Sexual health promotion for sexual and gender minorities in primary care: a scoping review protocol.

INTRODUCTION: Sexual and gender minorities (SGMs) face health disparities related to systemic discrimination and barriers to sexual health. Sexual health promotion encompasses strategies that enable individuals, groups and communities to make informed decisions regarding their sexual well-being. Our objective is to describe the existing sexual health promotion interventions tailored for SGMs within the primary care context. METHODS AND ANALYSIS: We will conduct a scoping review and search for articles in 12 medical and social science academic databases on interventions that are targeted towards SGMs in the primary care context in industrialised countries. Searches were conducted on 7 July 2020 and 31 May 2022. We defined sexual health interventions in the inclusion framework as: (1) promote positive sexual health, or sex and relationship education; (2) reduce the incidence of sexually transmitted infections; (3) reduce unintended pregnancies; or (4) change prejudice, stigma and discrimination around sexual health, or increase awareness surrounding positive sex. Two independent reviewers will select articles meeting inclusion criteria and extract data. Participant and study characteristics will be summarised using frequencies and proportions. Our primary analysis will include a descriptive summary of key interventional themes from content and thematic analysis. Gender-based Analysis Plus will be used to stratify themes based on gender, race, sexuality and other identities. The secondary analysis will include the use of the Sexual and Gender Minority Disparities Research Framework to analyse the interventions from a socioecological perspective. ETHICS AND DISSEMINATION: No ethical approval is required for a scoping review. The protocol was registered on the Open Science Framework Registries (https://doi.org/10.17605/OSF.IO/X5R47). The intended audiences are primary care providers, public health, researchers and community-based organisations. Results will be communicated through peer-reviewed publication, conferences, rounds and other opportunities to reach primary care providers. Community-based engagement will occur through presentations, guest speakers, community forums and research summary handouts.

Machine learning vs. conventional statistical models for predicting heart failure readmission and mortality.

AIMS: This study aimed to review the performance of machine learning (ML) methods compared with conventional statistical models (CSMs) for predicting readmission and mortality in patients with heart failure (HF) and to present an approach to formally evaluate the quality of studies using ML algorithms for prediction modelling. METHODS AND RESULTS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic literature search using MEDLINE, EPUB, Cochrane CENTRAL, EMBASE, INSPEC, ACM Library, and Web of Science. Eligible studies included primary research articles published between January 2000 and July 2020 comparing ML and CSMs in mortality and readmission prognosis of initially hospitalized HF patients. Data were extracted and analysed by two independent reviewers. A modified CHARMS checklist was developed in consultation with ML and biostatistics experts for quality assessment and was utilized to evaluate studies for risk of bias. Of 4322 articles identified and screened by two independent reviewers, 172 were deemed eligible for a full-text review. The final set comprised 20 articles and 686 842 patients. ML methods included random forests (n = 11), decision trees (n = 5), regression trees (n = 3), support vector machines (n = 9), neural networks (n = 12), and Bayesian techniques (n = 3). CSMs included logistic regression (n = 16), Cox regression (n = 3), or Poisson regression (n = 3). In 15 studies, readmission was examined at multiple time points ranging from 30 to 180 day readmission, with the majority of studies (n = 12) presenting prediction models for 30 day readmission outcomes. Of a total of 21 time-point comparisons, ML-derived c-indices were higher than CSM-derived c-indices in 16 of the 21 comparisons. In seven studies, mortality was examined at 9 time points ranging from in-hospital mortality to 1 year survival; of these nine, seven reported higher c-indices using ML. Two of these seven studies reported survival analyses utilizing random survival forests in their ML prediction models. Both reported higher c-indices when using ML compared with CSMs. A limitation of studies using ML techniques was that the majority were not externally validated, and calibration was rarely assessed. In the only study that was externally validated in a separate dataset, ML was superior to CSMs (c-indices 0.913 vs. 0.835). CONCLUSIONS: ML algorithms had better discrimination than CSMs in most studies aiming to predict risk of readmission and mortality in HF patients. Based on our review, there is a need for external validation of ML-based studies of prediction modelling. We suggest that ML-based studies should also be evaluated using clinical quality standards for prognosis research. Registration: PROSPERO CRD42020134867.

Readmission rates following heart failure: a scoping review of sex and gender based considerations.

BACKGROUND: Although hospital readmission for heart failure (HF) is an issue for both men and women, little is known about differences in readmission rates by sex. Consequently, strategies to optimize readmission reduction programs and care strategies for women and men remain unclear. Our study aims were: (1) to identify studies examining readmission rates according to sex, and (2) to provide a qualitative overview of possible considerations for the impact of sex or gender. METHODS: We conducted a scoping review using the Arksey and O'Malley framework to include full text articles published between 2002 and 2017 drawn from multiple databases (MEDLINE, EMBASE), grey literature (i.e. National Technical information, Duck Duck Go), and expert consultation. Eligible articles included an index heart failure episode, readmission rates, and sex/gender-based analysis. RESULTS: The search generated 5887 articles, of which 746 underwent full abstract text consideration for eligibility. Of 164 eligible articles, 34 studies addressed the primary outcome, 103 studies considered sex differences as a secondary outcome and 25 studies stratified data for sex. Good inter-rater agreement was reached: 83% title/abstract; 88% full text; kappa: 0.69 (95%CI: 0.53-0.85). Twelve of 34 studies reported higher heart failure readmission rates for men and six studies reported higher heart failure readmission rates for women. Using non composite endpoints, five studies reported higher HF readmission rates for men compared to three studies reporting higher HF readmission rates for women. Overall, there was heterogeneity between studies when examined by sex, but one observation emerged that was related to the timing of readmissions. Readmission rates for men were higher when follow-up duration was longer than 1 year. Women were more likely to experience higher readmission rates than men when time to event was less than 1 year. CONCLUSIONS: Future studies should consider different time horizons in their designs and avoid the use of composite measures, such as readmission rates combined with mortality, which are highly skewed by sex. Co-interventions and targeted post-discharge approaches with attention to sex would be of benefit to the HF patient population.

Comparison of Troponin Elevation, Prior Myocardial Infarction, and Chest Pain in Acute Ischemic Heart Failure.

BACKGROUND: Patients with heart failure (HF) with concomitant ischemic heart disease (IHD) have not been well characterized. We examined survival of patients with ischemic HF syndrome (IHFS), defined as presentation with acute HF and concomitant features suggestive of IHD. METHODS: Patients were included if they presented with acute HF to hospitals in Ontario, Canada. IHD was defined by any of the following criteria: angina/chest pain, prior myocardial infarction (MI), or troponin elevation that was above the upper limit of normal (mild) or suggestive of cardiac injury. Deaths were determined after hospital presentation. RESULTS: Of 5353 patients presenting with acute HF, 4088 (76.4%) exhibited features of IHFS. Patients with IHFS demonstrated a higher rate of 30-day (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.33-2.68) and 1-year death (HR, 1.16, 95% CI, 1.00-1.35) compared with those with nonischemic HF. Troponin elevation demonstrated the strongest association with mortality. Mildly elevated troponin was associated with increased hazard over 30-day (HR, 1.77; 95% CI, 1.12-2.81) and 1-year (HR, 1.63; 95% CI, 1.38-1.93) mortality. Troponins indicative of cardiac injury were associated with increased hazard of death over 30 days (HR, 2.33; 95% CI, 1.63-3.33) and 1 year (HR, 1.40; 95% CI, 1.21-1.61). The association between elevated troponin and higher mortality at 30 days was similar in left ventricular ejection fraction subcategories of HF with reduced ejection fraction, HF with mildly reduced ejection fraction, or HF with preserved ejection fraction (P interaction = 0.588). After multivariable adjustment, prior MI and angina were not associated with higher mortality risk. CONCLUSIONS: In acute HF, elevated troponin, but not prior MI or angina, was associated with a higher risk of 30-day and 1-year mortality irrespective of left ventricular ejection fraction.

CONTEXTE: Les patients présentant une insuffisance cardiaque et une cardiopathie ischémique (CI) concomitante ne sont pas bien caractérisés. Nous avons examiné les données sur la survie de patients atteints d'un syndrome d'insuffisance cardiaque ischémique (SICI), caractérisé par la présence d'une insuffisance cardiaque aiguë et de manifestations concomitantes évoquant une CI. MÉTHODOLOGIE: Les données examinées concernaient des patients atteints d'insuffisance cardiaque aiguë reçus en consultation dans des hôpitaux de l'Ontario, au Canada. Un patient était réputé atteint de CI s'il répondait à l'un des critères suivants : angine/douleur thoracique, antécédents d'infarctus du myocarde (IM) ou élévation de la concentration de troponine se situant au-delà de la limite supérieure de la normale (cas léger) ou évoquant une lésion cardiaque. La détermination des décès a été effectuée en aval des consultations hospitalières. RÉSULTATS: Parmi 5 353 patients atteints d'insuffisance cardiaque aiguë reçus en consultation, 4 088 (76,4 %) présentaient des caractéristiques de SICI. Chez les patients atteints d'un SICI, un taux plus élevé de mortalité à 30 jours (rapport des risques instantanés [RRI] : 1,89, intervalle de confiance [IC] à 95 % : 1,33-2,68) et à 1 an (RRI : 1,16, IC à 95 % : 1,00-1,35) a été noté comparativement aux patients atteints d'insuffisance cardiaque non ischémique. L'élévation de la concentration de troponine présentait la plus forte association avec la mortalité. Une légère élévation de la concentration de troponine se trouvait associée à un risque accru de mortalité à 30 jours (RRI : 1,77, IC à 95 % : 1,12-2,81) et à 1 an (RRI : 1,63, IC à 95 % : 1,38-1,93). Les concentrations de troponine témoignant de lésions cardiaques étaient associées à une augmentation du risque de mortalité à 30 jours (RRI : 2,33, IC à 95 % : 1,63-3,33) et à 1 an (RRI : 1,40, IC à 95 % : 1,21-1,61). L'association entre une concentration élevée de troponine et une augmentation du taux de mortalité à 30 jours était semblable dans les sous-catégories d'insuffisance cardiaque avec fraction d'éjection ventriculaire gauche réduite, légèrement réduite ou préservée (p = 0,588 pour l'interaction). Après correction multivariée, les antécédents d'IM et d'angine n'étaient pas associés à un risque accru de mortalité. CONCLUSIONS: Dans un contexte d'insuffisance cardiaque aiguë, l'élévation de la concentration de troponine était associée à un risque plus élevé de mortalité à 30 jours et à 1 an indépendamment de la fraction d'éjection ventriculaire gauche; les antécédents d'IM ou d'angine ne l'étaient toutefois pas.

Comparison of Readmission and Death Among Patients With Cardiac Disease in Northern vs Southern Ontario.

BACKGROUND: Geographic factors may influence cardiovascular disease outcomes in Canada. Circulatory diseases are a major reason for higher population mortality rates in Northern Ontario, but it is unknown if hospitalized patients with cardiovascular disease experience differential outcomes compared with those in the South. METHODS: We examined 30-day and 1-year mortality and readmissions for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), atrial fibrillation (AF), or stroke in Northern compared with Southern Ontario, using the Canadian Institute for Health Information Discharge Abstract Database (2005-2016). Northern patients were defined as those residing and hospitalized in the Northwest or Northeast Local Health Integration Network regions. We used multiple Cox proportional hazards regression analysis for time-to-first event and Prentice-Williams-Peterson method to evaluate repeat and multiply admitted patients. RESULTS: A total of 47,745 Northern and 465,353 Southern patients hospitalized with AMI (n = 182,158), HF (n = 130,770), AF (n = 72,326), or stroke (n = 127,844) were studied. Rates of first readmission were higher among Northern patients for AMI (adjusted hazard ratio [HR], 1.32), HF (HR, 1.16), AF (HR, 1.21), and stroke (HR, 1.27) compared with Southern patients (all P < 0.001). Repeat readmission rates among Northern patients for AMI (HR, 1.23), HF (HR, 1.13), AF (HR, 1.18), and stroke (HR, 1.22) were also increased (all P < 0.001 vs Southern). Thirty-day mortality did not differ significantly between Northern and Southern patients. CONCLUSIONS: Readmissions were increased in those residing and hospitalized in the North. To reduce readmissions in the North, the quality of postacute transitional care should be examined further.

Heart rate in patients with reduced ejection fraction: relationship between single time point measurement and mean heart rate on prolonged implantable cardioverter defibrillator monitoring.

BACKGROUND: Heart rate (HR) is a prognostic marker that is increasingly used as a therapeutic target in patients with cardiovascular disease. The association between resting and mean HR remains unclear. We therefore set out to determine the relationship between resting HR on the electrocardiogram (ECG) obtained at a single time point, and mean HR on implantable cardioverter defibrillator (ICD) interrogation amongst patients with a reduced left ventricular ejection fraction (LVEF). METHODS: Prospective ICD data were obtained from 54 patients with LVEF < 40%. Mean HR determined using the ICD HR histograms was compared with resting HR measured on the ECG performed in the clinic. RESULTS: Average resting and ICD mean HRs were 67.9 ± 10.1 and 67.8 ± 9.6 bpm respectively. There was good correlation in the overall cohort (r = 0.79), in those with resting ECG HRs ≤ 70 bpm (r = 0.62), and amongst the 27 patients on intermediate-to-high dose beta-blockers (r = 0.91). However, Bland-Altman analysis demonstrated wide limits of agreement in the overall cohort (- 12.5, 12.7 bpm), at resting HRs ≤ 70 bpm (- 12.7, 9.8 bpm), and on intermediate-to-high dose beta-blockers (- 8.9, 7.4 bpm). Moreover, resting HR did not predict the 10-bpm interval where the most time was spent. CONCLUSIONS: While resting HR correlated with mean HR in patients with reduced LVEF, and in important subgroups, the limits of agreement were unacceptably wide raising concern over the use of single time point resting HR as a therapeutic target.

Risk of Diabetes in Older Adults with Co-Occurring Depressive Symptoms and Cardiometabolic Abnormalities: Prospective Analysis from the English Longitudinal Study of Ageing.

High depressive symptoms and cardiometabolic abnormalities are independently associated with an increased risk of diabetes. The purpose of this study was to assess the association of co-occurring depressive symptoms and cardiometabolic abnormalities on risk of diabetes in a representative sample of the English population aged 50 years and older. Data were from the English Longitudinal Study of Ageing. The sample comprised of 4454 participants without diabetes at baseline. High depressive symptoms were based on a score of 4 or more on the 8-item binary Centre for Epidemiologic Studies-Depression scale. Cardiometabolic abnormalities were defined as 3 or more cardiometabolic risk factors (hypertension, impaired glycemic control, systemic inflammation, low high-density lipoprotein cholesterol, high triglycerides, and central obesity). Cox proportional hazards regressions assessed the association between co-occurring depressive symptoms and cardiometabolic abnormalities with incidence of diabetes. Multiple imputation by chained equations was performed to account for missing data. Covariates included age, sex, education, income, smoking status, physical activity, alcohol consumption, and cardiovascular comorbidity. The follow-up period consisted of 106 months, during which 193 participants reported a diagnosis of diabetes. Diabetes incidence rates were compared across the following four groups: 1) no or low depressive symptoms and no cardiometabolic abnormalities (reference group, n = 2717); 2) high depressive symptoms only (n = 338); 3) cardiometabolic abnormalities only (n = 1180); and 4) high depressive symptoms and cardiometabolic abnormalities (n = 219). Compared to the reference group, the hazard ratio for diabetes was 1.29 (95% CI 0.63, 2.64) for those with high depressive symptoms only, 3.88 (95% CI 2.77, 5.44) for those with cardiometabolic abnormalities only, and 5.56 (95% CI 3.45, 8.94) for those with both high depressive symptoms and cardiometabolic abnormalities, after adjusting for socio-demographic, lifestyle and clinical variables. These findings suggest that those with high depressive symptoms and cardiometabolic abnormalities are at a particularly increased risk of type 2 diabetes.

Evaluating lifestyle and health-related characteristics of older adults with co-occurring depressive symptoms and cardiometabolic abnormalities.

OBJECTIVE: Comorbid depression and cardiometabolic abnormalities might represent an important subgroup of depression. The aim of the present study was to evaluate lifestyle and health-related characteristics of individuals with both depressive symptoms and cardiometabolic abnormalities. METHODS: Data were from the English Longitudinal Study of Ageing. The sample was comprised of 5365 adults aged 50-80 years. High depressive symptoms were based on the eight-item Center for Epidemiologic Studies - Depression scale. Cardiometabolic abnormalities were defined as having ≥3 cardiometabolic risk factors (hypertension, impaired glycemic control, systemic inflammation, low high-density lipoprotein cholesterol, hypertriglyceridemia, and central obesity). Four groups were created based on Center for Epidemiologic Studies - Depression scores and cardiometabolic abnormalities: those with (i) comorbid depressive symptoms and cardiometabolic abnormalities (DCM); (ii) depressive symptoms only (DnoCM); (iii) cardiometabolic abnormalities only; and (iv) neither depressive symptoms nor cardiometabolic abnormalities. Lifestyle and health-related characteristics of the four groups were compared using chi-square tests. A modified Poisson regression analysis was performed to compare the DCM and the DnoCM groups with respect to lifestyle and health-related characteristics. RESULTS: Those in the DCM group were significantly less physically active (p = 0.003), had poorer self-rated health (p < 0.001), had lower income (p = 0.001), and were more likely to be retired (p < 0.001) than those in the DnoCM group. The pattern of results remained after controlling for other lifestyle and health-related factors. CONCLUSION: These results provide support for a cardiometabolic subgroup of depression that is associated with physical inactivity, poorer self-rated health, lower income, and retirement. Copyright © 2015 John Wiley & Sons, Ltd.