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ObjectiveThe purpose of this study was to investigate the gender-and race-specific predictive variations in COVID-19 cases and deaths in Georgia, USA.MethodsThe data were extracted from the Georgia Department of Public Health (GDPH). Statistical methods, such as descriptive statistics, Artificial neural networks (ANN), and Bayesian approach, were utilized to analyze the data.ResultsMore Whites died from COVID-19 than African-Americans/Blacks in Cobb, Hall, Gwinnett, and non-Georgia residents; however, more Blacks died in Dekalb and Fulton counties. The highest posterior mean for female deaths was obtained in Gwinnett County (77.17; 95% CI, 74.23–80.07) and for male deaths in Fulton County (73.48; 95% CI, 72.18–74.49). For overall race/ethnicity, Whites had the highest posterior mean for deaths (183.18; 95% CI, 128.29–238.27) compared with Blacks (162.48; 95% CI, 127.15– 197.42). Assessing the classification of the chronic medical conditions using ANN, Cobb and Hall Counties showed the highest mean AUC-ROC of the models (78% and 79%, respectively).ConclusionsThe predictive models of COVID-19 transmission will help public health practitioners and researchers to better understand the course of the COVID-19 pandemic. The study findings are generalizable to populations with geographic and racial/ethnic similarities and may be used to determine gender/race-specific future virus models for effective interventions or policy modifications.Human SubjectsNo personal identifiable information was obtained.

Coronavirus disease-2019 (COVID-19) has adversely impacted vulnerable communities. Community health workers (CHWs) are an evidence-based solution for helping communities navigate challenges and barriers. This case study describes the work of CHWs in a large Hispanic Chicago neighborhood who experienced a disproportionate number of COVID-19 cases. Methods included semistructured interviews and conventional qualitative content analysis. Results describe the problem; the situation; CHWs' roles, motivations and actions; outcomes; lessons learned; and recommendations. The case study concludes with a discussion of effective CHW engagement-particularly for underresourced communities-and presents recommendations for CHW workforce development and policies to strengthen the health care and public health systems.

Change is a fundamental component of contemporary restoration ecology. The environment, the research, and the ideas in this discipline are rapidly evolving and changing. The California Society for Ecological Restoration annual meeting was an inclusive, diverse meeting that significantly advanced new thinking in the field and provided an exemplar of the value of scientific discourse at meetings. The restoration work in this region also amplified and identified trends in the scientific community at large. A total of three future‐oriented strategic issues emerged from the discourse at this meeting. (1) Restoration ecologists need to consider alternative definitions of local for interventions within a region. (2) Restoration is never complete and must always incorporate people. (3) Indirect outcomes and the process of restoration have merit despite challenges of immediate identification of benefits. The science presented served as a platform for these advanced strategic issue examinations, and the grandest of challenges for restoration ecology necessarily includes people in every equation and embraces values and perceptions over longer time frames.

The COVID-19 pandemic has required the professional healthcare workforce not only to adjust methods of delivering care safely but also act as a trusted sources of information during a time of uncertainty and rapid research and discovery. The Community Health Worker COVID-19 Impact Survey is a cross-sectional study developed to better understand the impact of COVID-19 on this sector of the healthcare workforce, including training needs of those working through the pandemic. The survey was distributed in Texas, New Mexico, and Arizona. This study focuses on Texas, and the data presented (n = 693) is a sub-set of qualitative data from the larger survey. Results of the content analysis described in this paper are intended to inform current COVID-19-related CHW training curriculum, in addition to future infectious disease prevention and preparedness response trainings.

This study tested whether a cancer education intervention affected promotores' self-efficacy to deliver an intervention to Hispanics and which psychosocial determinants of promotores influenced the number of Hispanic residents reached by promotores in the subsequent education intervention. A quasi-experimental, pre/post-design with a treatment group (no control) assessed differences for promotores (n = 136) before and after exposure to the cancer education intervention. The design also included a cross-sectional evaluation of the number of residents promotores reached with the educational intervention. After being trained, the promotores delivered the intervention to Hispanic residents (n = 1,469). Paired t-tests demonstrated increases in promotores' self-efficacy from pre- to post-intervention. Regression models assessed associations between the numbers of residents reached and select psychosocial determinants of promotores. Age and promotores' years of experience influenced their delivery of a cervical cancer education intervention to Hispanics, but not their delivery of breast or colorectal cancer education interventions. This is the first study to examine which psychosocial determinants influence promotores delivery of cancer education interventions. The outcomes potentially have implications for CHW interventions and training by examining this potential connection between CHWs' psychosocial determinants and intervention outcomes.

This chapter describes the Community Health Worker Core Consensus (C3) Project carried out from 2014 to 2018. The focus of the C3 Project was to develop an updated contemporary list of CHW core roles and competencies (skills and qualities) common in the United States, using the National Community Health Advisor Study (NCHAS, 1994–1998) as a baseline. This chapter outlines the process of undertaking the Project and the methods incorporated to maximize CHW voice and leadership in the process. The chapter closes with a presentation of the C3 Project’s updated CHW core roles and competencies. Of those roles or areas of CHW scope of work, three were newly identified since the NCHAS. They are implementing individual and community assessments; conducting outreach; and participating in evaluation and research. These and the other seven roles named by the C3 Project serve as the foundation for the organization of the ten roles highlighted in this book. Skills newly identified or refined in the same time frame include individual and community assessment skills; outreach skills; professional skills and conduct; and evaluation and research skills. Finally, qualities embraced by the C3 Project are noted; these are based on previous research in the field. The most prominent is the quality of CHWs’ “connection to the community served.”

The role of advocating for individuals and communities not only includes advocating for the basic needs and resources of communities and entails conducting policy advocacy. This chapter provides two accounts of how CHWs provide advocacy and advocate for their profession. CHWs in Arizona advocated for their communities and their workforce on the state, local, and federal level to address the social determinants of health and structural issues such as poverty, unemployment, the built environment, and discrimination. The first team explores stories of CHWs who have advocated on multiple levels, including organizational and policy levels, and discusses the factors that support and hinder CHW advocacy efforts. The team describes how local and grassroots advocacy efforts ultimately helped to create a CHW workforce sustainability movement and support the statewide CHW professional association, Arizona Community Health Workers Association (AzCHOW), in advocating for voluntary certification on the state level. The second team provides timely information on how CHWs with Enlace Chicago advocated for their communities during COVID-19 to address social determinants of health, including poverty, unemployment, discrimination, and exploitation of worker rights, and provide basic needs. The CHW stories describe how advocacy efforts were instrumental in directing community members to food banks, personal protection equipment, sources of employment and workers’ rights, and emergency rental assistance programs. These stories underscore how CHWs were often the only links connecting their community members to what they needed while facilitating the community’s understanding to public health guidelines during COVID-19 and addressing mental health needs.

Community health workers (CHWs) have utilized their special skills and abilities to impact and improve community health for decades. Yet, despite the effectiveness of CHWs, several factors contribute to inconsistent and underutilization of CHWs in program management, clinical care, and research. For the past several years, CHWs have joined forces to actively and collaboratively seek and obtain respect and recognition of the CHW workforce and profession as a part of other health, social, and human service professions. CHWs must represent their communities at local, state, and national government as well as in health, social, and human service delivery systems. This chapter calls for full acceptance and incorporation of CHWs into clinical, research, or community-based care teams, which necessitates acknowledgment and trust of CHW expertise within the system; recognizing and verbalizing CHW work as essential to other public health, social, and human service professions and to the CHWs and communities they serve; and incorporating respect for the unique knowledge, experiences, and contributions CHW bring to the table, advocate for themselves. Our call to action for our readers is for you to find ways to become more involved with CHWs and join the movement to advocate for equity on behalf of all of our communities.

The process of implementing individual and community assessments includes recognizing the strengths, assets, needs, and challenges of a specified individual and/or community. While this chapter highlights two teams from different parts of the country, Hawai’i and Kansas City, Missouri, they both recount how community health workers (CHWs) participate in design, implementation, and interpretation of individual-level assessments and community-level assessments. The Hawai’i team shares multiple stories of CHWs’ deep knowledge base of program requirements, utilization of multiple eligibility tools and forms, cultural humility, and communication skills to clearly connect and converse with individuals in a way that is helpful and eases anxiety when facing multiple needs and barriers. The Kansas City team with KC CARE Health Center describes how assessments are a key component to understanding clients and their circumstances. CHWs share their stories on listening to clients, and these stories demonstrate the positive impact informal assessment have on CHWs’ relationship with their clients and how a supportive and sensitive partnership helps guide clients to success.

This introductory chapter describes Community Health Workers (CHWs), what they do, and why the CHW model should be fully engaged and embraced by the health and social services systems. This chapter uses the term Community Health Workers (CHWs) to describe a variety of titles that fall under the CHW umbrella; while there are numerous terms to describe CHWs, their roles and competencies are similar. CHWs are trusted members who understand their community, which allows CHWs to serve as a bridge between health and social service providers and the community in order to facilitate access to services as well as to improve the quality and cultural competence of services. CHWs perform many roles, including cultural mediation; culturally appropriate health education and information; care coordination, case management, and system navigation; coaching and social support; individual and community capacity; direct services; individual and community assessments; outreach; and evaluation and research. The chapter concludes with making the case for engaging CHWs, citing several positive outcomes for participants who received CHW services.

In 2016, the editors of this book, along with collaborators, developed a survey in order to gain input for the development of a call-for-chapters proposal. The survey served as an opportunity to elicit contributions about roles, responsibilities, and competencies of community health workers (CHWs), CHW instructors/trainers, CHW stakeholders/allies, and CHW employers. Survey collection occurred from July 15, 2016, to February 15, 2017. During that time, the survey collected responses from 773 participants. The survey consisted of approximately 180 questions. Each participant classified themselves as either a CHW, a CHW instructor or trainer, a CHW stakeholder or ally, or a CHW employer, and they completed a subset of the overall survey that corresponded to their current role. The survey took approximately 20 min to complete. This chapter summarizes and discusses the findings of this survey, with the intent to give our readers a glimpse of CHWs across the United States, and to provide context as readers proceed through each chapter with CHWs sharing their stories of how they do the work they do and the roles they fulfill to serve their places of work, communities, and clients.

Background The contemporary impact of glycemic control on patients with diabetes mellitus at high cardiovascular risk remains unclear. We evaluated the utility of hemoglobin A1c (HbA1c) as a marker of risk on the composite end point of cardiovascular death, nonfatal myocardial infarction, stroke, hospitalization for unstable angina, and coronary revascularization in an optimally treated population with diabetes mellitus and established coronary artery disease enrolled in the ACCELERATE (Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibition With Evacetrapib in Patients at a High Risk for Vascular Outcomes) trial. Methods and Results We included all patients with established diabetes mellitus and measured HbA1c (N=8145) and estimated Kaplan‐Meier (KM) events rates, stratified by increasing baseline HbA1c levels censored at 30 months. We then performed a multivariable regression for the primary end point. Increasing baseline HbA1c was strongly associated with the occurrence of the primary end point (KM estimate, 12.6–18.2; P P =0.003) as well as the individual end points of nonfatal myocardial infarction (KM estimate, 3.1–7.0; P P =0.003), and revascularization (KM estimate, 7.3–11.1; P =0.001), although not stroke (KM estimate, 1.4–2.4; P =0.45). The rates of cardiovascular mortality (KM estimate, 2.6–4.3; P =0.21) and all‐cause mortality ( KM estimate, 4.8–5.9; P =0.21) were similar regardless of baseline HbA1c levels. When adjusting for relevant baseline characteristics, baseline HbA1c was an independent predictor for the primary end point (hazard ratio, 1.06; 95% CI , 1.02–1.11; P =0.003). Conclusions Glycemic control, as measured by HbA1c, remains strongly and independently associated with cardiovascular outcomes in high‐risk patients with diabetes mellitus on statin therapy. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 01687998.

BackgroundHigh-density lipoprotein (HDL) levels are inversely associated with cardiovascular risk. Cholesteryl ester transfer protein inhibition with evacetrapib results in a marked increase in HDL and reduction in low-density lipoprotein (LDL) levels. We evaluated the impact of treatment with evacetrapib versus placebo in the subset of 8236 patients with diabetes mellitus (DM) enrolled in the Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibition with Evacetrapib in Patients at a High Risk for Vascular Outcomes trial.Methods and resultsTime to first occurrence of any component of the primary composite endpoint of cardiovascular death, myocardial infarction, stroke, revascularization, and hospitalization for unstable angina was compared among patients with DM randomized to treatment with evacetrapib (n=4127) or placebo (n=4109) over a median of 26 months of follow-up. The mean baseline LDL at initiation was 80 mg/dL with a mean baseline HDL of 44 mg/dL. In patients with DM, evacetrapib resulted in a 131% mean increase in HDL levels and a 32% mean decrease in LDL at 3 months that was sustained during the course of the trial. At 6 months, hemoglobin A1c (HbA1c) levels were lower with evacetrapib than placebo (7.08% vs 7.15%, p=0.023). Composite event rates were higher in patients with DM than without DM (Kaplan-Meier estimates: 15.2% vs 10.6%, HR 1.46, 95% CI 1.30 to 1.64, pConclusionDespite a favorable increase in HDL, and decreases in LDL and HbA1c levels in patients with DM, we observed no benefits of treatment with evacetrapib on prespecified clinical outcomes in this high-risk population.

IMPORTANCE: Visit-to-visit blood pressure variability (BPV) is associated with cardiovascular events, but mechanisms and therapeutic implications underlying this association are not well understood. OBJECTIVE: To examine the association of intraindividual BPV, coronary atheroma progression, and clinical outcomes using serial intravascular ultrasonography. DESIGN, SETTING, AND PARTICIPANTS: Post hoc patient-level analysis of 7 randomized clinical trials conducted from 2004 to 2016 involving 3912 patients in multicenter, international, clinic-based primary and tertiary care centers. Adult patients with coronary artery disease who underwent serial intravascular ultrasonography in the setting of a range of medical therapies were included. Data were analyzed between November 2017 and March 2019. EXPOSURES: Visit-to-visit BPV measured using intraindividual standard deviation over 3, 6, 12, 18, and 24 months. MAIN OUTCOMES AND MEASURES: Percent atheroma volume (PAV) progression and major adverse cardiovascular events (defined as death, myocardial infarction, stroke, urgent revascularization for acute coronary syndrome, and hospitalization for unstable angina). RESULTS: Of 3912 patients, the mean (SD) age was 58 (9) years, 1093 (28%) were women, and 3633 (93%) were white . Continuous change in PAV was significantly associated with systolic BPV (β, .049; 95% CI, 0.021-0.078; P = .001), diastolic BPV (β, .031; 95% CI, 0.002-0.059; P = .03), and pulse pressure variability (β, .036; 95% CI, 0.006-0.067; P = .02), without a signal for differential effect greater than or less than a mean BP of 140/90 mm Hg. The PAV progression as a binary outcome was significantly associated with systolic BPV (odds ratio, 1.09; 95% CI, 1.01-1.17; P = .02) but not diastolic BPV (odds ratio, 1.04; 95% CI, 0.97-1.11; P = .30) or pulse pressure variability (odds ratio, 1.03; 95% CI, 0.96-1.10; P = .47). Survival curves revealed a significant stepwise association between cumulative major adverse cardiovascular events and increasing quartiles of systolic BPV (Kaplan-Meier estimates for quartiles 1-4: 6.1% vs 8.5% vs 10.1% vs 12.0%, respectively; log-rank P

The total cholesterol to high-density lipoprotein cholesterol (TC/HDL-C) ratio may quantify atherogenic lipoproteins beyond low-density lipoprotein cholesterol (LDL-C), non-HDL-C and apolipoprotein B (apoB). We analyzed pooled data from 9 trials involving 4,957 patients with coronary artery disease undergoing serial intravascular ultrasonography to assess changes in percent atheroma volume (ΔPAV) and 2-year major adverse cardiovascular event (MACE) rates when TC/HDL-C levels were discordant with LDL-C, non-HDL-C, and apoB. Discordance was investigated when lipid levels were stratified by/≥median levels (TC/HDL-C 3.3 vs LDL-C 80, non-HDL-C 107, and apoB 76 mg/dl) or/≥very low percentile equivalent cutoffs (TC/HDL-C 2.5 vs LDL-C 70, non-HDL-C 89, and apoB 59 mg/dl). When stratified by median levels, TC/HDL-C was commonly observed to be discordant with LDL-C (26%), non-HDL-C (20%), and apoB (27%). In patients with LDL-C, non-HDL-C, or apoBmedian, those with a discordant TC/HDL-C ≥median demonstrated less PAV regression and greater MACE (18.9%, 17.7%, 19.8%, respectively) compared with TC/HDL-Cmedian (14.4%, 14.0%, 12.8%; p = 0.02, 0.14, 0.003, respectively). In patients with LDL-C, non-HDL-C, or apoB ≥median, those with a discordant TC/HDL-Cmedian demonstrated less PAV progression and lower MACE (15.0%, 17.3%, 19.9%, respectively) compared with TC/HDL-C ≥median (24.7%, 24.2%, 26.4%; p0.001, 0.003, 0.03, respectively). In conclusion, the TC/HDL-C ratio reclassifies atheroma progression and MACE rates when discordant with LDL-C, non-HDL-C, and apoB within subjects. Thus, using the ratio, in addition to individual lipid parameters, may identify patients who may benefit from more intensive lipid modification.

IMPORTANCE: Although lipoprotein(a) (Lp[a]) is a causal genetic risk factor for atherosclerotic cardiovascular disease, it remains unclear which patients with established atherosclerotic cardiovascular disease stand to benefit the most from Lp(a) lowering. Whether inflammation can modulate Lp(a)-associated cardiovascular (CV) risk during secondary prevention is unknown. OBJECTIVE: To examine whether Lp(a)-associated CV risk is modulated by systemic inflammation in optimally treated patients at high risk of CV disease. DESIGN, SETTING, AND PARTICIPANTS: A prespecified secondary post hoc analysis of the double-blind, multicenter randomized clinical Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibition With Evacetrapib in Patients at a High Risk for Vascular Outcomes (ACCELERATE) trial was conducted between October 1, 2012, and December 31, 2013; the study was terminated October 12, 2015. The study was conducted at 543 academic and community hospitals in 36 countries among 12 092 patients at high risk of CV disease (acute coronary syndrome, stroke, peripheral arterial disease, or type 2 diabetes with coronary artery disease) with measurable Lp(a) and high-sensitivity C-reactive protein (hsCRP) levels during treatment. Statistical analysis for this post hoc analysis was performed from September 26, 2018, to March 28, 2020. INTERVENTIONS: Participants received evacetrapib, 130 mg/d, or matching placebo. MAIN OUTCOMES AND MEASURES: The ACCELERATE trial found no significant benefit or harm of evacetrapib on 30-month major adverse cardiovascular events (CV death, myocardial infarction [MI], stroke, coronary revascularization, or hospitalization for unstable angina). This secondary analysis evaluated rates of CV death, MI, and stroke across levels of Lp(a). RESULTS: High-sensitivity C-reactive protein and Lp(a) levels were measured in 10 503 patients (8135 men; 8561 white; 10 134 received concurrent statins; mean [SD] age, 64.6 [9.4] years). In fully adjusted analyses, in patients with hsCRP of 2 mg/L or more but not less than 2 mg/L, increasing quintiles of Lp(a) were significantly associated with greater rates of death, MI, and stroke (P = .006 for interaction). Each unit increase in log Lp(a) levels was associated with a 13% increased risk of CV death, nonfatal MI, or stroke only in those with hsCRP levels of 2 mg/L or more (P = .008 for interaction). There was also a significant stepwise relationship between increasing Lp(a) quintiles and time to first CV death, MI, or stroke (log-rank P

High-sensitivity C-reactive protein (hsCRP) is a well-established predictor of cardiovascular events; however, the relationship between hsCRP variability and clinical outcomes has not been explored. We performed a post-hoc analysis of the Assessment of Clinical Effects of Cholesterol Ester Transfer

Aortic atherosclerosis has been linked with worse peri- and post-procedural outcomes following a range of aortic procedures. Yet, there are currently no standardized methods for non-invasive volumetric pan-aortic plaque assessment. We propose a novel means of more accurately assessing plaque volume across whole aortic segments using computed tomography angiography (CTA) imaging. Sixty patients who underwent CTA prior to trans-catheter aortic valve implantation were included in this analysis. Specialized software analysis (3mensio Vascular™, Pie Medical, Maastricht, Netherlands) was used to reconstruct images using a centerline approach, thus creating true cross-sectional aortic images, akin to those images produced with intravascular ultrasonography. Following aortic segmentation (from the aortic valve to the renal artery origin), atheroma areas were measured across multiple contiguous evenly spaced (10 mm) cross-sections. Percent atheroma volume (PAV), total atheroma volume (TAV) and calcium score were calculated. In our populations (age 79.9 ± 8.5 years, male 52 %, diabetes 27 %, CAD 84 %, PVD 20 %), mean ± SD number of cross sections measured for each patient was 35.1 ± 3.5 sections. Mean aortic PAV and TAV were 33.2 ± 2.51 % and 83,509 ± 17,078 mm(3), respectively. Median (IQR) calcium score was 1.5 (0.7-2.5). Mean (SD) inter-observer coefficient of variation and agreement for plaque area among 4 different analysts was 14.1 (5.4), and the mean (95 % CI) Lin's concordance correlation coefficient was 0.79 (0.62-0.89), effectively simulating a Core Laboratory scenario. We provide an initial validation of cross-sectional volumetric aortic atheroma assessment using CTA. This proposed methodology highlights the potential for utilizing non-invasive aortic plaque imaging for risk prediction across a range of clinical scenarios.

Aims Utilizing serial intravascular ultrasonography (IVUS), we aimed to exam the association of intra-individual lipid variability, coronary atheroma progression, and clinical outcomes. Methods and results We performed a post hoc patient-level analysis of nine clinical trials involving 4976 patients with coronary artery disease who underwent serial coronary IVUS in the setting of a range of medical therapies. We assessed the associations between progression in percent atheroma volume (ΔPAV), clinical outcomes, and visit-to-visit lipid variability including low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, total cholesterol (TC)/HDL-C, and apolipoprotein B (ApoB). Variability of lipid parameters was measured using intra-individual standard deviation over 3, 6, 12, 18, and 24 months. Atherogenic lipoprotein variability significantly associated with ΔPAV [odds ratio (95% confidence interval; P-value), LDL-C: 1.09 (1.02, 1.17, P = 0.01); non-HDL-C: 1.10 (1.02, 1.18, P = 0.01); TC/HDL-C: 1.14 (1.06, 1.24, P = 0.001); ApoB: 1.13 (1.03, 1.24, P = 0.01)]. Survival curves revealed significant stepwise relationships between cumulative major adverse cardiovascular events and increasing quartiles of atherogenic lipoprotein variability at 24-months follow-up (log-rank P

Older adult falls continue to be a public health priority across the United States, and Massachusetts (MA) is no exception. The MA Prevention and Wellness Trust Fund (PWTF) program within the MA Department of Public Health aims to reduce the physical and economic burdens of chronic health conditions by linking evidence-based clinical care with community intervention programs. The PWTF partnerships that focused on older adult falls prevention have integrated the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Death and Injuries toolkit into clinical settings. Partnerships also offer referrals for home safety assessments, Tai Chi and Matter of Balance (1) programs. This paper describes the PWTF program implementation process involving 49 MA organizations, while highlighting the successes achieved and lessons learned. With the unprecedented expansion of the U.S. Medicare beneficiary population, and the escalating incidence of falls, widespread adoption of effective prevention strategies will become increasingly important for both public health and for controlling healthcare costs. The lessons learned from this PWTF initiative offer insights and recommendations for future falls prevention program development and implementation.

High-density lipoprotein cholesterol (HDL-C) and apolipoprotein A-I (apoA-I) levels are inversely associated with adverse cardiovascular outcomes. Associations between these HDL-C-related measurements and coronary plaque progression have not been studied. We performed a retrospective analysis of 2,566 statin-treated patients with angiographic coronary artery disease who underwent serial evaluation of atheroma burden with intravascular ultrasound. Relations between achieved levels of HDL-related measurements with clinical characteristics and changes in plaque burden were determined. A strong correlation between HDL-C and apoA-I (r = 0.80, p0.001) was observed. HDL-C, apoA-I, and the HDL-C:apoA-I ratio demonstrated negative correlations with the change in percent atheroma volume and total atheroma volume (all p ≤0.001). Increasing levels of achieved HDL-C:apoA-I (p = 0.04), but not HDL-C (p = 0.18) or apoA-I (p = 0.67), were associated with less progression of percent atheroma volume. Similar results were seen for change in total atheroma volume, with less progression seen with increased HDL-C:apoA-I (p = 0.002) but not with increases in HDL-C (p = 0.09) or apoA-I (p = 0.19). In conclusion, increasing levels of HDL-C:apoA-I associated with less progression of coronary atherosclerosis. This suggests that interventions increasing the cholesterol content of HDL particles may be of cardiovascular benefit.

The burden of obesity disproportionately affects marginalized populations, such as Mexican-heritage (MH) children who reside in impoverished communities along the U.S.-Mexico border. These areas ar...

This article examines the idea of empowerment through food preparation and applies it to a specific context—that of the life of immigrant Mexican women from two South Texas settlement areas, or colonias. Based on ethnographic data gathered through participant observation by bilingual research teams of promotoras and formally educated health professionals embedded with participant families, we analyze the living situations of low-income Mexican women in the South Texas colonias, particularly their food procurement, storage, and preparation practices for their families. We acknowledge the existence of hegemonic gendered, economic, and racialized structures of domination that surround the women's role in food preparation. However, we also recognize food preparation as the domain in which otherwise oppressed and marginalized women, living a life of isolation filled with severe problems and uncertainties, exercise some degree of power and control within their lives and the well-being of their family members. I...

It remains unknown whether the factors associated with major adverse cardiovascular events (MACE) in the contemporary setting of statin therapy for high vascular risk patients differ, according to gender. The ACCELERATE trial compared the effects of evacetrapib and placebo on MACE (cardiovascular

Purpose: This study describes the perceptions of brain health among older Spanish-speaking Mexican Americans who reside in colonia areas of the Lower Rio Grande Valley of Texas. Design and Methods: In 2007, 33 Mexican American older adults (9 men and 24 women) were recruited by promotoras (community health workers) from clusters of colonias in Hidalgo County to participate in focus group discussions conducted in Spanish. After participants completed a 19-item questionnaire (in Spanish), a bilingual and bicultural researcher from the community, trained as a moderator, conducted 4 focus groups using a semistructured interview guide, culturally modifi ed with the assistance of promotoras . All discussions were audio recorded; audio recordings were transcribed verbatim in Spanish and then translated into English. Analyses were conducted in English. Results: Almost 85% had less than a high school education and 100% reported a household income less than $20,000/year. Groups attached cultural meaning to aging well. The idea of “ staying straight in the mind ” resonated as a depiction of brain health. Participants also mentioned the types of activities they could do to stay “ right in the mind. ” Implications: Particular attention must be focused on development of programs that provide satisfying culturally appropriate activities for older participants and the delivery of health messages th at take into consideration culture and language.

Introduction: Total to high-density lipoprotein cholesterol (TC/HDL-C), routinely available from the standard lipid profile, is postulated to characterize atherogenic lipids beyond low density lipoprotein cholesterol (LDL-C) and non-HDL-C Hypothesis: On-treatment TC/HDL-C significantly associates with coronary atheroma progression rates at variable levels of LDL-C, non-HDL-C, apolipoprotein B (apoB), triglycerides (TG), C-reactive protein (CRP), and irrespective of diabetes status, obesity or intensity of statin therapy Methods: We analyzed data from 9 trials involving 4957 patients with coronary disease undergoing serial intravascular ultrasonography and assessed the effect of on-treatment levels of TC/HDL-C [ Results: Discordance, defined by median cut points, between TC/HDL-C vs. LDL-C, non-HDL-C and apoB was sizeable at 26, 20 and 27%, respectively. Lower (< median) on-treatment TC/HDL-C associated with PAV regression (ΔPAV Conclusion: TC/HDL-C, available at no extra cost, correlates significantly with coronary atheroma progression rates when discordant with other lipid-metabolic parameters and in clinical scenarios such as diabetes, obesity and in patients receiving HIST. Future studies are needed to determine the implications of applying TC/HDL-C for reducing residual risk

This perspective paper describes processes in the development of an evidence-based fall prevention curriculum for community health workers/promotores (CHW/P) that highlights the development of the curriculum and addresses: (1) the need and rationale for involving CHW/P in fall prevention; (2) involvement of CHW/P and content experts in the curriculum development; (3) best practices utilized in the curriculum development and training implementation; and (4) next steps for dissemination and utilization of the CHW/P fall prevention curriculum. The project team of CHW/P and content experts developed, pilot tested, and revised bilingual in-person training modules about fall prevention among older adults. The curriculum incorporated the following major themes: (1) fall risk factors and strategies to reduce/prevent falls; (2) communication strategies to reduce risk of falling and strategies for developing fall prevention plans; and (3) health behavior change theories utilized to prevent and reduce falls. Three separate fall prevention modules were developed for CHW/P and CHW/P Instructors to be used during in-person trainings. Module development incorporated a five-step process: (1) conduct informal focus groups with CHW/P to inform content development; (2) develop three in-person modules in English and Spanish with input from content experts; (3) pilot-test the modules with CHW/P; (4) refine and finalize modules based on pilot-test feedback; and (5) submit modules for approval of continuing education units. This project contributes to the existing evidence-based literature by examining the role of CHW/P in fall prevention among older adults. By including evidence-based communication strategies such as message tailoring, the curriculum design allows CHW/P to personalize the information for individuals, which can result in an effective dissemination of a curriculum that is evidence-based and culturally appropriate.

This article describes the process and results of an effort to develop an outcome measurement system for evaluating and improving hospital-based wellness programs and services. The authors defined a set of outcome measures for each of the wellness programs and services offered by the hospital and piloted health-related outcome and patient satisfaction measures in the following four different types of programs: (a) a disease screening program (osteoporosis), (b) an educational program (diabetes), (c) an instructional participatory program (yoga and tai chi), and (d) a behavioral intervention program (group weight loss). These programs were chosen to represent the array of wellness programs and services available at the hospital. Results are reported for each pilot test, and recommendations are offered for dealing with issues and challenges encountered in developing a system for measuring wellness program performance.

PURPOSE: Stress and anxiety are potential consequences from arrhythmias and implantable cardioverter defibrillator (ICD) shocks that can contribute to substantial morbidity. We assessed anxiety associated with an ICD and whether cognitive behavioral therapy (CBT) reduces anxiety.METHODS: The study consisted of two parts: part 1 (N = 690) was a prospective cross-sectional observational study of consecutive ICD patients. Patients completed the Beck Anxiety Inventory (BAI), Generalized Anxiety Disorder Scale (GAD-7), Florida Shock Anxiety Scale (FSAS), and Florida Patient Acceptance Survey (FPAS) psychometric tests. Part 2 (N = 29) was a pilot randomized controlled trial of CBT (three sessions in 3 months) vs. usual care (UC) in patients with BAI ≥ 19 from part 1.RESULTS: The median BAI and GAD-7 scores were 5 and 2, respectively. By BAI scores, 64.5 % had minimal and 3.9 % had severe anxiety. By GAD-7 scores, 73.0 % had low probability of anxiety and 2.9 % had high anxiety. Higher anxiety levels were associated with recent (p = 0.017) and total number of shocks (p = 0.002). Any shock was associated with fear about shocks (FSAS, p CONCLUSIONS: Severe anxiety was present in a small proportion of ICD patients, but higher anxiety was associated with recent and total number of shocks. The small pilot study suggested that a simple program of CBT might lower moderate-high anxiety with lasting effects to 1 year and supports the need for a larger trial to validate these results.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00851071. URL: http://clinicaltrials.gov/ct2/show/NCT00851071?term=anxiety+in+icd+patients+cleveland+clinic&rank=1.

SummaryThe diagnosis of heparin-induced thrombocytopenia (HIT) can be challenging. The HIT Expert Probability (HEP) Score has recently been proposed to aid in the diagnosis of HIT. We sought to externally and prospectively validate the HEP score. We prospectively assessed pretest probability of HIT for 51 consecutive patients referred to our Consultative Service for evaluation of possible HIT between August 1, 2012 and February 1, 2013. Two Vascular Medicine fellows independently applied the 4T and HEP scores for each patient. Two independent HIT expert adjudicators rendered a diagnosis of HIT likely or unlikely. The median (interquartile range) of 4T and HEP scores were 4.5 (3.0, 6.0) and 5 (3.0, 8.5), respectively. There were no significant differences between area under receiver-operating characteristic curves of 4T and HEP scores against the gold standard, confirmed HIT [defined as positive serotonin release assay and positive anti-PF4/heparin ELISA] (0.74 vs 0.73, p = 0.97). HEP score ≥ 2 was 100 % sensitive and 16 % specific for determining the presence of confirmed HIT while a 4T score > 3 was 93 % sensitive and 35 % specific. In conclusion, the HEP and 4T scores are excellent screening pretest probability models for HIT, however, in this prospective validation study, test characteristics for the diagnosis of HIT based on confirmatory laboratory testing and expert opinion are similar. Given the complexity of the HEP scoring model compared to that of the 4T score, further validation of the HEP score is warranted prior to widespread clinical acceptance.

A preponderance of small, dense low-density lipoprotein (LDL) particles may promote the accelerated plaque progression seen on intravascular ultrasound (IVUS) imaging in patients with diabetes, even when LDL cholesterol appears to be well controlled [(1)][1]. The PERISCOPE (Pioglitazone Effect on

Aims Statins can inhibit the progression of coronary atherosclerosis. We aimed to characterize clinical factors that associate with differing measures of coronary atheroma volume following potent statin therapy. Methods and results SATURN employed serial intravascular ultrasound (IVUS) to monitor changes in measures of coronary atheroma burden [total atheroma volume (TAV) and per cent atheroma volume (PAV)] in 1039 patients with coronary artery disease, treated with rosuvastatin (40 mg) or atorvastatin (80 mg) daily for 24 months. Rosuvastatin-treated patients demonstrated greater reductions in low-density lipoprotein cholesterol (LDL-C, 47 vs. 40%, P < 0.001) and greater increases in high-density lipoprotein cholesterol (HDL-C, 13 vs. 10%, P = 0.02). These alterations in the lipid profile associated with greater TAV (−6.4 vs. −4.4 mm3, P = 0.01), but not PAV (−1.22 vs. −0.99%, P = 0.17) regression. Greater TAV reductions with rosuvastatin vs. atorvastatin occurred in patients with diabetes ( P = 0.01, treatment by diabetic status interaction P -value 0.05). Greater PAV reductions with rosuvastatin were evident in females ( P = 0.01, treatment by sex interaction P -value 0.03) and in those with greater than or equal to median baseline LDL-C ( P = 0.02, treatment by LDL-C group interaction P -value 0.03) or HDL-C levels ( P = 0.02, treatment by HDL-C group interaction P -value 0.04). On multivariable analysis assessing change in TAV and PAV, both higher baseline TAV and PAV independently associated with TAV and PAV regression, respectively (standardized estimates: TAV −0.25, P < 0.001; PAV −0.23, P < 0.001). Conclusion Higher-risk patients, particularly those with greater baseline coronary atheroma volume, are more likely to experience less disease progression with potent statin therapy.

Promotoras are trusted members of underserved, at-risk Hispanic communities experiencing social and health inequities. As promotora–researchers, promotoras have the unique ability and opportunity not only to provide outreach and education but also to be actively engaged in conducting research in their communities and serve as a cultural bridge between the community and researchers. In this article, we present a case study of personal and collective empowerment of six promotora–researchers who participated in seven community-based participatory research projects. Data sources included debriefing interviews with the promotora–researchers, milestone tracking and documentation completed during and after each study, and observations by the principal investigator and project managers regarding the role of the promotora–researchers in these studies. We qualitatively analyzed the data to identify the processes and decisions that were developed and implemented in a series of projects, which resulted in promotora–researcher empowerment. We found that active engagement empowered promotora–researchers personally and collectively in all phases of the research study. Common elements that contributed to the empowerment of promotora–researchers were valuing promotora–researchers’ input, enabling promotora–researchers to acquire and utilize new skills, and allowing promotora–researchers to serve as both researchers and traditional promotoras. Together, these elements enabled them to more fully participate in research projects, while allowing them to identify and address needs within their own communities.

There is an urgent need to improve nutritional health in health disparity communities, such as the growing Hispanic and Latino populations. However, efforts focused on complex nutritional health issues, such as obesity and food insecurity, can be more difficult in underserved and at risk communities, such as Mexican-origin residents living in communities along the Texas-Mexico border.(blinded for review) Some of these challenges include: Establishing trust and rapport with community residents who are markedly different from the university-based research team; Working with communities to recruit from a specified sampling frame and to minimize attrition over the life course of a study; Adapting data collection protocol and instruments to culturally appropriate and reliable measures of dietary and environmental exposures; Accommodating logistical challenges of study participants (e.g., family, social, employment conflicts, and transportation challenges) in order to acknowledge the time commitment, minimize attrition, and complete timely and comprehensive assessments; Capturing contextual factors for understanding food- and health-related behaviors. Further, it can be quite difficult to conduct research in a way that is both respectful of the community and residents’ norms, values, and traditions, and that possesses the rigor needed for the academy. A community-academic partnership where university-based researchers develop a partnership with promotoras de salud (promotoras) as research collaborators is one way to address these challenges in a culturally-competent manner.

Accounts of the retail food environment have been limited by research that focused on supermarkets, grocery stores, and restaurants as the principal food sources for consumers. Little is known about alternative retail food sources, especially in rural and underserved areas such as the colonias along the South Texas border with Mexico. Many colonias are located near pulgas (flea markets). This is the first study to examine this alternative food source for colonia residents. This study's purpose is to provide preliminary data on food availability in this unstudied element of the retail food environment. Five pulgas were identified for study by local informants. Two separate teams of two promotores (indigenous community health workers) conducted observations, wrote field notes, and surveyed vendors in each pulga. Traditional foods, prepared foods, and fresh fruits and vegetables were available in the observed pulgas. Traditional foods included staples, meal items, and snacks and sweets. Prepared foods were available in small stands run by independent operators, and each pulga had permanent restaurants that served prepared foods. A large variety of fresh fruits and vegetables were also available. An emphasis on supermarkets and grocery stores will provide an incomplete account of the retail food environment. Further studies should attempt to provide a more complete account by identifying alternative retail sources used by local residents. One such alternative retail food source, the pulga, provides a range of traditional food stuffs, prepared food items, and fruits and vegetables that complement conventionally studied aspects of the retail food environment.

Diabetes prevalence is higher along U.S.—Mexico border than in nonborder regions, and numerous community-based organizations are addressing this diabetes disparity through prevention and management programs. However, the nature, scope, and effectiveness of these efforts and programs are not well documented. This study aims at identifying key characteristics of diabetes programs in a Texas—Mexico border region with a predominately Hispanic, underserved population. A survey is administered to 84 community-based organizations in the Lower Rio Grande Valley (LRGV); 25 organizations respond. Nineteen programs related to diabetes and healthy lifestyle behaviors are identified in the LRGV. The majority of the programs are based on guidelines of national and state professional associations and agencies; target low-income and minority populations; are offered at no cost; and include program evaluation activities. Future research should examine the effectiveness, as well as the fidelity of the guidelines, of diabetes programs in the border region.

Introduction The diagnosis of heparin-induced thrombocytopenia (HIT) is challenging due to the overlap of its clinical features with other entities, variable specificity of ELISA-based tests, poor availability of functional tests such as the serotonin release assay (SRA) and suboptimal positive predictive values of pre-test probability clinical scoring models, such as the 4T and Lillo-Le Louėt models. Improved diagnostic tools are desirable to guide early therapeutic decisions in patients with suspected HIT and to reduce inappropriate use of alternative anticoagulants. The HIT Expert Probability (HEP) Score, a pre-test probability clinical scoring model for HIT based on broad expert opinion, has recently been proposed to improve the diagnosis of HIT compared to the 4T score. We sought to externally and prospectively validate the HEP score. Methods Pre-test probability of HIT was prospectively assessed for 51 consecutive patients referred to the Cleveland Clinic Vascular Medicine Consultative Service for evaluation of possible HIT between August 1, 2012 and February 1, 2013. Electronic medical records were reviewed to obtain clinical, biochemical (including IgG specific HIT ELISA and SRA tests) and imaging data, and two Vascular Medicine fellows independently applied the 4T and HEP scores for each patient. Two independent HIT expert adjudicators rendered a diagnosis of HIT likely or unlikely. Both scorers and adjudicators were blinded to the Results of HIT laboratory testing, consultative service inputs and scores generated by other raters. Results The median 4T and HEP scores were 4.5 [range 3.0, 6.0] and 5 [range 3.0, 8.5], respectively. Interobserver agreement was lower for the HEP Score compared to 4T score, intraclass correlation coefficient: 0.50 (95% CI 0.16–0.85) vs. 0.69 (0.54–0.86). There were no significant differences between area under receiver-operating characteristics curves of 4T and HEP score against HIT ELISA testing (0.62 vs. 0.58, P = 0.62), SRA (0.74 vs. 0.73, P = 0.97), expert panel diagnosis (0.71 vs. 0.79, P = 0.20), concordant HIT ELISA and SRA (0.76 vs. 0.72, P = 0.65), and positive SRA or positive HIT ELSA with HIT likely expert panel diagnosis (0.73 vs. 0.75, P = 0.80). The HEP score model was 100% sensitive and 17% specific for determining the presence of HIT as defined by positive SRA or positive HIT ELISA with HIT likely expert panel diagnosis compared to 4T score (sensitivity, 94%; specificity 38%) (Figure 1, Table 1). Conclusion The HEP and 4T scores are excellent screening pre-test probability models for HIT, however, in this prospective validation study, test characteristics for the diagnosis of HIT based on confirmatory laboratory testing and expert opinion are similar. Given the complexity of the HEP scoring model compared to that of the 4T model, further validation of the HEP score is warranted prior to widespread acceptance. Disclosures: Kim: Philips US: Consultancy; GE: Research Funding.

LVCR to exercise and thus OCAD cannot be excluded.We suggest alternate testing e.g. CT coronary angiography. http://dx.doi.org/10.1016/j.hlc.2013.05.114

Introduction Mexican-origin women in the U.S. living in colonias (new-destination Mexican-immigrant communities) along the Texas-Mexico border suffer from a high incidence of food insecurity and diet-related chronic disease. Understanding environmental factors that influence food-related behaviors among this population will be important to improving the well-being of colonia households. This article focuses on cultural repertoires that enable food choice and the everyday uses of technology in food-related practice by Mexican-immigrant women in colonia households under conditions of material hardship. Findings are presented within a conceptual framework informed by concepts drawn from sociological accounts of technology, food choice, culture, and material hardship. Methods Field notes were provided by teams of promotora-researchers (indigenous community health workers) and public-health professionals trained as participant observers. They conducted observations on three separate occasions (two half-days during the week and one weekend day) within eight family residences located in colonias near the towns of Alton and San Carlos, Texas. English observations were coded inductively and early observations stressed the importance of technology and material hardship in food-related behavior. These observations were further explored and coded using the qualitative data package Atlas.ti. Results Technology included kitchen implements used in standard and adapted configurations and household infrastructure. Residents employed tools across a range of food-related activities identified as forms of food acquisition, storage, preparation, serving, feeding and eating, cleaning, and waste processing. Material hardships included the quality, quantity, acceptability, and uncertainty dimensions of food insecurity, and insufficient consumption of housing, clothing and medical care. Cultural repertoires for coping with material hardship included reliance on inexpensive staple foods and dishes, and conventional and innovative technological practices. These repertoires expressed the creative agency of women colonia residents. Food-related practices were constrained by climate, animal and insect pests, women’s gender roles, limitations in neighborhood and household infrastructure, and economic and material resources. Conclusions This research points to the importance of socioeconomic and structural factors such as gender roles, economic poverty and material hardship as constraints on food choice and food-related behavior. In turn, it emphasizes the innovative practices employed by women residents of colonias to prepare meals under these constraints.

Background It has been recognized that the availability of foods in the home are important to nutritional health, and may influence the dietary behavior of children, adolescents, and adults. It is therefore important to understand food choices in the context of the household setting. Considering their importance, the measurement of household food resources becomes critical. Because most studies use a single point of data collection to determine the types of foods that are present in the home, which can miss the change in availability within a month and when resources are not available, the primary objective of this pilot study was to examine the feasibility and value of conducting weekly in-home assessments of household food resources over the course of one month among low-income Mexicano families in Texas colonias. Methods We conducted five in-home household food inventories over a thirty-day period in a small convenience sample; determined the frequency that food items were present in the participating households; and compared a one-time measurement with multiple measurements. After the development and pre-testing of the 252-item culturally and linguistically- appropriate household food inventory instrument that used direct observation to determine the presence and amount of food and beverage items in the home (refrigerator, freezer, pantry, elsewhere), two trained promotoras recruited a convenience sample of 6 households; administered a baseline questionnaire (personal info, shopping habits, and food security); conducted 5 in-home assessments (7-day interval) over a 30-day period; and documented grocery shopping and other food-related activities within the previous week of each in-home assessment. All data were collected in Spanish. Descriptive statistics were calculated for mean and frequency of sample characteristics, food-related activities, food security, and the presence of individual food items. Due to the small sample size of the pilot data, the Friedman Test and Kendall's W were used to assess the consistency of household food supplies across multiple observations. Results Complete data were collected from all 6 Mexicano women (33.2y ± 3.3; 6.5 ± 1.5 adults/children in household (HH); 5 HH received weekly income; and all were food insecure. All households purchased groceries within a week of at least four of the five assessments. The weekly presence and amounts of fresh and processed fruits and vegetables, dairy, meats, breads, cereals, beverages, and oils and fats varied. Further, the results revealed the inadequacy of a one-time measurement of household food resources, compared with multiple measures. The first household food inventory as a one-time measure would have mistakenly identified at least one-half of the participant households without fresh fruit, canned vegetables, dairy, protein foods, grains, chips, and sugar-sweetened beverages. Conclusions This study highlights the value of documenting weekly household food supplies, especially in households where income resources may be more volatile. Clearly, the data show that a single HFI may miss the changes in availability - presence and amount - that occur among low-income Mexicano households who face challenges that require frequent purchase of foods and beverages. Use of multiple household food inventories can inform the development and implementation of nutrition-related policies and culturally sensitive nutrition education programs.