Risk factors of stroke in Western and Asian countries: a systematic review and meta-analysis of prospective cohort studies.

BACKGROUND: There has been an increasing trend in the incidence of stroke worldwide in recent years, and the number of studies focusing on the risk factors for stroke has also increased every year. To comprehensively evaluate the risk factors of stroke identified in prospective Western and Asian cohort studies. METHODS: Population-based cohort studies on stroke were searched in databases (PubMed, EMBASE, Web of Science, Google Scholar, etc.), and the library of the Third Military Medical University was manually searched for relevant information. A meta-analysis of Western and Asian studies on risk factors was performed. The pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to assess the final group of cohort studies. RESULTS: After screening, 22 prospective cohort studies were included in the analyses of this investigation. Two factors, smoking and alcohol consumption, showed statistically significant differences between Western and Asian populations, and the results were as follows (W/A): 2.05 (95% CI, 1.68 ~ 2.49)/1.27 (95% CI, 1.04 ~ 1.55) and 0.89 (95% CI, 0.76 ~ 1.04)/1.28 (95% CI, 1.07 ~ 1.53). The factor BMI = 18.5-21.9 kg/m2 showed statistically significant differences only in Western populations, 0.96 (95% CI, 0.93 ~ 0.99); the factor SBP = 120-139 mm Hg showed statistically significant differences only in Asian populations, 2.29 (95% CI, 1.04 ~ 5.09). CONCLUSIONS: The prevalences of risk factors affect the stroke morbidity in Western and Asian populations, which may be biased by race. The meta-analysis of population-based studies suggests that different preventive measures should be adopted for Western and Asian population groups that are at high risk for stroke.

Long-term exposure to ambient air pollution and cognitive function in older US adults: The Multi-Ethnic Study of Atherosclerosis.

Air pollution effects on cognitive function have been increasingly recognized. Little is known about the impact of different sources of fine particulate (PM2.5). We aim to evaluate the associations between long-term air pollution exposure, including source-specific components in PM2.5, and cognition in older adults. Methods: Cognitive assessment, including the Cognitive Abilities Screening Instrument (CASI), Digit Symbol Coding (DSC), and Digit Span (DS), was completed in 4392 older participants in the United States during 2010-2012. Residence-specific air pollution exposures (i.e., oxides of nitrogen [NO2/NOx], PM2.5 and its components: elemental carbon [EC], organic carbon [OC], sulfur [S], and silicon [Si]) were estimated by geo-statistical models. Linear and logistic regression models were used to estimate the associations between each air pollutants metric and cognitive function. Results: An interquartile range (IQR) increase in EC (0.8 µg/m3) and Si (23.1 ng/m3) was associated with -1.27 (95% confidence interval [CI]: -0.09, -2.45) and -0.88 (95% CI: -0.21, -1.54) lower CASI scores in global cognitive function. For each IQR increase in Si, the odds of low cognitive function (LCF) across domains was 1.29 times higher (95% CI: 1.04, 1.60). For other tests, NO X was associated with slower processing speed (DSC: -2.01, 95% CI: -3.50, -0.52) and worse working memory (total DS: -0.4, 95% CI: -0.78, -0.01). No associations were found for PM2.5 and two PM2.5 components (OC and S) with any cognitive function outcomes. Conclusion: Higher exposure to traffic-related air pollutants including both tailpipe (EC and NO x ) and non-tailpipe (Si) species were associated with lower cognitive function in older adults.

Assisted living pilot program: utilization and cost findings.

Objective. The Department of Veterans Affairs funded assisted living, adult family home, and adult residential care for the first time in the Assisted Living Pilot Program (ALPP). This article compares the use and cost for individuals that entered ALPP and a comparison group. Method. This was a nonrandomized study. The comparison group consisted of VA patients who were eligible but did not enter an ALPP facility. The ALPP (n = 393) and comparison (n = 259) groups were followed for 12 months to assess ALPP facility, case management, and health care costs. Results. ALPP facility and ALPP case management costs were respectively $5,560 and $2,830 per individual. Total health care costs, including ALPP costs, were $11,533 higher for the ALPP group compared to the comparison group after adjusting for baseline differences. Discussion. Although ALPP successfully helped individuals transition to longer term care in these facilities, it was more costly than the comparison group.

The Characteristics of Human Resources and Related Research Activities among Basic Stem Cell Research Groups in China.

BACKGROUND: This study aimed to evaluate the characteristics of faculty and research activities of basic stem cell research groups in China. METHODS: A questionnaire was administered to persons who knew the information among 46 basic stem cell research groups in China. Multiple linear regression models and repeated-measures analyses of variance were used. Repeated-measures analyses of variance were used. RESULTS: Of the 46 groups, 39.1% did not have any faculty recruited from abroad from 2009 to 2013, 37.0% did not have any faculty with junior-level title, 34.8% had ≤25.0% faculty with either M.D. or Ph.D. degree. Papers published in SCI journals per faculty and having faculty recruited from abroad were positively associated with research funding per faculty. The groups with faculty recruited from abroad had significantly higher research funding per faculty over time compared with the group without faculty recruited from abroad. Repeated-measures analyses of variance showed the group with faculty recruited from abroad had significantly higher research funding per faculty over time compared with the group without faculty recruited from abroad. CONCLUSION: To increase the development of basic stem cell research, some characteristics of human resources should be improved, and the groups should recruit more faculty with overseas experience.

Cost-effectiveness of improving primary care treatment of late-life depression.

CONTEXT: Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care. OBJECTIVE: To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001. SETTING: Eighteen primary care clinics from 8 health care organizations in 5 states. PARTICIPANTS: A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy). MAIN OUTCOME MEASURES: Total outpatient costs, depression-free days, and quality-adjusted life-years. RESULTS: Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were USD $295 (95% CI, -$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was USD $2.76 (95% CI, -$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from USD $2519 (95% CI, -$4517 to $9554) to USD $5037 (95% CI, -$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was "dominant" (ie, lower costs and greater effectiveness). CONCLUSIONS: The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.

Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization.

OBJECTIVE: To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system. DATA SOURCES/STUDY SETTING: Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008). STUDY DESIGN: We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it. PRINCIPAL FINDINGS: We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging. CONCLUSIONS: Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.

Improving the rates of quitting smoking for veterans with posttraumatic stress disorder.

OBJECTIVE: Smoking is highly prevalent and refractory among people with posttraumatic stress disorder (PTSD). This study aimed to improve the rate of quitting smoking for veterans with PTSD by integrating treatment for nicotine dependence into mental health care. METHOD: Smokers undergoing treatment for PTSD (N=66) were randomly assigned to 1) tobacco use treatment delivered by mental health providers and integrated with psychiatric care (integrated care) versus 2) cessation treatment delivered separately from PTSD care by smoking-cessation specialists (usual standard of care). Seven-day point prevalence abstinence was the primary outcome, measured at 2, 4, 6, and 9 months after random assignment. Data were analyzed by using a generalized estimating equations approach following the intent-to-treat principle. RESULTS: Subjects assigned to integrated care were five times more likely than subjects undergoing the usual standard of care to abstain from smoking across follow-up assessment intervals (odds ratio=5.23). Subjects in the integrated care condition were significantly more likely than subjects in usual standard of care to receive transdermal nicotine and nicotine gum. They also received a greater number of smoking-cessation counseling sessions. Stopping smoking was not associated with worsening symptoms of PTSD or depression. CONCLUSIONS: Smoking-cessation interventions can be safely incorporated into routine mental health care for PTSD and are more effective than treatment delivered separately by a specialized smoking-cessation clinic. Integrating cessation treatment into psychiatric care may have the potential for improving smoking quit rates in other populations of chronically mentally ill smokers.

Major depressive disorder and cardiometabolic disease risk among sub-Saharan African adults.

OBJECTIVE: We sought to evaluate the extent to which major depressive disorder (MDD) is associated with cardiometabolic diseases and risk factors. METHODS: This was a cross-sectional epidemiologic study of 1924 employed adults in Ethiopia. Structured interview was used to collect sociodemographic data, behavioral characteristics and MDD symptoms using a validated Patient Health Questionnaire-9 (PHQ-9) depression scale. Fasting blood glucose, insulin, C-reactive protein, and lipid concentrations were measured using standard approaches. Multivariate logistic regression models were fitted to estimate odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: A total of 154 participants screened positive for MDD on PHQ-9 (8.0%; 95% CI: 6.7-9.2%). Among women, MDD was associated with more than 4-fold increased odds of diabetes (OR=4.14; 95% CI: 1.03-16.62). Among men the association was not significant (OR=1.12; 95% CI: 0.63-1.99). Similarly, MDD was not associated with metabolic syndrome among women (OR=1.51; 95% CI: 0.69-3.29) and men (OR=0.61; 95% CI: 0.28-1.34). Lastly, MDD was not associated with increased odds of systemic inflammation. CONCLUSION: The results of our study do not provide convincing evidence that MDD is associated with cardiometabolic diseases among Ethiopian adults. Future studies need to evaluate the effect of other psychiatric disorders on cardiometabolic disease risk.

Resident outcomes of Medicaid-funded community residential care.

PURPOSE: Washington State's initiatives to increase the availability and quality of community residential care presented an opportunity to describe clients entering adult family homes, adult residential care, and assisted living and to identify outcomes of care. DESIGN AND METHODS: We enrolled 349 residents, 243 informal caregivers, and 299 providers in 219 settings. We conducted interviews at enrollment and 12 months later, and we collected data from state databases. RESULTS: The average resident was a 78 year old woman reporting dependence in two of six activities of daily living. Residents in adult family homes demonstrated significantly more disability. Seventy-eight percent of residents survived at the 12-month follow-up. In analyses that controlled for differences at enrollment, residents in the three types of settings were very similar in health outcomes at follow-up. IMPLICATIONS: State policies should reflect the wide range of needs of residents seeking care in these settings. Choices among type of setting can be based on the match of needs to individual preferences.

Design and analysis of post-marketing research.

A post-marketing study is an integral part of research that helps to ensure a favorable risk-benefit profile for approved drugs used in the market. Because most of post-marketing studies use observational designs, which are liable to confounding, estimation of the causal effect of a drug versus a comparative one is very challenging. This article focuses on methodological issues of importance in designing and analyzing studies to evaluate the safety of marketed drugs, especially marketed traditional Chinese medicine (TCM) products. Advantages and limitations of the current designs and analytic methods for postmarketing studies are discussed, and recommendations are given for improving the validity of postmarketing studies in TCM products.

Diagnostic validity of the composite international diagnostic interview (CIDI) depression module in an East African population.

OBJECTIVE: To evaluate the validity and reliability of the structured Composite International Diagnostic Interview (CIDI) in diagnosing current major depressive disorder (MDD) among East African adults. METHODS: A sample of 926 patients attending a major referral hospital in Ethiopia participated in this diagnostic assessment study. We used a two-stage study design where participants were first interviewed using an Amharic version of the CIDI and a stratified random sample underwent a follow-up semi-structured clinical interview conducted by a psychiatrist, blinded to the screening results, using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) instrument. We tested construct validity by examining the association of the CIDI and World Health Organization Quality of Life (WHO-QOL) questionnaire. We calculated the psychometric properties of the CIDI using the SCAN diagnostic interview as a gold standard. RESULTS: We found that the Amharic version of the CIDI diagnostic interview has good internal reliability (Cronbach's alpha = 0.97) among Ethiopian adults. Compared to the SCAN reference standard, the CIDI had fair specificity (72.2%) but low sensitivity (51.0%). Our study provided evidence for unidimensionality of core depression screening questions on the CIDI interview with good factor loadings on a major core depressive factor. CONCLUSION: The Amharic language version of the CIDI had fair specificity and low sensitivity in detecting MDD compared with psychiatrist administered SCAN diagnosis. Our findings are generally consistent with prior studies. Use of fully structured interviews such as the CIDI for MDD diagnosis in clinical settings might lead to under-detection of DSM-IV MDD.

Pharmacological treatment of Alzheimer's disease: effect of race and demographic variables.

Existing research shows differences in medication use for Alzheimer's disease (AD) based on demographics such as race, ethnicity, and geographical location. To determine individual and community characteristics associated with differences in acetylcholinesterase inhibitor (AChEI) and memantine use in AD, 3,049 AD subjects were drawn from 30 centers and evaluated using the Uniform data set (UDS). Cases were evaluated at the individual level within the context of 31 communities (one center encompassed two separate geographical regions). Multivariate analysis was used to determine the significance of individual variables on medication use. Compared to non-Hispanic Whites, Blacks were less likely to use AChEI and memantine with odds ratios (OR) of 0.59 (95% CI 0.46-0.76) and 0.43 (95% CI 0.32-0.57), respectively. Compared to non-Hispanic Whites, non-Black Hispanics were less likely to use memantine (OR=0.69 (95% CI 0.49-0.98)). No association was found between the proportion of Blacks or non-Black Hispanics versus non-Hispanic Whites at an Alzheimer Disease Center and individual use of AChEI or memantine. Other significant variables include gender, age, marital status, dementia severity, source of referral, AChEI use, and education. Education and age somewhat mitigated disparity. Significant racial and ethnic differences in AChEI and memantine use exist at the individual level regardless of the racial and ethnic composition of the individual's community. Research and initiatives at the societal level may be an important consideration toward addressing these differences.

Assessing the equality of means of healthcare costs.

The main analytic problems for assessing the equality of means of healthcare costs are the skewed and heteroscedastic nature of the distribution of healthcare costs and the occurrence of persons with zero cost values. Without taking these special features into consideration, any statistical method may lead to the wrong conclusion. The available analytic methods that are appropriate for handling these features of healthcare costs are reviewed.