Aspirin use predicts prolonged survival in patients with oropharyngeal cancer: Nationwide Veterans Affairs database study.

BACKGROUND: Single-institution studies suggest that aspirin reduces the risk of death in head and neck cancer. The aim of this study was to investigate the effect of aspirin use on overall survival (OS) in veterans with oropharyngeal cancer (OPC). METHODS: A total of 23 083 veterans with OPC were identified between 2005 and 2018 from the Veterans Health Administration Corporate Data Warehouse. Records were queried for clinical-demographic data, aspirin prescriptions, and outcomes. Three-year OS was estimated. A Cox model was used to estimate hazard ratios (HR) for aspirin use. RESULTS: Among the 23 083 identified veterans, 17 206 veterans met inclusion criteria. 21.8% used aspirin. Three-year OS was prolonged for aspirin users (66%) compared to nonaspirin users (54%; P < .001). Adjusted HR for death for nonaspirin users was 1.75 (95% confidence interval (CI) [1.60-1.91]). The average treatment effect of aspirin on survival using inverse probability weighting was 10% (95% CI [0.08-0.11]). CONCLUSION: Aspirin use following OPC diagnosis was independently associated with improved 3-year OS among veterans nationwide.

Incidence and clearance of penile human papillomavirus infection among circumcised Kenyan men.

Prospective data are limited on human papillomavirus (HPV) acquisition and clearance among circumcised men from resource-limited geographical regions, particularly Africa. The goal of this study was to estimate incidence and clearance of type-specific genital HPV infection in men. Penile exfoliated cell specimens were collected from the glans/coronal sulcus and shaft of 1,037 circumcised Kenyan men at baseline and 6-, 12- and 18-month follow-up visits between 2003-2007. Specimens were tested with GP5+/6+ PCR to detect 44 HPV types. The median age of participants at baseline was 21 years (range 18-28). The 12- and 18-month incidence rates (IRs) for any HPV were 34.9/100 person-years (95% confidence interval [CI]: 31.2-39.0) and 36.4/100 person-years (95% CI: 32.9-40.2), respectively. The 18-month cumulative risk for high-risk HPV was 30% compared to 16% for low-risk HPV. Cumulative risk was not associated with age or anatomical site. The estimated probability of any HPV infection clearing by 12 months was 0.92. Time until HPV clearance was not associated with age, anatomical site, or whether HPV infection type was high-risk or low-risk. HPV IRs among circumcised men in this study were comparable to other circumcised populations.

Association Between Antipsychotics and All-Cause Mortality Among Community-Dwelling Older Adults.

BACKGROUND: Antipsychotics are prescribed to treat various symptoms in older adults, however, their safety in this context has not been fully evaluated. The objective was to evaluate mortality risks associated with off-label use of antipsychotics among older adults with no preexisting mental illness or dementia relative to those with diagnosis of dementia. METHODS: Data (2007-2015) were derived from Department of Veterans Affairs registries for 730,226 patients (≥65 years) with no baseline serious mental illness, dementia). We estimated the cumulative incidence of antipsychotics prescription and 10-year all-cause mortality. The extended Cox models were used to estimate Hazard Ratios (HRs) associated with antipsychotics prescription, adjusted for time-varying covariates, dementia diagnosis, comorbidity index score, and age at time of first exposure to antipsychotics. RESULTS: The study included 98% males, 13% African Americans, and 81% Caucasian. Patients with dementia and antipsychotics had the highest risk of mortality (78.0%), followed by (73.0%) for patients with dementia alone and compared with patients without dementia or antipsychotics exposure who had the lowest mortality risk (42.0%). Exposure to typical antipsychotics was associated with (HR: 2.1, confidence interval [CI] 2.0-2.2) compared with atypical antipsychotics (HR: 1.5, CI 1.4-1.5, p = <.0001). CONCLUSION: In a large cohort of older adults, antipsychotics were associated with an increased risk of all-cause mortality. While significant increase in mortality was attributable to the diagnosis of dementia, the addition of antipsychotics resulted in added mortality risk among all patients. Antipsychotic medications should be used cautiously in all older adults, not only those with dementia.

Impact of Hospice and Palliative Care Service Utilization on All-Cause 30-Day Readmission Rate for Older Adults Hospitalized with Heart Failure.

BACKGROUND: Acute decompensated heart failure (HF) is the leading cause for hospital readmission. Large-scale sustainable interventions to reduce readmission rate have not been fully explored or proven effective. OBJECTIVE: We studied the impact of hospice and palliative care service utilization on 30-day all-cause hospital readmissions for patients with HF. METHODS AND RESULTS: Data were retrieved from the Department of Veterans Affairs Corporate Data Warehouse. The study included 238 116 HF admissions with primary diagnosis of HF belonging to 130 812 patients. Among these patients, 2592 had hospice and palliative care utilizations and 68 245 patients did not. Rehospitalization was calculated within 30 days of index hospitalization. Propensity scores were used to match hospice and nonhospice patients on demographics, Charlson comorbidity categories, and 30-day survival. In the matched group, logistic regression was used to estimate effects of hospice on readmission, controlling for any covariates that had failed to balance. The average age of the matched patients was 74 years old, 14% were African American, 75% Caucasian, 2% Asian, and 17% female. After propensity matching, the odds ratio for readmission was 1.29. The 95% confidence interval for the odds was 1.13 to 1.48, suggesting that veterans receiving services have a higher chance of readmission. CONCLUSION: In a large cohort study of older US Veterans, utilization of hospice and palliative care services was associated with a higher 30-day all-cause readmission rate among hospitalized patients with HF. Further prospective studies should be conducted to confirm results and test generalizability outside the Veterans Affairs system of care.

Association between lifetime risk of atrial fibrillation and mortality in the oldest old.

BACKGROUND: Age is the strongest predictor of atrial fibrillation (AF), yet little is known about AF incidence in the oldest old. HYPOTHESIS: AF incidence declines after age 90 years, and morbidity is compressed into a brief period at the end of life. METHODS: In this retrospective, longitudinal cohort study of patients (born 1905-1935), we examined cumulative lifetime incidence of AF and its impact on mortality. Data included records from 1 062 610 octogenarians, 317 161 nonagenarians, and 3572 centenarians. Kaplan-Meier curves were used to estimate cumulative incidence of AF by age group, incidence rates were compared using log-rank tests, and Cox proportional hazards model was used to estimate unadjusted hazard ratios. The primary outcome was AF incidence at age > 80 years; the secondary outcome was mortality. RESULTS: The cumulative AF incidence rate was 5.0% in octogenarians, 5.4% in nonagenarians, and 2.3% in centenarians. Octogenarians and nonagenarians had a higher risk of AF incidence compared to centenarians (adjusted hazard ratio 8.74, 95% confidence interval [CI]: 6.31-12.04; and 2.98, 95% CI: 2.17-4.1, respectively). The lowest hazard ratio for mortality in patients with AF compared to those without was 2.3 (95% CI: 2.3-2.4) in patients who were on antiplatelet and anticoagulant medication and had a score of 0 on the Elixhauser comorbidity index score. CONCLUSIONS: Although AF incidence increased with age, being a centenarian was associated with reduced incidence and compression of morbidity. Patients with AF had a higher adjusted mortality rate. However, data suggest that a regimen of anticoagulants and antiplatelets may reduce risk of mortality in patients over 80 with an AF diagnosis.

Characteristics and Incidence of Chronic Illness in Community-Dwelling Predominantly Male U.S. Veteran Centenarians.

OBJECTIVES: To assess the incidence of chronic illness and its effect on veteran centenarians. DESIGN: Retrospective longitudinal cohort study. SETTING: United States Veterans Affairs Corporate Data Warehouse (CDW). PARTICIPANTS: Community-dwelling veterans born between 1910 and 1915 who survived to at least age 80 (N = 86,892; 31,121 octogenarians, 52,420 nonagenarians, 3,351 centenarians). MEASUREMENTS: The Kaplan-Meier method was used to estimate cumulative incidence of chronic conditions according to age group. Incidence rates were compared using the log-rank test. Cox proportional hazards models were used to estimate unadjusted hazard ratios. RESULTS: Ninety-seven percent of Centenarians were male, 88.0% were white, 31.8% were widowed, 87.5% served in World War II, and 63.9% did not have a service-related disability. The incidence rates of chronic illnesses were higher in octogenarians than centenarians (atrial fibrillation, 15.0% vs 0.6%, P < .001; heart failure, 19.3% vs 0.4%, P < .001; chronic obstructive pulmonary disease, 17.9% vs 0.6%, P < .001; hypertension, 29.6% vs 3.0%, P < .001; end-stage renal disease, 7.2% vs 0.1%, P < .001; malignancy, 14.1% vs 0.6%, P < .001; diabetes mellitus, 11.1% vs 0.4%, P < .001; stroke, 4.6% vs 0.4%, P < .001) and in nonagenarians than centenarians (atrial fibrillation, 13.2% vs 3.5%, P < .001; heart failure, 15.8% vs 3.3%, P < .001; chronic obstructive pulmonary disease, 11.8% vs 3.5%, P < .001; hypertension, 27.2% vs 12.8%, P < .001; end-stage renal disease, 11.9% vs 4.5%, P < .001; malignancy, 8.6% vs 2.3%, P < .001; diabetes mellitus, 7.5% vs 2.2%, P < .001; and stroke, 3.5% vs 1.3%, P < .001). CONCLUSION: In a large cohort of predominantly male community-dwelling elderly veterans, centenarians had a lower incidence of chronic illness than those in their 80s and 90s, demonstrating similar compression of morbidity and extension of health span observed in other studies.

Frequent nevirapine resistance in infants infected by HIV-1 via breastfeeding while on nevirapine prophylaxis.

OBJECTIVE: The objective of this study is to assess nevirapine (NVP) resistance in infants who became infected in the three arms of the Breastfeeding, Antiretrovirals and Nutrition (BAN) study: daily infant NVP prophylaxis, triple maternal antiretrovirals or no extra intervention for 28 weeks of breastfeeding. DESIGN: A prospective cohort study. METHODS: The latest available plasma or dried blood spot specimen was tested from infants who became HIV-positive between 3 and 48 weeks of age. Population sequencing was used to detect mutations associated with reverse transcriptase inhibitor resistance. Sequences were obtained from 22 out of 25 transmissions in the infant-NVP arm, 23 out of 30 transmissions in the maternal-antiretroviral arm and 33 out of 38 transmissions in the control arm. RESULTS: HIV-infected infants in the infant-NVP arm were significantly more likely to have NVP resistance than infected infants in the other two arms of the trial, especially during breastfeeding through 28 weeks of age (56% in infant-NVP arm vs. 6% in maternal-antiretroviral arm and 11% in control arm, P»0.004). There was a nonsignificant trend, suggesting that infants with NVP resistance tended to be infected earlier and exposed to NVP while infected for a greater duration than infants without resistance. CONCLUSION: Infants on NVP prophylaxis during breastfeeding are at a reduced risk of acquiring HIV, but are at an increased risk of NVP resistance if they do become infected. These findings point to the need for frequent HIV testing of infants while on NVP prophylaxis, and for the availability of antiretroviral regimens excluding NVP for treating infants who become infected while on such a prophylactic regimen.

Plasma and breast-milk selenium in HIV-infected Malawian mothers are positively associated with infant selenium status but are not associated with maternal supplementation: results of the Breastfeeding, Antiretrovirals, and Nutrition study.

BACKGROUND: Selenium is found in soils and is essential for human antioxidant defense and immune function. In Malawi, low soil selenium and dietary intakes coupled with low plasma selenium concentrations in HIV infection could have negative consequences for the health of HIV-infected mothers and their exclusively breastfed infants. OBJECTIVE: We tested the effects of lipid-based nutrient supplements (LNS) that contained 1.3 times the Recommended Dietary Allowance of sodium selenite and antiretroviral drugs (ARV) on maternal plasma and breast-milk selenium concentrations. DESIGN: HIV-infected Malawian mothers in the Breastfeeding, Antiretrovirals, and Nutrition study were randomly assigned at delivery to receive: LNS, ARV, LNS and ARV, or a control. In a subsample of 526 mothers and their uninfected infants, we measured plasma and breast-milk selenium concentrations at 2 or 6 (depending on the availability of infant samples) and 24 wk postpartum. RESULTS: Overall, mean (± SD) maternal (range: 81.2 ± 20.4 to 86.2 ± 19.9 µg/L) and infant (55.6 ± 16.3 to 61.0 ± 15.4 µg/L) plasma selenium concentrations increased, whereas breast-milk selenium concentrations declined (14.3 ± 11.5 to 9.8 ± 7.3 µg/L) from 2 or 6 to 24 wk postpartum (all P < 0.001). Compared with the highest baseline selenium tertile, low and middle tertiles were positively associated with a change in maternal plasma or breast-milk selenium from 2 or 6 to 24 wk postpartum (both P < 0.001). With the use of linear regression, we showed that LNS that contained selenium and ARV were not associated with changes in maternal plasma and breast-milk selenium, but maternal selenium concentrations were positively associated with infant plasma selenium at 2 or 6 and 24 wk postpartum (P < 0.001) regardless of the study arm. CONCLUSIONS: Selenite supplementation of HIV-infected Malawian women was not associated with a change in their plasma or breast-milk selenium concentrations. Future research should examine effects of more readily incorporated forms of selenium (ie, selenomethionine) in HIV-infected breastfeeding women.

Synergy to reduce emergency department visits for uncontrolled hyperglycemia.

PURPOSE: The purpose of this pilot study was to evaluate the safety and preliminary efficacy of a treatment algorithm and education intervention for the management of patients with type 2 diabetes and hyperglycemia presenting to the emergency department (ED) and stable enough to be discharged home. METHODS: Urban hospital ED patients (n = 86) with BG ≥ 200 mg/dL were enrolled in a 4-week prospective, nonrandomized pilot intervention with historic self-controls. Follow-up visits occurred at 12 to 72 hours, 2 and 4 weeks, and 6 months. T2DM medications were initiated or adjusted at each visit using a guideline-based diabetes medication management algorithm. Survival skills diabetes self-management education and navigation to outpatient services were provided. RESULTS: Participants were 51.8% male and 92% black, and 87.3% had private or public insurance. The top reasons for presenting to the ED were no provider appointment available (41.7%) and no primary care provider (14.6%). No hypoglycemia occurred in the first 24 hours following ED T2DM medication initiation or titration and overall hypoglycemia rates were low. BG was reduced from 356 ± 110 mg/dL at baseline to 183 ± 103 mg/dL at 4 weeks (P < .001). CONCLUSION: Diabetes medication management and survival skills education for uncontrolled diabetes may be safely initiated in the ED, as demonstrated by the multidisciplinary STEP-DC intervention, which effectively enabled glycemic control in this pilot study.

Recruitment of black subjects for a natural history study of intracerebral hemorrhage.

Historically, recruitment of minority subjects for clinical research has been challenging. We developed culturally-tailored recruitment materials for a longitudinal, natural history study of intracerebral hemorrhage (ICH) and trained recruiting coordinators in cultural competence. Of 285 subjects meeting inclusion criteria, 158 (55% of those eligible) agreed to participate (60% of eligible Blacks vs. 45% of eligible non-Blacks, p..02). Of those enrolled, 138 (87%) agreed to participate in the genetic sub-study (86% of Blacks vs. 90% of non-Blacks enrolled, p..78). Of those subjects who refused enrollment, lack of interest in research (42%) was the most common reason given for the study as a whole. A higher rate of enrollment was achieved in Blacks vs. non-Blacks in this ICH clinical research study employing culturally tailored recruitment approaches and training of recruitment coordinators to overcome traditional recruitment barriers to research participation in minority patients.

Preventing recurrence of thromboembolic events through coordinated treatment in the District of Columbia.

RATIONALE: PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack. Within one-year of hospital discharge, up to one-third of patients no longer adhere to secondary prevention behaviors. Adherence rates are lower in minority-underserved groups, contributing to health disparities. In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals. In these groups, low literacy, limited healthcare access, and sparse community resources may reduce adherence. Lay community health workers (navigators) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services. AIMS AND DESIGN: PROTECT DC is a Phase II, single-blind, randomized, controlled trial comparing in-hospital education plus stroke navigators to usual care. Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington, DC hospitals. Navigators meet with participants during the index hospitalization, perform home visits, and meet by phone. They focus on stroke education, medication compliance, and overcoming practical barriers to adherence. The interventions are driven by the theories of reasoned action and planned behavior. STUDY OUTCOMES: The primary dependent measure is a summary score of four objective measures of stroke risk factor control: systolic blood pressure, low-density lipoprotein, hemoglobin Hb A1C, and antiplatelet agent pill counts. Secondary outcomes include stroke knowledge, exercise, dietary modification, and smoking cessation. CONCLUSION: PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted.

Racial disparities in tissue plasminogen activator treatment rate for stroke: a population-based study.

BACKGROUND AND PURPOSE: Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (tPA) use for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. METHODS: Systematic chart abstraction was performed on consecutive hospitalized patients with ischemic stroke from all 7 acute care hospitals in the District of Columbia from February 1, 2008, to January 31, 2009. RESULTS: Of 1044 patients with ischemic stroke, 74% were black, 19% non-Hispanic white, and 5% received intravenous tPA. Blacks were one third less likely than whites to receive intravenous tPA (3% versus 10%, P<0.001). However, blacks were also less likely than whites to present within 3 hours of symptom onset (13% versus 21%, P=0.004) and also less likely to be tPA-eligible (5% versus 13%, P<0.001). Of those who presented within 3 hours, blacks were almost half as likely to be treated with intravenous tPA than whites (27% versus 46%, P=0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% versus 76%, P=0.62). CONCLUSIONS: In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with intravenous tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population.

Understanding reasons for delay in seeking acute stroke care in an underserved urban population.

BACKGROUND AND PURPOSE: Few patients arrive early enough at hospitals to be eligible for emergent stroke treatment. There may be barriers specific to underserved, urban populations that need to be identified before effective educational interventions to reduce delay times can be developed. METHODS: A survey of respondents' likely action in a hypothetical stroke situation was given to 253 community volunteers in the catchment areas of a large urban community hospital. Concurrently, 100 structured interviews were conducted in the same hospital with patients with acute stroke or a proxy. RESULTS: In this predominantly urban, black population, if faced with a hypothetical stroke, 89% of community volunteers surveyed said they would call 911 first, and few felt any of the suggested potential barriers applied to them. However, only 12% of patients with stroke interviewed actually called 911 first (OR, 63.9; 95% CI, 29.5 to 138.2). Instead, 75% called a relative/friend. Eighty-nine percent of patients with stroke reported significant delay in seeking medical attention, and almost half said the reason for the delay was thinking the symptoms were not serious and/or they would self-resolve. For those arriving by ambulance, only 25% did so because they thought it would be faster, whereas 35% cited having no other transportation options. CONCLUSIONS: In this predominantly black urban population, although 89% of community volunteers report the intent of calling 911 during a stroke, only 12% of actual patients with stroke did so. Further research is needed to determine and conquer the barriers between behavioral intent and actual behavior to call 911 for witnessed stroke.

The ABCs of diabetes: diabetes self-management education program for African Americans affects A1C, lipid-lowering agent prescriptions, and emergency department visits.

PURPOSE: The purpose of the study was to examine the feasibility and impact of a concise community-based program on diabetes self-management education (DSME), according to frequency of emergency department visits and knowledge of, prescriptions for, and control of A1C, blood pressure, and low-density lipoprotein (LDL) cholesterol. METHODS: A free community-based DSME program was placed in a public library. Adults with diabetes (N, 360) consented to participate in this prospective nonrandomized cohort study with preintervention-postintervention design. The small-group interactive DSME (two 2.5-hour classes) focused on improving cardiovascular disease risk factors and facilitating communication with the primary care physician. RESULTS: An increase in knowledge of American Diabetes Association-recommended targets for A1C, blood pressure, and LDL cholesterol from baseline to postintervention was seen among participants. Significant clinical outcomes included reduction in self-reported emergency department visits and reduction in mean A1C. However, despite an increase in prescriptions written for lipid-lowering drugs, blood pressure and LDL cholesterol did not change. Participants who started on insulin were more likely to achieve or maintain A1C < 7% compared to those who either did not take or stopped taking insulin during the study. CONCLUSIONS: Offering DSME classes for African Americans at a public library was feasible and significantly affected 6-month clinical outcomes, including a reduction in A1C, an increased likelihood of attaining a target A1C of < 7% if insulin was started during the study period, and a two-thirds reduction in emergency department visits for uncontrolled diabetes. Observed results suggest that partnering with community-based organizations such as public libraries offers an accessible and well-received location for offering DSME programs.