Residential medication management reviews of antithrombotic therapy in aged care residents with atrial fibrillation: assessment of stroke and bleeding risk.

WHAT IS KNOWN AND OBJECTIVE: Antithrombotics reduce the risk of stroke in individuals with atrial fibrillation (AF). However, optimal prescribing of antithrombotics in older people remains a challenge. The objective of this study was to assess the risk of stroke for aged care home residents with AF and to examine the pharmacist-led medication reviews on the utilization of antithrombotic therapy. METHODS: This retrospective study included a random sample of de-identified residential medication management reviews (RMMRs) conducted by accredited pharmacists in aged care homes in Sydney, Australia, between August 2011 and December 2012. The study participants were 146 residents aged 65 years and older with AF living in low- and high-care residential aged care facilities. Antithrombotic therapy was examined among the residents, before and after medication review. CHADS2 , CHA2 DS2 -VASc, and HEMORR2 HAGES scoring tools were used to assess the risk of stroke and bleeding and indicate the appropriateness of antithrombotic therapy. RESULTS AND DISCUSSION: The mean age (±SD) of individuals was 88·4 (7·5) years, and 63·7% (n = 93) were female. The majority of residents (n = 99, 67·8%) were aged between 85 and 99 years. The mean (±SD) CHADS2 score was 3·1 (1·1), CHA2 DS2 -VASc was 4·6 (1·5), and HEMORR2 HAGES was 2·3 (1·0). All residents were classified as being at high risk of developing stroke. A total of 115 of 146 (78·8%) residents with AF were prescribed antithrombotics. There was a relatively low usage of anticoagulation (28·1%), and few recommendations from the medication review pharmacists to alter the thromboprophylactic therapy in AF. Application of the CHA2 DS2 -VASc risk tool indicated that 146 residents were eligible for antithrombotic treatments; of these, 74 (50·7%) were prescribed antiplatelets and 41 (28·1%) were prescribed anticoagulants. Of the 31 (21·2%) residents with AF were not prescribed antithrombotics, 21 (67·7%) had relative contraindications for anticoagulant treatments. WHAT IS NEW AND CONCLUSION: Although there was a high overall use of antithrombotic agents, the study found a reluctance to prescribe or recommend anticoagulants in eligible older people with AF, potentially due to associated contraindications and multimorbidity. The use of guideline-recommended stroke risk tools could assist medication review pharmacists in optimizing antithrombotic therapy in older adults with AF.

Relationships between the family environment and school-based obesity prevention efforts: can school programs help adolescents who are most in need?

Identifying factors that contribute to students' behavior and weight improvements during school-based obesity prevention interventions is critical for the development of effective programs. The current study aims to determine whether the support and resources that adolescent girls received from their families were associated with improvements in physical activity (PA), television use, dietary intake, body mass index (BMI) and body composition during participation in New Moves, a school-based intervention to prevent obesity and other weight-related problems. Adolescent girls in the intervention condition of New Moves (n = 135), and one parent of each girl, were included in the current analysis. At baseline, parents completed surveys assessing the family environment. At baseline and follow-up, 9-12 months later, girls' behaviors were self-reported, height and weight were measured by study staff and body fat was assessed using dual-energy X-ray absorptiometry. Results showed few associations between family environment factors and girls' likelihood of improving behavior, BMI or body composition. These findings suggest that in general, school-based interventions offer similar opportunities for adolescent girls to improve their PA, dietary intake, and weight, regardless of family support.

Low heart rate variability in a 2-minute rhythm strip predicts risk of coronary heart disease and mortality from several causes: the ARIC Study. Atherosclerosis Risk In Communities.

BACKGROUND: Low heart rate variability (HRV) is associated with a higher risk of death in patients with heart disease and in elderly subjects and with a higher incidence of coronary heart disease (CHD) in the general population. METHODS AND RESULTS: We studied the predictive value of HRV for CHD and death from several causes in a population study of 14 672 men and women without CHD, aged 45 to 65, by using the case-cohort design. At baseline, in 1987 to 1989, 2-minute rhythm strips were recorded. Time-domain measures of HRV were determined in a random sample of 900 subjects, for all subjects with incident CHD (395 subjects), and for all deaths (443 subjects) that occurred through 1993. Relative rates of incident CHD and cause-specific death in tertiles of HRV were computed with Poisson regression for the case-cohort design. Subjects with low HRV had an adverse cardiovascular risk profile and an elevated risk of incident CHD and death. The increased risk of death could not be attributed to a specific cause and could not be explained by other risk factors. CONCLUSIONS: Low HRV was associated with increased risk of CHD and death from several causes. It is hypothesized that low HRV is a marker of less favorable health.

The Minneapolis childrn's blood pressure study. Part 2: multiple determinants of children's blood pressure.

Among 9977 public school children aged 6 to 9 years screened in late winter and spring of 1978 in Minnesota, systolic blood pressure (SBP) and diastolic fourth phase blood pressure (DBP4) were found to be unrelated to age when height and body mass index (kg/m2) were taken into account. Weight was the best single measure of body size for predicing blood pressure. Black and white children had small and inconsistent, although statistically significant, differences in blood pressure after adjusting for other variables. The same was true for boys and girls. The problems of establishing normal blood pressures for children are discussed. The current analyses suggest the use of blood pressure centiles by height.

Validation of death certificate diagnosis of out-of-hospital sudden cardiac death.

The validity of death certificate diagnosis of out-of-hospital sudden cardiac death (OOH-SCD) was studied among 108,676 30- to 74-year-old residents in 5 Minnesota communities using 6-year mortality data (1985 to 1990). Among 4,244 total deaths, location of death was listed on the certificate as out of hospital in 2,035 cases. Of those, 911 were judged not to have OOH-SCD because they had actually been admitted to the hospital or were noncardiovascular deaths. Among the remaining 1,124, 254 were diagnosed as OOH-SCD using a thorough, physician-based procedure that used clinical records, autopsy reports, and an informant (next-of-kin) interview. We used only death certificate information to define OOH-SCD simply and inexpensively as ICD-9 code 427.5 (cardiac arrest) plus location of death listed as out-of-hospital. Compared with the physician diagnosis, sensitivity was only 24%, whereas specificity was 85%. When the definition of OOH-SCD was expanded to include ICD codes 410-414 (acute myocardial infarction and chronic coronary artery disease), sensitivity improved to 87%, whereas specificity became 66%. However, even with this higher sensitivity and specificity, only 27% of the cases labeled OOH-SCD by death certificate agreed with the physician diagnosis. Death certificate diagnosis of OOH-SCD included many erroneous cases, and may not have been suitable for study of etiologic factors, such as cardiac dysrhythmias. Death certificate diagnosis may be useful to assess population time trends in OOH-SCD, provided that misclassification (false-positive rate) remains constant over time.

Prognostic associations of Minnesota Code serial electrocardiographic change classification with coronary heart disease mortality in the Multiple Risk Factor Intervention Trial.

A central requirement for epidemiologic studies and clinical trials is a bias-free, objective determination of cardiac incidence rates between comparison groups. Epidemiologic studies and clinical trials frequently use changes in the Minnesota Code to document incident ischemic events. An electrocardiographic (ECG) classification system was developed to document significant ECG pattern change using objective comparison rules for side-by-side annual ECG comparison. Previously, we showed that major evolving Q waves were strongly and independently associated with total and coronary disease mortality. Using baseline-to-annual ECG comparisons in the Multiple Risk Factor Intervention Trial, we evaluated major evolving Q waves, minor evolving Q waves combined with major evolving ST-T waves and major evolving ST-T waves alone for their prognostic associations with coronary, cardiovascular, and total mortality during 16 years of follow-up. The 16-year coronary mortality rate in men with evolving minor Q waves plus evolving ST-T waves had an average adjusted relative risk of 4, equivalent to that of a major evolving Q wave. These risk ratios held whether a clinical infarction had occurred. Silent evolving ST-T waves without Q-wave change had an average adjusted relative coronary mortality risk of 1.6. Serial comparison methodology documents additional incident ischemic ECG events beyond the traditional major Minnesota Q-code change used in older epidemiologic studies. The procedure is standardized, quantitative, and repeatable. It is applicable for any study, present or past, that used Minnesota coding. The method is also well suited for incorporation in computer analysis programs.

Cyclic seasonal variation in plasma lipid and lipoprotein levels: the Lipid Research Clinics Coronary Primary Prevention Trial Placebo Group.

Seasonal plasma lipid and lipoprotein cycles were studied in 1446 hypercholesterolemic 35-59 year-old men followed for 7 years as the placebo group of the Lipid Research Clinics (LRC) Coronary Primary Prevention Trial (CPPT). Separate periodic time series were calculated for each study participant; mean parameter estimates were obtained by vector algebra. Highly significant (p less than 0.001) synchronous sinusoidal seasonal cycles, peaking in the first month of winter, were demonstrated for plasma levels of total (TOT-C), low-density lipoprotein (LDL-C), and high-density lipoprotein (HDL-C) cholesterol. Their mean seasonal changes (nadir to zenith) were 7.4, 6.4, and 0.8 mg/dl, respectively. An irregular but statistically significant seasonal pattern was also observed for plasma triglyceride (TG) levels, with peak levels in the autumn. The variation of these seasonal effects among subgroups and geographic locales and their correlation with seasonal weight and dietary patterns yielded few clues as to their underlying etiologic mechanisms.

Analysis of community-based cardiovascular disease prevention studies--evaluation issues in the North Karelia Project and the Minnesota Heart Health Program.

Karelia project of the Minnesota Heart Health Program. International Journal of Epidemiology 1986, 15: 176-182. Community-based cardiovascular disease control studies represent an effort to change cardiovascular disease rates in entire communities. Communities, rather than individuals, are the primary units of analysis. The cross-community multiple time series model to estimate and test the effects is based on multiple communities that are evaluated at several points over time. Issues that influence the power of the analysis include: the number of communities to be studied, community size and composition, sample sizes of surveys, the decision to use cohorts or cross-sectional surveys, the number of surveys conducted in each community, and assumptions of latencies in the effects. These points are illustrated using the experiences of the North Karelia Project and the Minnesota Heart Health Program. The North Karelia Project was a community-based cardiovascular disease (CVD) prevention programme consisting of a five-year intervention period in 1972-7. It took place in two provinces in Finland. The Minnesota Heart Health Program is similar, taking place between 1980 and 1990 in six communities in the American Midwest.

Weight-related behaviors among adolescent girls and boys: results from a national survey.

OBJECTIVE: The study objectives were to assess (1) the prevalence of dieting and disordered eating among adolescents; (2) the sociodemographic, anthropometric, psychosocial, and behavioral correlates of dieting and disordered eating; and (3) whether adolescents report having discussed weight-related issues with their health care providers. DESIGN: Cross-sectional school-based survey. STUDY POPULATION: A nationally representative sample of 6728 adolescents in grades 5 to 12 who completed the Commonwealth Fund surveys of the health of adolescent girls and boys. MAIN OUTCOME MEASURES: Dieting and disordered eating (binge-purge cycling). RESULTS: Approximately 24% of the population was overweight. Almost half of the girls (45%) reported that they had at some point been on a diet, compared with 20% of the boys. Disordered eating was reported by 13% of the girls and 7% of the boys. Strong correlates of these behaviors included overweight status, low self-esteem, depression, suicidal ideation, and substance use. Almost half of the adolescents (38%-53%) reported that a health care provider had at some point discussed nutrition or weight with them. Discussions on eating disorders were reported by lower percentages of girls (24%) and boys (15%). CONCLUSIONS: The high prevalence of weight-related concerns suggests that all youth should be reached with appropriate interventions. Special attention needs to be directed toward youth at greatest risk for disordered eating behaviors, such as overweight youth, youth engaging in substance use behaviors, and youth with psychological concerns such as low self-esteem and depressive symptoms.

Seasonal variation in plasma cholesterol distributions: implications for screening and referral.

In 3,377 men and 3,900 women who participated in a community-based plasma cholesterol screening program, we found a significant cyclic time-trend in cholesterol levels, with maximum peak in January. The 95% confidence interval (CI) of the peak to trough distance was 5.8-13.8 mg/dL (0.15-0.36 mmol/L) in men, corresponding to 2.6%-6.3% of the average cholesterol level. Corresponding figures for women were 2.0-9.3 mg/dL (0.05-0.24 mmol/L) or 1.0%-4.6%. Applying the cutoff level for high cholesterol risk proposed by the National Cholesterol Education Program (< or = 240 mg/dL [6.21 mmol/L]) to sex-specific bimonthly distributions, we found a statistically significant variation in prevalence, attributable to seasonal trends, in men (P < .01), but not in women. In men, the age-adjusted prevalence in winter (25.4%) was double that in the summer (13.5%). Seasonal variation is an important determinant of the prevalence of hypercholesterolemia in men and should be considered in patient follow-up and screening.

Planning for the appropriate analysis in school-based drug-use prevention studies.

School-based drug-use prevention studies often apply interventions to entire schools. A major problem for these studies results from the intragroup dependence often seen when intact social groups are assigned to study conditions. Analysis of data from 2 such studies revealed intraclass correlation coefficients between 0.02 and 0.05 for common drug use measures. Because even such modest intragroup dependence can invalidate the traditional fixed-effects analyses, researchers should adopt alternative methods that acknowledge this dependence. These alternative methods are reviewed, and appropriate methods for computing sample size requirements are illustrated. Investigators should consider these analysis issues when planning future studies, because the number of schools required for an unbiased analysis may be substantially greater than for the traditional methods.

Primary prevention of disordered eating among preadolescent girls: feasibility and short-term effect of a community-based intervention.

OBJECTIVE: To evaluate a community-based intervention aimed at the primary prevention of disordered eating among preadolescent girls. DESIGN: Girl Scout troop members were randomized into control and intervention groups. Program feasibility and effect at postintervention and 3-month follow-up were evaluated. SUBJECTS/SETTING: 226 girls (mean age = 10.6 years, standard deviation = 0.7) from 24 Girl Scout troops. INTERVENTION: Six 90-minute sessions focusing on media literacy and advocacy skills. MAIN OUTCOME MEASURES: Evaluation focused on program satisfaction and short-term effect on dieting behaviors, body image attitudes, and media knowledge, attitudes, and habits. STATISTICAL ANALYSES: Performed t tests, chi 2 tests, and analyses of covariance including troop as a random source of variation. RESULTS: At baseline, 29% of the girls were trying to lose weight. The program had a notable positive influence on media-related attitudes and behaviors including internalization of sociocultural ideals, self-efficacy to impact weight-related social norms, and print media habits. A modest program effect on body-related knowledge and attitudes was apparent at post-intervention (i.e., on body size acceptance, puberty knowledge, and perceived weight status) but not at follow-up. Significant changes were not noted for dieting behaviors, but they were in the hypothesized direction. Satisfaction with the program was high among girls, parents, and leaders. APPLICATIONS/CONCLUSIONS: It is feasible to use community youth settings, such as the Girl Scouts, to implement interventions to prevent disordered eating behaviors. The program led to positive trends in outcome variables; however, longer and more intensive interventions are needed for lasting changes in body image and dieting behaviors.

A food frequency questionnaire can detect pregnancy-related changes in diet.

OBJECTIVE: To determine whether a food frequency questionnaire (FFQ) can detect changes in dietary intake before pregnancy to mid-pregnancy relative to a 4-day food record. DESIGN: FFQs and 4-day, weighed food records (4DRs) were completed during similar time intervals before pregnancy and again near mid-pregnancy by women served by a large health maintenance organization in the Minneapolis-St Paul, Minn, area. The outcome of interest was change in the intake of energy and 16 nutrients. Participants were members of the Diana Project, a prospective study of relationships among prepregnancy and pregnancy nutritional and other exposures and reproductive outcomes. Fifty-six (51%) of the eligible women completed the study. SUBJECTS: Well-educated, healthy, white women. STATISTICAL ANALYSES PERFORMED: Spearman rank order correlations. RESULTS: Mean energy and nutrient intake levels estimated using the 4DR were generally higher than those estimated using the FFQ. Correlations between change in energy and nutrient intakes measured by the 4DR and FFQ ranged from .75 for vitamin C to .02 for cholesterol and averaged .48. APPLICATIONS: Comparisons with 4DRs indicate that the FFQ used in this study is appropriate for obtaining reliable estimates of prepregnancy to mid-pregnancy changes in intake of energy and a number of nutrients in similar groups of women.

Relationship between socio-demographic and behaviour variables, and body mass index in a population with high-normal blood pressure: Hypertension Prevention Trial.

The relationship between socio-demographic and behaviour variables and body mass index (BMI: weight/height2) adjusted for age were studied in a population with high-normal blood pressure who participated in the Hypertension Prevention Trial. The BMI of the participants ranged from 19.1 to 35.1 kg/m2 in men and from 16.0 to 35.1 kg/m2 in women. The prevalence of obesity (BMI greater than or equal to 25.0 kg/m2) was 77 per cent in men and 61 per cent in women, with prevalence of severe obesity (BMI greater than or equal to 30.0 kg/m2) being 23 per cent and 19 per cent respectively. Stepwise regression was carried out to identify the most important correlates of BMI. In men, they were family income (+), occupation (-), leisure time exercise frequency (-), number of meals eaten out (-), alcohol intake (-), smoking (-), caffeinated drink intake (+), and meal planner. Men who planned meals with their partners had a higher BMI than men who planned their own meals or had someone else plan their meals. Correlates of little importance were marital status, race, education, number of members in household, energy intake, percentage of total calories from fat, occupation activity level, and vitamin/mineral supplement intake. In women the most important correlates of BMI were alcohol intake (-), caffeinated drink intake (+), and race. Black women had a higher mean BMI than white women. The important socio-demographic and behaviour variables in both men and women accounted for about 20 per cent of the variance in BMI which leaves about 80 per cent of the variation unexplained. This indicates the presence of other factor(s) which may be determining body weight.

Binge and purge behavior among adolescents: associations with sexual and physical abuse in a nationally representative sample: the Commonwealth Fund survey.

OBJECTIVES: (1) To examine associations between binge and purge behavior and sexual and physical abuse among adolescents; (2) to determine if these associations remain significant after controlling for sociodemographic and anthropometric characteristics; and (3) to identify aspects of abuse associated with binge and purge behavior. METHOD: A nationally representative sample of 6728 adolescents in 5th-12th grades completed the Commonwealth Fund Survey of the Health of Adolescent Girls and Boys. RESULTS: Binge and purge behavior was nearly twice as prevalent among girls (13%) as boys (7%), and was significantly associated with all abuse types (physical, sexual, or both). Associations were strongest among individuals who had experienced both physical and sexual abuse [odds ratios 4.28 (girls) and 8.25 (boys)]. Differences in binge and purge behavior by gender and type of abuse across abuse characteristics were limited. A higher percentage of abused youth that did not discuss their abuse reported binge-purge behavior than those who did discuss their abuse. Abused girls and boys who did talk to someone about the abuse most often discussed the abuse with their best friend (42.5% and 18.0%, respectively), their mother (38.8% and 32.2%, respectively), and their friends (27.2% and 19.5%, respectively). DISCUSSION: Being physically and/or sexually abused was associated with greater likelihood for engaging in binge and purge behaviors. Discussing the abuse experience with another person may help to reduce binge-purge behavior, as abused adolescents who did not discuss the abuse were more likely to report binge-purge behavior than those who did discuss their abuse.

Gauss or Bernoulli? A Monte Carlo comparison of the performance of the linear mixed-model and the logistic mixed-model analyses in simulated community trials with a dichotomous outcome variable at the individual level.

This Monte Carlo study compares performance of the linear and the logistic mixed-model analyses of simulated community trials having event rates of 37%, 13%, or 5%, intraclass correlations between 0.01 and 0.05, and 17 or 5 denominator degrees of freedom. Type I or Type II error rates showed no essential difference between the two analysis methods. They showed depressed error rates when the event rate or the denominator degrees of freedom were small. The authors conclude that in studies with adequate denominator degrees of freedom, the researcher may use either method of analysis but should accept negative estimates of components of variance to avoid depression of error rates.

A Monte Carlo study of alternative responses to intraclass correlation in community trials. Is it ever possible to avoid Cornfield's penalties?

Strategies to avoid the penalties of extra variation and reduced degrees of freedom in community trials were compared in Monte Carlo simulations. Three conditions were found necessary to ensure nominal Type I and II error rates: (a) Condition variation must be assessed against assignment unit variation, (b) the critical value for the test statistic must be based on the assignment unit degrees of freedom, and (c) estimation of negative intraclass correlations must be allowed in the analysis. Using other test statistics and other degrees of freedom, and fixing negative intraclass correlations at zero often gave Type I and II error rates far from their nominal levels.

A method of recording condylar movements and joint sounds.

A commercial tracking system has been adapted within the University of Melbourne, which is designed to track the movement of infra-red light emitting diodes (LEDs). The movement of the diodes was recorded by photosensimetric recording devices, and sent to a data recorder, then to a differential amplifier, and the signal stored on magnetic tape, or viewed on a cathode ray oscilloscope, or plotted on a chart plotter or an X-Y plotter. The equipment was used to track the movement of LEDs, which were secured to a lower arch face bow, which was in turn secured to the teeth via a universal joint, and an acrylic clutch. A method was established in a preliminary study, enabling recording of condylar movements in the sagittal plane, and results were presented for four subjects. Subsequently, condylar movements and joint sounds were recorded concurrently for two of these four subjects.