Chizobam Ani

Elevated red blood cell distribution width predicts mortality in persons with known stroke

BACKGROUND Red cell distribution width (RDW) is a hematological parameter routinely obtained as part of the complete blood count. Recently, RDW has emerged as a potential independent predictor of clinical outcome in patients with established cardiovascular disease. However, little is known about the role of RDW as a prognosticator among persons with stroke, especially with regard to an incontrovertible endpoint like mortality. We assessed the association of RDW with stroke, and its effect on mortality among persons with stroke. METHODS Data from the National Health and Nutrition Examination Survey (NHANES) a nationally representative sample of United States adults were analyzed. The study population consisted of 480 individuals aged > or =25 years with a baseline history of stroke followed-up from survey participation (1988-1994) through mortality assessment in 2000. Proportional hazard regression (Cox) was utilized to explore the independent relationship between RDW and mortality after adjusting for potential confounders. RESULTS Among the cohort, 52.4% were female, 64% aged > or =65 years. Mean RDW was significantly higher among persons with stroke compared to individuals without a stroke (13.7% vs.13.2%,p<0.001). Baseline RDW was higher among persons with known stroke who later died vs. remained alive (13.9% vs.13.4%,p<0.001). After adjusting for confounders, those with elevated RDW (fourth vs. first quartile) were more likely to have experienced a stroke (OR 1.71, CI=1.20-2.45). Higher RDW level (fourth vs. first quartile) among those with known stroke independently predicted subsequent cardiovascular deaths (HR=2.38 and CI=1.41-4.01) and all-cause deaths (HR=2.0, CI=1.25-3.20). CONCLUSIONS Elevated RDW is associated with stroke occurrence and strongly predicts both cardiovascular and all-cause deaths in persons with known stroke.

Depression symptomatology and diagnosis: discordance between patients and physicians in primary care settings

BackgroundTo examine the agreement between depression symptoms using an assessment tool (PHQ-9), and physician documentation of the same symptoms during a clinic visit, and then to examine how the presence of these symptoms affects depression diagnosis in primary care settings.MethodsInterviewer administered surveys and medical record reviews. A total of 304 participants were recruited from 2321 participants screened for depression at two large urban primary care community settings.ResultsOf the 2321 participants screened for depression 304 were positive for depression and of these 75.3% (n = 229) were significantly depressed (PHQ-9 score ≥ 10). Of these, 31.0% were diagnosed by a physician with a depressive disorder. A total of 57.6% (n = 175) of study participants had both significant depression symptoms and functional impairment. Of these 37.7% were diagnosed by physicians as depressed. Cohens Kappa analysis, used to determine the agreement between depression symptoms elicited using the PHQ-9 and physician documentation of these symptoms showed only slight agreement (0.001–0.101) for all depression symptoms using standard agreement rating scales. Further analysis showed that only suicidal ideation and hypersomnia or insomnia were associated with an increased likelihood of physician depression diagnosis (OR 5.41 P sig < .01 and (OR 2.02 P sig < .05 respectively). Other depression symptoms and chronic medical conditions had no affect on physician depression diagnosis.ConclusionTwo-thirds of individuals with depression are undiagnosed in primary care settings. While functional impairment increases the rate of physician diagnosis of depression, the agreement between a structured assessment and physician elicited and or documented symptoms during a clinical encounter is very low. Suicidality, hypersomnia and insomnia are associated with an increase in the rate of depression diagnosis even when physician and self report of the symptom differ. Interventions that emphasize the use of routine structured screening of primary care patients might also improve the rate of diagnosis of depression in these settings. Further studies are needed to explore depression symptom assessment during physician patient encounter in primary care settings.

Preventive, Lifestyle, and Personal Health Behaviors among Physicians.

ObjectiveThis study examines personal health behaviors and wellness, health-related lifestyles, and prevention screening practices among licensed physicians.MethodsAn anonymous questionnaire was mailed to a random sample of 1,875 physicians practicing in California. Data from 763 returned questionnaires (41%) were analyzed.ResultsOur data show that 7% of this sample were clinically depressed, 13% reported using sedatives or tranquilizers, over 53% reported severe to moderate stress, and only 38% described their level of daily stress as slight. About 4% self-reported recent marijuana use. More than 6% screened positive for alcohol abuse and 5% for gambling problems. Thirty-five percent of participants reported “no” or “occasional” exercise. About 27% self-reported “never” or “occasionally” eating breakfast. In addition, 34% reported 6 or fewer hours of sleep daily, while 21% self-reported working more than 60 hours per week. Physicians’ excessive number of work hours (more than 65 hours per week) was associated with lack of exercise, not eating breakfast, and sleeping fewer than 6 hours per night. California physicians report breast, cervical, colorectal, and prostate cancer screening behaviors that exceeded population estimates in California and Healthy People 2010 national goals.ConclusionAdditional interventions designed to improve physicians’ lifestyles and personal health behaviors should be encouraged. A focus on creating healthy lifestyles will benefit physicians as much as the general population.

Comorbid Chronic Illness and the Diagnosis and Treatment of Depression in Safety Net Primary Care Settings

Objective: To estimate the impact of chronic medical conditions on depression diagnosis, treatment, and follow-up care in primary care settings. Design: This was a cross-sectional study that used interviewer-administered surveys and medical record reviews. Three hundred fifteen participants were recruited from 3 public primary care clinics. Depression diagnosis, guideline-concordant treatment, and follow-up care were the primary outcomes examined in individuals with depression alone compared with individuals with depression and chronic medical conditions measured using the Charlson Comorbidity Index (CCI). Results: Physician diagnosis of depression (32.6%), guideline-concordant depression treatment (32.7%), and guideline-concordant follow-up care (16.3%) were all low. Logistic regression analysis showed no significant difference in the likelihood of depression diagnosis, guideline-concordant treatment, or follow-up care in individuals with depression alone compared with those with both depression and chronic medical conditions. Participants with severe depression were, however, twice as likely to receive a diagnosis of depression as participants with moderate depression. In addition, participants with moderately severe and severe depression received much less appropriate follow-up care than participants with moderate depression. Among participants receiving a depression diagnosis, 74% received guideline-concordant treatment. Conclusion: Physician depression care in primary care settings is not influenced by competing demands for care for other comorbid medical conditions.

Correlates of complementary and alternative medicine utilization in depressed, underserved african american and Hispanic patients in primary care settings.

OBJECTIVES This study seeks to examine the correlates of complementary and alternative medicine (CAM) use in depressed underserved minority populations receiving medical care in primary care settings. METHODS A prospective study using interviewer-administered surveys and medical record reviews was conducted at 2 large outpatient primary care clinics providing care primarily to underserved African American and Hispanic individuals located in Los Angeles, California. A total of 2321 patients were screened for depression. Of these, 315 met the Patient Health Questionnaire-9 criteria for mild to severe depression. RESULTS Over 57% of the sample reported using CAM sometimes or often (24%) and frequently (33%) for treatment of their depressive symptoms. Controlling for demographic characteristics, lack of health care coverage remained one of the strongest predictors of CAM use. Additionally, being moderately depressed, using psychotherapeutic prescription medications, and poorer self-reported health status were all associated with increased frequency of CAM utilization for treating depression. CONCLUSIONS The underserved African American and Hispanic individuals meeting the diagnostic criteria for depression or subsyndromal depression use CAM extensively for symptoms of depression. CAM is used as a substitute for conventional care when access to care is not available or limited. Since CAM is used so extensively for depression, understanding domains, types, and correlates of such use is imperative. This knowledge could be used to design interventions aimed at improving care for depression.

Increasing HIV Testing Among Latinos by Bundling HIV Testing with Other Tests

Latinos in the United States are disproportionately impacted by HIV/AIDS. They accounted for 20.4% of the AIDS cases reported in 2003, despite the fact that they represent 13.3% of the civilian non-institutional population of the United States. Thus it is important to identify ways to increase HIV testing among Latinos engaging in high risk behaviors. One approach that has been proposed for increasing HIV testing is the “bundling” of HIV prevention interventions with other relevant services. This study examined whether offering HIV testing with screening for other conditions would increase HIV testing among Latino men who frequent gay bars. A cross-sectional survey of 394 Latino men was conducted at both urban and suburban gay bars. Overall, no statistical differences were found in the number of individuals who took the HIV test or who tested HIV-positive when the HIV test was offered with screening for other conditions (alcohol problems, drug dependence, depression, syphilis, gonorrhea and chlamydia) compared to when it was offered by itself. However, multivariate analysis found that three groups of Latino men were more likely to test for HIV when it was bundled with other tests: those who reported having sex primarily with women, those with other risk factors that could also be tested through a bundled test approach, and those who were clients of the suburban gay bar that was farthest from a large geographical gay community. Further studies of bundled HIV testing should be conducted with other key subpopulations that may be more willing to take an HIV test when it is offered with other relevant tests than when offered by itself.

Relation of baseline presence and severity of renal disease to long-term mortality in persons with known stroke

BACKGROUND Little is known about the long-term prognostic impact of baseline chronic kidney disease (CKD) on outcomes after stroke. We assessed the association of diagnosis and severity of baseline CKD with risk of mortality among persons with a history of stroke. METHODS Data from the National Health and Nutrition Examination Survey (NHANES) a nationally representative sample of US adults were analyzed. The study population consisted of 425 individuals aged > or =55 years with a baseline history of stroke followed-up from NHANES III survey participation (1988-1994) through mortality assessment in 2000. CKD outcomes were glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) and urinary albumin to creatinine ratio (UACR) >30 mg/g of creatinine. CKD severity was categorized per national guidelines. Proportional hazard regression (Cox) was utilized to explore the independent relationship between CKD vs. all-cause and cardiovascular mortality after adjusting for confounders. RESULTS Among the cohort, 55.8% were female, 77.3% aged > or =65 years. Baseline serum creatinine was higher among persons with known stroke who later died vs. remained alive (p<0.01). Multivariable models showed that persons with low GFR (HR, 1.87 95% CI=1.30-2.68), CKD stages 1-2 (HR 1.84; 95% CI=1.06-3.20), 3 (HR 2.58; 95% CI=1.54-4.32), and 4-5 (HR 5.93; 95% CI=2.31-5.20) but not elevated UACR, had an independently higher relative hazard of death compared to individuals without these conditions. Similar results were seen with cardiovascular-specific mortality. CONCLUSIONS Baseline CKD, even of mild severity, is an independent predictor of future mortality among persons with known stroke.

Renal Dysfunction, Metabolic Syndrome and Cardiovascular Disease Mortality

Background. Renal disease is commonly described as a complication of metabolic syndrome (MetS) but some recent studies suggest that Chronic Kidney disease (CKD) may actually antecede MetS. Few studies have explored the predictive utility of co-clustering CKD with MetS for cardiovascular disease (CVD) mortality. Methods. Data from a nationally representative sample of United States adults (NHANES) was utilized. A sample of 13115 non-pregnant individuals aged ≥35 years, with available follow-up mortality assessment was selected. Multivariable Cox Proportional hazard regression analysis techniques explored the relationship between co-clustered CKD, MetS and CVD mortality. Bayesian analysis techniques tested the predictive accuracy for CVD Mortality of two models using co-clustered MetS and CKD and MetS alone. Results. Co-clustering early and late CKD respectively resulted in statistically significant higher hazard for CVD mortality (HR = 1.80, CI = 1.45–2.23, and HR = 3.23, CI = 2.56–3.70) when compared with individuals with no MetS and no CKD. A model with early CKD and MetS has a higher predictive accuracy (72.0% versus 67.6%), area under the ROC (0.74 versus 0.66), and Cohens kappa (0.38 versus 0.21) than that with MetS alone. Conclusion. The study findings suggest that the co-clustering of early CKD with MetS increases the accuracy of risk prediction for CVD mortality.

Age- and Sex-Specific In-Hospital Mortality after Myocardial Infarction in Routine Clinical Practice

Background. Literature regarding the influence of age/sex on mortality trends for acute myocardial infarction (AMI) hospitalizations is limited to hospitals participating in voluntary AMI registries. Objective. Evaluate the impact of age and sex on in-hospital AMI mortality using a nationally representative hospital sample. Methods. Secondary data analysis using AMI hospitalizations identified from the Nationwide-Inpatient-Sample (NIS). Descriptive and Cox proportional hazards analysis explored mortality trends by age and sex from 1997–2006 while adjusting for the influence of, demographics, co-morbidity, length of hospital stay and hospital characteristics. Results. From 1997–2006, in-hospital AMI mortality rates decreased across time in all subgroups (P < .001), except for males aged <55 years. The greatest decline was observed in females aged <55 years, compared to similarly aged males, mortality outcomes were poorer in 1997-1998 (RR 1.47, 95% CI  =  1.30–1.66), when compared with 2005-2006 (RR 1.03, 95% CI  =  0.90–1.18), adjusted P value for trend demonstrated a statistically significant decline in the relative AMI mortality risk for females when compared with males (<0.001). Conclusion. Over the last decade, in-hospital AMI mortality rates declined for every age/sex group except males <55 years. While AMI female-male mortality disparity has narrowed, some room for improvement remains.

Cuff leak test and laryngeal survey for predicting post-extubation stridor

Background and Aims: Evidence for the predictive value of the cuff leak test (CLT) for post-extubation stridor (PES) is conflicting. We evaluated the association and accuracy of CLT alone or combined with other laryngeal parameters with PES. Methods: Fifty-one mechanically ventilated adult patients in a medical-surgical intensive care unit were tested prior to extubation using; CLT, laryngeal ultrasound and indirect laryngoscopy. Biometric, laryngeal and endotracheal tube (ETT) parameters were recorded. Results: PES incidence was 4%. CLT demonstrated ′no leak′ in 20% of patients. Laryngeal oedema was present in 10% of the patients on indirect laryngoscopy, and 71% of the patients had a Grades 1-3 indirect laryngoscopic view. Mean air column width on laryngeal ultrasound was 0.66 ± 0.15 cm (cuff deflated), mean ratio of ETT to laryngeal diameter was 0.48 ± 0.07, and the calculated CLT and laryngeal survey composite was 0.86 ± 1.25 (range 0-5). CLT and the CLT and Laryngeal survey composite measure were not associated with or predict PES. Age, sex, peri-extubation steroid use, intubation duration and body mass index were not associated with PES. Conclusion: Even including ultrasonographic and indirect laryngoscopic examination of the airway, no single aspect of the CLT or combination with laryngeal parameters accurately predicts PES.