark brown urine at least once were 8.27/100 person-months (95% CI, 7.69–8.93), 47.91/100 person-months (95% CI, 44.22–51.58), and 682.11/100 person-months (95% CI, 635.49–728.52), respectively. The sole identified independent factor related to the incidence of heat-related illnesses was a BMI ≥30 kg/m2 (adjusted IRR = 2.66, 95% CI, 1.01–7.03). In conclusion, a high BMI was associated with heat-related illnesses among conscripts undergoing basic training in Thailand. Daily monitoring of heat-related illnesses, body temperature, body weight and urine color in each new conscript during basic military training was feasible. [ABSTRACT FROM AUTHOR]

Background: Noma (cancrum oris), a neglected tropical disease, rapidly disintegrates the hard and soft tissue of the face and leads to severe disfiguration and high mortality. The disease is poorly understood. We aimed to estimate risk factors for diagnosed noma to better guide existing prevention and treatment strategies using a case-control study design. Methods: Cases were patients admitted between May 2015 and June 2016, who were under 15 years of age at reported onset of the disease. Controls were individuals matched to cases by village, age and sex. Caretakers answered the questionnaires. Risk factors for diagnosed noma were estimated by calculating unadjusted and adjusted odds ratios (ORs) and respective 95% confidence intervals (CI) using conditional logistic regression. Findings: We included 74 cases and 222 controls (both median age 5 (IQR 3, 15)). Five cases (6.5%) and 36 (16.2%) controls had a vaccination card (p = 0.03). Vaccination coverage for polio and measles was below 7% in both groups. The two main reported water sources were a bore hole in the village (cases n = 27, 35.1%; controls n = 63, 28.4%; p = 0.08), and a well in the compound (cases n = 24, 31.2%; controls n = 102, 45.9%; p = 0.08). The adjusted analysis identified potential risk and protective factors for diagnosed noma which need further exploration. These include the potential risk factor of the child being fed pap every day (OR 9.8; CI 1.5, 62.7); and potential protective factors including the mother being the primary caretaker (OR 0.08; CI 0.01, 0.5); the caretaker being married (OR 0.006; CI 0.0006, 0.5) and colostrum being given to the baby (OR 0.4; CI 0.09, 2.09). Interpretation: This study suggests that social conditions and infant feeding practices are potentially associated with being a diagnosed noma case in northwest Nigeria; these findings warrant further investigation into these factors. [ABSTRACT FROM AUTHOR]

Background: Evidence supports the integration of prevention and management for tuberculosis (TB) with non-communicable diseases (NCDs). Bi-directional screening for TB and diabetes mellitus (DM) is already implemented in India, a country with a dual burden of TB and NCDs. However, very limited programmatic data are available on the feasibility of adding other NCDs and their risk factors in such screening programme. Objective: To assess the yield, feasibility, and acceptability of a two-stage integrated screening for NCDs and risk factors for NCDs among patients with TB ≥20 years and treated in DOTS centres of two medical colleges in Delhi, between October 2016 and March 2017. Methods: It was a mixed-methods, triangulation study with a quantitative component (cross-sectional study using questionnaires, anthropometric measurements and records review) and a qualitative component (descriptive study using interview data). Results: Amongst 403 patients screened, the prevalence of hypertension was 7% (n = 28) with 20 new cases detected and 8% for DM (n = 32) with 6 new cases diagnosed. The number needed to screen to find a new case was 20 and 63 for hypertension and DM respectively. The most frequent NCD-risk factors were inadequate vegetable (80%) and fruits (72%) intake, alcohol use (34%), use of smokeless tobacco (33%) and smoking (32%). Clustering of four or more risk factors was associated with increasing age and male sex (p<0.05). Both patients and health providers considered the screening relevant and acceptable. However, waiting time and costs involved in blood tests were considered as bothersome by the patients, while health providers perceived increased workload, inadequate medical supplies and inadequate skills and knowledge as key challenges in implementation of the screening. Conclusion: Integrating screening for NCDs and their risk factors in the existing TB programme produces high yield and it is feasible and acceptable by patients and health providers provided the challenges are overcome. [ABSTRACT FROM AUTHOR]

Ukraine is among the top 20 highest drug-resistant tuberculosis burden countries in the world. Driving the high drug-resistant tuberculosis rates is an unchecked treatment default rate. This evaluation measures the effect of social support provided to tuberculosis patients at risk of defaulting on treatment during outpatient treatment. Five tuberculosis patient cohorts, served in three oblasts from 2011 and 2012, were constructed from medical records to compare risk factors for default, receipt of social services, and treatment outcome. Regression analyses were used to identify risk factors predictive of treatment default and to estimate the impact of the social support program on treatment default, controlling for risk, disease status, and demographics. In 2012, tuberculosis patients receiving social support in Ukraine reduced their probability of defaulting on continuation treatment by 10 percentage points compared to high-risk patients who did not receive social support in 2012 or 2011. Treatment success rates for the high-risk patients receiving social support were comparable to the low-risk cohorts and significantly improved over the high-risk comparison cohorts. Further research is recommended to quantify the costs and benefits for scaling-up social support services, evaluate social support program fidelity, identify which populations respond best to select services, and what barriers might still exist to achieve better adherence. With that information, tailoring programs to most effectively reach and serve clients in a patient-centered approach may reap substantial rewards for Ukraine. [ABSTRACT FROM AUTHOR]

Background: Little prospective evidence exists about risk factors and prognosis of acute pancreatitis in China. We examined the associations of certain metabolic and lifestyle factors with risk of acute pancreatitis in Chinese adults.Methods and Findings: The prospective China Kadoorie Biobank (CKB) recruited 512,891 adults aged 30 to 79 years from 5 urban and 5 rural areas between 25 June 2004 and 15 July 2008. During 9.2 years of follow-up (to 1 January 2015), 1,079 cases of acute pancreatitis were recorded. Cox regression was used to estimate adjusted hazard ratios (HRs) for acute pancreatitis associated with various metabolic and lifestyle factors among all or male (for smoking and alcohol drinking) participants. Overall, the mean waist circumference (WC) was 82.1 cm (SD 9.8) cm in men and 79.0 cm (SD 9.5) cm in women, 6% had diabetes, and 6% had gallbladder disease at baseline. WC was positively associated with risk of acute pancreatitis, with an adjusted HR of 1.35 (95% CI 1.27-1.43; p < 0.001) per 1-SD-higher WC. Individuals with diabetes or gallbladder disease had HRs of 1.34 (1.07-1.69; p = 0.01) and 2.42 (2.03-2.88; p < 0.001), respectively. Physical activity was inversely associated with risk of acute pancreatitis, with each 4 metabolic equivalent of task (MET) hours per day (MET-h/day) higher physical activity associated with an adjusted HR of 0.95 (0.91-0.99; p = 0.03). Compared with those without any metabolic risk factors (i.e., obesity, diabetes, gallbladder disease, and physical inactivity), the HRs of acute pancreatitis for those with 1, 2, or ≥3 risk factors were 1.61 (1.47-1.76), 2.36 (2.01-2.78), and 3.41 (2.46-4.72), respectively (p < 0.001). Among men, heavy alcohol drinkers (≥420 g/week) had an HR of 1.52 (1.11-2.09; p = 0.04, compared with abstainers), and current regular smokers had an HR of 1.45 (1.28-1.64; p = 0.02, compared with never smokers). Following a diagnosis of acute pancreatitis, there were higher risks of pancreatic cancer (HR = 8.26 [3.42-19.98]; p < 0.001; 13 pancreatic cancer cases) and death (1.53 [1.17-2.01]; p = 0.002; 89 deaths). Other diseases of the pancreas had similar risk factor profiles and prognosis to acute pancreatitis. The main study limitations are ascertainment of pancreatitis using hospital records and residual confounding.Conclusions: In this relatively lean Chinese population, several modifiable metabolic and lifestyle factors were associated with higher risks of acute pancreatitis, and individuals with acute pancreatitis had higher risks of pancreatic cancer and death. [ABSTRACT FROM AUTHOR]

Background: Harmful effects of long-term exposure to moderately elevated low-density lipoprotein (LDL)-cholesterol and blood pressure on coronary heart disease (CHD) have not been rigorously examined. We estimated the risk of CHD under long-term exposure to moderately elevated LDL-cholesterol and blood pressure compared with the risk under shorter exposures to higher levels of the same risk factors. Methods: Observational study using data from 2,714 adults in Framingham Offspring Study who were free of existing cardiovascular disease and aged <70 years at baseline (1987–1991). We used the parametric g-formula to estimate 16-year CHD risk under different levels and durations of exposure to LDL-cholesterol (low: <130 mg/dL, moderate: 130 to <160 mg/dL, high 160 to <190 mg/dL, and very high: ≥190 mg/dL) and systolic blood pressure (low: <120 mmHg, prehypertension: 120 to <140 mmHg, stage 1 hypertension: 140 to <160 mmHg, and stage 2 hypertension: ≥160 mmHg). Results: The estimated 16-year CHD risk under exposure to low LDL was 8.2% (95% CI = 7.0–9.6). The 16-year CHD risk under exposure to moderate LDL was 8.9% (7.8–10.1) which was similar to CHD risk under 8 years of low LDL followed by 8 years of high LDL at 9.0% (7.7–10.3); and 12 years of low LDL followed by 4 years of very high LDL at 8.8% (7.6–10.1). The results for blood pressure were similar. Conclusions: Long-term exposure to moderate levels of LDL-cholesterol and blood pressure had a similar impact on CHD risk as shorter exposures to levels considered ‘high’ per clinical guidelines. [ABSTRACT FROM AUTHOR]

Introduction: Cardioembolic (CE) risks is usually considered as the main mechanism of ischemic stroke in non-valvular atrial fibrillation (NVAF) patients. However, a substantial number of ischemic strokes in NVAF patients are related to non-CE mechanisms. The aim of this study was to investigate the non-CE risk factors in ischemic stroke patients had NVAF. Methods: We included 401 patients (65.6% male, 68.6 ± 9.6 years old) who had been hospitalized due to ischemic stroke and had a known or newly diagnosed NVAF. The CE (intracardiac thrombus, dense spontaneous echo contrast, or low left atrial appendage flow velocity) and non-CE (complex aortic plaque, significant carotid stenosis, or intracranial arterial stenosis) risk factors were investigated at the time of the index stroke. Results: The number of CE and non-CE risk factors increased with increasing CHA2DS2-VASc scores (p for trends < 0.001). The presence of CE risk factors was independently associated with persistent atrial fibrillation (p < 0.001), body mass index (p = 0.003), heart failure (p = 0.003), and left atrial volume index (p < 0.001). In contrast, the presence of non-CE risk factors was independently associated with age (p < 0.001), hypertension (p = 0.049), diabetes (p = 0.030), and coronary artery calcium score (CACS; p < 0.001). CACS had the added value in predicting non-CE risk factors of ischemic stroke regardless of the CHA2DS2-VASc risk category (p < 0.001). Conclusion: Non-CE risk factors in ischemic stroke patients with NVAF are associated with high CHA2DS2-VASc score and CACS. Atherosclerotic non-CE risk factors should be considered as potential mechanisms of stroke even in patients with AF-associated ischemic stroke. [ABSTRACT FROM AUTHOR]

Objective: The current guideline recommends lowering low-density lipoprotein cholesterol (LDL-C) for the primary management of dyslipidemia in patients at high-risk of cardiovascular events. Patients who have achieved LDL-C levels below the recommended targets may still experience cardiovascular events, suggesting additional therapeutic targets beyond LDL-C. The aim of this study was to investigate whether high-density lipoprotein cholesterol (HDL-C) levels had an impact on plaque stabilization in patients with acute coronary syndrome (ACS). Methods: This study consisted of 90 ACS patients with untreated dyslipidemia. In optical coherence tomography (OCT) analysis, a plaque with fibrous cap thickness ≦160 μm was defined as a high-risk plaque. We registered one high-risk plaque per one patient by baseline OCT imaging, and then administrated high-intensity statin. Based on the follow-up OCT results, patients whose registered plaque was no longer high-risk plaque were classified into a responder group and the remains into a non-responder group. Results: No differences were observed in the baseline LDL-C and HDL-C levels between the two groups. Reduction of LDL-C levels (δ LDL-C: −53 ± 21 mg/dL vs. −42 ± 29 mg/dL, p = 0.036) and increase of HDL-C levels (δ HDL-C: 2.5 ± 5.9 mg/dL vs. −0.3 ± 6.7 mg/dL, p = 0.039) were greater in the responder group. On multivariate logistic regression analysis, δ LDL-C levels (OR: 0.956, 95% CI: 0.921–0.993; p = 0.020) and δ HDL-C levels (OR: 1.143; 95% CI: 1.005–1.300, p = 0.041) were independent contributors for plaque stabilization. Conclusions: Increase of HDL-C levels is associated with plaque stabilization in patients with ACS. HDL-C could be a therapeutic target for residual risk management. [ABSTRACT FROM AUTHOR]

Multiple cardiovascular risk factors are directly related to the severity of atherosclerosis, even in children and adolescents. In this context accurate assessment of risk factors at the individual level play a decisive role in cardiovascular disease (CVD) prevention. The objective of this study was to estimate the prevalence of cardiovascular risk factors, the frequency of their coexistence in individuals, and identify possible determinants associated with this coexistence in Brazilian adolescents. A cross-sectional study with 1170 students (12–17 years) from public and private schools of a large city was conducted. In addition to family history, modifiable cardiovascular risk factors were assessed including: tobacco use, alcohol consumption, sedentary lifestyle, overweight/obesity, increased waist circumference, and high blood pressure (office and home). We built a linear regression model to identify determinants associated with increasing number of modifiable risk factors. Mean study population age was 14.7±1.6 years, 67% were enrolled in public schools and 33% in private ones. The majority of the adolescents had at least two risk factors (68.9%), more than 10% had more than 4 risk factors, and in only 6.7% of the sample no risk factor was identified. Family history of CVD (β-coefficient = 1.20; 95%CI 1.07–1.34; p<0.001), increasing age (β-coefficient = 0.08; 95%CI 0.04–0.11; p<0.001), and being enrolled in private schools (β-coefficient = 0.16; 95%CI 0.02–0.30; p = 0.023) were directly associated with the modifiable CV risk factors. In conclusion, the prevalence of multiple cardiovascular risk factors was high in the population of adolescents studied. School based interventions should be addressed to change this scenario. [ABSTRACT FROM AUTHOR]

Background: Functional social support has a stronger association with medical treatment adherence than structural social support in several populations and disease conditions. Using a contemporary U.S. population of adults treated with medications for coronary heart disease (CHD) risk factors, the association between social support and medication adherence was examined. Methods: We included 17,113 black and white men and women with CHD or CHD risk factors aged ≥45 years recruited 2003–2007 from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants reported their perceived social support (structural social support: being partnered, number of close friends, number of close relatives, and number of other adults in household; functional social support: having a caregiver in case of sickness or disability; combination of structural and functional social support: number of close friends or relatives seen at least monthly). Medication adherence was assessed using a 4-item scale. Multi-variable adjusted Poisson regression models were used to calculate prevalence ratios (PR) for the association between social support and medication adherence. Results: Prevalence of medication adherence was 68.9%. Participants who saw >10 close friends or relatives at least monthly had higher prevalence of medication adherence (PR = 1.06; 95% CI: 1.00, 1.11) than those who saw ≤3 per month. Having a caregiver in case of sickness or disability, being partnered, number of close friends, number of close relatives, and number of other adults in household were not associated with medication adherence after adjusting for covariates. Conclusions: Seeing multiple friends and relatives was associated with better medication adherence among individuals with CHD risk factors. Increasing social support with combined structural and functional components may help support medication adherence. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the levels of agreement between self-reported responses to the Adult Pre-exercise Screening System (APSS) questionnaire using online versus face-to-face (F2F) modalities. Design: Convenience sample of adults completing a pre-exercise screening questionnaire using different modalities. Methods: Adult volunteers (n = 94) were recruited to complete the APSS using both online and F2F modalities. Participants were provided a URL link to an online APSS questionnaire then followed-up the next day in a F2F interview. Objective health risk factors were also measured. Comparisons between responses were undertaken using kappa and correlation statistics to determine levels of agreement. Results: The levels of agreement between online versus F2F responses for the seven compulsory Stage 1 questions (known diseases and signs and/or symptoms of disease) were 94% (kappa = 0.644–0.794). Response comparisons for Stage 2 questions on health risk factors were also generally high (82% agreement) but there were larger differences between reported and measured risk factors in Stage 3. Conclusions: Levels of agreement between the Stage 1 responses were substantial and support the use of this online option for pre-exercise screening. There were larger differences between self-reported and objectively measured health risk factors in Stages 2 and 3. [ABSTRACT FROM AUTHOR]

In a Perspective, David Peiris and Dorairaj Prabhakaran discuss implications and challenges of cardiovascular disease risk assessments in the population of India. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the prevalence and risk factors of acquired long QT syndrome (LQTS) on admission to a general Intensive Care Unit (ICU), and to assess the risk of LQTS associated with prescribed medications. Methods: Prospective observational, cross-sectional study approved by the Institutional Review Board. Between May 2014 and July 2016, 412 patients >18 years-old consecutively admitted to the ICU of a university hospital were included. LQTS was defined as a QT interval on the admission electrocardiogram corrected using Bazett’s formula (QTc) >460 ms for men and >470 ms for women. All medications administered within 24 hours before admission were recorded. Logistic regression was used. Results: LQTS prevalence was 27.9%. In LQTS patients, 70.4% had ≥ 1 LQTS-inducing drug prescribed in the 24 hours prior to ICU admission versus 70.4% in non-LQTS patients (p = 0.99). Bradycardia and Charlson morbidity index score are independent risk factors for LQTS. Haloperidol (OR 4.416), amiodarone (OR 2.509) and furosemide (OR 1.895) were associated with LQTS, as well as another drug not yet described, namely clopidogrel (OR 2.241). Conclusions: The LQTS is highly prevalent in critically ill patients, ICU patients are often admitted with LQTS-inducing medications, and patients with slow heart rate or with high Charlson comorbidity index should be evaluated for LQTS. [ABSTRACT FROM AUTHOR]

Background: Modifiable risk factors such as smoking and sedentary lifestyle adversely affect multiple sclerosis (MS) progression. Few multimodal behavioural interventions have been conducted for people with MS, and follow-up beyond 1 year is rare for lifestyle interventions. This study assessed adoption and adherence to healthy lifestyle behaviours and health outcomes 3 years after a lifestyle modification intervention, using generalized estimating equation models to account for within-participant correlation over time. Methods: 95 people with MS completed baseline surveys before participating in 5-day MS lifestyle risk-factor modification workshops. 76 and 78 participants completed the 1-year and 3-year follow-up surveys respectively. Mean age at 3-year follow-up was 47 years, 72% were female, most (62.8%) had MS for 5 years or less, and 73% had relapsing remitting MS (RRMS). Results: Compared to baseline, participants reported clinically meaningful increases in physical (mean difference (MD): 8.0, 95% Confidence Interval (CI): 5.2–10.8) and mental health (MD: 9.2, CI: 5.8–12.6) quality of life (QOL) at 1-year, and physical (MD: 8.7, CI: 5.3–12.2) and mental health (MD: 8.0, CI: 4.2–11.8) QOL at 3-year follow-up. There was a small decrease in disability from baseline to 1-year follow-up (MD: 0.9, CI: 0.9,1.0) and to 3-year follow-up (MD: 1.0, CI: 0.9,1.0), which was not clinically meaningful. Of those with RRMS, compared to baseline, fewer had a relapse during the year before 1-year follow-up (OR: 0.1, CI 0.0–0.2) and 3-year follow-up (OR: 0.15, CI 0.06–0.33). Participants’ healthy diet score, the proportion meditating ≥1 hours a week, supplementing with ≥ 5000IU vitamin D daily, and supplementing with omega-3 flaxseed oil increased at 1-year follow-up and was sustained, although slightly lower at 3-year follow-up. However, there was no evidence for a change in physical activity and not enough smokers to make meaningful comparisons. Medication use increased at 1-year follow-up and at 3-year follow-up. Conclusion: The results provide evidence that lifestyle risk factor modification is feasible and sustainable over time, in a small self-selected and motivated sample of people with MS. Furthermore, participation in a lifestyle intervention is not associated with a decrease in MS medication use. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity is increasingly common and is associated with adverse health outcomes, highlighting the need to broaden the single-disease framework that dominates medical research. We examined the role of midlife clinical characteristics, socioeconomic position, and behavioural factors in the development of cardiometabolic multimorbidity (at least 2 of diabetes, coronary heart disease, and stroke), along with how these factors modify risk of mortality.Methods and Findings: Data on 8,270 men and women were drawn from the Whitehall II cohort study, with mean follow-up of 23.7 years (1985 to 2017). Three sets of risk factors were assessed at age 50 years, each on a 5-point scale: clinical profile (hypertension, hypercholesterolemia, overweight/obesity, family history of cardiometabolic disease), occupational position, and behavioural factors (smoking, alcohol consumption, diet, physical activity). The outcomes examined were cardiometabolic disease (diabetes, coronary heart disease, stroke), cardiometabolic multimorbidity, and mortality. We used multi-state models to examine the role of risk factors in 5 components of the cardiometabolic disease trajectory: from healthy state to first cardiometabolic disease, from first cardiometabolic disease to cardiometabolic multimorbidity, from healthy state to death, from first cardiometabolic disease to death, and from cardiometabolic multimorbidity to death. A total of 2,501 participants developed 1 of the 3 cardiometabolic diseases, 511 developed cardiometabolic multimorbidity, and 1,406 died. When behavioural and clinical risk factors were considered individually, only smoking was associated with all five transitions. In a model containing all 3 risk factor scales, midlife clinical profile was the strongest predictor of first cardiometabolic disease (hazard ratio for the least versus most favourable profile: 3.74; 95% CI: 3.14-4.45) among disease-free participants. Among participants with 1 cardiometabolic disease, adverse midlife socioeconomic (1.54; 95% CI: 1.10-2.15) and behavioural factors (2.00; 95% CI: 1.40-2.85), but not clinical characteristics, were associated with progression to cardiometabolic multimorbidity. Only midlife behavioural factors predicted mortality among participants with cardiometabolic disease (2.12; 95% CI: 1.41-3.18) or cardiometabolic multimorbidity (3.47; 95% CI: 1.81-6.66). A limitation is that the study was not large enough to estimate transitions between each disease and subsequent outcomes and between all possible pairs of diseases.Conclusions: The importance of specific midlife factors in disease progression, from disease-free state to single disease, multimorbidity, and death, varies depending on the disease stage. While clinical risk factors at age 50 determine the risk of incident cardiometabolic disease in a disease-free population, midlife socioeconomic and behavioural factors are stronger predictors of progression to multimorbidity and mortality in people with cardiometabolic disease. [ABSTRACT FROM AUTHOR]

Background: To examine the trend of cardiovascular diseases (CVD) risk factors among a Middle Eastern population with prevalent CVD during a median follow up of 12 years. Methods: Patients with prevalent CVD (n = 282, men = 167), with a mean age of 60.76 years were evaluated in four study phases of the TLGS (Tehran lipid glucose study), 2002–2005, 2005–2008, 2008–2011, and 2011–2014. Trends of CVD risk factors were estimated using generalized estimation equation (GEE) models, by adjusting for gender, age and propensity scores. Result: The adjusted prevalence of general and central adiposity, diabetes and physical inactivity at baseline was 25.18, 60.14, 25.03 and 43.74%, respectively and had increasing trends during the study period, reaching 41.32, 66.74, 43.20 and 50.32%, respectively, at the last visit. Although systolic, but not diastolic blood pressure, decreased from 134.88 to 129.86 mmHg, the prevalence of hypertension did not decrease (64.21% vs 68%, p value = 0.326). The prevalence of low high density lipoprotein cholesterol (HDL-C), hypertriglyceridemia and high non-HDL-C at baseline was 74.54, 59.89 and 96.53%, respectively, and showed improved trends reaching 44.87, 47.12 and 96.06% respectively; however, the favorable trend was not observed for high low density cholesterol. Significant increasing trends were observed in the consumption of anti-hypertensive, lipid and glucose lowering medications, but not for aspirin. The prevalence of current smoking (11.05 vs 16.83%, p value = 0.042) and chronic kidney disease (44.16 vs 51.65%, p value = 0.054) increased during follow up. Conclusion: Except for lipid profile status, dangerous trends for other CVD risk factors were demonstrated among CVD patients, which can be a harbinger for high rates of CVD mortality; these findings highlight the need for urgent implementation of multicomponent interventions to control CVD risk factors among these patients. [ABSTRACT FROM AUTHOR]

The relationship between body height and the risk of non‒communicable diseases such as cardiovascular disease and cancer has been the subject of much debate in the epidemiological literature. Concerns have recently arisen over spurious associations due to confounding factors like birth cohort, especially in the context of epidemiological transition. The population of Sardinia represents an interesting case study, as the average physical stature of inhabitants was the lowest recorded in Europe until a few decades ago. In this population we tested whether height is an independent risk factor for cardiovascular disease and cancer. We analysed the stature of 10,427 patients undergoing endoscopy for any reason, for whom a detailed clinical history of cardiovascular disease and/or malignancies had been documented. Poisson regression modelling was used to test the association between stature and disease risk. When patients were subdivided according to sex and height tertiles, the risk of cardiovascular disease proved significantly greater for subjects in the lowest tertile irrespective of sex (men: 1.87; 95%CI 1.41‒2.47; women: 1.23; 95%CI 0.92‒1.66) and smaller for those in the highest tertile (men: 0.51; 95%CI 0.35‒0.75; women: 0.41; 95%CI 0.27‒0.61). However, after adjusting the risk for birth cohort and established risk factors, it mostly resulted in non-significant values, although the overall trend persisted. Similar results were obtained for all-cancer risk (relative risk for men and women in the lowest tertile: 1.44; 95%CI 1.09–1.90 and 1.17; 95%CI 0.93–1.48, in the highest tertile: 0.51; 95%CI 0.36–0.72 and 0.62; 95%CI 0.47–0.81, respectively) as well as for some of the most common types of cancer. We concluded that the risk of developing cardiovascular disease and malignancies does not vary significantly with stature in the Sardinian population, after adjusting for birth cohort and more obvious risk factors. [ABSTRACT FROM AUTHOR]

Aims: Carotid intima media thickness (CIMT) predicts cardiovascular (CVD) events, but the predictive value of CIMT change is debated. We assessed the relation between CIMT change and events in individuals at high cardiovascular risk. Methods and results: From 31 cohorts with two CIMT scans (total n = 89070) on average 3.6 years apart and clinical follow-up, subcohorts were drawn: (A) individuals with at least 3 cardiovascular risk factors without previous CVD events, (B) individuals with carotid plaques without previous CVD events, and (C) individuals with previous CVD events. Cox regression models were fit to estimate the hazard ratio (HR) of the combined endpoint (myocardial infarction, stroke or vascular death) per standard deviation (SD) of CIMT change, adjusted for CVD risk factors. These HRs were pooled across studies. In groups A, B and C we observed 3483, 2845 and 1165 endpoint events, respectively. Average common CIMT was 0.79mm (SD 0.16mm), and annual common CIMT change was 0.01mm (SD 0.07mm), both in group A. The pooled HR per SD of annual common CIMT change (0.02 to 0.43mm) was 0.99 (95% confidence interval: 0.95–1.02) in group A, 0.98 (0.93–1.04) in group B, and 0.95 (0.89–1.04) in group C. The HR per SD of common CIMT (average of the first and the second CIMT scan, 0.09 to 0.75mm) was 1.15 (1.07–1.23) in group A, 1.13 (1.05–1.22) in group B, and 1.12 (1.05–1.20) in group C. Conclusions: We confirm that common CIMT is associated with future CVD events in individuals at high risk. CIMT change does not relate to future event risk in high-risk individuals. [ABSTRACT FROM AUTHOR]

There is a suspected but unproven association between long-term exposure to ambient air pollution and mental health. The aim of this study is to investigate the association between long-term exposure to ambient air pollution and subjective stress, depressive disorders, health-related quality of life (QoL) and suicide. We selected 124,205 adults from the Korean Community Health Survey in 2013 who were at least 19 years old and who had lived in their current domiciles for > five years. Based on the computer-assisted personal interviews to measure subjective stress in daily life, EuroQoL-5 dimensions, depression diagnosis by a doctor, suicidal ideation, and suicidal attempts, we evaluated the risk of mental disorders using multiple logistic regression analysis according to the quartiles of air pollutants, such as particulate matter <10μm (PM10), nitrogen dioxide (NO2), carbon monoxide (CO), and sulfur dioxide, using yearly average concentration between August 2012 and July 2013. The prevalence of high stress, poor QoL, depressiveness, diagnosis of depression, and suicide ideation was positively associated with high concentrations of PM10, NO2, and CO after adjusting for confounding factors. Men were at increased risk of stress, poor QoL, and depressiveness from air pollution exposure than were women. The risk of higher stress or poor QoL in subjects < age 65 increased with air pollution more than did that in subjects ≥ age 65. Long-term exposure to ambient air pollution may be an independent risk factor for mental health disorders ranging from subjective stress to suicide ideation. [ABSTRACT FROM AUTHOR]

Background: Medication non-adherence can result in poor health outcomes. Understanding differences in adherence rates to non-vitamin K oral anticoagulants (NOACs) could guide treatment decisions and improve clinical outcomes among patients with non-valvular atrial fibrillation (NVAF). Objective: To compare adherence to rivaroxaban and apixaban among the overall NVAF population and subgroups of prior oral anticoagulant (OAC) users (e.g., multiple comorbidities, non-adherence risk factors). Methods: Using healthcare claims from the Truven Health Analytics MarketScan (7/2012-7/2015), adult patients with ≥2 dispensings of rivaroxaban or apixaban ≥ 180 days apart with > 60 days of supply, ≥ 6 months of pre- and post-index eligibility, ≥ 1 atrial fibrillation diagnosis pre- or on the index date, and without valvular involvement were identified. Propensity-score methods adjusting for potential baseline confounders were used to create matched cohorts of rivaroxaban and apixaban patients. Adherence was assessed during the implementation phase using the percentage of patients with proportion of days covered (PDC) ≥0.8 at 6 months. Subgroups of patients with prior OAC use were evaluated; additional subgroups were identified and evaluated by Quan-Charlson Comorbidity index ≥2 and presence of non-adherence risk factors (i.e., mental disorders, stress, isolation, and rheumatoid arthritis). Results: A total of 13,890 NVAF subjects were included in each of the 2 matched cohorts. All baseline characteristics were balanced between cohorts. At 6 months, significantly more rivaroxaban users were adherent to treatment compared to apixaban users (81.8% vs. 78.0%; absolute difference of 3.8%; p<.001). Rivaroxaban users had significantly higher adherence rates in all subgroups examined. Conclusion: Rivaroxaban users had consistently higher adherence rates than apixaban users overall and among all NVAF subgroups examined. [ABSTRACT FROM AUTHOR]

Background: Hypertension is a significant global public health problem and recognized as an important risk factor for cardiovascular diseases. This study was designed to assess the current prevalence of hypertension and to explore risk factors associated with hypertension by urban and rural status to guide the prevention and control of hypertension in Jilin province. Methods: A multi-stage stratified random cluster sampling method was used to obtain data on hypertension, which was investigated by physical examination and face-to-face questionnaire in July 2014-December 2015. Sample data were analyzed by complex weighted statistical analysis to estimate blood pressure levels and prevalence of hypertension in the province. Multivariable logistic regression analysis was used to identify factors influencing hypertension rates. Results: The prevalence of hypertension was significantly higher in rural areas than urban areas (25.93% versus 22.73%, respectively). The rates of hypertension known (46.7% versus 38.1%, respectively), control (13.7% versus 5.0%, respectively), and controlled among treated subjects (38.3% versus 17.5%, respectively) were higher in urban areas than in rural areas (all p < 0.001), while the treatment rate was not statistically significantly different between urban and rural areas (35.9% versus 28.4%, respectively). After adjusting for demographic covariates, hypertension prevalence in rural areas was still significantly greater than in urban areas (adjusted OR = 1.22; 95%CI: 1.10, 1.36; p < 0.001). Common risk factors for hypertension among urban and rural residents included older age; male; married; employed; less education; overweight/obese; greater abdominal waist circumference; family history of hypertension, stroke, or coronary heart disease; current smoker; alcohol consumption; higher visceral adiposity index; and higher body fat percentage. Conclusions: This study identified an increased risk for hypertension in rural regions of Jilin province, suggesting that rural hypertension screening and treatment guidelines should receive greater attention. [ABSTRACT FROM AUTHOR]

In a Perspective, Joshua Knowles and Euan Ashley discuss the potential for use of genetic risk scores in clinical practice. [ABSTRACT FROM AUTHOR]

Background: African Americans are disproportionately affected by both HIV and hypertension. Failure to modify risk factors for cardiovascular disease and chronic kidney disease such as hypertension among HIV-infected patients may attenuate the benefits conferred by combination antiretroviral therapy. In the general population, African Americans with hypertension are less likely to have controlled blood pressure than whites. However, racial differences in blood pressure control among HIV-infected patients are not well studied. Methods: We conducted a cross-sectional study evaluating racial differences in hypertension prevalence, treatment, and control among 1,664 patients attending the University of Alabama at Birmingham HIV Clinic in 2013. Multivariable analyses were performed to calculate prevalence ratios (PR) with 95% confidence intervals (CI) as the measure of association between race and hypertension prevalence and control while adjusting for other covariates. Results: The mean age of patients was 47 years, 77% were male and 54% African-American. The prevalence of hypertension was higher among African Americans compared with whites (49% vs. 43%; p = 0.02). Among those with hypertension, 91% of African Americans and 93% of whites were treated (p = 0.43). Among those treated, 50% of African Americans versus 60% of whites had controlled blood pressure (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg) (p = 0.007). After multivariable adjustment for potential confounders, prevalence of hypertension was higher among African Americans compared to whites (PR 1.25; 95% CI 1.12–1.39) and prevalence of BP control was lower (PR 0.80; 95% CI 0.69–0.93). Conclusions: Despite comparable levels of hypertension treatment, African Americans in our HIV cohort were less likely to achieve blood pressure control. This may place them at increased risk for adverse outcomes that disproportionately impact HIV-infected patients, such as cardiovascular disease and chronic kidney disease, and thus attenuate the benefits conferred by combination antiretroviral therapy. [ABSTRACT FROM AUTHOR]

Objective: To determine whether latent tuberculosis infection risk factors are associated with an increased likelihood of latent tuberculosis infection testing in the US private healthcare sector. Data source: A national sample of medical and pharmacy claims representing services rendered January 2011 through December 2013 for 3,997,986 commercially insured individuals in the US who were 0 to 64 years of age. Study design: We used multivariable logistic regression models to determine whether TB/LTBI risk factors were associated with an increased likelihood of Interferon-Gamma Release Assay (IGRA) or Tuberculin Skin Test (TST) testing in the private sector. Principal findings: 4.31% (4.27–4.34%) received at least one TST/IGRA test between 2011 and 2013 while 1.69% (1.67–1.72%) received a TST/IGRA test in 2013. Clinical risk factors associated with a significantly increased likelihood of testing included HIV, immunosuppressive therapy, exposure to tuberculosis, a history of tuberculosis, diabetes, tobacco use, end stage renal disease, and alcohol use disorder. Other significant variables included gender, age, asthma, the state tuberculosis rate, population density, and percent of foreign-born persons in a county. Conclusions: Private sector TST/IGRA testing is not uncommon and testing varies with clinical risk indicators. Thus, the private sector can be a powerful resource in the fight against tuberculosis. Analyses of administrative data can inform how best to leverage private sector healthcare toward tuberculosis prevention activities. [ABSTRACT FROM AUTHOR]

Background: Previous studies have established a correlation between coronary artery calcification (CAC) measured by ECG-gated chest computed tomography (CT) and cardiovascular disease. Recent reports which included asymptomatic patients suggest that CAC measured on non-ECG gated CT is similarly associated with cardiovascular risk. This study investigates the correlation between the Framingham Risk Score (FRS) and an incidental finding of CAC on a non-gated chest CT performed for non-cardiac indications in young and seemingly healthy adults. Methods: A cross-sectional study that included 162 CT scans performed in young patients aged 18–50 years old for non-cardiac indications in our institution was conducted. CAC score (CACS) was calculated using the Agatston method. FRS was calculated and compared to the CACS using three different approaches. The correlations between the CACS and several specific factors (i.e. age, body mass index, smoking, statins, etc.), were also evaluated. Results: Mean age of patients was 36.43 year old and 105 (64.8%) were male. We found a significant positive correlation between the CACS and the FRS in all three approaches (p<0.05). Increased age, smoking and statin use were the only individual factors clearly associated with an increase in CACS (p = 0.002, p = 0.045 and p = 0.009, respectively). Conclusion: This is the first report indicating that incidental CACS identified in non-gated MDCT is also associated with cardiovascular risk evaluated by FRS in a young population. Our findings suggest that young asymptomatic individuals with incidental CAC should be seriously evaluated for cardiovascular risk factors despite presumption of belonging to a low cardiovascular risk category. [ABSTRACT FROM AUTHOR]

Backgrounds: Lower health literacy (HL) is associated with several cardiovascular disease (CVD) risk factors such as diabetes, hypertension, and metabolic syndrome (MS). The aim of our study was to investigate the association between HL and the Framingham 10-year risk score of CVD. Methods: From 2015–2016, 1010 subjects aged 23 to 88 years receiving health check-up in Taipei Veterans General Hospital had complete clinical evaluations and laboratory examinations. Fatty liver was diagnosed by ultrasonography. The short form questionnaire adapted from the Mandarin Health Literacy Scale was used to assess HL. The Framingham risk score was calculated by patient characteristics. Results: Subjects with higher BMIs were associated with lower HL scores. The proportion of subjects with MS was higher in the lower health literacy score group (≤ 9) at 28.8%; further analysis found that lower HL was significantly associated with MS in women but not in men. The Spearman’s rho demonstrated that the HL score was significantly associated with the BMI-based (rho = -0.11; P < 0.001) or lipid-based (rho = -0.09; P < 0.004) Framingham risk score. Conclusions: Higher HL scores were associated with less CVD risk such as lower BMIs, less MS in women, and less fatty liver disease. Furthermore, HL had an inverse association with the Framingham risk score as expected. Therefore, HL in patients with CVD risk should be improved and considered as an important issue in terms of CVD reduction. [ABSTRACT FROM AUTHOR]

Depression is a common mental health problem with a higher prevalence in medical students than in the general population. This study aims to investigate the association between depressive symptoms, particularly those in each domain of the Center for Epidemiological Studies Depression (CES-D) Scale, and related factors. A cross-sectional study was conducted with a random sample of 1319 medical students at Haiphong University of Medicine and Pharmacy in 2016. The CES-D scale and a self-reported questionnaire were used to identify the prevalence of depressive symptoms and related risk factors. Univariate and multivariate logistic regression were performed to assess the risk factors associated with depressive symptoms and the score for each structure factor. Depressive symptoms were observed in 514 (39%) students, including more males than females (44.2% vs 36.9%, p = 0.015). Students whose mothers’ highest education level was primary school had a higher prevalence of depressive symptoms than students whose mothers had higher education levels (p = 0.038). There was a significant relationship between depressive symptoms and stressful life events, especially a decline in personal health. A higher correlation was found between the somatic complaints and depressive affect domains. The impacts of risk factors differed for each domain of the depression scale. Only the factor of achieving excellence showed no statistically significant associations with depressive symptoms and the scores on the four domains considered in this study. The high prevalence of depressive symptoms among medical students with risk factors and the impact of these risk factors on each domain of depression scale need further clarification to alleviate depression in students during their medical training. [ABSTRACT FROM AUTHOR]

Background: An unfavorable body composition is often present in chronic arthritis patients. This unfavorable composition is a loss of muscle mass, with a stable or increased (abdominal) fat mass. Since it is unknown when this unfavorable composition develops, we compared body composition in disease-modifying antirheumatic drugs (DMARD)-naive early arthritis patients with non-arthritis controls and explored the association, in early arthritis patients, with disease activity and traditional cardiovascular risk factors. Methods: 317 consecutive early arthritis patients (84% rheumatoid arthritis according to 2010 ACR/EULAR criteria) and 1268 age-/gender-/ethnicity-matched non-arthritis controls underwent a Dual-energy X-ray absorptiometry scan to assess fat percentage, fat mass index, fat mass distribution and appendicular lean (muscle) mass index. Additionally, disease activity, health assessment questionnaire (HAQ), acute phase proteins, lipid profile and blood pressure were evaluated. Results: Loss of muscle mass (corrected for age suspected muscle mass) was 4–5 times more common in early arthritis patients, with a significantly lower mean appendicular lean mass index (females 6% and males 7% lower, p<0.01). Patients had more fat distributed to the trunk (females p<0.01, males p = 0.07) and females had a 4% higher mean fat mass index (p<0.01). An unfavorable body composition was associated with a higher blood pressure and an atherogenic lipid profile. There was no relationship with disease activity, HAQ or acute phase proteins. Conclusion: Loss of muscle mass is 4–5 times more common in early arthritis patients, and is in early arthritis patients associated with a higher blood pressure and an atherogenic lipid profile. Therefore, cardiovascular risk is already increased at the clinical onset of arthritis making cardiovascular risk management necessary in early arthritis patients. [ABSTRACT FROM AUTHOR]

Background and objectives: Chronic kidney disease (CKD) is a global health burden and is independently associated with increased cardiovascular disease risk. Assessment of cardiovascular risk in the general population using prognostic models based on routinely collected risk factors is embedded in clinical practice. In CKD, prognostic models may misrepresent risk due to the interplay of traditional atherosclerotic and non-traditional risk factors. This systematic review’s aim was to identify routinely collected risk factors for inclusion in a CKD-specific cardiovascular prognostic model. Design, setting, participants and measurements: Systematic review and meta-analysis of observational cohort studies and randomized controlled trials. Studies identified from MEDLINE and Embase searches using a pre-defined and registered protocol (PROSPERO ID—2016:CRD42016036187). The main inclusion criteria were individuals ≥18 years of age with non-endstage CKD. Routinely collected risk factors where multi-variable adjustment for established cardiovascular risk factors had occurred were extracted. The primary outcome was fatal and non-fatal cardiovascular events. Results: The review of 3,232, abstracts identified 29 routinely collected risk factors of which 20 were presented in more than 1 cohort. 21 cohorts were identified in relation to 27,465 individuals and 100,838 person-years. In addition to established traditional general population cardiovascular risk factors, left ventricular hypertrophy, serum albumin, phosphate, urate and hemoglobin were all found to be statistically significant in their association with future cardiovascular events. Conclusions: These non-traditional risk factors should be assessed in the development of future cardiovascular prognostic models for use in individuals with CKD. [ABSTRACT FROM AUTHOR]

Background: The prevalence of diabetes, heart disease, and stroke multimorbidity (co-occurrence of two or three of these conditions) has increased rapidly. Little is known about how the three conditions progress from one to another sequentially through the life course. We aimed to delineate this progression in middle-aged women and to determine the roles of common risk factors in the accumulation of diabetes, heart disease, and stroke multimorbidity.Methods and Findings: We used data from 13,714 women aged 45-50 years without a history of any of the three conditions. They were participants in the Australian Longitudinal Study on Women's Health (ALSWH), enrolled in 1996, and surveyed approximately every 3 years to 2016. We characterized the longitudinal progression of the three conditions and multimorbidity. We estimated the accumulation of multimorbidity over 20 years of follow-up and investigated their association with both baseline and time-varying predictors (sociodemographic factors, lifestyle factors, and other chronic conditions). Over 20 years, 2,511 (18.3%) of the women progressed to at least one condition, of whom 1,420 (56.6%) had diabetes, 1,277 (50.9%) had heart disease, and 308 (12.3%) had stroke; 423 (16.8%) had two or three of these conditions. Over a 3-year period, the age-adjusted odds of two or more conditions was approximately twice that of developing one new condition compared to women who did not develop any new conditions. For example, the odds for developing one new condition between Surveys 7 and 8 were 2.29 (95% confidence interval [CI], 1.93-2.72), whereas the odds for developing two or more conditions was 6.51 (95% CI, 3.95-10.75). The onset of stroke was more strongly associated with the progression to the other conditions (i.e., 23.4% [95% CI, 16.3%-32.2%] of women after first onset of stroke progressed to other conditions, whereas the percentages for diabetes and heart disease were 9.9% [95% CI, 7.9%-12.4%] and 11.4% [95% CI, 9.1%-14.4%], respectively). Being separated, divorced, or widowed; being born outside Australia; having difficulty managing on their available income; being overweight or obese; having hypertension; being physically inactive; being a current smoker; and having prior chronic conditions (i.e., mental disorders, asthma, cancer, osteoporosis, and arthritis) were significantly associated with increased odds of accumulation of diabetes, heart disease, and stroke multimorbidity. The main limitations of this study were the use of self-reported data and the low number of events.Conclusions: Stroke was associated with increased risk of progression to diabetes or heart disease. Social inequality, obesity, hypertension, physical inactivity, smoking, or having other chronic conditions were also significantly associated with increased odds of accumulating multimorbidity. Our findings highlight the importance of awareness of the role of diabetes, heart disease, and stroke multimorbidity among middle-aged women for clinicians and health-promotion agencies. [ABSTRACT FROM AUTHOR]

In 2013, a large measles epidemic occurred in the Aketi Health Zone of the Democratic Republic of Congo. We conducted a two-stage, retrospective cluster survey to estimate the attack rate, the case fatality rate, and the measles-specific mortality rate during the epidemic. 1424 households containing 7880 individuals were included. The estimated attack rate was 14.0%, (35.0% among children aged <5 years). The estimated case fatality rate was 4.2% (6.1% among children aged <5 years). Spatial analysis and linear regression showed that younger children, those who did not receive care, and those living farther away from Aketi Hospital early in the epidemic had a higher risk of measles related death. Vaccination coverage prior to the outbreak was low (76%), and a delayed reactive vaccination campaign contributed to the high attack rate. We provide evidences suggesting that a comprehensive case management approach reduced measles fatality during this epidemic in rural, inaccessible resource-poor setting. [ABSTRACT FROM AUTHOR]