Association of Contrast Sensitivity With Eye Disease and Vision-Related Quality of Life.

PURPOSE: To investigate contrast sensitivity (CS) as a screening tool to detect eye disease and assess its association with both eye disease and vision-related quality of life. DESIGN: Cross-sectional study. METHODS: Setting and population: Adults receiving care from a free clinic and a Federally Qualified Health Center in Michigan. MAIN OUTCOME MEASURES: Screening positive for eye disease and Visual Function Questionnaire (VFQ) score. OBSERVATION: Participants received a vision exam reviewed via telemedicine for disease, completed a demographic survey, and the 9-item VFQ. The ability of CS to predict eye disease was explored and area under the curve (AUC) is reported. Logistic and linear regression were used to investigate the continuous effect of CS on the probability of screening positive for eye disease and VFQ score, respectively, adjusting for age and visual acuity. RESULTS: 1159 included participants were, on average, 54.9 ± 14.5 years old, 62% identified as female, 34% as White, 54% as Black, 10% as Hispanic/Latino, and reported mean VFQ score of 79.7 ± 15.3. CS ranged from 0.00 to 1.95 log units (mean = 1.54 ± 0.24), 21% of eyes had glaucoma, 19% cataract, 6% DR, and 2% AMD. AUCs were 0.53 to 0.73. A 0.3 log unit decrease in better eye CS was associated with increased odds of glaucoma (odds ratio [OR] = 1.35, confidence interval [CI] = 1.09-1.67), cataract (OR = 1.35, CI = 1.05-1.72), DR (OR = 2.05, CI = 1.51-2.77), and AMD (OR = 2.08, CI = 1.10-3.91). A 0.3 log unit increase in better eye CS was associated with a 5.9 unit increase in VFQ. CONCLUSION: While CS alone is not sufficient to identify people with eye disease, it is an important measure of visual function that can add value to comprehensive eye screening.

Perceptions, Coping Strategies, and Mental Health of Residents during COVID-19.

OBJECTIVES: Since the inception of the coronavirus disease 2019 (COVID-19) pandemic, the United States has been the leader in cases and deaths. Healthcare workers treating these severely ill patients are at risk of many deleterious consequences. Residents, in particular, may be affected by physical as well as psychological consequences. Because data are sparse on perceptions, coping strategies, and the mental health of residents during COVID-19, we explored these issues in survey data from a community-based academic program in the southeastern United States. METHODS: In May 2020, when US deaths from COVID-19 reached 100,000, we administered multiple-choice online anonymous surveys to assess resident perceptions, coping strategies, and self-reported levels of depression, anxiety, and stress. We used the COPE inventory to assess coping strategies and the Depression, Anxiety, and Stress Scale-21 questionnaire. RESULTS: A total of 59 (41.3%) of 143 eligible residents completed the survey, 52 (88.1%) of whom believed that they were likely or very likely to become infected with COVID-19. If infected, 17 (28.8%) believed that their illness would be serious or very serious. The top three strategies to cope with COVID-19 included acceptance, self-distraction, and use of emotional support. With respect to depression, anxiety, and stress, all of the mean scores were in the normal range. CONCLUSIONS: During COVID-19, residents in a southern community-based program with an academic affiliation reported effective coping strategies, predominantly acceptance, self-distraction, and use of emotional support. They reported concerns about becoming infected and, if they did, that their illness would likely be serious. Finally, they have not experienced depression, anxiety, or reported stress. The findings may be restricted in generalizability to a southern community-based program with an academic affiliation.

Primary care providers should prescribe aspirin to prevent cardiovascular disease based on benefit-risk ratio, not age.

Recent guidelines restricted aspirin (ASA) in primary prevention of cardiovascular disease (CVD) to patients <70 years old and more recent guidance to <60.In the most comprehensive prior meta-analysis, the Antithrombotic Trialists Collaboration reported a significant 12% reduction in CVD with similar benefit-risk ratios at older ages. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four trials were added to an updated meta-analysis.ASA produced a statistically significant 13% reduction in CVD with 95% confidence limits (0.83 to 0.92) with similar benefits at older ages in each of the trials.Primary care providers should make individual decisions whether to prescribe ASA based on benefit-risk ratio, not simply age. When the absolute risk of CVD is >10%, benefits of ASA will generally outweigh risks of significant bleeding. ASA should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit such as statins, which are, at the very least, additive to ASA. Our perspective is that individual clinical judgements by primary care providers about prescription of ASA in primary prevention of CVD should be based on our evidence-based solution of weighing all the absolute benefits and risks rather than age. This strategy would do far more good for far more patients as well as far more good than harm in both developed and developing countries. This new and novel strategy for primary care providers to consider in prescribing ASA in primary prevention of CVD is the same as the general approach suggested by Professor Geoffrey Rose decades ago.

Establishing and Maintaining Research Integrity at Academic Institutions: Challenges and Opportunities.

Integrity and trust are essential attributes of medical researchers. Research misconduct represents clear and present dangers to academic institutions and their faculty, residents, students, and staff. To achieve and maintain public trust, medical researchers must achieve and maintain research integrity. To do so requires synchronicity and collaboration between and within academic institutions. Substantial failures to maintain research integrity by institutional leadership will lead to increasing demands to do so from the funding organizations and the general public. This, in turn, will lead to avoidable consequences of substantial penalties, financial and otherwise, adverse publicity, and reputational damage. Researchers must self-regulate to avoid pitfalls, including those created by changes in the medical care delivery system that have decreased the influence of health care providers and increased the influence of outside legal and business interests. Our common goal should be to return public trust in our research enterprise that has done so much good for so many, but requires the establishment and maintenance of vigilance to establish and maintain research integrity.

Alarming Trends in Mortality from Firearms Among United States Schoolchildren.

BACKGROUND: Mortality from firearms among US schoolchildren is an increasingly major clinical and public health crisis. We explored temporal trends in mortality from firearms among US schoolchildren from 1999 to 2017 by age and race. METHODS: We used the Multiple Cause of Death Files of the United States National Center for Health Statistics; PubMed searches, and joinpoint regressions for trend analyses and calculated mortality rates and 95% confidence limits. RESULTS: From 1999 to 2017, the 38,942 deaths due to firearms in school-age children ranged from 340 per year at ages 5-14 to 2050 at 15-18 years. One epidemic among 5- to 14-year-olds began in 2009 and another among 15- to 18-year-olds began in 2014. The listed intents were 61% assault, 32% suicide, 5% accidental, and 2% undetermined. Blacks accounted for 41% of overall deaths, but only 17% of the school-age deaths. 86% of all deaths were boys. CONCLUSIONS: Mortality from firearms in US schoolchildren is increasing at alarming rates, especially among blacks and those aged 15-18 years. To the best of our knowledge, this is the first report to quantify these recent epidemics. Although federal laws prohibited them until recently, analytic studies designed a priori to do so are necessary to test the hypotheses generated by these descriptive data. We believe that combatting the epidemic of mortality from firearms among US schoolchildren without addressing firearms is analogous to combatting the epidemic of mortality from lung cancer from cigarettes without addressing cigarettes.

Pediatric Screening: Development, Anemia, and Lead.

Screening and prevention are important components of general pediatric health care. Infants and young children should be screened for iron deficiency anemia, lead poisoning, and developmental disorders as essential parts of the well-child visit. Developmental and behavioral screening early in childhood is necessary to identify developmental delays and facilitate timely treatment. Lead screening is recommended for at-risk pediatric patients to treat children with elevated lead levels. Infants and children are also at risk for iron deficiency anemia and must be screened appropriately. Familiarization with pediatric screening guidelines is critical for primary care providers caring for children.

Benefits and Risks of Nonsteroidal Anti-inflammatory Drugs: Methodologic Limitations Lead to Clinical Uncertainties.

Nonsteroidal anti-inflammatory drugs (NSAIDs) include traditional (tNSAIDs), such as ibuprofen, naproxen, and diclofenac, as well as selective cyclooxygenase-2 inhibitors (COXIBs), principally celecoxib. COXIBs were developed to decrease gastrointestinal side effects. Recently, the US Food and Drug Administration strengthened its warning about the risks of non-aspirin NSAIDs on myocardial infarction and stroke. The Cyclooxygenase 2 and Non-Steroidal Anti-Inflammatory Drug Trialist collaboration conducted a comprehensive worldwide meta-analysis using individual patient data exploring the risks of various COXIBs and NSAIDs on cardiovascular disease (CVD). Recently, the results of the Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen (PRECISION) trial were published that tested risks of COXIBs and NSAIDs on CVD. Generally, data from meta-analyses of trials not designed a priori to test hypotheses are less reliable than large-scale randomized trials to test small to moderate benefits or harm. When the sample size is large, randomization provides control of confounding not possible to achieve in any observational study. Further, observational studies, and especially claims data, have inherent confounding by indication larger than the effects being sought. Nonetheless, trials must be of sufficient size and duration and achieve high compliance and follow-up to avoid bias and confounding. In this regard, PRECISION has high rates of nonadherence and losses to follow-up that may have introduced bias and confounding. At present, therefore, it may be most prudent for clinicians to remain uncertain about benefits and risks of these drugs and make individual clinical judgments for each of their patients.

Improving Health Outcomes for Immigrant Families Through IPV Screening: Resources and Recommendations for Pediatric Health Care Providers.

Intimate partner violence (IPV) is a significant yet preventable public health problem affecting 1 in 15 children annually. Children exposed to IPV exhibit lifelong consequences including increased risks of social, emotional, psychological and behavioral problems (mood and anxiety disorders, post-traumatic stress disorders, substance abuse, and school-related problems). Limited research exists in identifying and assessing gaps in IPV screening and surveillance techniques for vulnerable populations such as immigrants, refugees, or in families where English is not spoken in the home. The U.S. Department of Health and Human Services recommends IPV screening and counseling as part of pediatric office visits, without providing culturally appropriate tools for use. The nature of the patient-physician relationship and opportunities for intervention occurring during well child visits uniquely positions pediatric health care providers to identify and provide support for IPV victims and children. IPV screening should be routine, culturally appropriate, administered to all caregivers and all providers should be trained in surveilling and screening for IPV in immigrant and vulnerable populations.

Altitude and Variable Effects on Infant Mortality in the United States.

Levine, Robert S., Jason L. Salemi, Maria C. Mejia de Grubb, Sarah K. Wood, Lisa Gittner, Hafiz Khan, Michael A. Langston, Baqar A. Husaini, George Rust, and Charles H. Hennekens. Altitude and variable effects on infant mortality in the United States. High Alt Med Biol. 19:265-271, 2018. AIMS: To explore whether altitude has different effects on infant mortality from newborn respiratory distress, nontraumatic intracranial hemorrhage, and necrotizing enterocolitis. RESULTS: Infants born in the US Mountain Census Division (AR, CO, ID, NV, NM, UT, and WY) had lower mortality from newborn respiratory distress (p < 0.001, mortality rate ratios [MRR] = 0.5 for non-Hispanic blacks and non-Hispanic whites and 0.6 for Hispanic whites) relative to infants born elsewhere in the United States, while Mountain Division non-Hispanic white infants had significantly higher mortality from nontraumatic intracranial hemorrhage (MRR = 1.3 [1.1, 1.6] p < 0.001). After adjustment for state average birth weight, gestational age, and income inequality, a statistically significant, inverse association remained between state average altitude and non-Hispanic white infant mortality from newborn respiratory distress. County altitude (3058 counties in 9 categories from ≤0 to ≥7000 feet) was negatively correlated with newborn respiratory distress (r = -0.91, p < 0.001) and necrotizing enterocolitis (r = -0.81, p = 0.006) at ≤0 to ≥7000 feet and positively correlated with nontraumatic intracranial hemorrhage at ≤0 to 6000-6999 feet (r = 0.78, p = 0.02). CONCLUSIONS: These data show variable cause-specific effects of altitude on infant mortality. Analytic epidemiologic research is needed to confirm or refute the hypotheses generated by these descriptive data.

Texting Brief Podcasts to Deliver Faculty Development to Community-Based Preceptors in Longitudinal Integrated Clerkships.

Introduction: Longitudinal integrated clerkships (LICs) are an increasingly popular clerkship model that relies heavily on community-based preceptors. The availability of an engaged and prepared community-based faculty is crucial to the success of these programs. Teachers in these programs are often geographically separate from medical school campuses, are engaged in busy practices, and have limited time to devote to faculty development activities. Methods: We created a series of five brief faculty development podcasts directed towards community-based teachers in LICs from three US medical schools. Topics included encouraging continuity, bedside teaching, encouraging student ownership of patients, communicating and managing patient results between clinic days, and choosing the right patients for continuity. The podcasts were sent via a grouped text message just prior to preceptors' morning commute time. Pre- and postsurveys assessed the acceptability and effectiveness of the podcasts. Results: Among the 33 postintervention survey responders, 27 (81.8%) listened to at least three podcasts, 21 (63.6%) found them moderately or very helpful, 23 (69.7%) perceived that the podcasts altered their teaching style, 23 (69.7%) would likely or highly likely listen to further podcasts, and 18 (54.5%) would likely or highly likely recommend the podcasts to colleagues. Discussion: In a cohort of multispecialty faculty teaching in LICs, educational podcasts were well received and perceived by preceptors to impact their teaching style. Texting these podcasts to other community-based preceptors may offer an effective strategy for providing faculty development to busy clinicians.

Aspirin in Older Adults: Need for Wider Utilization in Secondary Prevention and Individual Clinical Judgments in Primary Prevention.

In the treatment or secondary prevention of cardiovascular disease (CVD), there is general consensus that the absolute benefits of aspirin far outweigh the absolute risks. Despite evidence from randomized trials and their meta-analyses, older adults, defined as aged 65 years or older, are less likely to be prescribed aspirin than their middle-aged counterparts. In primary prevention, the optimal utilization of aspirin is widely debated. There is insufficient randomized evidence among apparently healthy participants at moderate to high risk of a first CVD event, so general guidelines seem premature. Among older adults, randomized data are even more sparse but trials are ongoing. Further, older adults commonly take multiple medications due to comorbidities, which may increase deleterious interactions and side effects. Older adults have higher risks of occlusive events as well as bleeding. All these considerations support the need for individual clinical judgments in prescribing aspirin in the context of therapeutic lifestyle changes and other adjunctive drug therapies. These include statins for lipids and usually multiple drugs to achieve control of high blood pressure. As regards aspirin, the clinician should weigh the absolute benefit on occlusion against the absolute risk of bleeding. These issues should be considered with each patient to facilitate an informed and person-centered individual clinical judgment. The use of aspirin in primary prevention is particularly attractive because the drug is generally over the counter and, for developing countries where CVD is becoming the leading cause of death, is extremely inexpensive. The more widespread use of aspirin in older adults with prior CVD will confer net benefits to risks and even larger net benefits to costs in the United States as well as other developed and developing countries. In primary prevention among older adults, individual clinical judgments should be made by the health-care professional and each of his or her patients.

Mapping mental health finances in Ghana, Uganda, Sri Lanka, India and Lao PDR.

BACKGROUND: Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services. METHODS: A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions. RESULTS: National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels. CONCLUSIONS: Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs.