Exploring the Discursive Emphasis on Patients and Coaches Who Participated in Technology-Assisted Diabetes Self-management Education: Clinical Implementation Study of Health360x.

BACKGROUND: A critical unmet need for underserved patients with diabetes is regular access to sufficient support for diabetes self-management. Although advances in digital technologies have made way for eHealth applications that provide a scalable path for tailored interventions for self-management of chronic conditions, health and digital literacy has remained an obstacle to leveraging these technologies for effective diabetes self-management education. Studies have shown that the availability of coaches helps to maintain engagement in internet-based studies and improves self-efficacy for behavior change. However, little is known about the substances involved in these interactions. OBJECTIVE: This study aims to compare the content of conversations between patient-coach pairs that achieved their self-management goals and those that did not. The context is a clinical implementation study of diabetes self-management behavior change using Health360x within the practices of the Morehouse Choice Accountable Care Organization in the Atlanta metro area. Health360x is a coach-assisted consumer health information technology designed to support self-management skills acquisition and behavior among underserved, high-risk patients with diabetes. METHODS: We provide a novel analysis of the discursive emphasis on patients and coaches. We examined transcripts of visits using a structural topic model to estimate topic content and prevalence as a function of patient and coach characteristics. We compared topics between patient-coach pairs that achieved diabetes-related self-management goals and those who did not. We also estimated a regression in which utterances are the units, the dependent variable is the proportion of an utterance that is about a given topic, and the independent variables are speaker types and explored other themes. RESULTS: Transcripts from 50 patients who were recruited and consented, starting in February 2015, were analyzed. A total of 44 topics were estimated for patient-coach pairs that achieved their intended health goals and 50 topics for those who did not. Analysis of the structural topic model results indicated that coaches in patient-coach pairs that were able to achieve self-management goals provided more contextual feedback and probed into patients' experience with technology and trust in consumer information technologies. We also found that discussions around problem areas and stress, support (ßCoach=.015; P<.001), initial visits (ßCoach=.02; P<.001), problems with technology (ßCoach=.01; P<.001), health eating goals (ßCoach=.01; P=.04), diabetes knowledge (ßCoach=.02; P<.001), managing blood sugar (ßCoach=.03; P<.001), and using Health360x (ßCoach=.003; P=.03) were dominated by coaches. CONCLUSIONS: Coach-facilitated, technology-based diabetes self-management education can help underserved patients with diabetes. Our use of topic modeling in this application sheds light on the actual dynamics in conversations between patients and coaches. Knowledge of the key elements for successful coach-patient interactions based on the analysis of transcripts could be applied to understanding everyday patient-provider encounters, given the recent paradigm shift around the use of telehealth.

The association between health care coverage and prevalence of cardiovascular diseases and diabetes over a 10-year period.

Persons without health care coverage have poorer health outcomes. We investigated the association between health care coverage and trends in the prevalence of cardiovascular disease (CVD) and diabetes pre- and post-Affordable Care Act (ACA) periods. Using data from 3,824,678 surveyed adults in the Behavioral Risk Factor Surveillance System survey from 2007 - 2016, we calculated the yearly prevalence of CVD and diabetes. Using logistic regression, we investigated the association between health care coverage and CVD and diabetes, controlling for sociodemographic factors (age, sex, race, marital status, education and income). The mean age of participants was 55.3 ± 18.9 years. Health care coverage increased from 88.6% in 2007 to 93% in 2016. The prevalence of CVD and diabetes increased from pre- to post-ACA periods. After adjustment, in pre-ACA period, the odds ratio (OR) for the association between health care coverage and CVD and diabetes was 1.32 (95% CI:1.30-1.34) and 1.44 (95% CI:1.41-1.46), respectively; in the post-ACA period, the OR was 1.26 (95% CI:1.22-1.30) and 1.48 (95% CI:1.44-1.52), respectively. We found a significant association between health care coverage and trends in the prevalence of CVD and diabetes in the pre- and post-ACA periods.

Racial Disparities in HPV-related Knowledge, Attitudes, and Beliefs Among African American and White Women in the USA.

The objective of this study was to assess the differences in HPV-related knowledge, attitudes, and beliefs among African American and non-Hispanic white women and to determine their communication preferences for cancer-related information. Data was obtained from the National Cancer Institute's (NCI) 2014 Health Interview National Trends Survey (HINTS), a cross-sectional survey of US adults 18 years of age or older. Descriptive statistics, bivariate, and multivariate logistic regression were used to identify differences in awareness and knowledge. Data was collected in 2014 and analyzed in 2016. HPV awareness (71 vs. 77%) and knowledge that HPV causes cervical cancer (64 vs. 81%) were significantly lower among blacks. Additionally, there were significant disparities in awareness of the HPV vaccine (66 vs. 79%), with only 25% of Black women indicating that they or a family member was recommended the HPV vaccine by a health care professional. There were also differences in cancer communication preferences. Blacks were more likely than Whites to trust cancer information from family (OR 2.7, confidence interval [CI] 0.725-10.048), television (OR 3.0, 95% [CI] 0.733-12.296), government health agencies (OR 5.8, [CI] 0.639-52.818), and religious organizations (OR 6.4, 95% [CI] 1.718-23.932). Study results indicate that racial/ethnic differences exist in HPV knowledge/awareness and cancer communication preferences. These results highlight the need to increase HPV prevention and education efforts using methods that are tailored to Black women. To address HPV/cervical cancer disparities, future interventions should utilize preferred communication outlets to effectively increase HPV knowledge and vaccine awareness.

DEMOCRATIZING DISCOVERY HEALTH WITH N=Me.

Health 360x is a mobile health application and social platform that integrates self-monitoring and decision support for preventive health. We studied 240 diabetic patients in primary care practices and a church community in metropolitan Atlanta. Health coaches were trained on the Health 360x curriculum, which was adapted from the American Association of Diabetes Educators. Participants worked with the health coaches to set goals for diabetes self-management. The intervention included weekly coaching for 12 weeks and online peer networking. Outcome variables included blood pressure, physical activity, and blood glucose that showed significant improvement at 12 weeks and 12 months compared to baseline. Focus group testing revealed that references for empowerment and engagement were associated with positive clinical outcomes. Barriers to adoption and use of the technology were inability to use the internet and concern about privacy and security of health data. Future efforts will integrate a multidisciplinary training dashboard with considerable attention to education on security features including data encryption and sign-on verification.

Health-related quality of life of African-American female breast cancer survivors, survivors of other cancers, and those without cancer.

PURPOSE: The purpose of this study was to compare differences in health-related quality of life (HRQOL) between African-American female breast cancer survivors, African-American female survivors of other cancers, and African-American women with no history of cancer. METHODS: Using data from the 2010 National Health Interview Survey (NHIS), the HRQOL of African-American women aged 35 years or older was compared by cancer status. Physical and mental health items from the Patient-Reported Outcomes Measurement Information System (PROMIS) global health scale were used to assess differences in HRQOL. RESULTS: For summary physical and mental health measures, no significant differences were found between breast cancer survivors and women with no history of cancer; survivors of other cancers reported poorer physical and mental health than did women with no history of cancer. Similar differences were found at the item level. When we examined the two African-American female cancer survivor groups, we found that cancer survivors whose cancer was being treated reported substantially poorer physical health and mental health than did those whose cancer was not being treated. Survivors who had private insurance and were cancer free reported better physical and mental health than did those who did not have private insurance and those who were not cancer free. Breast cancer survivors reported slightly better physical and mental health than did survivors of other cancers. CONCLUSIONS: Our findings highlight the need for public health agencies to adopt practices to improve the mental and physical health of African-American female survivors of cancer.

Persons Who Failed to Obtain Colorectal Cancer Screening Despite Participation in an Evidence-Based Intervention.

In a previous report, we demonstrated the efficacy of an educational intervention focused on increasing colorectal cancer screening rates among African Americans. Despite participating in the intervention, however, nearly two-thirds of participants did not seek and receive screening. Participants were African-Americans over age 49 (N = 257) who had not been screened for colorectal cancer according to guidelines. At baseline, participants completed tests measuring fatalism, perceived stress, self-esteem, attitudes/benefits/barriers, social support, and social network diversity. Those who completed the educational intervention were followed up by telephone to learn if they had been screened. We compared the scores on the psychometric tests of the participants who had been screened against the scores of those who had not. Only the mean scores on the attitudes, benefits, and barriers scale distinguished participants who had been screened from those who had not (p = 0.0816 on bivariate testing and p = 0.0276 in the logistic regression model). Social interaction among participants or social cognitive learning may have played a role in determining which participants were screened, but we were not able to demonstrate this. The major factor distinguishing participants who were not screened was their attitude toward screening at baseline. There is a subset of African Americans who are persistently resistant to screening, and their perspective in this regard must be addressed if colorectal cancer disparities are to be reduced.

An Examination of Perceptions in Integrated Care Practice.

Successful integration of behavioral health and primary care services is informed by perceptions of its usefulness to the consumer. An examination of provider, staff and patient perceptions was conducted across five integrated care sites in order to describe and examine perceptions and level of satisfaction with integrated care. A quantitative study was conducted with data collected through surveys administered to 51 patients, 27 support staff, and 11 providers in integrated care settings. Survey responses revealed high levels of satisfaction with integration of primary and behavioral health services. Integrated care can be enhanced by addressing provider competency and confidence concerns through continued education, increased collaboration and utilization of diagnostic tools. This analysis provides evidence to support that successful integration increases access to mental healthcare, which is instrumental in reduction of the mental health treatment gap by scaling up services for mental and substance use disorders among individuals with chronic medical conditions.

Effects of social determinants on the health outcomes and academic success of international college students in Georgia, United States.

Objective: Although there are many international college students in the state of Georgia, few studies have been conducted on how social determinants affect their health outcomes and academic success. This study examined the effects of social determinants on the health outcomes and academic success of international college students in Georgia. Participants: Participants were international college students (n = 136) in Georgia. Methods: A mixed methods cross-sectional design was used for the study. Results: The lack of access to sufficient funds caused study participants to experience anxiety (39.0%), depression (20.6%), and stress (52.9%). Cultural differences (16.9%), lack of access to health care (15.4%), transportation (14.7%), poor housing (7.4%), and financial insecurity (54.5%) affected study participant health outcomes and academic success. Conclusion: Addressing financial insecurity, the lack of access to health care, poor housing, transportation issues, and cultural differences experienced by international college students in Georgia, is crucial to their health outcomes and academic success.

Evaluating the availability and quality of services for lymphatic filariasis morbidity in Ghana.

BACKGROUND AND METHODOLOGY: In districts where lymphatic filariasis (LF) is endemic, the goal is to provide 100% geographical coverage of the essential package of care. Additionally, countries seeking elimination status must document the availability of services for lymphoedema and hydrocele in all endemic areas. To do this, the WHO recommends conducting assessments of the readiness and quality of services provided to identify service delivery and quality gaps. This study used the recommended WHO Direct Inspection Protocol (DIP), which consists of 14 core indicators related to LF case management, medicine and commodities, staff knowledge and patient tracking. The survey was administered in 156 health facilities across Ghana designated and trained to provide LF morbidity management services. Patient and health provider interviews were also conducted to assess challenges and feedback. PRINCIPAL FINDINGS: The highest performing indicators across the 156 surveyed facilities were related to staff knowledge; 96.6% of health workers correctly identified two or more signs and symptoms. The lowest scoring indicators concerned medication availability, with the two lowest scoring indicators in the survey being availability of antifungals (26.28%) and antiseptics (31.41%). Hospitals performed best with an overall score of 79.9%, followed by health centers (73%), clinics (67.1%) and CHPS compounds (66.8%). The most commonly reported challenge from health worker interviews was lack of medications and supplies, followed by a lack of training or poor motivation. CONCLUSIONS AND SIGNIFICANCE: The findings from this study can help the Ghana NTD Program identify areas of improvement as they seek to achieve LF elimination targets and continue to improve access to care for those with LF-related morbidity as part of overall health systems strengthening. Key recommendations include prioritizing refresher and MMDP training for health workers, ensuring reliable patient tracking systems, and integrating lymphatic filariasis morbidity management into the routine healthcare system to ensure medicine and commodity availably.

HIV destigmatization: perspectives of people living with HIV in the Kumasi Metropolis in Ghana.

Background: Human immunodeficiency virus (HIV)-related stigma has been identified as one of the principal factors that undermines HIV prevention efforts and the quality of life of people living with HIV (PLWH) in many developing countries including Ghana. While studies have been conducted on HIV-related stigma reduction, very few have sought the views of PLWH on how this might be done. The purpose of the study was to (i) identify factors that cause HIV-related stigma in Ghana from the perspective of PLWH, (ii) identify challenges that HIV-related stigma poses to the treatment and care of PLWH, and (iii) to obtain recommendations from PLWH on what they think various groups (community members, health care providers, and adolescents) including themselves should do to help reduce HIV-related stigma in Ghana. Methods: A mixed methods cross-sectional study design was used to collect data from 404 PLWH at the Suntreso Government Hospital in the Kumasi Metropolis of Ghana across six domains using Qualtrics from November 1-30, 2022. Quantitative data was analyzed using the Statistical Package for Social Sciences (SPSS) version 26 and the Statistical Analysis System (SAS) version 9.4. Qualitative data was analyzed using a thematic approach. Results: Most of the study participants (70.5%) said HIV-related stigma in Ghana is due to ignorance. Of this population, 90.6% indicated that they had experienced stigma because they have HIV, causing them to feel depressed (2.5%), ashamed (2.2%), and hurt (3.0%). Study participants (92.8%) indicated that the challenges associated with HIV-related stigma has affected their treatment and care-seeking behaviors. Recommendations provided by study participants for HIV destigmatization include the need for PLWH not to disclose their status (cited 94 times), community members to educate themselves about HIV (96.5%), health care providers to identify their stigmatizing behaviors (95.3%), health care providers to avoid discriminating against PLWH (96.0%), and the need for adolescents to be educated on HIV and how it is transmitted (97.0%). Conclusion: It is important for the government and HIV prevention agencies in Ghana to target and address co-occurring HIV-related stigma sources at various levels of intersection simultaneously This will help to shift harmful attitudes and behaviors that compromise the health and wellbeing of PLWH effectively.

Colorectal Cancer Knowledge and Screening Change in African Americans: Implementation Phase Results of the EPICS Cluster RCT.

Introduction: African Americans are disproportionately affected by mortality risk for colorectal cancer. This study aimed to determine the most effective educational approach of 4 study arms that enhances the likelihood of pursuing subsequent colorectal cancer screening, and to identify the associated factors. Methods: Age-eligible adults (N=2,877) were recruited to participate in a cluster randomized control dissemination and intervention implementation trial titled Educational Program to Increase Colorectal Cancer Screening. The project began in May 2012 and ended in March 2017 (the implementation phase lasted 36 months). Educational sessions were conducted through 16 community coalitions that were randomized into 1 of 4 conditions: website access (to facilitator training materials and toolkits) without technical assistance, website access with technical assistance, in-person training (provided by research staff and website access) without technical assistance, and in-person training with technical assistance. A follow-up to determine participant CRC screening was conducted 3 months later. Results: Compared with the website access with technical assistance intervention group, 2 groups, in-person training with technical assistance and without technical assistance, indicated significantly higher odds for obtaining colorectal cancer screening (OR=1.31; 95% CI=1.04, 1.64; p=0.02 and OR=1.35; 95% CI=1.07, 1.71; p=0.01, respectively). Though sociodemographic factors were not significantly associated with pursuing subsequent colorectal cancer screening, the postintervention cancer knowledge increased significantly among the study participants. Conclusions: The importance of in-person interactions, local coalitions, and community contexts may play a key role for successfully increasing colorectal cancer screening rates among African Americans as reflected through this study. The integration of telehealth and use of other virtual technologies to engage the public in research have increased since the COVID-19 pandemic and should be assessed to determine their impact on the degree to which in-person interventions are significantly more effective when compared with solely web-assisted ones. Trial registration: The study is registered at www.clinicaltrials.gov NCT01805622.

Implicit Racial Bias, Health Care Provider Attitudes, and Perceptions of Health Care Quality Among African American College Students in Georgia, USA.

OBJECTIVE: Due to racism, over 20% of African Americans, including college students in Georgia, receive poor quality health care. Consequently, most students are reluctant to utilize health care services in the state. This study examined biased racial attitudes of health care providers in Georgia, and African American Georgia State University (GSU) School of Public Health (SPH) students' perceptions of the quality of health care they receive from providers, the effects of such care, and student recommendations for the way forward. DESIGN: A mixed-methods cross-sectional design was used to collect data from 63 students across six domains using Qualtrics. RESULTS: Provider brushes off patient concerns when providing medical care (29.9%), stereotyping (26.9%), and the lack of communication during medical care (25.4%) were the three main implicit racial attitudes identified by GSU SPH students. Owing to the poor quality of care they receive from their health care providers, some students (28.4%) are reluctant to utilize health care services, distrust doctors that are not from their race (34.3%), do not adhere to treatment (19.4%), and prefer to use home remedies (28.4%) when ill. Students recommended cultural competency training, holding health care providers accountable for their actions, and increasing African American health care providers in Georgia as ways to address health care provider attitudes and quality of care. CONCLUSION: Negative provider attitudes impact the health and health-seeking behavior of African American college students in Georgia. These attitudes must be eliminated so barriers to clinical participation are removed, and student health outcomes optimized.

Impact of COVID-19 on the Research Career Advancement of Health Equity Scholars from Diverse Backgrounds.

The COVID-19 pandemic has significantly taxed scientific research and seems to have exacerbated existing inequities within the research field, particularly for early-stage investigators (ESIs). This study examines the effects of the COVID-19 pandemic on traditionally underrepresented ESIs enrolled in an NIH-supported study evaluating the effectiveness of developmental networks, grant writing coaching, and mentoring on research career advancement. The survey consisted of 24 closed-ended (quantitative) and 4 open-ended questions (qualitative) linked to a participant's ability to meet grant submission deadlines, research and professional development disruptions, stress level, career transition level, self-efficacy and management of scholarly tasks, and familial responsibilities. Results from 32 respondents (53%) suggest that COVID-19 adversely impacted the continuity of research (81%) and grant submissions (63%). On average, grant submissions were delayed by 6.69 months (i.e., greater than one grant cycle). We also conducted additional analyses characterizing nonresponse and found that there were no significant predictors of nonresponse, indicating a limited threat to the validity of our findings. The disruption caused by COVID-19 to the careers of ESIs from underrepresented groups in the biomedical workforce has been profound in the short term. The long-term consequences to the future success of these groups are unknown but is a worthwhile area of research and potential innovation.

From the Lab to People's Home: Lessons from Accessing Blind Participants' Interactions via Smart Glasses in Remote Studies.

Researchers have adopted remote methods, such as online surveys and video conferencing, to overcome challenges in conducting in-person usability testing, such as participation, user representation, and safety. However, remote user evaluation on hardware testbeds is limited, especially for blind participants, as such methods restrict access to observations of user interactions. We employ smart glasses in usability testing with blind people and share our lessons from a case study conducted in blind participants' homes (N = 12), where the experimenter can access participants' activities via dual video conferencing: a third-person view via a laptop camera and a first-person view via smart glasses worn by the participant. We show that smart glasses hold potential for observing participants' interactions with smartphone testbeds remotely; on average 58.7% of the interactions were fully captured via the first-person view compared to 3.7% via the third-person. However, this gain is not uniform across participants as it is susceptible to head movements orienting the ear towards a sound source, which highlights the need for a more inclusive camera form factor. We also share our lessons learned when it comes to dealing with lack of screen reader support in smart glasses, a rapidly draining battery, and Internet connectivity in remote studies with blind participants.

Blind Users Accessing Their Training Images in Teachable Object Recognizers.

Teachable object recognizers provide a solution for a very practical need for blind people - instance level object recognition. They assume one can visually inspect the photos they provide for training, a critical and inaccessible step for those who are blind. In this work, we engineer data descriptors that address this challenge. They indicate in real time whether the object in the photo is cropped or too small, a hand is included, the photos is blurred, and how much photos vary from each other. Our descriptors are built into open source testbed iOS app, called MYCam. In a remote user study in (N = 12) blind participants' homes, we show how descriptors, even when error-prone, support experimentation and have a positive impact in the quality of training set that can translate to model performance though this gain is not uniform. Participants found the app simple to use indicating that they could effectively train it and that the descriptors were useful. However, many found the training being tedious, opening discussions around the need for balance between information, time, and cognitive load.

Preparing Students for the Public Health Workforce: The Role of Effective High-Impact Educational Practices in Undergraduate Public Health Program Curricula.

There are several institutions of higher learning in the United States that award degrees in public health to undergraduate students. While these institutions serve as potential pipelines for the public health workforce, it is unclear if the curricula and training students receive from these institutions, really prepare them for the public health workforce or higher education. The questions sometimes asked are whether the programs offered by these institutions exist to provide students with a good understanding of public health issues so they can become good citizens for building a responsible society, or if it is to prepare students for graduate school. Regardless of what the goals are, students in undergraduate public health programs need to be exposed to curricula that adequately prepare them to enter well-defined careers in public health. Thus, institutions of higher learning offering degrees in public health to undergraduate students need to understand the market, assess, and understand the needs of public health agencies, and tailor course curricula to match those needs. Georgia State University established its undergraduate public health program in 2016. Since then, over 200 students have graduated from the program. The purpose of the study was to assess student perception of the role of high impact educational practices such as study abroad, signature experience, and undergraduate research curricula in preparing them for careers in public health.

Characterising spatial patterns of neglected tropical disease transmission using integrated sero-surveillance in Northern Ghana.

BACKGROUND: As prevalence decreases in pre-elimination settings, identifying the spatial distribution of remaining infections to target control measures becomes increasingly challenging. By measuring multiple antibody responses indicative of past exposure to different pathogens, integrated serological surveys enable simultaneous characterisation of residual transmission of multiple pathogens. METHODOLOGY/PRINCIPAL FINDINGS: Here, we combine integrated serological surveys with geostatistical modelling and remote sensing-derived environmental data to estimate the spatial distribution of exposure to multiple diseases in children in Northern Ghana. The study utilised the trachoma surveillance survey platform (cross-sectional two-stage cluster-sampled surveys) to collect information on additional identified diseases at different stages of elimination with minimal additional cost. Geostatistical modelling of serological data allowed identification of areas with high probabilities of recent exposure to diseases of interest, including areas previously unknown to control programmes. We additionally demonstrate how serological surveys can be used to identify areas with exposure to multiple diseases and to prioritise areas with high uncertainty for future surveys. Modelled estimates of cluster-level prevalence were strongly correlated with more operationally feasible metrics of antibody responses. CONCLUSIONS/SIGNIFICANCE: This study demonstrates the potential of integrated serological surveillance to characterise spatial distributions of exposure to multiple pathogens in low transmission and elimination settings when the probability of detecting infections is low.

The law of non-usage attrition in a technology-based behavioral intervention for black adults with poor cardiovascular health.

Digital health innovations, such as telehealth and remote monitoring, have shown promise in addressing patient barriers to accessing evidence-based programs and providing a scalable path for tailored behavioral interventions that support self-management skills, knowledge acquisition and promotion of relevant behavioral change. However, significant attrition continues to plague internet-based studies, a result we believe can be attributed to characteristics of the intervention, or individual user characteristics. In this paper, we provide the first analysis of determinants of non usage attrition in a randomized control trial of a technology-based intervention for improving self-management behaviors among Black adults who face increased cardiovascular risk factors. We introduce a different way to measure nonusage attrition that considers usage over a specific period of time and estimate a cox proportional hazards model of the impact of intervention factors and participant demographics on the risk of a nonusage event. Our results indicated that not having a coach (compared to having a coach) decreases the risk of becoming an inactive user by 36% (HR = .63, P = 0.04). We also found that several demographic factors can influence Non-usage attrition: The risk of nonusage attrition amongst those who completed some college or technical school (HR = 2.91, P = 0.04) or graduated college (HR = 2.98, P = 0.047) is significantly higher when compared to participants who did not graduate high school. Finally, we found that the risk of nonsage attrition among participants with poor cardiovascular from "at-risk" neighborhoods with higher morbidity and mortality rates related to CVD is significantly higher when compared to participants from "resilient" neighborhoods (HR = 1.99, P = 0.03). Our results underscore the importance of understanding challenges to the use of mhealth technologies for cardiovascular health in underserved communities. Addressing these unique barriers is essential, because a lack of diffusion of digital health innovations exacerbates health disparities.

Risk factors for acute non-ST-segment elevation myocardial infarction in a population sample of predominantly African American patients with chest pain and normal coronary arteries.

BACKGROUND: We sought to investigate the relationship between echocardiographic left ventricular hypertrophy (LVH) and acute non-ST-elevation segment myocardial infarction (NSTE-MI) in patients with chest pain and angiographically normal coronary arteries. METHODS: Retrospective analysis of patients admitted for acute chest pain in a large urban hospital serving predominantly African American patients. RESULTS: 131 (of 700) patients had normal coronary arteries or only minimal luminal irregularities (ie, <10% luminal narrowing) on cardiac angiography and available cardiac biomarker data to define the presence or absence of MI. Mean age was 53 +/- 10 years, 76% were African Americans, 88% had a history of hypertension (49% uncontrolled) and 74% had LVH by echocardiography. Of these 131 patients, 22 (17%) had an acute NSTE-MI by creatine kinase MB criteria. The mean systolic blood pressure (BP) was significantly higher in patients with NSTE-MI compared with non-NSTE-MI group (156 +/- 30 vs 143 +/- 25 mm Hg, P=.04). Patients with NSTE-MI were more likely to have LVH (95% vs 70%, P=.03). NSTE-MI was present in 22% of patients with LVH compared with 3% without LVH (P=.02). The in-hospital course of NSTE-MI patients with LVH was not benign: 19% had persistent angina and positive stress thallium suggestive of recurrent myocardial ischemia and 48% had congestive heart failure. The results of multivariable model after adjusting for selected variables revealed that these two preexisting conditions were independently associated with NSTE-MI: LVH (OR=4.0, CI 1.06-10.05) and elevated systolic BP (OR=3.7, CI 1.01-10.64). CONCLUSION: These findings provide preliminary evidence that LVH and uncontrolled hypertension predispose to NSTE-MI in this patient group.

Surveillance for peri-elimination trachoma recrudescence: Exploratory studies in Ghana.

INTRODUCTION: To date, eleven countries have been validated as having eliminated trachoma as a public health problem, including Ghana in 2018. Surveillance for recrudescence is needed both pre- and post-validation but evidence-based guidance on appropriate strategies is lacking. We explored two potential surveillance strategies in Ghana. METHODOLOGY/PRINCIPAL FINDINGS: Amongst randomly-selected communities enrolled in pre-validation on-going surveillance between 2011 and 2015, eight were identified as having had trachomatous-inflammation follicular (TF) prevalence ≥5% in children aged 1-9 years between 2012 and 2014. These eight were re-visited in 2015 and 2016 and neighbouring communities were also added ("TF trigger" investigations). Resident children aged 1-9 years were then examined for trachoma and had a conjunctival swab to test for Chlamydia trachomatis (Ct) and a dried blood spot (DBS) taken to test for anti-Pgp3 antibodies. These investigations identified at least one community with evidence of probable recent Ct ocular transmission. However, the approach likely lacks sufficient spatio-temporal power to be reliable. A post-validation surveillance strategy was also evaluated, this reviewed the ocular Ct infection and anti-Pgp3 seroprevalence data from the TF trigger investigations and from the pre-validation surveillance surveys in 2015 and 2016. Three communities identified as having ocular Ct infection >0% and anti-Pgp3 seroprevalence ≥15.0% were identified, and along with three linked communities, were followed-up as part of the surveillance strategy. An additional three communities with a seroprevalence ≥25.0% but no Ct infection were also followed up ("antibody and infection trigger" investigations). DBS were taken from all residents aged ≥1 year and ocular swabs from all children aged 1-9 years. There was evidence of transmission in the group of communities visited in one district (Zabzugu-Tatale). There was no or little evidence of continued transmission in other districts, suggesting previous infection identified was transient or potentially not true ocular Ct infection. CONCLUSIONS/SIGNIFICANCE: There is evidence of heterogeneity in Ct transmission dynamics in northern Ghana, even 10 years after wide-scale MDA has stopped. There is added value in monitoring Ct infection and anti-Ct antibodies, using these indicators to interrogate past or present surveillance strategies. This can result in a deeper understanding of transmission dynamics and inform new post-validation surveillance strategies. Opportunities should be explored for integrating PCR and serological-based markers into surveys conducted in trachoma elimination settings.