Post-acute Withdrawal Syndrome.

Post-acute withdrawal syndrome is an underresearched topic that affects many patients with substance use disorders after the cessation of substance use. Post-acute withdrawal syndrome is exemplified by the occurrence of substance-specific withdrawal signs and symptoms lasting well past the known timeframe for acute withdrawal of a used substance. Post-acute withdrawal syndrome may also include signs and symptoms that are not substance specific that persist, evolve, or appear well past the expected acute withdrawal timeframe. Unfortunately, there is very little scientific literature on post-acute withdrawal syndrome. As a result of this, there are no diagnostic criteria for post-acute withdrawal syndrome, and there is no consensus on the proper name for the condition. We present a case of a 38-year-old man who developed post-acute withdrawal syndrome after treatment with buprenorphine for opioid use disorder and review the limited existing literature on post-acute withdrawal syndrome.

Willingness-to-pay tuition and risk-taking proclivities among public health students.

Objective: To quantify students' risk tolerance for in-person classes and willingness-to-pay for online-only instruction during the COVID-19 pandemic. Participants: 46 Columbia University public health graduate students. Methods: We developed a survey tool with a "standard gamble" exercise administered online by an interactive chat bot with full anonymity by students. Students were asked to trade between the risk of infection with COVID-19 and: (1) attending classes in-person, and (2) attending community parties. We also assessed willingness-to-pay for online-only tuition. Results: Students accepted a 23% (standard error [SE]: 4%) risk of infection to attend classes in-person and 15% of them expressed willingness to attend community parties even if the COVID-19 prevalence were high. Students were willing-to-pay only 48% (SE: 3%) of the regular, in-person tuition fees for online instruction. Conclusions: Public health students with a strong knowledge of COVID-19 transmission were willing to accept a significant risk of infection for in-person instruction.Trial registration:NA.

The cost-effectiveness of common strategies for the prevention of transmission of SARS-CoV-2 in universities.

BACKGROUND: Most universities that re-open in the United States (US) for in-person instruction have implemented the Centers for Disease Prevention and Control (CDC) guidelines. The value of additional interventions to prevent the transmission of SARS-CoV-2 is unclear. We calculated the cost-effectiveness and cases averted of each intervention in combination with implementing the CDC guidelines. METHODS: We built a decision-analytic model to examine the cost-effectiveness of interventions to re-open universities. The interventions included implementing the CDC guidelines alone and in combination with 1) a symptom-checking mobile application, 2) university-provided standardized, high filtration masks, 3) thermal cameras for temperature screening, 4) one-time entry ('gateway') polymerase chain reaction (PCR) testing, and 5) weekly PCR testing. We also modeled a package of interventions ('package intervention') that combines the CDC guidelines with using the symptom-checking mobile application, standardized masks, gateway PCR testing, and weekly PCR testing. The direct and indirect costs were calculated in 2020 US dollars. We also provided an online interface that allows the user to change model parameters. RESULTS: All interventions averted cases of COVID-19. When the prevalence of actively infectious cases reached 0.1%, providing standardized, high filtration masks saved money and improved health relative to implementing the CDC guidelines alone and in combination with using the symptom-checking mobile application, thermal cameras, and gateway testing. Compared with standardized masks, weekly PCR testing cost $9.27 million (95% Credible Interval [CrI]: cost-saving-$77.36 million)/QALY gained. Compared with weekly PCR testing, the 'package' intervention cost $137,877 (95% CrI: $3,108-$19.11 million)/QALY gained. At both a prevalence of 1% and 2%, the 'package' intervention saved money and improved health compared to all the other interventions. CONCLUSIONS: All interventions were effective at averting infection from COVID-19. However, when the prevalence of actively infectious cases in the community was low, only standardized, high filtration masks clearly provided value.

Association of Low Socioeconomic Status With Premature Coronary Heart Disease in US Adults.

Importance: Individuals with low socioeconomic status (SES) bear a disproportionate share of the coronary heart disease (CHD) burden, and CHD remains the leading cause of mortality in low-income US counties. Objective: To estimate the excess CHD burden among individuals in the United States with low SES and the proportions attributable to traditional risk factors and to other factors associated with low SES. Design, Setting, and Participants: This computer simulation study used the Cardiovascular Disease Policy Model, a model of CHD and stroke incidence, prevalence, and mortality among adults in the United States, to project the excess burden of early CHD. The proportion of this excess burden attributable to traditional CHD risk factors (smoking, high blood pressure, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, type 2 diabetes, and high body mass index) compared with the proportion attributable to other risk factors associated with low SES was estimated. Model inputs were derived from nationally representative US data and cohort studies of incident CHD. All US adults aged 35 to 64 years, stratified by SES, were included in the simulations. Exposures: Low SES was defined as income below 150% of the federal poverty level or educational level less than a high school diploma. Main Outcomes and Measures: Premature (before age 65 years) myocardial infarction (MI) rates and CHD deaths. Results: Approximately 31.2 million US adults aged 35 to 64 years had low SES, of whom approximately 16 million (51.3%) were women. Compared with individuals with higher SES, both men and women in the low-SES group had double the rate of MIs (men: 34.8 [95% uncertainty interval (UI), 31.0-38.8] vs 17.6 [95% UI, 16.0-18.6]; women: 15.1 [95% UI, 13.4-16.9] vs 6.8 [95% UI, 6.3-7.4]) and CHD deaths (men: 14.3 [95% UI, 13.0-15.7] vs 7.6 [95% UI, 7.3-7.9]; women: 5.6 [95% UI, 5.0-6.2] vs 2.5 [95% UI, 2.3-2.6]) per 10 000 person-years. A higher burden of traditional CHD risk factors in adults with low SES explained 40% of these excess events; the remaining 60% of these events were attributable to other factors associated with low SES. Among a simulated cohort of 1.3 million adults with low SES who were 35 years old in 2015, the model projected that 250 000 individuals (19%) will develop CHD by age 65 years, with 119 000 (48%) of these CHD cases occurring in excess of those expected for individuals with higher SES. Conclusions and Relevance: This study suggested that, for approximately one-quarter of US adults aged 35 to 64 years, low SES was substantially associated with early CHD burden. Although biomedical interventions to modify traditional risk factors may decrease the disease burden, disparities by SES may remain without addressing SES itself.

Independent Relationship of Changes in Death Rates with Changes in US Presidential Voting.

BACKGROUND: The outcome of the 2016 presidential election is commonly attributed to socioeconomic and ethnic/racial issues, but health issues, including "deaths of despair," may also have contributed. OBJECTIVE: To assess whether changes in age-adjusted death rates were independently associated with changes in presidential election voting in 2016 vs. 2008. DESIGN: We used publicly available data in each of 3112 US counties to correlate changes in a county's presidential voting in 2016 compared with 2008 with recent changes in its age-adjusted death rate, after controlling for population and rural-urban status, median age, race/ethnicity, income, education, unemployment rate, and health insurance rate. DESIGN SETTING: Cross-sectional analysis of county-specific data. SETTING/PARTICIPANTS: All 3112 US counties. MAIN MEASURES: The independent correlation of a county's change in age-adjusted death rate between 2000 and 2015 with its net percentage Republican gain or loss in the presidential election of 2016 vs. 2008. KEY RESULTS: In 2016, President Trump increased the Republican presidential vote percentage in 83.8% of counties compared with Senator McCain in 2008. Counties with an increased Republican vote percentage in 2016 vs. 2008 had a 15% higher 2015 age-adjusted death rate than counties with an increased Democratic vote percentage. Since 2000, overall death rates declined by less than half as much, and death rates from drugs, alcohol, and suicide increased 2.5 times as much in counties with Republican gains compared with counties with Democratic gains. In multivariable analyses, Republican net presidential gain in 2016 vs. 2008 was independently correlated with slower reductions in a county's age-adjusted death rate. Although correlation cannot infer causality, modest reductions in death rates might theoretically have shifted Pennsylvania, Michigan, and Wisconsin to Secretary Clinton. CONCLUSIONS: Less of a reduction in age-adjusted death rates was an independent correlate of an increased Republican percentage vote in 2016 vs. 2008. Death rates may be markers of dissatisfactions and fears that influenced the 2016 Presidential election outcomes.

Current state of practice regarding digital radiography exposure indicators and deviation indices: Report of AAPM Imaging Physics Committee Task Group 232.

Beginning with the advent of digital radiography systems in 1981, manufacturers of these systems provided indicators of detector exposure. These indicators were manufacturer-specific, and users in facilities with equipment from multiple manufacturers found it a challenge to monitor and manage variations in indicated exposure in routine clinical use. In 2008, a common definition of exposure index (EI) was realized in International Electrotechnical Commission (IEC) International Standard 62494-1 Ed. 1, which also introduced and defined the deviation index (DI), a number quantifying the difference between the detector EI for a given radiograph and the target exposure index (EIT ). An exposure index that differed by a constant from that established by the IEC and the concept of the deviation index also appear in American Association of Physicists in Medicine (AAPM) Report No. 116 published in 2009. The AAPM Report No. 116 went beyond the IEC standard in supplying a table (Table II in the report of TG-116) titled "Exposure Indicator DI Control Limits for Clinical Images," which listed suggested DI ranges and actions to be considered for each range. As the IEC EI was implemented and clinical DI data were gathered, concerns were voiced that the DI control limits published in the report of TG-116 were too strict and did not accurately reflect clinical practice. The charge of task group 232 (TG-232) and the objective of this final report was to investigate the current state of the practice for CR/DR Exposure and Deviation Indices based on AAPM TG 116 and IEC-62494, for the purpose of establishing achievable goals (reference levels) and action levels in digital radiography. Data corresponding to EI and DI were collected from a range of practice settings for a number of body parts and views (adults and pediatric radiographs) and analyzed in aggregate and separately. A subset of radiographs was also evaluated by radiologists based on criteria adapted from the European Guidelines on Quality Criteria for Diagnostic Radiographic Images from the European Commission. Analysis revealed that typical DI distribution was characterized by a standard deviation (SD) of 1.3-3.6 with mean DI values substantially different from 0.0, and less than 50% of DI values fell within the significant action limits proposed by AAPM TG-116 (-1.0 ≤ DI ≤ 1.0). Recommendations stemming from this analysis include targeting a mean DI value of 0.0 and action limits at ±1 and ±2 SD of the DI based on actual DI data of an individual site. EIT values, DI values, and associated action limits should be reviewed on an ongoing basis and optimization of DI values should be a process of continuous quality improvement with a goal of reducing practice variation.

Potential Cardiovascular and Total Mortality Benefits of Air Pollution Control in Urban China.

BACKGROUND: Outdoor air pollution ranks fourth among preventable causes of China's burden of disease. We hypothesized that the magnitude of health gains from air quality improvement in urban China could compare with achieving recommended blood pressure or smoking control goals. METHODS: The Cardiovascular Disease Policy Model-China projected coronary heart disease, stroke, and all-cause deaths in urban Chinese adults 35 to 84 years of age from 2017 to 2030 if recent air quality (particulate matter with aerodynamic diameter ≤2.5 µm, PM2.5) and traditional cardiovascular risk factor trends continue. We projected life-years gained if urban China were to reach 1 of 3 air quality goals: Beijing Olympic Games level (mean PM2.5, 55 µg/m3), China Class II standard (35 µg/m3), or World Health Organization standard (10 µg/m3). We compared projected air pollution reduction control benefits with potential benefits of reaching World Health Organization hypertension and tobacco control goals. RESULTS: Mean PM2.5 reduction to Beijing Olympic levels by 2030 would gain ≈241,000 (95% uncertainty interval, 189 000-293 000) life-years annually. Achieving either the China Class II or World Health Organization PM2.5 standard would yield greater health benefits (992 000 [95% uncertainty interval, 790 000-1 180 000] or 1 827 000 [95% uncertainty interval, 1 481 00-2 129 000] annual life-years gained, respectively) than World Health Organization-recommended goals of 25% improvement in systolic hypertension control and 30% reduction in smoking combined (928 000 [95% uncertainty interval, 830 000-1 033 000] life-years). CONCLUSIONS: Air quality improvement in different scenarios could lead to graded health benefits ranging from 241 000 life-years gained to much greater benefits equal to or greater than the combined benefits of 25% improvement in systolic hypertension control and 30% smoking reduction.

Evaluating the Impact and Cost-Effectiveness of Statin Use Guidelines for Primary Prevention of Coronary Heart Disease and Stroke.

BACKGROUND: Statins are effective in the primary prevention of atherosclerotic cardiovascular disease. The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline expands recommended statin use, but its cost-effectiveness has not been compared with other guidelines. METHODS: We used the Cardiovascular Disease Policy Model to estimate the cost-effectiveness of the ACC/AHA guideline relative to current use, Adult Treatment Panel III guidelines, and universal statin use in all men 45 to 74 years of age and women 55 to 74 years of age over a 10-year horizon from 2016 to 2025. Sensitivity analyses varied costs, risks, and benefits. Main outcomes were incremental cost-effectiveness ratios and numbers needed to treat for 10 years per quality-adjusted life-year gained. RESULTS: Each approach produces substantial benefits and net cost savings relative to the status quo. Full adherence to the Adult Treatment Panel III guideline would result in 8.8 million more statin users than the status quo, at a number needed to treat for 10 years per quality-adjusted life-year gained of 35. The ACC/AHA guideline would potentially result in up to 12.3 million more statin users than the Adult Treatment Panel III guideline, with a marginal number needed to treat for 10 years per quality-adjusted life-year gained of 68. Moderate-intensity statin use in all men 45 to 74 years of age and women 55 to 74 years of age would result in 28.9 million more statin users than the ACC/AHA guideline, with a marginal number needed to treat for 10 years per quality-adjusted life-year gained of 108. In all cases, benefits would be greater in men than women. Results vary moderately with different risk thresholds for instituting statins and statin toxicity estimates but depend greatly on the disutility caused by daily medication use (pill burden). CONCLUSIONS: At a population level, the ACC/AHA guideline for expanded statin use for primary prevention is projected to treat more people, to save more lives, and to cost less compared with Adult Treatment Panel III in both men and women. Whether individuals benefit from long-term statin use for primary prevention depends more on the disutility associated with pill burden than their degree of cardiovascular risk.

Comparative Cost-Effectiveness of Conservative or Intensive Blood Pressure Treatment Guidelines in Adults Aged 35-74 Years: The Cardiovascular Disease Policy Model.

The population health effect and cost-effectiveness of implementing intensive blood pressure goals in high-cardiovascular disease (CVD) risk adults have not been described. Using the CVD Policy Model, CVD events, treatment costs, quality-adjusted life years, and drug and monitoring costs were simulated over 2016 to 2026 for hypertensive patients aged 35 to 74 years. We projected the effectiveness and costs of hypertension treatment according to the 2003 Joint National Committee (JNC)-7 or 2014 JNC8 guidelines, and then for adults aged ≥50 years, we assessed the cost-effectiveness of adding an intensive goal of systolic blood pressure <120 mm Hg for patients with CVD, chronic kidney disease, or 10-year CVD risk ≥15%. Incremental cost-effectiveness ratios <$50 000 per quality-adjusted life years gained were considered cost-effective. JNC7 strategies treat more patients and are more costly to implement compared with JNC8 strategies. Adding intensive systolic blood pressure goals for high-risk patients prevents an estimated 43 000 and 35 000 annual CVD events incremental to JNC8 and JNC7, respectively. Intensive strategies save costs in men and are cost-effective in women compared with JNC8 alone. At a willingness-to-pay threshold of $50 000 per quality-adjusted life years gained, JNC8+intensive had the highest probability of cost-effectiveness in women (82%) and JNC7+intensive the highest probability of cost-effectiveness in men (100%). Assuming higher drug and monitoring costs, adding intensive goals for high-risk patients remained consistently cost-effective in men, but not always in women. Among patients aged 35 to 74 years, adding intensive blood pressure goals for high-risk groups to current national hypertension treatment guidelines prevents additional CVD deaths while saving costs provided that medication costs are controlled.

Gait Speed as a Guide for Blood Pressure Targets in Older Adults: A Modeling Study.

OBJECTIVES: To evaluate the potential for gait speed to inform decisions regarding optimal systolic blood pressure targets in older adults. DESIGN: Forecasting study from 2014 to 2023 using the Cardiovascular Disease Policy Model, a Markov model. SETTING: National Health and Nutrition Examination Survey. PARTICIPANTS: U.S. adults aged 60-94 stratified into fast walking, slow walking, and poor functioning (noncompleters) based on measured gait speed. MEASUREMENTS: Lowering SBP to a target of 140 or 150 mmHg was modeled in persons with (secondary prevention) and without (primary prevention) a history of coronary heart disease or stroke. Based on clinical trials and observational studies, it was projected that slow-walking and poor-functioning participants would have greater noncardiovascular mortality. Myocardial infarctions (MIs), strokes, deaths, cost, and disability-adjusted life years (DALYs) were measured. RESULTS: Regardless of gait speed, it was projected that secondary prevention to a systolic blood pressure (SBP) of 140 mmHg would prevent more events and save more money than secondary prevention to 150 mmHg. Similarly, primary prevention to 140 mmHg in fast-walking adults was projected to prevent events and save money. In slow-walking adults, primary prevention to 150 mmHg was projected to prevent MIs and strokes and save DALYs but was cost saving only in men; intensification to 140 mmHg is of uncertain benefit in slow-walking individuals. Primary prevention in poor-functioning adults to a target of 140 or 150 mmHg SBP is projected to decrease DALYs. CONCLUSION: The most cost-effective SBP target varies according to history of cardiovascular disease and gait speed in persons aged 60-94. These projections highlight the need for better estimates of the benefits and harms of antihypertensive medications in a diverse group of older adults, because the net benefit is sensitive to the characteristics of the population treated.

Comparative Cost-Effectiveness of Hypertension Treatment in Non-Hispanic Blacks and Whites According to 2014 Guidelines: A Modeling Study.

BACKGROUND: We compared the cost-effectiveness of hypertension treatment in non-Hispanic blacks and non-Hispanic whites according to 2014 US hypertension treatment guidelines. METHODS: The cardiovascular disease (CVD) policy model simulated CVD events, quality-adjusted life years (QALYs), and treatment costs in 35- to 74-year-old adults with untreated hypertension. CVD incidence, mortality, and risk factor levels were obtained from cohort studies, hospital registries, vital statistics, and national surveys. Stage 1 hypertension was defined as blood pressure 140-149/90-99mm Hg; stage 2 hypertension as ≥150/100mm Hg. Probabilistic input distribution sampling informed 95% uncertainty intervals (UIs). Incremental cost-effectiveness ratios (ICERs) < $50,000/QALY gained were considered cost-effective. RESULTS: Treating 0.7 million hypertensive non-Hispanic black adults would prevent about 8,000 CVD events annually; treating 3.4 million non-Hispanic whites would prevent about 35,000 events. Overall 2014 guideline implementation would be cost saving in both groups compared with no treatment. For stage 1 hypertension but without diabetes or chronic kidney disease, cost savings extended to non-Hispanic black males ages 35-44 but not same-aged non-Hispanic white males (ICER $57,000/QALY; 95% UI $15,000-$100,000) and cost-effectiveness extended to non-Hispanic black females ages 35-44 (ICER $46,000/QALY; $17,000-$76,000) but not same-aged non-Hispanic white females (ICER $181,000/QALY; $111,000-$235,000). CONCLUSIONS: Compared with non-Hispanic whites, cost-effectiveness of implementing hypertension guidelines would extend to a larger proportion of non-Hispanic black hypertensive patients.

Projected Impact of Salt Restriction on Prevention of Cardiovascular Disease in China: A Modeling Study.

OBJECTIVES: To estimate the effects of achieving China's national goals for dietary salt (NaCl) reduction or implementing culturally-tailored dietary salt restriction strategies on cardiovascular disease (CVD) prevention. METHODS: The CVD Policy Model was used to project blood pressure lowering and subsequent downstream prevented CVD that could be achieved by population-wide salt restriction in China. Outcomes were annual CVD events prevented, relative reductions in rates of CVD incidence and mortality, quality-adjusted life-years (QALYs) gained, and CVD treatment costs saved. RESULTS: Reducing mean dietary salt intake to 9.0 g/day gradually over 10 years could prevent approximately 197 000 incident annual CVD events [95% uncertainty interval (UI): 173 000-219 000], reduce annual CVD mortality by approximately 2.5% (2.2-2.8%), gain 303 000 annual QALYs (278 000-329 000), and save approximately 1.4 billion international dollars (Int$) in annual CVD costs (Int$; 1.2-1.6 billion). Reducing mean salt intake to 6.0 g/day could approximately double these benefits. Implementing cooking salt-restriction spoons could prevent 183 000 fewer incident CVD cases (153 000-215 000) and avoid Int$1.4 billion in CVD treatment costs annually (1.2-1.7 billion). Implementing a cooking salt substitute strategy could lead to approximately three times the health benefits of the salt-restriction spoon program. More than three-quarters of benefits from any dietary salt reduction strategy would be realized in hypertensive adults. CONCLUSION: China could derive substantial health gains from implementation of population-wide dietary salt reduction policies. Most health benefits from any dietary salt reduction program would be realized in adults with hypertension.

Ongoing quality control in digital radiography: Report of AAPM Imaging Physics Committee Task Group 151.

Quality control (QC) in medical imaging is an ongoing process and not just a series of infrequent evaluations of medical imaging equipment. The QC process involves designing and implementing a QC program, collecting and analyzing data, investigating results that are outside the acceptance levels for the QC program, and taking corrective action to bring these results back to an acceptable level. The QC process involves key personnel in the imaging department, including the radiologist, radiologic technologist, and the qualified medical physicist (QMP). The QMP performs detailed equipment evaluations and helps with oversight of the QC program, the radiologic technologist is responsible for the day-to-day operation of the QC program. The continued need for ongoing QC in digital radiography has been highlighted in the scientific literature. The charge of this task group was to recommend consistency tests designed to be performed by a medical physicist or a radiologic technologist under the direction of a medical physicist to identify problems with an imaging system that need further evaluation by a medical physicist, including a fault tree to define actions that need to be taken when certain fault conditions are identified. The focus of this final report is the ongoing QC process, including rejected image analysis, exposure analysis, and artifact identification. These QC tasks are vital for the optimal operation of a department performing digital radiography.