The Evidence Project: Protocol for Systematic Reviews of Behavioral Interventions and Behavioral Aspects of Biomedical Interventions for HIV Prevention, Treatment, and Health Service Delivery in Low- and Middle-Income Countries.

The Evidence Project conducts systematic reviews and meta-analyses of HIV behavioral interventions, behavioral aspects of biomedical interventions, combination prevention strategies, modes of service delivery, and integrated programs in low- and middle-income countries. Here, we present the overall protocol for our reviews. For each topic, we conduct a comprehensive search of five online databases, complemented by secondary reference searching. Articles are included if they are published in peer-reviewed journals and present pre/post or multi-arm data on outcomes of interest. Data are extracted from each included article by two trained coders working independently using standardized coding forms, with differences resolved by consensus. Risk of bias is assessed with the Evidence Project tool. Data are synthesized descriptively, and meta-analysis is conducted when there are similarly measured outcomes across studies. For over 20 years, this approach has allowed us to synthesize literature on the effectiveness of interventions and contribute to the global HIV response.

The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects.

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16-0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22-0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

RESUMEN: Realizamos una revisión sistemática y un metanálisis del impacto de los programas de intercambio de agujas y jeringas (NSP, por sus siglas en inglés) de los comportamientos de uso compartido de agujas tanto a nivel individual como comunitario y otros resultados relacionados con el VIH en países de ingresos bajos y medianos (LMIC, por sus siglas en inglés). Realizamos búsquedas sistemáticas en cinco bases de datos hasta julio de 2021 en busca de ensayos revisados por pares o estudios cuasiexperimentales. En general, 42 intervenciones informadas en 35 estudios entre 56 751 participantes cumplieron los criterios de inclusión. El metanálisis de efectos aleatorios de ocho estudios a nivel individual y 12 a nivel comunitario con 11 075 participantes en total mostró una asociación protectora significativa entre la exposición a NSP y los comportamientos de compartir agujas (individual: OR 0,25, IC95%: 0,16­0,39; comunidad: OR 0,39, IC95%:0,22­0,69), aunque con una heterogeneidad importante. Cuando se estratificó por la direccionalidad del intercambio de agujas, la exposición a NSP permaneció asociada con un intercambio receptivo reducido, pero no con un intercambio distributivo. La exposición a NSP también se asoció con una incidencia reducida del VIH y un aumento de las pruebas del VIH, pero no hubo asociaciones consistentes para la prevalencia de infecciones transmitidas por la sangre. La evidencia actual sugiere impactos positivos de los NSP en los LMIC.

Improving Colposcopy Education Through Images: A Preliminary Assessment of an Image-Based Mobile App for Colposcopic Education.

OBJECTIVES: Colposcopy is an indispensable part of cervical cancer screening. However, in most training programs, there is little by way of a formalized curriculum. We created an image-based teaching tool and hypothesized that this tool, in a mobile app format, would increase resident comfort with colposcopic practice and quantitatively increase their ability to correlate colposcopic images with impressions. MATERIALS AND METHODS: This was a pilot study conducted among ObGyn residents during March 2021. Thirty-eight residents participated and were randomized to either an app user or an independent study control group. Both groups were surveyed before and after their assigned training and completed a postintervention standardized cognitive examination. The primary end points were subjective improvements in comfort with colposcopy. The secondary end point was performance on a standardized image quiz. RESULTS: Of the 46 targeted residents, 38 participated and 26 completed all elements of the study. On the image examination, app users performed slightly better when compared with the independent study group (mean score, 14.9/25 [SD = 2.15] vs 14.0/25 [SD = 3.27], p = .39). App users also were more likely to be confident in providing an overall colposcopic impression (73% vs 30%, p = .111). One hundred percent of the participants in the app user group said that they would recommend the tool to other residents and residency programs. CONCLUSIONS: Image-based teaching tools, such as the ICE-TI app, are valued by learners and can be a useful adjunct to standardized colposcopy curricula. In addition, making use of a mobile platform facilitated convenience learning.

Randomised controlled trial on the effect of simethicone bowel preparation on rectal variability during image-guided radiation therapy for prostate cancer (SPoRT study).

INTRODUCTION: The purpose of this study was to assess whether simethicone reduces the rectal volume (RV) and gas volume (GV), to increase treatment accuracy and to decrease toxicity of prostate radiation therapy. METHODS: 30 patients were randomised to simethicone or no intervention. Cone-beam computed tomography (CBCT) scans were performed on Days 1-3 and weekly until completion of radiation. RV and GV were measured using volume delineation. Toxicity data were collected. RESULTS: 264 CBCTs were analysed. RV and GV were not significantly different in the simethicone group compared with the control group at each time point (P >0.05) after adjusting for Week 0 values as a covariate. The simethicone group showed an average reduction in RV and GV of 10% and 21%, respectively, compared with the control group (P >0.05). Standard deviations were calculated over 10 time points, which were grouped to represent the first 2-3 weeks of radiation therapy versus subsequent weeks. These were not significantly different between the simethicone and control group. However, there was a statistically significant decrease in the variability of RV at time points 6-10 compared with time points 1-5 within the simethicone group (P = 0.012), but no significant difference was found between these grouped time points in the control group (P = 0.581). The toxicity questionnaires showed no significant difference between the groups. CONCLUSIONS: Simethicone did not decrease the RV or GV overall. However, simethicone appeared to significantly decrease the RV variability from Week three onwards. This suggests that taking simethicone two to three weeks before starting radiation therapy may reduce RV variability, although a larger study is needed to confirm this.

A survey of acute pain service in Canadian teaching hospitals.

BACKGROUND: The first national survey to ascertain the prevalence, structure, and functioning of the APS in Canadian university affiliated hospitals was conducted in 1991. This is a follow-up survey to assess the current status of the APS in Canada. METHODS: We requested completion of a 26-question survey from lead personnel of the APS teams or Anesthesia departments of Canadian teaching hospitals. RESULTS: Among the 32 centers that were contacted, 21 (65.6%) responded. Of these respondents, 18 (85.7%) indicated that they have a structured APS (72.22% adults, 5.56% pediatrics, 22.22% mixed). Among the 18 centers with an APS, 16 of the services are led by an anesthesiologist. Eight centers (44.44%) have a regional anesthesia group, of which five (27.75%) have a regional anesthesia group that is distinct from the APS team. Nine centers (50%) offer ambulatory nerve catheter analgesia after discharge home. Fifteen centers (83.33%) use standardized order sets, and 13 centers (72.22%) use an electronic record for APS. More than 50% of the centers use intravenous lidocaine and ketamine as a part of their multimodal analgesia. CONCLUSION: Most Canadian teaching hospitals do have a functioning APS. This survey has the potential to generate research questions about the availability of standardized and advanced acute pain management in Canada's teaching hospitals.

Patient barrier acceptance during airway management among anesthesiologists: a simulation pilot study.

BACKGROUND: Protection of healthcare providers (HCP) has been a serious challenge in the management of patients during the coronavirus 2019 (COVID-19) pandemic. Additional physical barriers have been created to enhance personal protective equipment (PPE). In this study, user acceptability of two novel barriers was evaluated and the performance of airway management using PPE alone versus PPE plus the additional barrier were compared. METHODS: An open-label, double-armed simulation pilot study was conducted. Each participant performed bag-mask ventilation and endotracheal intubation using a GlideScope in two scenarios: 1) PPE donned, followed by 2) PPE donned plus the addition of either the isolation chamber (IC) or aerosol box (AB). Endotracheal intubation using videolaryngoscopy was timed. Participants completed pre- and post-simulation questionnaires. RESULTS: Twenty-nine participants from the Department of Anesthesia were included in the study. Pre- and post-simulation questionnaire responses supported the acceptance of additional barriers. There was no significant difference in intubating times across all groups (PPE vs. IC 95% CI, 26.3, 35.1; PPE vs. AB 95% CI, 25.9, 35.5; IC vs. AB 95% CI, 23.6, 39.1). Comparison of post-simulation questionnaire responses between IC and AB showed no significant difference. Participants did not find the additional barriers negatively affected communication, visualization, or maneuverability. CONCLUSIONS: Overall, the IC and AB were comparable, and there was no negative impact on performance under testing conditions. Our study suggests the positive acceptance of additional patient protection barriers by anesthesia providers during airway management.

Medications for the prevention of pruritus in women undergoing cesarean delivery with Intrathecal morphine: A systematic review and bayesian network meta-analysis of randomized controlled trials.

PURPOSE: Intrathecal morphine-induced pruritus can cause significant discomfort in parturients and is refractory to conventional antipruritic treatment. This systematic review and network meta-analysis evaluates the effectiveness of the medications used for prevention of intrathecal (IT) morphine-induced pruritus after cesarean delivery under spinal anesthesia. METHODS: A literature search was conducted from 1946 up to October 2019. We included all randomized controlled trials (RCTs) that compared medications used for prevention of pruritus with a control group in women undergoing cesarean delivery under spinal anesthesia with IT morphine. The primary outcome examined was the incidence of pruritus up to 24 h after cesarean delivery. Dichotomous data were extracted and summarized using odds ratios (OR) and 95% credible intervals (CrI) with Bayesian random effects network meta-analysis model. The GRADE approach was used to evaluate quality of the studies and effect evidence. RESULTS: Of the 26 studies included in the systematic review, 21 studies with a total of 2594 patients were included in the network meta-analysis [prophylaxis, n = 1603 (62%) vs. control, n = 991 (38%)]. These studies investigated seven classes of drugs including serotonin-receptor antagonists, dopamine-receptor antagonists, opioid agonist-antagonists, opioid-receptor antagonists, histamine-receptor antagonists, propofol and celecoxib. The network meta-analysis showed that serotonin-receptor antagonists' prophylaxis [control vs. prophylaxis: 60% vs. 47%; OR (95% CrI): 2.69 (1.43-5.36)] and opioid agonist-antagonists prophylaxis [control vs. prophylaxis: 72% vs. 47%; OR (95% CrI): 4.57 (1.67-12.91)] decreased the incidence of pruritus compared to the control group. Although all included studies were at low risk of bias, the quality of the overall network meta-analysis pooled estimates was low. CONCLUSION: This bayesian network meta-analysis of RCTs demonstrates serotonin-receptor antagonists and opioid agonist-antagonists may prevent pruritus in women undergoing cesarean delivery with intrathecal morphine compared to control group. However, further RCTs of adequate power and clearly defined end points are warranted.

Effect of intrathecal lipophilic opioids on the incidence of shivering in women undergoing cesarean delivery after spinal anesthesia: a systematic review and bayesian network meta- analysis of randomized controlled trials.

BACKGROUND: Shivering is a common side effect in women having cesarean delivery (CD) under spinal anesthesia, which can be bothersome to the patient, and it can also interfere with perioperative monitoring. In several studies, the intrathecal (IT) addition of a lipophilic opioid to local anesthetics has been shown to decrease the incidence of shivering. OBJECTIVE: We performed this network meta-analysis to evaluate the effects of intrathecal lipophilic opioids in preventing the incidence of shivering in patients undergoing CD. METHODS: This review was planned according to the PRISMA for Network Meta-Analysis (PRISMA-NMA) guidelines. An English literature search of multiple electronic databases was conducted. We included randomized controlled trials (RCTs) that reported on the incidence of shivering, with study groups receiving either IT fentanyl, sufentanil, or meperidine in women undergoing CD under spinal anesthesia. Quality of the studies was assessed using the modified Oxford scoring system. Using random-effects modeling, dichotomous data were extracted and summarized using odds ratio (OR) with a 95% credible interval (CrI). Statistical analysis was conducted using R studio version 1.0.153 - Inc. RESULTS: Twenty-one studies consisting of 1433 patients (Control group: 590 patients in twenty-one studies; Fentanyl group:199 patients in seven studies; Sufentanil group: 156 patients in five studies; Meperidine group: 488 patients in ten studies) met the inclusion criteria for this systematic review investigating the effect of intrathecal lipophilic opioids in preventing the incidence of shivering in women undergoing cesarean delivery under spinal anesthesia. Methodological validity scores ranged from 3 to 7. The Bayesian mixed network estimate showed the incidence of shivering was significantly lower with IT fentanyl (pooled odds ratio (OR): 0.13; 95% credible interval (CrI): 0.04 to 0.35; P = 0.0004) and IT meperidine (OR: 0.12; 95% CrI: 0.05 to 0.29; P < 0.00001), but not with IT sufentanil (OR: 0.37; 95% CrI: 0.11 to 1.22; P = 0.23). The IT fentanyl group had a significantly lower incidence of intraoperative discomfort [Risk Ratio (RR): 0.19; 95% CI: 0.10-0.35; P < 0.00001], the IT sufentanil group had a significantly higher incidence of pruritus (RR: 6.18; 95% CI: 1.18-32.46; P = 0.03) The IT meperidine group had a significantly lower incidence of intraoperative discomfort (2.7% vs. 13.6%; RR: 0.22; 95% CI: 0.09-0.55; P = 0.001), but there was a significant increase in nausea and vomiting (IT meperidine group vs. Control group: 42.7% vs. 19.4%; RR: 2.56; 95% CI: 1.14-5.75; P = 0.02). Meta-regression analysis based on the opioid dose and quality of the study did not impact the final inference of our result. CONCLUSION: IT fentanyl significantly decreased the incidence of shivering in women undergoing CD under spinal anesthesia without increasing maternal adverse events, confirming that routine use in this patient population is a good choice. IT sufentanil did not decrease the incidence of shivering. IT meperidine decreased the incidence and severity of shivering, but its use was also associated with significant nausea and vomiting.

Condom Social Marketing Effects in Low- and Middle-Income Countries: A Systematic Review Update, 1990 to 2019.

OBJECTIVE: To update the prior systematic review from studies published in the past 9 years that examine the effects of condom social marketing (CSM) programs on condom use in low- and middle-income countries. DATA SOURCES: PubMed, CINAHL, PsycINFO, Sociological Abstracts, and EMBASE. Hand searching of AIDS, AIDS and Behavior, AIDS Care, and AIDS Education and Prevention. STUDY INCLUSION AND EXCLUSION CRITERIA: (a) Published from 1990 to January 16, 2019, (b) low- or middle-income country, (c) evaluated CSM, (d) analyses across preintervention to postintervention exposure or across multiple study arms, (e) measured condom use behavior, and (f) sought to prevent HIV transmission. DATA EXTRACTION: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 reviewers extracted citation, inclusion criteria, methods, study population, setting, sampling, study design, unit of analysis, loss to follow-up, comparison group characteristics, intervention characteristics, and eligible outcome results. DATA SYNTHESIS: The 2012 review found 6 studies (combined N = 23 048). In a meta-analysis, the pooled odds ratio for condom use was 2.01 (95% confidence interval [CI]: 1.42-2.84) for the most recent sexual encounter and 2.10 (95% CI: 1.51-2.91) for a composite of all condom use outcomes. Studies had significant methodological limitations. Of 518 possible new citations identified in the update, no new articles met our inclusion criteria. CONCLUSIONS: More studies are needed with stronger methodological rigor to help provide evidence for the continued use of this approach globally. There is a dearth of studies over the past decade on the effectiveness of CSM in increasing condom use in low- and middle-income countries (LMIC).

Risk/benefit perceptions underlying lower African American Students' illicit stimulant use.

Researchers have documented lower illicit use of prescription stimulants (IUPS) in African American (AA) populations but have not provided empirically-based explanations for this finding. Four gender-balanced groups of AA and Caucasian male/female college students (n = 120/group, mean age of 19.23, SD = 1.30) reported any IUPS and rated their ADHD symptoms (using the Adult ADHD Self-Report Scale; ASRS). AA participants endorsed IUPS less frequently compared to Caucasian participants (9.2% vs. 21.3%; χ2(1) = 13.59, p < .001) and reported lower levels of ADHD symptoms (M = 4.65, SD = 4.17) compared to Caucasians (M = 5.84, SD = 4.22), F(1,473) = 9.83, p < .01. Second, AA participants perceived lower benefits for IUPS than Caucasian participants for targets of concentration (M = 2.29, SD = 1.22 vs. M = 1.79, SD = 1.04, F(1,473) = 23.57, p < .001), alertness (M = 2.29, SD = 1.24 vs. M = 1.92, SD = 0.93, F(1,473) = 18.04, p < .001), and help with studying (M = 2.53, SD = 1.25 vs. M = 1.90, SD = 1.05, F(1,473) = 35.69, p < .001). Third, AA participants perceived higher social risk (M = 2.63, SD = 1.11) than Caucasian participants (M = 3.03, SD = 0.91, F(1,476) = 18.44, p < .001). No significant differences were found for legal or health risks. Despite lower rates of IUPS in AA populations, prevention and treatment programs for AA students are still needed and may benefit from targeting the observed risk/benefit belief patterns.

Improving patient flow in a regional anaesthesia block room.

University Hospital is a tertiary academic centre in London, Ontario, Canada. A designated space known as the block room (BR) supports a model of care to perform regional anaesthesia prior to entering the resource intense operating room (OR). Stress due to time pressure was reported by BR staff. It was presumed that upstream delays in patient admission, preparation, transportation and in the BR resulted in late OR starts. There was limited data for a patient's preoperative transit at our institution. A prospective quality improvement project was conceived to understand and address concerns surrounding patient flow. Using Plan-Do-Study-Act (PDSA) methodology, we collected baseline data of patients perioperative transit and performed three PDSA cycles for improvement. We established targets for OR entry time and patient arrival to the BR. We examined communication between the surgical preparation unit, BRandORs, involved stakeholders in decision making and continuously sourced feedback for improvement. Over three incremental rapid PDSA cycles and reaudit of our baseline, we found a statistically significant improvement in patients arriving to the BR 60 min prior to the scheduled OR time from a baseline of 31%-53% (p=0.04) and patient operations commencing on time improved from 52% to 65% (p=0.03). The availability of patients in the BR within 15 min of a decision to have them available reached 98% from a baseline of 69% (p<0.001). As a result of the quality improvement process, we were able to significantly improve the flow of the preoperative patient journey at our institution. With a better understanding of complex preoperative processes, we can strategically intervene and potentially improve efficiency, morale and safety.

Linac-Based Radiosurgery for Patients With Brain Oligometastases From a Breast Primary, in the Trastuzumab Era-Impact of Tumor Phenotype and Prescribed SRS Dose.

Background: The role of stereotactic radiosurgery (SRS) in the treatment of limited numbers of brain metastases in selected breast cancer patients is well-established. Aims: To analyse outcome from a single institutional experience with SRS, to identify any significant prognostic factors and to assess the influence of Her-2, estrogen receptor status, and prescribed dose on outcome. Methods: The medical records of 56 patients treated at in a single institution between 2009 and 2014 were reviewed. Demographic, treatment related and outcome data were analyzed to identify prognostic factors in this patient population. The primary endpoints were overall survival and local control. Secondary endpoint was distant intra-cranial progression-free survival. Results: The median follow- up time for the entire cohort was 10.33 months (1.25-97.28). The overall median survival was 12.5months (95%CI = 5.8-19.2), with 53.3%, and 35.8% surviving at 1- and 2- years post-SRS. After adjustment for the effect of Her 2 status, uncontrolled extra-cranial disease at the time of SRS predicted for shorter survival (HR for death = 3.1, 95% CI = 1.4-6.9, p = 0.006). At the time of death, 75% of the patients had active, uncontrolled intra-cranial disease, with 56% these patients presenting intra-cranial disease only. Sustained local control was observed in 56 (59.6%) of 94 treated metastases. In univariate analysis, Her2 status, ERHer2 group status?, and prescribed SRS dose were highly significant for local progression free-survival (LPFS). After adjustment for the effect of Her 2 status, patients receiving 12-16 Gy can expect shorter LPFS than those receiving 18-20 Gy (HR = 1.7, 95% CI = 1.0-2.8, p = 0.043). After adjustment for the effect of dose group, patients with Her 2 negative cancer can expect shorter LPFS than those with Her 2 positive cancer (HR = 2.6, 95% CI = 1.5-4.4, p < 0.0005). Use of prior WBRT did not impact survival, local or distant intra-cranial progression-free survival. Conclusions: Survival outcome is similar to the published literature. Improved outcomes are observed in patients with Her 2-positive, controlled extracranial disease at the time of SRS and higher SRS dose delivered. Achieving intra-cranial control appears to be an important factor for the survival of the breast cancer patients in the era of targeted therapies.

Illicit Use of Prescription Stimulants: Gender Differences in Perceptions of Risk.

Background: Little research exists on gender differences regarding the relationship between illicit use of prescription stimulants (IUPS) and perceptions of risk of illicit use. Risk perception is a common target for both prevention and intervention programs. Objectives: To measure gender differences in prevalence rates of illicit use and perceptions of legal, health, and social risks of illicit use. Method: Data from undergraduate students at a large, southeastern university (N = 1,714) were examined for gender differences in prevalence of illicit use and related risk perceptions. Results: More men engaged in illicit use than women (26.2% vs. 18.7%). Overall, men perceived lower legal, health, and social risks related to illicit use. Further, illicit users also perceived lower legal, health, and social risks. Nonusing men perceived lower legal and health risks than nonusing women, but similar levels of social risks. Within the subgroup of illicit users, men perceived lower health risks than women, but similar levels of legal and social risk. Conclusions/Importance: There were significant gender differences in IUPS and risk perception, with particular importance of lack of social risk perceived for all groups and lower health risk perception for men who had engaged in IUPS. It is unclear if the lower risk perceptions are present prior to or after illicit use begins and whether risk perceptions affect the development, maintenance, or termination of illicit use behaviors. Future research is needed to clarify these relationships and to evaluate whether increasing risk perceptions is a viable target for prevention or intervention efforts.

The Evidence Project risk of bias tool: assessing study rigor for both randomized and non-randomized intervention studies.

BACKGROUND: Different tools exist for assessing risk of bias of intervention studies for systematic reviews. We present a tool for assessing risk of bias across both randomized and non-randomized study designs. The tool was developed by the Evidence Project, which conducts systematic reviews and meta-analyses of behavioral interventions for HIV in low- and middle-income countries. METHODS: We present the eight items of the tool and describe considerations for each and for the tool as a whole. We then evaluate reliability of the tool by presenting inter-rater reliability for 125 selected studies from seven published reviews, calculating a kappa for each individual item and a weighted kappa for the total count of items. RESULTS: The tool includes eight items, each of which is rated as being present (yes) or not present (no) and, for some items, not applicable or not reported. The items include (1) cohort, (2) control or comparison group, (3) pre-post intervention data, (4) random assignment of participants to the intervention, (5) random selection of participants for assessment, (6) follow-up rate of 80% or more, (7) comparison groups equivalent on sociodemographics, and (8) comparison groups equivalent at baseline on outcome measures. Together, items (1)-(3) summarize the study design, while the remaining items consider other common elements of study rigor. Inter-rater reliability was moderate to substantial for all items, ranging from 0.41 to 0.80 (median κ = 0.66). Agreement between raters on the total count of items endorsed was also substantial (κw = 0.66). CONCLUSIONS: Strengths of the tool include its applicability to a range of study designs, from randomized trials to various types of observational and quasi-experimental studies. It is relatively easy to use and interpret and can be applied to a range of review topics without adaptation, facilitating comparability across reviews. Limitations include the lack of potentially relevant items measured in other tools and potential threats to validity of some items. To date, the tool has been applied in over 30 reviews. We believe it is a practical option for assessing risk of bias in systematic reviews of interventions that include a range of study designs.

Executive Functioning and Impairment in Emerging Adult College Students With ADHD Symptoms.

Objective: To better understand current issues with adult ADHD assessment contributing to adult ADHD being under recognized and undertreated. Method: This study examined the relationship between symptoms, impairment, and executive functioning (EF) in a college sample. Results: Among individuals screening negative for ADHD, those higher in EF experienced significantly less impairment than those lower in EF. Executive functioning was shown to have a negative relationship with impairment while ADHD symptomology was shown to have a positive relationship with impairment. In addition, impairment was significantly predicted by ADHD symptom level and EF, and there was a significant interaction between EF and ADHD symptom level in predicting impairment. However, high EF did not significantly protect against impairment in individuals reporting a significant level of ADHD symptoms. Conclusion: Further research is needed to clarify the relationships between these variables in emerging adult college students.

Stroke in Indigenous Africans, African Americans, and European Americans: Interplay of Racial and Geographic Factors.

BACKGROUND AND PURPOSE: The relative contributions of racial and geographic factors to higher risk of stroke in people of African ancestry have not been unraveled. We compared stroke type and contributions of vascular risk factors among indigenous Africans (IA), African Americans (AA), and European Americans (EA). METHODS: SIREN (Stroke Investigative Research and Educational Network) is a large multinational case-control study in West Africa-the ancestral home of 71% AA-whereas REGARDS (Reasons for Geographic and Racial Differences in Stroke) is a cohort study including AA and EA in the United States. Using harmonized assessments and standard definitions, we compared data on stroke type and established risk factors for stroke in acute stroke cases aged ≥55 years in both studies. RESULTS: There were 811 IA, 452 AA, and 665 EA stroke subjects, with mean age of 68.0±9.3, 73.0±8.3, and 76.0±8.3 years, respectively (P<0.0001). Hemorrhagic stroke was more frequent among IA (27%) compared with AA (8%) and EA (5.4%; P<0.001). Lacunar strokes were more prevalent in IA (47.1%), followed by AA (35.1%) and then EA (21.0%; P<0.0001). The frequency of hypertension in decreasing order was IA (92.8%), followed by AA (82.5%) and then EA (64.2%; P<0.0001) and similarly for diabetes mellitus IA (38.3%), AA (36.8%), and EA (21.0%; P<0.0001). Premorbid sedentary lifestyle was similar in AA (37.7%) and EA (34.0%) but lower frequency in IA (8.0%). CONCLUSIONS: Environmental risk factors such as sedentary lifestyle may contribute to the higher proportion of ischemic stroke in AA compared with IA, whereas racial factors may contribute to the higher proportion of hypertension and diabetes mellitus among stroke subjects of African ancestry.

Prevention of chronic post-surgical pain: the importance of early identification of risk factors.

Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored.

Perceptions of Risks and Benefits Among Nonprescription Stimulant Consumers, Diverters, and Non-Users.

BACKGROUND: Few studies have examined perceptions of legal and health risks along with the perceived benefits of nonprescription stimulant (NPS) use in college students (e.g., using stimulants such as Ritalin, Vvyanse, Concerta, or Adderall without a prescription). OBJECTIVE: This study sought to better understand how college students perceived legal and health risks, as well as motivations associated with NPS use. The perceived risks and benefits were examined between those involved and those uninvolved. METHOD: The sample comprised 988 undergraduates at a southeastern university. Of the participants, 65.3% (645) were females, 69.1% (682) were freshmen, and 76.5% (756) were Caucasian. Participants from a convenience sample of general psychology students (enrolled August to December 2013) completed an on-line survey regarding behaviors and beliefs about the risks/benefits and motivations related to NPS use. Non-parametric Kruskal-Wallis analyses were conducted to examine perceptions of risks and motivations between those involved and those uninvolved in NPS use. RESULTS: In the sample, 8.1% (n = 80) had a current prescription, with 30 individuals classified as diverters. Of participants, 23.1% (n = 228) reported that they were consumers of NPS medication. Results of the Kruskal-Wallis analyses showed that, compared with uninvolved students, those involved with stimulant medications perceived significantly greater cognitive benefits but less legal and health risks. Conclusions/Importance: College students involved in the misuse (using a stimulant without a prescription or diverting stimulant medication to others) of NPS medications may underestimate associated risks and overestimate benefits.

Exploring Overlaps Between the Genomic and Environmental Determinants of LVH and Stroke: A Multicenter Study in West Africa.

BACKGROUND: Whether left ventricular hypertrophy (LVH) is determined by similar genomic and environmental risk factors with stroke, or is simply an intermediate stroke marker, is unknown. OBJECTIVES: We present a research plan and preliminary findings to explore the overlap in the genomic and environmental determinants of LVH and stroke among Africans participating in the SIREN (Stroke Investigative Research and Education Network) study. METHODS: SIREN is a transnational, multicenter study involving acute stroke patients and age-, ethnicity-, and sex-matched control subjects recruited from 9 sites in Ghana and Nigeria. Genomic and environmental risk factors and other relevant phenotypes for stroke and LVH are being collected and compared using standard techniques. RESULTS: This preliminary analysis included only 725 stroke patients (mean age 59.1 ± 13.2 years; 54.3% male). Fifty-five percent of the stroke subjects had LVH with greater proportion among women (51.6% vs. 48.4%; p < 0.001). Those with LVH were younger (57.9 ± 12.8 vs. 60.6 ± 13.4; p = 0.006) and had higher mean systolic and diastolic blood pressure (167.1/99.5 mm Hg vs 151.7/90.6 mm Hg; p < 0.001). Uncontrolled blood pressure at presentation was prevalent in subjects with LVH (76.2% vs. 57.7%; p < 0.001). Significant independent predictors of LVH were age <45 years (adjusted odds ratio [AOR]: 1.91; 95% confidence interval [CI]: 1.14 to 3.19), female sex (AOR: 2.01; 95% CI: 1.44 to 2.81), and diastolic blood pressure > 90 mm Hg (AOR: 2.10; 95% CI: 1.39 to 3.19; p < 0.001). CONCLUSIONS: The prevalence of LVH was high among stroke patients especially the younger ones, suggesting a genetic component to LVH. Hypertension was a major modifiable risk factor for stroke as well as LVH. It is envisaged that the SIREN project will elucidate polygenic overlap (if present) between LVH and stroke among Africans, thereby defining the role of LVH as a putative intermediate cardiovascular phenotype and therapeutic target to inform interventions to reduce stroke risk in populations of African ancestry.