Stroke services in MENA: What is there and what is needed.

OBJECTIVES: Stroke represents a health care challenge to most parts of the world including the Middle East and North Africa (MENA) region. The MENA represents 6% of the world population with an age-standardized stroke rate of 87.7 (78.2-97.6) per 100,000 population. This number is subject to increase given that the cause of morbidity has recently shifted from infectious diseases to non-communicable diseases. Thus, in the coming years, treatment of stroke will pose a major burden on MENA countries which mostly lie in the low to middle income economies. Accordingly, we need to study the state of MENA stroke services in order to recognize and further inform policy makers about any gaps that need to be bridged in this domain. METHODS AND RESULTS: Stroke specialists representing 16 countries filled an online survey that included: screening for risk factors, acute management, diagnostics, medications, post-discharge services, and stroke registries. Results showed that 11 countries screen for risk factors, 16 have neuroimaging studies, 15 provide intravenous thrombolysis (IVT), 13 mechanical thrombectomy (MT) while medications for secondary prevention are available in all countries. However, stroke units are not equally available and even absent in 4 countries, and despite the availability of IVT yet, the rate of administration is still low in 6 countries (<5%), and ranges from 5-20% in 7 countries. Stroke registries and training still need to be implemented in most countries. CONCLUSION: Although imaging, revascularization therapies and medications for secondary prevention are available in most MENA countries, yet the rate of revascularization is low, so is the number of stroke units insufficient in some countries. Additionally, registries and structured training are still defective. Further field studies are required for more accurate determination of the status of stroke services in the MENA region.

Transgenerational Inheritance and Systemic Racism in America.

Objective: It is well established that personal experiences of trauma, adversity, and discrimination can "get under the skin" and increase risk for a whole host of negative mental and physical health outcomes. The aim of this article is to review emerging research on transgenerational epigenetic inheritance which suggests that negative exposures in one generation, can also be passed down to affect the health and well-being of future generations. Method: This paper reviews key concepts in transgenerational epigenetic inheritance research, select animal and human studies examining the role of epigenetic mechanisms in transmitting the impact of ancestral stress and trauma, poor nutrition, and toxicant exposure across generations, and factors that can mitigate the effects of these experiences. Results: The animal studies provide compelling evidence for a role for these mechanisms in the transmission of the negative effects associated with ancestral adversities. Animal and clinical studies also suggest that the negative impact of personal and ancestral traumas can be prevented, with a role for in humans for evidence-based trauma treatments, culturally adapted prevention and intervention programs, and enrichment opportunities strongly indicated. Conclusions: Although comparable definitive data is lacking in multigenerational human cohorts, preliminary data supports a potential role for transgenerational epigenetic mechanisms in explaining persistent health disparities in the absence of personal exposures, and further elucidation of these mechanisms may guide the design of novel interventions. In addressing ancestral traumas, however, true change and healing will require acknowledgement of the harms that were done, and broader systemic policy level changes.

A comprehensive framework for operationalizing structural racism in health research: The association between mass incarceration of Black people in the U.S. and adverse birth outcomes.

Structural racism represents a key determinant of the racial health disparities that has characterized the U.S. population throughout its existence. While this reality has recently begun to gain increasing acknowledgment and acceptance within the health sciences, there are still considerable challenges related to defining the concept of structural racism and operationalizing it in empirical study. In this paper, building on the existing evidence base, we propose a comprehensive framework that centers structural racism in terms of its historical roots and continued manifestation in most domains of society, and offer solutions for the study of this phenomenon and the pathways that connect it to population-level health disparities. We showcase our framework by applying it to the known link between spatial and racialized clustering of incarceration - a previously cited representation of structural racism - and disparities in adverse birth outcomes. Through this process we hypothesize pathways that focus on social cohesion and community-level chronic stress, community crime and police victimization, as well as infrastructural community disinvestment. First, we contextualize these mechanisms within the relevant extant literature. Then, we make recommendations for future empirical pathway analyses. Finally, we identify key areas for policy, community, and individual-level interventions that target the impact of concentrated incarceration on birth outcomes among Black people in the U.S.

Racial and ethnic disparities in "stop-and-frisk" experience among young sexual minority men in New York City.

Although racial/ethnic disparities in police contact are well documented, less is known about other dimensions of inequity in policing. Sexual minority groups may face disproportionate police contact. We used data from the P18 Cohort Study (Version 2), a study conducted to measure determinants of inequity in STI/HIV risk among young sexual minority men (YSMM) in New York City, to measure across-time trends, racial/ethnic disparities, and correlates of self-reported stop-and-frisk experience over the cohort follow-up (2014-2019). Over the study period, 43% reported stop-and-frisk with higher levels reported among Black (47%) and Hispanic/Latinx (45%) than White (38%) participants. Stop-and-frisk levels declined over follow-up for each racial/ethnic group. The per capita rates among P18 participants calculated based on self-reported stop-and-frisk were much higher than rates calculated based on New York City Police Department official counts. We stratified respondents' ZIP codes of residence into tertiles of per capita stop rates and observed pronounced disparities in Black versus White stop-and-frisk rates, particularly in neighborhoods with low or moderate levels of stop-and-frisk activity. YSMM facing the greatest economic vulnerability and mental disorder symptoms were most likely to report stop-and-frisk. Among White respondents levels of past year stop-and-frisk were markedly higher among those who reported past 30 day marijuana use (41%) versus those reporting no use (17%) while among Black and Hispanic/Latinx respondents stop-and-frisk levels were comparable among those reporting marijuana use (38%) versus those reporting no use (31%). These findings suggest inequity in policing is observed not only among racial/ethnic but also sexual minority groups and that racial/ethnic YSMM, who are at the intersection of multiple minority statuses, face disproportionate risk. Because the most socially vulnerable experience disproportionate stop-and-frisk risk, we need to reach YSMM with community resources to promote health and wellbeing as an alternative to targeting this group with stressful and stigmatizing police exposure.

A Population-Level Assessment of Smoking Cessation following a Diagnosis of Tobacco- or Nontobacco-Related Cancer among United States Adults.

INTRODUCTION: Smoking cessation after a cancer diagnosis can significantly improve treatment outcomes and reduce the risk of cancer recurrence and all-cause mortality. AIM: We sought to measure the association between cancer diagnosis and subsequent smoking cessation. METHODS: Data was sourced from the Population Assessment of Health and Tobacco (PATH) study, a representative population-based sample of United States adults. Our analytic sample included all adult smokers at Wave I, our baseline. The exposure of interest was either a tobacco-related cancer diagnosis, nontobacco-related cancer diagnosis, or no cancer diagnosis (the referent) reported at Wave II or III. The primary outcome was smoking cessation after diagnosis, at Wave IV. Results/Findings. Our sample was composed of 7,286 adult smokers at the baseline representing an estimated 40.9 million persons. Smoking cessation rates after a diagnosis differed after a tobacco-related cancer (25.9%), a nontobacco-related cancer (8.9%), and no cancer diagnosis (17.9%). After adjustment, diagnosis with a tobacco-related cancer was associated with a higher odds of smoking cessation (OR 1.83, 95% CI 1.00-3.33) compared to no cancer diagnosis. Diagnosis with a nontobacco-related cancer was not significantly linked to smoking cessation (OR 0.52, 95% CI 0.48-1.45). CONCLUSION: Diagnosis with a tobacco-related cancer is associated with greater odds of subsequent smoking cessation compared to no cancer diagnosis, suggesting that significant behavioral change may occur in this setting.

Development and validation of an economical uric acid-Fe3+/Fe2+-ferrozine-based colorimetric assay to estimate uric acid level of pure and biological samples.

This work presents the development and validation of a simple, rapid, and cost-effective spectrophotometric method for quantitative analysis of uric acid in biological samples. The method relies upon uric acid-led reduction of Fe(III) to Fe(II) of sample/standard solutions which stoichiometrically engages ferrozine to form a magenta-colored complex. Different parameters including pH, metal and chelator concentrations, temperature, etc., were optimized for the maximum intensity and stability of the complex. The uric acid concentrations of synthetic/plasma solutions were determined by comparing the color intensity of Fe(ferrozine)3 2+ complex produced by test solution with the standard curve formed by known uric acid concentrations. The method was validated in accordance with ICH guidelines and subjected to human plasma analysis. The results obtained were compared with a reference (enzymatic) method which revealed that there was no significant difference between the two methods at 95% confidence level. The method is highly specific, precise, linear, accurate, and robust.

Impact Of Lady Health Workers On The Contraceptive Prevalence Rate In District Mardan.

BACKGROUND: Pakistan being the 6th populous country with a population of 207,774,520, and a growth rate of 2.6%, if left unchecked can reach 335 million by 2050. The total demand of family planning in Pakistan is 55% while the contraceptive prevalence rate is 35% with an unmet need for family planning is 20%. METHODS: The contraceptive prevalence rate and frequently used contraceptive method in an area with Lady Health Worker services versus an area without Lady Health Worker services of union council Pat Baba were compared over a period of 6 months. 322 households were selected, 161 from LHW covered and 161 from LHW uncovered area of union council Pat Baba District Mardan. RESULTS: The knowledge of contraceptive methods was 98.1% in the women of covered area and this knowledge was 90.1% in the uncovered area in union council Pat Baba. The source of information for the women in the covered area was mostly LHWs 87% and in uncovered area 25.5% of the women were informed by the LHWs, followed by elderly family members 7.5% in the covered, and 37.9% of the women in uncovered area. The contraceptive prevalence rate was 59% in covered areas and in uncovered areas it was 51.6%. The most frequently used contraceptive method in covered area was condom 16.8% and in the uncovered area it was withdrawal method 26.1%. CONCLUSIONS: There was a significant association between the LHWs presence on knowledge scores and contraceptive prevalence rate.

A conceptual model for understanding post-release opioid-related overdose risk.

Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons (PRJP). Informed by the proximate determinants framework, this paper presents the Post-Release Opioid-Related Overdose Risk Model. It explores the underlying, intermediate, proximate and biological determinants which contribute to risk of post-release opioid-related overdose mortality. PRJP share the underlying exposure of incarceration and the increased prevalence of several moderators (chronic pain, HIV infection, trauma, race, and suicidality) of the risk of opioid-related overdose. Intermediate determinants following release from the criminal justice system include disruption of social networks, interruptions in medical care, poverty, and stigma which exacerbate underlying, and highly prevalent, substance use and mental health disorders. Subsequent proximate determinants include interruptions in substance use treatment, including access to medications for opioid use disorder, polypharmacy, polydrug use, insufficient naloxone access, and a return to solitary opioid use. This leads to the final biological determinant of reduced respiratory tolerance and finally opioid-related overdose mortality. Mitigating the risk of opioid-related overdose mortality among PRJP will require improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, and reduce interruptions in care continuity and reduce stigma. Healthcare services and harm reduction strategies, such as safe injection sites, should be tailored to the needs of PRJP. Expanding access to opioid agonist therapy and naloxone around the post-release period could reduce overdose deaths. Programs are also needed to divert individuals with substance use disorder away from the criminal justice system and into treatment and social services, preventing incarceration exposure.

Depression, Executive Dysfunction, and Prior Economic and Social Vulnerability Associations in Incarcerated African American Men.

Low executive function (EF) and depression are each determinants of health. This study examined the synergy between deficits in EF (impaired cognitive flexibility; >75th percentile on the Wisconsin Card Sorting Test perseverative error score) and depressive symptoms (modified Centers for Epidemiologic Studies-Depression) and preincarceration well-being among incarcerated African American men ( N = 189). In adjusted analyses, having impaired EF and depression was strongly associated with pre-incarceration food insecurity (odds ratio [ OR] = 3.81, 95% confidence interval [CI] = [1.35, 10.77]), homelessness ( OR = 3.00, 95% CI [1.02, 8.80]), concern about bills ( OR = 3.76, 95% CI [1.42, 9.95]), low significant other support ( OR = 4.63, 95% CI [1.62, 13.24]), low friend support ( OR = 3.47, 95% CI [1.30, 9.26]), relationship difficulties ( OR = 2.86, 95% CI [1.05, 7.80]), and binge drinking ( OR = 3.62, 95% CI [1.22, 10.80]). Prison-based programs to treat depression and improve problem-solving may improve postrelease success.

Differential Patterns of Risk and Vulnerability Suggest the Need for Novel Prevention Strategies for Black Bisexual Men in the HPTN 061 Study.

BACKGROUND: Black men who have sex with men (BMSM) and some who also have sex with women (BMSMW) account for over 70% of new HIV infections in the United States representing an elevated HIV risk in this group, also informing risks of HIV transmission to other BMSM and female sexual partners. SETTINGS: We examined trajectories of self-reported substance use, HIV-related sexual risk behaviors, and psychosocial vulnerabilities among BMSMW versus BMSM over a 1-year study period. METHODS: We analyzed baseline, 6-, and 12-month follow-up data from the HIV Prevention Trials Network "BROTHERS" Study (HPTN 061; n = 1126). Categorizing participants by sexual partner type across 3 time points: (1) BMSMO: having male and no female partners across assessments and (2) BMSMW: having sex with male and one or more female partners at least at 1 time point. Using generalized estimating equations, we estimated associations between being BMSMW (versus BMSMO) and changes in psychosocial vulnerability, substance use, and HIV-related sexual risk behaviors. RESULTS: Generalized estimating equation models controlling for sociodemographics, time-varying effects, and intervention status showed that BMSMW versus BMSMO had 50% increased odds of crack use, 71% increased odds of alcohol use during condomless anal intercourse (CAI), 51% greater odds of using drugs at last CAI, and twice the odds of receiving goods at last CAI. CONCLUSIONS: Findings show stable and comparatively elevated illicit drugs, alcohol, and exchange sex during last CAI among BMSMW. Future intervention research should focus on ways to address changes in substance-related HIV-transmission behaviors over time in this population of men.

Determinants of institutional delivery among women of childbearing age in rural Haiti.

Institutional delivery is an important factor associated with reduced maternal mortality rate (MMR). MMR in Haiti is high (350 per 100,000) and institutional delivery is low-just over 25 % of women delivered at a health facility in 2010. There also exists substantial rural-urban disparity in delivery with more hospital deliveries in urban than in rural areas. We aimed to study the prevalence and determinants of institutional delivery in a sample of women of childbearing age in rural Haiti. The study took place in Fond des Blancs and Villa, as part of a baseline assessment undertaken prior to implementation of a maternal, child health, nutrition, and water and sanitation program. From October to November 2011, women 15-49 years old (N = 575) were selected using a cross-sectional two-stage sampling strategy. We used descriptive and multivariate logistic regression analyses to assess the prevalence of and factors associated with institutional delivery. The prevalence of institutional delivery was 45.4 %; a rate higher than the national average of 25 %. In adjusted analyses, correlates of institutional delivery were younger maternal age (25 years and younger) (OR 1.82; CI 1.15, 2.90; P = 0.0112), antenatal care receipt (OR 3.70; CI 1.84, 7.43; P = 0.0003) and those who were poor according to our poverty index score classification (OR 2.04; CI 1.13, 3.69; P = 0.0187). This study shows that increased hospital delivery is likely explained by accessibility to antenatal care. Programs that improve access to antenatal care, with concurrent efforts to address structural inequalities that drive socio-economic deprivation, are likely critical to increasing institutional delivery.

Terrorism, civil war and related violence and substance use disorder morbidity and mortality: a global analysis.

INTRODUCTION: The purpose of this study is to examine associations between deaths owing to terrorism, civil war, and one-sided violence from 1994-2000 and substance use disorder disability-adjusted life years (DALYs). METHODS: The relationship between terrorism, and related violence and substance use disorder morbidity and mortality among World Health Organization Member States in 2002, controlling for adult per capita alcohol consumption, illicit drug use, and economic variables at baseline in 1994. RESULTS: Deaths as a result of terrorism and related violence were related to substance use disorder DALYs: a 1.0% increase in deaths as a result of terrorism, war and one-sided violence was associated with an increase of between 0.10% and 0.12% in alcohol and drug use disorder DALYs. Associations were greater among males and 15-44 year-old. CONCLUSION: Terrorism, war and one-sided violence may influence morbidity and mortality attributable to substance use disorders in the longer-term suggests that more attention to be given to rapid assessment and treatment of substance use disorders in conflict-affected populations with due consideration of gender and age differences that may impact treatment outcomes in these settings. Priorities should be established to rebuild substance abuse treatment infrastructures and treat the many physical and mental comorbid disorders.

HIV prevalence and risk behaviors among African American Women Who Trade Sex for Drugs Versus Economic Resources.

Trading sex for money, drugs, goods, services, or a place to stay is prevalent among women who use drugs and has been associated with women's risk of HIV acquisition. There is evidence that trading sex for drugs only may be associated with elevated risk of HIV compared with trading sex for money. The purpose of this study was to assess whether HIV risk behaviors and HIV prevalence differ among African American drug using women (N = 92) who traded sex for drugs only, traded sex for economic resources (defined as money, shelter, or other resources) only, or traded sex for both economic resources and drugs. In this study, lower rates of condom use and higher rates of HIV were found among women who traded sex for drugs only compared to women who traded sex for economic resources or for economic resources and drugs. These findings suggest that African American women who trade sex for drugs only represent an understudied yet highly vulnerable group.

Conflict and diarrheal and related diseases: a global analysis.

The purpose of this study was to determine the association between deaths owing to terrorism, civil war and one-sided violence from 1994-2000 and disability-adjusted life years (DALYs) attributable to diarrheal and related diseases, schistosomiasis, trachoma and the nematode infections (DSTN diseases) in 2002 among World Health Organization Member States. Deaths resulting from terrorism, civil war and one-sided violence were significantly related to DSTN DALYs across the majority of sex-age subgroups of the populace, after controlling for baseline levels of improved water/sanitation and a variety of economic measures: overall, a 1.0% increase in deaths owing to terrorism and related violence was associated with an increase of 0.16% in DALYs lost to DSTN diseases. Associations were greatest among 0-to-4-year olds. The results of the present study suggest that DSTN disease control efforts should target conflict-affected populations with particular attention to young children who suffer disproportionately from DSTN diseases in these settings. In view of the evidence that terrorism and related violence may influence DSTN DALYs in the longer term, control strategies should move beyond immediate responses to decrease the incidence and severity of DSTN diseases to seek solutions through bolstering health systems infrastructure development among conflict-affected populations.

Growing burden of stroke in Pakistan: a review of progress and limitations.

Stroke rates in middle-aged people are five to ten times higher in Pakistan, India, Russia, China, and Brazil, compared with the United Kingdom or United States. South Asia is home to 20% of the world's population and has one of the highest burdens of cardiovascular disease in the world. With an aging population, there is an expected increase in the number of stroke cases and a corresponding increase in the burden of stroke in developing countries including South Asian countries like Pakistan. Limited data from prior studies in developing countries indicate that stroke epidemiology differs between these and Western countries. These differences include a higher incidence of stroke at younger ages, a higher prevalence of hemorrhagic stroke, and higher age-specific prevalence rates of stroke in women. The reasons for these differences in stroke epidemiology in developing countries are not clear. This may be explained by higher prevalence of established stroke risk factors, or potential nontraditional risk factors such as water pipe smoking, use of daldaghee or naswaar, and paan chewing; hepatitis and rheumatic heart disease may also contribute to these differences. Acute and long-term stroke treatment has shown limited progress in Pakistan like other developing countries because of poor awareness of patients and general physician on stroke symptomatology, management of stroke risk factors, lack of specialized stroke units in the country, very low utilization of thrombolytic therapy because of financial constraints and, above all, poor knowledge of physicians on the role of rehabilitation and its different aspects in the management of post stroke disability.

Terrorism, civil war, one-sided violence and global burden of disease.

Armed conflict and related violence, including terrorism and one-sided violence, has profound effects on people's health and lives. The purpose of this study was to determine the relationship between deaths due to terrorism, civil war and one-sided violence from 1994-2000 and disability-adjusted life years (DALYs) occurring in 2002 attributable to all causes and specific communicable and noncommunicable diseases. Deaths resulting from terrorism, war and one-sided violence were positively associated with all cause as well as a number of communicable and noncommunicable disease-specific DALYs across the majority of sex and age subgroups of the populace, controlling for an array of economic factors empirically shown to affect public health. Overall, a 1.0% increase in deaths due to terrorism, civil war and one-sided violence from 1994-2000 was associated with a 0.16% increase in DALYs lost to all causes in 2002 in the total world population. There was little variation in the magnitude of these associations between males and females and between communicable and noncommunicable diseases. The results of the present study can begin to guide post-conflict recovery by focusing on interventions targeting both noncommunicable as well as communicable diseases, thereby highlighting the full health costs of war and ultimately providing a strong rationale for promoting peace.

Longitudinal associations between adolescent alcohol use and adulthood sexual risk behavior and sexually transmitted infection in the United States: assessment of differences by race.

OBJECTIVES: We examined race differences in the longitudinal associations between adolescent alcohol use and adulthood sexually transmitted infection (STI) risk in the United States. METHODS: We estimated multivariable logistic regression models using Waves I (1994-1995: adolescence) and III (2001-2002: young adulthood) of the National Longitudinal Study of Adolescent Health (n = 10 783) to estimate associations and assess differences between Whites and African Americans. RESULTS: In adjusted analyses, adolescent alcohol indicators predicted adulthood inconsistent condom use for both races but were significantly stronger, more consistent predictors of elevated partnership levels for African Americans than Whites. Among African Americans but not Whites, self-reported STI was predicted by adolescent report of any prior use (adjusted odds ratio [AOR] = 1.47; 95% confidence interval [CI] = 1.00, 2.17) and past-year history of getting drunk (AOR = 1.53; 95% CI = 1.01, 2.32). Among Whites but not African Americans, biologically confirmed STI was predicted by adolescent report of past-year history of getting drunk (AOR = 1.68; 95% CI = 1.07, 2.63) and consistent drinking (AOR = 1.65; 95% CI = 1.03, 2.65). CONCLUSIONS: African American and White adolescent drinkers are priority populations for STI prevention. Prevention of adolescent alcohol use may contribute to reductions in adulthood STI risk.

Assessing criminal justice involvement as an indicator of human immunodeficiency virus risk among women in methadone treatment.

This study examines the relationship between criminal justice involvement and high-risk sexual partnerships among a random sample of 416 women in methadone treatment in New York City. Logistic regression models were used to estimate the associations between recent criminal justice involvement (arrest or incarceration in the past 6 months) and recent high-risk partnerships (multiple sex partners, sex trading, or sex with a risky partner in the past 6 months) when adjusting for sociodemographic factors and recent regular drug use. Women with recent criminal justice involvement demonstrated higher odds of engaging in high-risk sex partnerships. Although regular drug use was a significant confounder of several of these relationships, recent arrest or incarceration remained significantly associated with multiple sex partnerships, sex with a risky partner, and engaging in unprotected sex and a high-risk partnership even after controlling for regular drug use and other social stressors. This study highlights the vulnerability of drug-involved women offenders to human immunodeficiency virus (HIV) risk and points to the need for investigation into the role of arrest and incarceration as factors that may contribute to HIV infection.