Direct Oral Anticoagulants: Probability of Recurrent Venous Thromboembolism and Bleeding Risk in an Obese Population.

BACKGROUND: Direct-acting oral anticoagulants (DOACs) have become the preferred drugs for managing venous thromboembolism (VTE). Despite their advantages over vitamin K antagonists such as warfarin, their use in obese patients remains controversial with many providers reluctant to switch patients managed on warfarin. Outcome research that opts to increase provider confidence when prescribing DOACs for patients with obesity will be invaluable. OBJECTIVE: This investigation evaluated whether patients with a body mass index (BMI) 35 kg/m2 or greater who were prescribed a DOAC had a higher risk for a recurrent VTE or bleed event relative to warfarin. METHODS: The study was conducted in West Virginia which has the highest rate of obesity in the United States. RESULTS: Of the total study population (1633), 2.3% (37) had a recurrent thrombotic event, 5.5% (89) had a major bleed event, and 10.7% (174) had some type of bleeding event. No individual patient characteristic was associated with recurrent thrombosis-including BMI. Older age, antiplatelet use, and taking a medication with a theoretical risk of increasing the effect of DOACs were associated with any and major bleeding events. The use of warfarin was associated with major bleeding events more frequently versus a DOAC. Body mass index was not a predictor for recurrent VTE or any bleed or major bleed events. CONCLUSIONS: These findings support the conclusion that DOACs are an appropriate and effective drug class for the management of VTE in patients with obesity.

Subclinical atherosclerosis, cardiovascular health, and disease risk: is there a case for the Cardiovascular Health Index in the primary prevention population?

BACKGROUND: Current primary prevention guidelines for cardiovascular disease (CVD) prioritize risk identification, risk stratification using clinical and risk scores, and risk reduction with lifestyle interventions and pharmacotherapy. Subclinical atherosclerosis is an early indicator of atherosclerotic burden and its timely recognition can slow or prevent progression to CVD. Thus, individuals with subclinical atherosclerosis are a priority for primary prevention. This study takes a practical approach to answering a challenge commonly faced by primary care practitioners: in patients with no known CVD, how can individuals likely to have subclinical atherosclerosis be easily identified using existing clinical data and/or information provided by the patient? METHODS: Using NHANES (1999-2004), 6091 men and women aged ≥40 years without any CVD comprised the primary prevention population for this study. Subclinical atherosclerosis was determined via ankle-brachial index (ABI) using established cutoffs (subclinical atherosclerosis defined as ABI (0.91-0.99); normal defined as ABI (1.00-1.30)). Three common scores were calculated: the Framingham Risk Score (FRS), the Metabolic Syndrome (MetS), and the Cardiovascular Health Index (CVHI). Logistic regression analysis assessed the association between these scores and subclinical atherosclerosis. The sensitively and specificity of these scores in identifying subclinical atherosclerosis was determined. RESULTS: In eligible participants, 3.8% had subclinical atherosclerosis. Optimum and average CVHI was associated with decreased odds for subclinical atherosclerosis. High, but not intermediate-risk, FRS was associated with increased odds for subclinical atherosclerosis. MetS was not associated with subclinical atherosclerosis. Of the 3 scores, CVHI was the most sensitive in identifying subclinical atherosclerosis and had the lowest number of missed cases. The FRS was the most specific but least sensitive of the 3 scores, and had almost 10-fold more missed cases vs. the CVHI. The MetS had "middle" sensitivity and specificity, and 10-fold more missed cases vs. the CVHI. CONCLUSIONS: Results from this study suggest that routine administration of the CVHI in a primary prevention population would yield the benefits of identifying patients with existing subclinical CVD not identified through traditional CVD risk factors or scores, and bring physical activity and nutrition to the forefront of provider-patient discussions about lifestyle factors critical to maintaining and prolonging cardiovascular health.

Risk factors for metabolic syndrome in self-identified and questioning sexual minority women.

OBJECTIVE: Studies have shown sexual minority women (SMW) have a higher incidence of obesity, but the risk of metabolic syndrome (MetS) in SMW is unclear. We examined the association between sexual orientation and MetS and its components. METHODS: Data were extracted from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2016 examining women aged 20 to 59 years. Participants were divided into three categories: heterosexual, self-identified SMW, and questioning SMW. Logistic regression was used to analyze the association between sexual orientation and MetS. RESULTS: Of 12,755 women, 708 (5.6%) were self-identified SMW, and 365 (2.9%) were questioning SMW. The incidence of MetS was not significantly different across the groups. Logistic regression demonstrated that self-identified SMW had significantly higher odds of large waist circumference (odds ratio [OR] 1.39; 95% CI: 1.14-1.71) and obesity (OR 1.53; 95% CI: 1.24-1.90), while questioning SMW had significantly higher odds of low levels of high-density lipoprotein (OR 1.5; 95% CI: 1.13-1.98) compared with heterosexual women. CONCLUSIONS: Self-identified and questioning SMW did not have an increased incidence of MetS compared with heterosexual women, but they had higher odds of large waist circumference and low high-density lipoprotein, respectively. Further studies are needed to identify the gaps in social determinants of health in SMW.

Rural Appalachian Women Will Suffer Disproportionately if Attempts to Further Restrict Emergency Contraception are Successful.

The removal of federal abortion protection has incited fear that restrictions on contraception may be next. Many states now imposing abortion restrictions and bans are in the South and Appalachian Regions of the U.S., where rates of unplanned pregnancy and poor health outcomes are already disproportionately high. Numerous studies have documented variable access to levonorgestrel EC (LNG EC) in community pharmacies, with particularly low rates of access at independent pharmacies that are more likely to be located in rural communities than chain pharmacies. Since the overturn of Roe v. Wade, some large chain pharmacies and online retailers are restricting the purchase of LNG EC, limiting its availability. Some legislators and activists are calling for a ban on EC based on a misunderstanding about its mechanism of action, equating it with abortion. At a time when access to the full range of contraceptive options is more critical than ever, already limited access to LNG EC is worsening. Extensive data on LNG EC availability in 509 pharmacies and 400 health clinics across West Virginia, contextualized with socioeconomic demographics, illustrate existing disparities in LNG EC access.

Seronegative immunity to SARS-CoV-2: a case study.

BACKGROUND: COVID-19 presents with a variable clinical course from asymptomatic to severe respiratory distress with nearly 25% mortality in mechanically-ventilated patients. As such, there is uncertainty regarding how host factors modulate the disease course. CASE PRESENTATION: This report examines these factors in two geriatric patients with multiple comorbid conditions who were residents of the long-term care facility in West Virginia that was the epicenter of COVID-19 in the state. Each patient had substantial, unprotected exposure to SARS-CoV-2 with subsequent negative PCR and antibody testing. CONCLUSIONS: These cases could represent an important step in understanding host factors that modulate the disease course and susceptibility of patients exposed to SARS-CoV-2, and illustrate the need for further research into host resistance relating to this pandemic.

Responding to a COVID-19 Outbreak at a Long-Term Care Facility.

This article describes an outbreak of COVID-19 in a long-term care facility (LTCF) in West Virginia that was the epicenter of the state's pandemic. Beginning with the index case, we describe the sequential order of procedures undertaken by the facility including testing, infection control, treatment, and communication with facility residents, staff, and family members. We also describe the lessons learned during the process and provide recommendations for handling an outbreak at other LTCFs.

Palliative Opioids May Be a Bridge to Care for Rural Long-Term Care Facility Residents with Severe COVID-19 Symptoms.

PURPOSE: Long term care facility (LTCF) residents are at high risk for severe COVID-19 symptoms, but those in rural and resource-limited areas, such as West Virginia (WV) and the larger Appalachian region, may experience delays in obtaining higher levels of medical care due to isolated geography and limited transportation. The study examined the outcomes between residents from 1 LCTF in WV who were moved to a hospital as compared to those remaining in the facility. METHODS: This cohort study compares mortality outcomes among severely symptomatic residents desiring hospitalization and those electing to stay at the facility receiving palliative opioids with supplemental oxygen. FINDINGS: Forty residents tested positive for COVID-19 with 11 developing severe respiratory symptoms. Eight residents elected to receive care at the LTCF while 3 desired hospitalization. Mortality was assessed at 4 time points and was not statistically different between those who were hospitalized versus those who received palliative opioids at the LTCF. Although not significant, the difference in mortality between those hospitalized (66.7%) and those receiving opioids at the LTCF (12.5%) in the acute phase trended toward significance (P = .072). Overall mortality at the 6-month time point among all residents who developed severe respiratory symptoms at this LTCF was 54.5%. CONCLUSIONS: LTCF residents choosing different levels of therapeutic intervention for severe COVID-19 symptoms had no mortality difference. Palliative opioids may be an effective treatment for LTCF residents with severe COVID-19 and also a bridge to care in rural areas with limited resources until more advanced treatments can be accessed.

Comorbidity among older American Indians: the native elder care study.

Comorbidity is a growing challenge and the older adult population is most at risk of developing comorbid conditions. Comorbidity is associated with increased risk of mortality, increased hospitalizations, increased doctor visits, increased prescription medications, nursing home placement, poorer mental health, and physical disability. American Indians experience some of the highest rates of chronic conditions, but to date there have been only two published studies on the subject of comorbidity in this population. With a community-based sample of 505 American Indians aged 55 years or older, this study identified the most prevalent chronic conditions, described comorbidity, and identified socio-demographic, functional limitations, and psychosocial correlates of comorbidity. Results indicated that older American Indians experience higher rates of hypertension, diabetes, back pain, and vision loss compared to national statistics of older adults. Two-thirds of the sample experienced some degree of comorbidity according to the scale used. Older age, poorer physical functioning, more depressive symptomatology, and lower personal mastery were all correlates of higher comorbidity scores. Despite medical advances increasing life expectancy, morbidity and mortality statistics suggest that the health of older American Indians lags behind the majority population. These findings highlight the importance of supporting chronic care and management services for the older American Indian population.

Multimorbidity Trends in United States Adults, 1988-2014.

IMPORTANCE: The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing primary care. OBJECTIVE: The purpose of this study was to determine the prevalence of multi-morbidity and to document changes in prevalence during the last 25 years. DESIGN/SETTING: Cross-sectional study using multiple years (1988-2014) of the National Health and Nutrition Examination Survey (NHANES) were analyzed. SETTING: Multiple years (1988 to 2014) of the National Health and Nutrition Examination Survey (NHANES) from the United States were analyzed. PARTICIPANTS: Noninstitutionalized adults. MAIN OUTCOMES AND MEASURES: Number of chronic conditions per individual analyzed by age, race, gender, and socioeconomic factors. RESULTS: A total of 57,303 individuals were surveyed regarding the presence of multi-morbidity in separate surveys spanning 1988-2014. The overall current prevalence in 2013-2014 of >2 morbidities was 59.6% (95% CI 58.1%-61.1%), 38.5% had 3 or more, and 22.7% had 4 or more morbidities, which was significantly higher than in 1988 (45.7%, 95% CI 43.5%-47.8%, with >2 morbidities). Among individuals with 2 or more morbidities, 54.1% have obesity compared to 41.9% in 1988. Among adults age >65, prevalence was 91.8% for 2 or more morbidities. Whites and Blacks had significantly higher prevalence (59.2% and 60.1%) than Hispanic or "other" race (45.0%, P < .0001). Women (58.4%) had more current multi-morbidities (>2) than men (55.9%, P = .01). CONCLUSIONS AND RELEVANCE: Multimorbidity is common and has been increasing over the last 25 years. This finding has implications for public health policy and anticipated health costs for the coming years.

Rubella immunity and serum perfluoroalkyl substances: Sex and analytic strategy.

BACKGROUND: Perfluoroalkyl substances (PFASs) have been associated with decreased immunity to childhood tetanus and diphtheria immunizations. If these vaccinations are vulnerable to influence from PFASs, questions arise about associations with other common inoculations. OBJECTIVE: To examine whether serum PFASs were associated with reduced immunity to rubella immunization, and whether interactions with sex or ethnicity warranted analytic stratification. Usually, toxicology analyses are calculated controlling for race and sex. However, sex differences in immune function have been reported and a reduction of immunity to rubella in women could pose risks such miscarriage. METHODS: We analyzed a nationally representative sample of individuals ≥ 12 years from the National Health and Nutrition Examination Survey (NHANES) for years 1999-2000 and 2003-2004 for whom PFAS measures were available. Our analytic strategy was to start with separate analyses for youth and adults controlling for several covariates including ethnicity and sex, as well as the interaction of these terms with PFASs. If there was a main effect of PFASs and an interaction term, we would stratify analyses of effect size. The outcome variable was Rubella IgG titers by quartile of perfluoroalkyl substances. RESULTS: After exclusion for missing data, the analyzed sample contained 581 adult women, 621 adult men, and 1012 youth. There was no significant effect of PFASs on immunity in youths but a significant effect of both PFOA and PFOS in adults, as well as a significant interaction of PFOA x sex and a borderline significant interaction of PFOS x sex. When effect size analyses were stratified by sex, a significant association between rubella titres and PFOA was found in men but not women and PFOS was not significant in either sex. CONCLUSIONS: These results support our earlier studies showing sex specific responses to PFASs and indicate the importance of thinking carefully about analytic strategies in population based toxicology research.

Healthcare resource availability and cardiovascular health in the USA.

OBJECTIVES: Cardiovascular disease (CVD) remains the leading cause of death in the USA. Reducing the population-level burden of CVD disease will require a better understanding and support of cardiovascular health (CVH) in individuals and entire communities. The objectives for this study were to examine associations between community-level healthcare resources (HCrRes) and CVH in individuals and entire communities. SETTING: This study consisted of a retrospective, cross-sectional study design, using multivariable epidemiological analyses. PARTICIPANTS: All participants in the 2011 Behavioral Risk Factor Surveillance System (BRFSS) survey were examined for eligibility. CVH, defined using the American Heart Association CVH Index (CVHI), was determined using self-reported responses to 2011 BRFSS questions. Data for determining HCrRes were obtained from the Area Health Resource File. Regression analysis was performed to examine associations between healthcare resources and CVHI in communities (linear regression) and individuals (Poisson regression). RESULTS: Mean CVHI was 3.3±0.005 and was poorer in the Southeast and Appalachian regions of the USA. Supply of primary care physicians and physician assistants were positively associated with individual and community-level CVHI, while CVD specialist supply was negatively associated with CVHI. Individuals benefiting most from increased supply of primary care providers were: middle aged; female; had non-Hispanic other race/ethnicity; those with household income <$25 000/year; and those in non-urban communities with insurance coverage. CONCLUSIONS: Our results support the importance of primary care provider supply for both individual and community CVHI, though not all sociodemographic groups benefited equally from additional primary care providers. Further research should investigate policies and factors that can effectively increase primary care provider supply and influence where they practice.

Changes in Cardiovascular Health in the United States, 2003-2011.

BACKGROUND: Cardiovascular disease is the leading cause of death in the United States, making improving cardiovascular health a key population health goal. As part of efforts to achieve this, the American Heart Association has developed the first comprehensive cardiovascular health index (CVHI). Our objective was to investigate the changes in CVHI in US states from 2003 to 2011. METHODS AND RESULTS: CVHI was examined using Behavioral Risk Factor Surveillance System data between 2003 and 2011 (odd-numbered years). Total CVHI decreased from 3.73±0.01 in 2003 to 3.65±0.01 in 2009. The majority of states (88%) experienced a decline in CVHI and an increase in the prevalence of "poor" CVHI between 2003 and 2009. Among CVHI components, the highest prevalence of "ideal" was observed for blood glucose followed by smoking, whereas the lowest prevalence of "ideal" was observed for physical activity and diet. Between 2003 and 2009, prevalence of "ideal" smoking and diet status increased, while "ideal" prevalence of blood pressure, cholesterol, blood glucose, body mass index, and physical activity status decreased. We observed statistically significant differences between 2009 and 2011, outside the scope of the 2003-2009 trend, which we hypothesize are partially attributable to differences in sample demographic characteristics related to changes in Behavioral Risk Factor Surveillance System methodology. CONCLUSIONS: Overall, CVHI decreased, most likely due to decreases in "ideal" blood pressure, body mass index, and cholesterol status, which may stem from low prevalence of "ideal" physical activity and diet status. These findings can be used to inform state-specific strategies and targets to improve cardiovascular health.