Background: Bullying behaviors whether verbal, emotional, or physical impact nurses in several ways. Aim: The purpose of this study was to describe how newly licensed nurses managed the bullying behaviors they experienced. Methods: A qualitative descriptive design was used with 24 newly licensed nurses. Interviews followed an open-ended, semi-structured interview guide. Colaizzi's procedural steps for phenomenological analysis were used to analyze the transcript data. Results: Six themes emerged from the qualitative data: The Bullying, The Perception of the Event, How Bullying Affected Them, How They Dealt with Bullying, How They Wished Bullying Had Been Managed, and What the School Should Do. Conclusions: Organizational support, in the form of policies and procedures, could reduce bullying behaviors and improve nurse efficiency. Additionally, nursing schools can incorporate education about bullying into their curricula to both better prepare new nurses and break the cycle of bullying among nurses. © 2024 The Authors

Despite zoonotic potential, data are lacking on enteric infection diversity in wild apes. We employed a novel molecular diagnostic platform to detect enteric infections in wild chimpanzees and gorillas. Prevalent Cryptosporidium parvum, adenovirus, and diarrheagenic Escherichia coli across divergent sites and species demonstrates potential widespread circulation among apes in Africa.

IMPORTANCE: Depression is a common mental health disorder in the US. Depressive symptoms have been associated with increased cardiovascular disease incidence and mortality, but studies have largely focused on narrow population subgroups. OBJECTIVE: To examine the association between depressive symptoms and mortality in a large, diverse, nationally representative sample of US adults, and to examine how lifestyle factors mediate this association. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective cohort study of a nationally representative sample of US adults using National Health and Nutrition Examination Survey 2005 to 2018 data linked with the National Death Index through 2019 for adults aged 20 years and older. Data were analyzed between March 1 and May 26, 2023. MAIN OUTCOMES AND MEASURES: All-cause, cardiovascular disease, and ischemic heart disease mortality. Depressive symptoms were defined by Patient Health Questionnaire-9 scores and were categorized as none or minimal, mild, and moderate to severe. Secondarily, we assessed degree of mediation by lifestyle factors. RESULTS: A total of 23 694 participants were included (unweighted n = 11 862 male [weighted 49.8%]; mean [SE] age, 44.7 [0.24] years). Prevalences of mild and moderate to severe depression were 14.9% and 7.2%, respectively. For all-cause mortality, hazard ratios were 1.35 (95% CI, 1.07-1.72) for mild depressive symptoms vs none and 1.62 (95% CI, 1.24-2.12) for moderate to severe depressive symptoms vs none. The corresponding hazard ratios were 1.49 (95% CI, 1.11-2.00) and 1.79 (95% CI, 1.22-2.62) for cardiovascular disease mortality and 0.96 (95% CI, 0.58-1.60) and 2.21 (95% CI, 1.24-3.91) for ischemic heart disease mortality. The associations were largely consistent across subgroups. Approximately 11.0% to 16.1% of the associations between depression and mortality could be explained by lifestyle factors. Feeling tired or having little energy, poor appetite or overeating, and having little interest in doing things were independently associated with all-cause and cardiovascular disease mortality but not with ischemic heart disease mortality. CONCLUSIONS AND RELEVANCE: In this prospective cohort study of a nationally representative sample of US adults, there was a graded positive association between depressive symptoms and mortality. Public health efforts to improve awareness and treatment of depression and associated risk factors could support a comprehensive, nationwide strategy to reduce the burden of depression.

BACKGROUND: Exposure to protracted public violence is increasingly referenced as a risk factor for domestic violence, but limited quantitative evidence has demonstrated this association to date. This study analyzes associations in Colombia between lifetime experiences of external violence, including the Colombia civil conflict and community interpersonal violence, and experiences of household violence, including intimate partner and caregiver violence. METHODS AND FINDINGS: We use the 2018 Colombia Violence Against Children and Youth Survey, employing multi-variable logistic regressions to determine the association between exposure to external violence and household violence victimization for females aged 13-24 (n = 1406). Adjusted models controlled for age, ever married, currently in school, and past 12-mo work experience and standard errors were adjusted to account for the multi-stage sampling design. Females who had ever witnessed community violence (39.23 %) faced increased risks of experiencing both physical violence (aOR = 2.81; 95 % CIs: 1.54-5.14; p < 0.001) and emotional violence (aOR: 2.48; 95 % CIs: 1.29-4.75; p < 0.01) from caregivers. Females who had ever witnessed internal conflict (15.99 %) had a greater likelihood of experiencing emotional violence from caregivers (aOR: 5.24; 95 % CIs: 1.86-14.76; p < 0.01) as well as physical violence perpetrated by intimate partners (aOR: 3.31; 95 % CIs: 1.22-8.95; p < 0.05). CONCLUSIONS: This study demonstrates the connection between exposure to community violence and internal conflict and household violence victimization among adolescent and young adult females in Colombia. Findings build the evidence base for more holistic and coordinated policy and programming efforts and foreground the need to identify and support vulnerable populations across socioecological domains in contexts of chronic violence.

BACKGROUND: The American College of Cardiology/American Heart Association Blood Cholesterol Guideline was published in 2013 (2013 Cholesterol Guideline) and the Multi-society Guideline on the Management of Blood Cholesterol in 2018 (2018 Cholesterol Guideline). OBJECTIVE: To compare differences in population level estimates for statin recommendations and use between guidelines. METHODS: Using four 2-year cycles from the National Health and Nutrition Examination Survey (2011-2018), we analyzed data from 8,642 non-pregnant adults aged ≥20 years with complete information for blood cholesterol measurements and other cardiovascular risk factors used to define treatment recommendations in the 2013 or 2018 Cholesterol Guidelines. We compared the prevalence of statin recommendations and use between the guidelines, overall and among patient management groups. RESULTS: Under the 2013 Cholesterol Guideline, an estimated 77.8 million (33.6%) adults would be recommended statins, compared to 46.1 million (19.9%) recommended and 50.1 million (21.6%) considered for statins by the 2018 Cholesterol Guideline. Statin use among those recommended treatment was similar utilizing the 2018 Cholesterol Guideline (47.4%) compared to the 2013 Cholesterol Guideline (47.0%). Differences were observed across demographic and patient management groups. CONCLUSION: Compared to the 2013 Cholesterol Guideline, the prevalence of statin recommendations decreased utilizing the 2018 Cholesterol Guideline algorithm, though additional persons would be considered for treatment after risk factor assessment and patient-clinician discussion under the 2018 Cholesterol Guideline. Statin use was suboptimal (<50%) for those recommended treatment under either guideline. Optimizing patient-clinician risk discussions and shared decision making may be needed to improve treatment rates.

BACKGROUND: Obesity increases the risk for metabolic and cardiovascular disease, and this risk occurs at lower body mass index (BMI) thresholds in Asian adults than in White adults. The degree to which obesity prevalence varies across heterogeneous Asian American subgroups is unclear because most obesity estimates combine all Asian Americans into a single group. OBJECTIVE: To quantify obesity prevalence in Asian American subgroups among U.S. adults using both standard BMI categorizations and categorizations tailored to Asian populations. DESIGN: Cross-sectional. SETTING: United States, 2013 to 2020. PARTICIPANTS: The analytic sample included 2 882 158 adults aged 18 years or older in the U.S. Behavioral Risk Factor Surveillance System surveys (2013 to 2020). Participants self-identified as non-Hispanic White ([NHW] n = 2 547 965); non-Hispanic Black ([NHB] n = 263 136); or non-Hispanic Asian ([NHA] n = 71 057), comprising Asian Indian (n = 13 916), Chinese (n = 11 686), Filipino (n = 11 815), Japanese (n = 12 473), Korean (n = 3634), and Vietnamese (n = 2618) Americans. MEASUREMENTS: Obesity prevalence adjusted for age and sex calculated using both standard BMI thresholds (≥30 kg/m(2)) and BMI thresholds modified for Asian adults (≥27.5 kg/m(2)), based on self-reported height and weight. RESULTS: Adjusted obesity prevalence (by standard categorization) was 11.7% (95% CI, 11.2% to 12.2%) in NHA, 39.7% (CI, 39.4% to 40.1%) in NHB, and 29.4% (CI, 29.3% to 29.5%) in NHW participants; the prevalence was 16.8% (CI, 15.2% to 18.5%) in Filipino, 15.3% (CI, 13.2% to 17.5%) in Japanese, 11.2% (CI, 10.2% to 12.2%) in Asian Indian, 8.5% (CI, 6.8% to 10.5%) in Korean, 6.5% (CI, 5.5% to 7.5%) in Chinese, and 6.3% (CI, 5.1% to 7.8%) in Vietnamese Americans. The prevalence using modified criteria (BMI ≥27.5 kg/m(2)) was 22.4% (CI, 21.8% to 23.1%) in NHA participants overall and 28.7% (CI, 26.8% to 30.7%) in Filipino, 26.7% (CI, 24.1% to 29.5%) in Japanese, 22.4% (CI, 21.1% to 23.7%) in Asian Indian, 17.4% (CI, 15.2% to 19.8%) in Korean, 13.6% (CI, 11.7% to 15.9%) in Vietnamese, and 13.2% (CI, 12.0% to 14.5%) in Chinese Americans. LIMITATION: Body mass index estimates rely on self-reported data. CONCLUSION: Substantial heterogeneity in obesity prevalence exists among Asian American subgroups in the United States. Future studies and public health efforts should consider this heterogeneity. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.

BACKGROUND: Hypertension, defined as blood pressure (BP) 130/80mm Hg or antihypertensive medication use, affects approximately half of US adults, and appropriately-sized BP cuffs are important for accurate BP measurement and hypertension management. METHODS: This cross-sectional study analyzed 13,038 US adults (18y) in the National Health and Nutrition Examination Survey 2015-March 2020 cycles. Recommended BP cuff sizes were categorized based on mid-arm circumference: small adult (26cm), adult (>26 to 34cm), large adult (>34 to 44cm), and extra-large adult (>44cm). Analyses were weighted and proportions were extrapolated to the US population. RESULTS: Among US adults (246 million), recommended cuff sizes were: 6% (16 million) small adult, 51% adult (125 million), 40% large adult (98 million), and 3% extra-large adult (8 million). Among adults with hypertension (116 million), large or extra-large cuffs were needed by over half (51%) overall, including 65% of those aged 18-34 and 84% of those with obesity (BMI 30kg/m 2). By race/ethnicity, the proportion needing a large or extra-large cuff was 57% of non-Hispanic Black adults, 54% of Hispanic adults, 51% of non-Hispanic White adults, and 23% of non-Hispanic Asian adults. Approximately 40% of adults with hypertension in Medicare needed a large or extra-large cuff, compared to 54% for private insurance and 53% for Medicaid. CONCLUSIONS: Over half of US adults with hypertension need a large or extra-large BP cuff.

OBJECTIVE: Ultraprocessed food (UPF) intake is associated with BMI, but effects on regional adipose depots or related to minimally processed food (MPF) intake are unknown. METHODS: Data included 12,297 adults in the National Health and Nutrition Examination Survey (NHANES), 2011 to 2016. This study analyzed associations between usual percentage of kilocalories from UPFs and MPFs and three adiposity indicators: supine sagittal abdominal diametertoheight ratio (SADHtR, estimates visceral adiposity); waist circumferencetoheight ratio (WHtR, estimates abdominal adiposity); and BMI, using linear and multinomial logistic regression. RESULTS: Standardized coefficients per 10% increase in UPF intake were 0.0926, 0.0846, and 0.0791 for SADHtR, WHtR, and BMI, respectively (all p<0.001; p>0.26 for pairwise differences). For MPF intake, the coefficients were-0.0901, -0.0806, and-0.0688 (all p<0.001; p>0.18 pairwise). Adjusted odds ratios (95% CI) for adiposity tertile 3 versus tertile 1 (comparing UPF intake quartiles 2, 3, and 4 to quartile 1) were 1.33 (1.22-1.45), 1.67 (1.43-1.95), and 2.24 (1.76-2.86), respectively, for SADHtR; 1.31 (1.19-1.44), 1.62 (1.37-1.91), and 2.13 (1.63-2.78), respectively, for WHtR; and 1.27 (1.16-1.39), 1.53 (1.31-1.79), and 1.96 (1.53-2.51), respectively, for BMI. MPF intake showed inverse associations with similar trends in association strength. CONCLUSIONS: Among US adults, abdominal and visceral adiposity indictors were positively associated with UPFs and inversely associated with MPFs.

BACKGROUND: Measuring clinically relevant opioid-related problems in health care systems is challenging due to the lack of standard definitions and coding practices. Well-defined, opioid-related health problems (ORHPs) would improve prevalence estimates and evaluation of clinical interventions, crisis response, and prevention activities. We sought to estimate prevalence of opioid use disorder (OUD), opioid misuse, and opioid poisoning among inpatients at a large, safety net, health care institution. METHODS: Our study included events documented in the electronic health records (EHRs) among hospitalized patients at Denver Health Medical Center during January 1, 2017 to December 31, 2018. Multiple EHR markers (ie, opioid-related diagnostic codes, clinical assessment, laboratory results, and free-text documentation) were used to develop diagnosis-based and extended definitions for OUD, opioid misuse, and opioid poisoning. We used these definitions to estimate number of hospitalized patients with these conditions. RESULTS: During a 2-year study period, 715 unique patients were identified solely using opioid-related diagnostic codes; OUD codes accounted for the largest proportion (499/715, 69.8%). Extended definitions identified an additional 973 unique patients (~136% increase), which includes 155/973 (15.9%) who were identified by a clinical assessment marker, 1/973 (0.1%) by a laboratory test marker, and 817/973 (84.0%) by a clinical documentation marker. CONCLUSIONS: Solely using diagnostic codes to estimate prevalence of clinically relevant ORHPs missed most patients with ORHPs. More inclusive estimates were generated using additional EHR markers. Improved methods to estimate ORHPs among a health care system's patients would more fully estimate organizational and economic burden to more efficiently allocate resources and ensure capacity to provide clinical services.

Escherichia albertii is an emerging enteric bacterial pathogen causing watery diarrhea, abdominal distension, vomiting and fever in humans. E. albertii has caused many foodborne outbreaks in Japan and was also reported in other countries worldwide. However, the important animal reservoirs of this pathogen are still largely unknown, impeding us to combat this emerging pathogen. Recently, we reported that wild raccoons (Procyon lotor) and broiler chickens are significant reservoirs of E. albertii in Japan and the U.S., respectively. Here, we performed a longitudinal surveillance to monitor prevalence of E. albertii in wild raccoons in the U.S. and conducted comprehensive comparative analyses of the E. albertii of different origins. A total of 289 fecal swab samples were collected from wild raccoons in Tennessee and Kentucky in the U.S. (2018-2020). Approximately 26% (74/289) of the raccoons examined were PCR-positive for E. albertii and eventually 22 E. albertii isolates were obtained. PFGE analysis showed the U.S. raccoon E. albertii were phylogenetically distant even though the corresponding raccoons were captured from a small area. Unlike the high prevalence of multidrug resistance (83%) observed in previous chicken E. albertii survey, antibiotic resistance was rarely observed in all the U.S. raccoon and 22 Japan raccoon strains with only one Japan strain displaying multidrug resistance (2%). Whole genome sequencing of 54 diverse E. albertii strains and subsequent comparative genomics analysis revealed unique clusters that displayed close evolutionary relationships and similar virulence gene profiles among the strains of different origins in terms of geographical locations (e.g., U.S. and Japan) and hosts (raccoon, chicken, swine, and human). Challenge experiment demonstrated raccoon E. albertii strains could successfully colonize in the chicken intestine at 3 and 8 days postinfection. A pilot environmental survey further showed all the four tested water samples from Tennessee river were E. albertii-positive; two different E. albertii strains, isolated from a single water sample, showed close relationships to those of human origin. Together, the findings from this study provide new insights into the ecology, evolution, and pathobiology of E. albertii, and underscore the need to control the emerging E. albertii in a complex ecosystem using One Health approach.

Extreme heat exposure increases the risk for heat-related illnesses (HRIs) and deaths, and comprehensive strategies to prevent HRIs are increasingly important in a warming climate (1). An estimated 702 HRI-associated deaths and 67,512 HRI-associated emergency department visits occur in the United States each year (2,3). In 2020, Phoenix and Yuma, Arizona, experienced a record 145 and 148 days, respectively, of temperatures >100°F (37.8°C), and a record 522 heat-related deaths occurred in the state. HRIs are preventable through individual and community-based strategies*(,)(†); cooling centers,(§) typically air-conditioned or cooled buildings designated as sites to provide respite and safety during extreme heat, have been established in Maricopa and Yuma counties to reduce HRIs among at-risk populations, such as older adults. This analysis examined trends in HRIs by age during 2010-2020 for Maricopa and Yuma counties and data from a survey of older adults related to cooling center availability and use in Yuma County during 2018-2019. Data from CDC's Social Vulnerability Index (SVI) were also used to overlay cooling center locations with SVI scores. During 2010-2020, heat days, defined as days with an excessive heat warning issued by the National Weather Service Phoenix Office,(¶) for any part of Maricopa and Yuma counties (4), increased in both Maricopa County (1.18 days per year) and Yuma County (1.71 days per year) on average. Adults aged ≥65 years had higher rates of HRI hospitalization compared with those aged <65 years. In a survey of 39 adults aged ≥65 years in Yuma County, 44% reported recent HRI symptoms, and 18% reported electricity cost always or sometimes constrained their use of air conditioning. Barriers to cooling center access among older adults include awareness of location and transportation. Collaboration among diverse community sectors and health profession education programs is important to better prepare for rising heat exposure and HRIs. States and communities can implement adaptation and evaluation strategies to mitigate and assess heat risk, such as the use of cooling centers to protect communities disproportionately affected by HRI during periods of high temperatures.

BACKGROUND: Controlled blood pressure can prevent or reduce adverse health outcomes. Social and structural determinants may contribute to the disparity that despite equivalent proportions on anti-hypertensive medication, non-Hispanic Black (Black) adults have lower blood pressure control and more cardiovascular events than non-Hispanic White (White) adults. METHODS: Data from 2013-2018 National Health and Nutrition Examination Survey were pooled to assess control among Black and White adults by anti-hypertensive medication use and selected characteristics using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Blood Pressure Guideline definition (systolic blood pressure <130mm Hg and diastolic blood pressure <80mm Hg) among 4,739 adults. RESULTS: Among those treated with anti-hypertensive medication, an estimated 34.9% of Black and 45.0% of White adults had controlled blood pressure. Control was lower for Black and White adults among most subgroups of age, sex, education, insurance status, usual source of care, and poverty-income ratio. Black adults had higher use of diuretics (28.5%--Black adults vs. 23.5%--White adults) and calcium channel blockers (24.2%--Black adults vs. 14.7%--White adults) compared to White adults. Control among Black adults was lower than White adults across all medication classes including diuretics (36.1%--Black adults vs. 47.3%--White adults), calcium channel blockers (30.2%--Black adults vs. 40.1%--White adults), and number of medication classes used. CONCLUSIONS: Sub-optimal blood pressure control rates and disparities warrant increased efforts to improve control, which could include addressing social and structural determinants along with emphasizing implementation of the 2017 ACC/AHA Blood Pressure Guideline into clinical practice.

During November 19-21, 2021, an indoor convention (event) in New York City (NYC), was attended by approximately 53,000 persons from 52 U.S. jurisdictions and 30 foreign countries. In-person registration for the event began on November 18, 2021. The venue was equipped with high efficiency particulate air (HEPA) filtration, and attendees were required to wear a mask indoors and have documented receipt of at least 1 dose of a COVID-19 vaccine.* On December 2, 2021, the Minnesota Department of Health reported the first case of community-acquired COVID-19 in the United States caused by the SARS-CoV-2 B.1.1.529 (Omicron) variant in a person who had attended the event (1). CDC collaborated with state and local health departments to assess event-associated COVID-19 cases and potential exposures among U.S.-based attendees using data from COVID-19 surveillance systems and an anonymous online attendee survey. Among 34,541 attendees with available contact information, surveillance data identified test results for 4,560, including 119 (2.6%) persons from 16 jurisdictions with positive SARS-CoV-2 test results. Most (4,041 [95.2%]), survey respondents reported always wearing a mask while indoors at the event. Compared with test-negative respondents, test-positive respondents were more likely to report attending bars, karaoke, or nightclubs, and eating or drinking indoors near others for at least 15 minutes. Among 4,560 attendees who received testing, evidence of widespread transmission during the event was not identified. Genomic sequencing of 20 specimens identified the SARS-CoV-2 B.1.617.2 (Delta) variant (AY.25 and AY.103 sublineages) in 15 (75%) cases, and the Omicron variant (BA.1 sublineage) in five (25%) cases. These findings reinforce the importance of implementing multiple, simultaneous prevention measures, such as ensuring up-to-date vaccination, mask use, physical distancing, and improved ventilation in limiting SARS-CoV-2 transmission, during large, indoor events.(†).

Climate change is already affecting public health through pathways like pollen, air quality, wildfires, and precipitation extremes or temperature extremes.1,2 This Perspective highlights some climate change–related health impacts and US public health response activities affecting allergy-immunology.

This survey study examines prevalence of coronary heart disease and the trend from 2011 to 2018 using self-reported data from the Behavioral Risk Factor Surveillance System.

PURPOSE: Studies of the association between ultraprocessed foods (UPF) and cardiovascular disease risk factors have been mainly focused on the adult population. This study examined the association between usual percentage of calories (%kcal) from UPF and the American Heart Association's seven cardiovascular health (CVH) metrics among U.S. adolescents aged 12-19 years. METHODS: We used data from the National Health and Nutrition Examination Survey 2007-2018 (n = 5,565). The NOVA food system was used to classify UPF according to the extent and purpose of food processing. Each CVH metric was given a score of 0, 1, or 2 (poor, intermediate, or ideal health, respectively). Scores of six metrics were summed (excluding diet) to categorize CVH as low (0-7), moderate (8-10), or high (11-12). The National Cancer Institute's methods were used to estimate usual %kcal from UPF. Multivariable linear regression and multinomial logistic regression were used to evaluate the association between UPF and CVH. RESULTS: Among youth, 12.1% had low CVH, 56.3% moderate, and 31.6% high. The mean usual %kcal from UPF was 65.7%. Every 5% increase in calories from UPF was associated with .13 points lower CVH scores (p < .001). Comparing Q2, Q3, and Q4 to Q1 of UPF intake, the adjusted odds ratios for low versus high CVH were 1.43 (95% confidence interval 1.16-1.76), 1.86 (1.29-2.66), and 2.59 (1.49-4.55), respectively. The pattern of association was largely consistent across subgroups. CONCLUSIONS: U.S. adolescents consume about two thirds of daily calorie from UPF. There was a graded inverse association between %kcal from UPF and CVH score.

Hypertension, which can be brought on by excess sodium intake, affects nearly one half of U.S. adults and is a major risk factor for heart disease, the leading cause of death in the United States (1). In 2019, the National Academies of Sciences, Engineering, and Medicine (NASEM) established the Chronic Disease Risk Reduction (CDRR) intake, a chronic-disease-specific recommendation for dietary sodium of 2,300 mg/day. Reducing daily sodium to CDRR intake is expected to reduce chronic disease risk among healthy persons, primarily by lowering blood pressure (2). Although the 2019 sodium CDRR intake is equivalent in number to the 2005 Tolerable Upper Limit (UL) released by NASEM (then known as the Institute of Medicine), the UL was intended to provide guidance on safe intake levels, not to serve as an intake goal (2). To describe excess sodium intake in the context of the CDRR intake goal, this report analyzed National Health and Nutrition Examination Survey (NHANES) data from 2003 to 2016 to yield temporal trends in usual sodium intake >2,300 mg/day and in mean sodium intake, unadjusted and adjusted for total energy intake, among U.S. adults aged ≥19 years. The percentage of U.S. adults with sodium intake above CDRR intake was 87.0% during 2003-2004 and 86.7% during 2015-2016. Among U.S. adults overall, no significant linear trend was noted from 2003 to 2016 in unadjusted or energy intake-adjusted mean sodium intake. Small, significant declines were observed in mean usual sodium intake among some groups (adults aged 19-50 years, non-Hispanic White adults, adults experiencing obesity, and adults without hypertension). However, after energy adjustment, only adults aged ≥71 years and Mexican American adults demonstrated significant change in usual sodium intake. Many U.S. adults might be at risk for chronic disease associated with sodium intake above CDRR intake, and efforts to lower sodium intake could improve population cardiovascular health. The results of this report support enhanced efforts to reduce population sodium intake and cardiovascular disease risk, including the Food and Drug Administration's (FDA's) recently released guidance for the reduction of sodium in the commercially processed, packaged, and prepared food supply.

Growing research suggests that posttraumatic stress disorder (PTSD) may be a risk factor for poor cardiovascular health, and yet our understanding of who might be at greatest risk of adverse cardiovascular outcomes after trauma is limited. In this study, we conducted the first examination of the individual and synergistic contributions of PTSD symptoms and blood pressure genetics to continuous blood pressure levels. We harnessed the power of the Psychiatric Genomics Consortium-PTSD Physical Health Working Group and investigated these associations across 11 studies of 72,224 trauma-exposed individuals of European (n = 70,870) and African (n = 1,354) ancestry. Genetic contributions to blood pressure were modeled via polygenic scores (PGS) for systolic blood pressure (SBP) and diastolic blood pressure (DBP) that were derived from a prior trans-ethnic blood pressure genome-wide association study (GWAS). Results of trans-ethnic meta-analyses revealed significant main effects of the PGS on blood pressure levels [SBP: β = 2.83, standard error (SE) = 0.06, p < 1E-20; DBP: β = 1.32, SE = 0.04, p < 1E-20]. Significant main effects of PTSD symptoms were also detected for SBP and DBP in trans-ethnic meta-analyses, though there was significant heterogeneity in these results. When including data from the largest contributing study - United Kingdom Biobank - PTSD symptoms were negatively associated with SBP levels (β = -1.46, SE = 0.44, p = 9.8E-4) and positively associated with DBP levels (β = 0.70, SE = 0.26, p = 8.1E-3). However, when excluding the United Kingdom Biobank cohort in trans-ethnic meta-analyses, there was a nominally significant positive association between PTSD symptoms and SBP levels (β = 2.81, SE = 1.13, p = 0.01); no significant association was observed for DBP (β = 0.43, SE = 0.78, p = 0.58). Blood pressure PGS did not significantly moderate the associations between PTSD symptoms and blood pressure levels in meta-analyses. Additional research is needed to better understand the extent to which PTSD is associated with high blood pressure and how genetic as well as contextual factors may play a role in influencing cardiovascular risk.

Anthropogenic activities, such as human population expansion and land-use change, create ecological overlap between humans, domesticated animals, and wildlife and can exacerbate the zoonotic transmission of parasites. To improve our understanding of this dynamic, we employed multi-locus genotyping to conduct a cross-sectional study of the potential for zoonotic transmission of the protozoan parasite Giardia duodenalis among humans, household associated livestock and dogs, and black and gold howler monkeys (Alouatta caraya) in the Corrientes Province of Argentina. We found Giardia prevalence to be highest in howler monkeys (90.3% (47/52)), followed by humans (61.1% (22/36)), dogs (44.4% (16/36)), and cattle (41.9% (18/43)). We further established that howler monkeys exclusively harbored strains of assemblage B (100%) while humans were infected with either assemblage A (13.3%) or B (80%) or A and B (6.7%), and cattle and dogs were infected with either assemblage A (cattle, 94.1%; dogs, 80%)), A and C (10%), or their host-adapted assemblage (cattle, 5.9%; dogs, 10%). Our finding of G. duodenalis in both humans and domesticated animals (assemblage A) and humans and wild primates (assemblage B) suggests that cross-species transmission of multiple assemblages of G. duodenalis may occur in rural complexes such as northern Argentina where people, domesticated animals, and wildlife overlap. We further highlight the need to investigate the implications of these results for human health, the economics of livestock production, and wildlife conservation in this and similar systems. This article is protected by copyright. All rights reserved.

Infectious disease outbreaks pose a significant threat to the conservation of chimpanzees (Pan troglodytes) and all threatened nonhuman primates. Characterizing and mitigating these threats to support the sustainability and welfare of wild populations is of the highest priority. In an attempt to understand and mitigate the risk of disease for the chimpanzees of Gombe National Park, Tanzania, we initiated a long-term health-monitoring program in 2004. While the initial focus was to expand the ongoing behavioral research on chimpanzees to include standardized data on clinical signs of health, it soon became evident that the scope of the project would ideally include diagnostic surveillance of pathogens for all primates (including people) and domestic animals, both within and surrounding the National Park. Integration of these data, along with in-depth post-mortem examinations, have allowed us to establish baseline health indicators to inform outbreak response. Here, we describe the development and expansion of the Gombe Ecosystem Health project, review major findings from the research and summarize the challenges and lessons learned over the past 16 years. We also highlight future directions and present the opportunities and challenges that remain when implementing studies of ecosystem health in a complex, multispecies environment.

Infectious disease is recognized as the greatest threat to the endangered chimpanzees made famous by the groundbreaking work of Dr. Jane Goodall at Gombe National Park (GNP), Tanzania. The permeable boundary of this small protected area allows for regular wildlife-human and wildlife-domestic animal overlap, which may facilitate cross-species transmission of pathogens and antimicrobial resistance. Few studies have examined the prevalence of antimicrobial resistance in wild ape populations. We used molecular techniques to investigate the presence of genes conferring resistance to sulfonamides (often used to treat diarrheal illness in human settings in this region) and tetracycline (used in the past-though much less so now) in fecal specimens from humans, domestic animals, chimpanzees, and baboons in and around GNP. We also tested stream water used by these groups. Sulfonamide resistance was common in humans (74%), non-human primates (43%), and domestic animals (17%). Tetracycline resistance was less common in all groups: humans (14%), non-human primates (3%), and domestic animals (6%). Sul resistance genes were detected from 4/22 (18%) of streams sampled. Differences in sul gene frequencies did not vary by location in humans nor in chimpanzees.

INTRODUCTION: Little information is available about racial/ethnic and geographic variations in long-term survival among older patients (≥65) after acute ischemic stroke (AIS). METHODS: We examined data on 1,019,267 Medicare fee-for-service (FFS) beneficiaries aged 66 or older, hospitalized with a primary diagnosis of AIS from 2008 through 2012. Survival was defined as the time from the date of AIS to date of death, or an end of follow-up date of December 31, 2017. We used Cox proportional hazard models to estimate 5-year survival after AIS, adjusted for age, sex, race and Hispanic ethnicity, poverty level, Charlson Comorbidity Index, and state. RESULTS: Among 1,019,267 Medicare FFS beneficiaries hospitalized with AIS from 2008 through 2012, we documented 701,718 deaths (68.8%) during a median of 4 years of follow-up with 4.08 million person-years. The overall adjusted 5-year survival was 44%. Non-Hispanic Black men had the lowest 5-year survival, and 5-year survival varied significantly by state, from the highest at 49.1% (North Dakota) to the lowest at 40.5% (Hawaii). The ranges between the highest and lowest 5-year survival rates across states also varied significantly by racial/ethnic groups, with percentage point differences of 9.6 among non-Hispanic White, 11.3 among non-Hispanic Black, 17.7 among Hispanic, and 28.5 among other racial/ethnic beneficiaries. CONCLUSION: We identified significant racial/ethnic and geographic variations in 5-year survival rates after AIS among 2008-2012 Medicare FFS beneficiaries. Further study is needed to understand the reasons for these variations and develop prevention strategies to improve survival and racial disparities in survival after AIS.

Objective: Workplace bullying exists in today's healthcare system and often targets newly licensed nurses. Experiences of workplace bullying behavior may negatively affect the nurses' physical and psychological health and impact job satisfaction and staff turnover rates at an organizational level. The purpose of this study was to explore strategies suggested by newly licensed nurses to prevent and intervene during incidents of workplace bullying behavior. Methods: An exploratory qualitative design guided this study. Three open-ended questions asked included: What do you think could be done to prevent a future, similar incident of workplace bullying? If you or someone else attempted to the stop the bullying incident, please describe the actions taken. If you or someone else did not attempt to stop the bullying incident, please state what would need to happen for you to intervene on behalf of yourself or someone else. Surveys were distributed electronically to newly licensed nurses from three baccalaureate nursing programs who had participated in a workplace bullying education intervention study as students. A total of 79 responses were received. Responses to three open-ended questions about recent incidents of workplace bullying behavior were coded and analyzed. Then the Social-Ecological Model was used to organize results into individual, relationship, and organizational level strategies. Results: Most respondents reported experiencing workplace bullying behaviors in the previous six months. Three domains of strategies were identified: Preventing Future Bullying Behavior, Stopping Incidents of Bullying Behavior, and Promoting Others to Act. Conclusions: Results indicated newly licensed nurses desire to be supported by their peers and organization as well as strategies to intervene when bullying behaviors occur. Implications for clinical practice and education are presented.

Habitat disturbance, a common consequence of anthropogenic land use practices, creates human–animal interfaces where humans, wildlife, and domestic species can interact. These altered habitats can influence host–microbe dynamics, leading to potential downstream effects on host physiology and health. Here, we explored the effect of ecological overlap with humans and domestic species and infection with the protozoan parasite Giardia duodenalis on the bacteria of black and gold howler monkeys (Alouatta caraya), a key sentinel species, in northeastern Argentina. Fecal samples were screened for Giardia duodenalis infection using a nested PCR reaction, and the gut bacterial community was characterized using 16S rRNA gene amplicon sequencing. Habitat type was correlated with variation in A. caraya gut bacterial community composition but did not affect gut bacterial diversity. Giardia presence did not have a universal effect on A. caraya gut bacteria across habitats, perhaps due to the high infection prevalence across all habitats. However, some bacterial taxa were found to vary with Giardia infection. While A. caraya's behavioral plasticity and dietary flexibility allow them to exploit a range of habitat conditions, habitats are generally becoming more anthropogenically disturbed and, thus, less hospitable. Alterations in gut bacterial community dynamics are one possible indicator of negative health outcomes for A. caraya in these environments, since changes in host–microbe relationships due to stressors from habitat disturbance may lead to negative repercussions for host health. These dynamics are likely relevant for understanding organism responses to environmental change in other mammals.

BACKGROUND: Recent studies reported increasing trends in hospitalization of stroke patients aged 35-64 years. AIM: To examine changes in risk factor profiles among patients aged 35-64 years hospitalized with acute ischemic stroke between 2006 and 2017 in the United States. METHODS: We used data from the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2006 through 2017. Principal ICD-9-CM/ICD-10-CM codes were used to identify acute ischemic stroke hospitalizations, and secondary codes were used to identify the presence of four major stroke risk factors: hypertension, diabetes, lipid disorders, and tobacco use. We used the relative percent change to assess the changes in the prevalence of risk profile between 2006-2007 and 2016-2017 and linear regression models to obtain the p values for the overall trends across six time periods. RESULTS: Approximately 1.5 million acute ischemic stroke hospitalizations occurred during 2006-2017. The prevalence of having all four risk factors increased from 4.1% in 2006-2007 to 9.1% in 2016-2017 (relative percent change 122.0%, p < 0.001 for trend), prevalence of any three risk factors increased from 24.5% to 33.8% (relative percent change 38.0%, p < 0.001). Prevalence of only two risk factors decreased from 36.1% to 32.7% (p < 0.001), only one risk factor decreased from 25.2% to 18.1% (p < 0.001), and absence of risk factors decreased from 10.1% to 6.2% (p < 0.001). The most prevalent triad of risk factors was hypertension, diabetes, and lipid disorders (14.3% in 2006-2007 and 19.8% in 2016-2017), and the most common dyad risk factors was hypertension and lipid disorders (12.6% in 2006-2007 and 11.9% in 2016-2017). CONCLUSIONS: The prevalence of hospitalized acute ischemic stroke patients aged 35-64 years with all four or any three of four major stroke risk factors increased by 122% and 38%, while those with only one risk factor or no risk factor has declined by 28% and 39%, respectively, from 2006 to 2017. Younger adults are increasingly at higher risk for stroke from preventable and treatable risk factors. This growing public health problem will require clinicians, healthcare systems, and public health efforts to implement more effective prevention strategies among this population.

BACKGROUND: To better understand the relation between sleep problems and CKD, we examined temporal trends in the prevalence of self-reported sleep problems in adults in the United States and their associations with CKD and all-cause mortality. METHODS: Using data from 27,365 adult participants in five biannual National Health and Examination Surveys (2005-2006 through 2013-2014), we studied five self-reported sleep problems-trouble sleeping, sleep disorder, nocturia (urinating ≥2 times/night), inadequate sleep (<7 hours/night), and excessive sleep (>9 hours/night)-plus a composite index. We conducted three types of analysis: temporal trends in the prevalence of each sleep measure by CKD status, using model-based standardization; cross-sectional analysis of associations between four CKD measures and each sleep measure, using logistic regression; and survival analysis of the association between each sleep measure and mortality, using Cox regression. RESULTS: The prevalence of trouble sleeping and sleep disorder increased over the five surveys by 4% and 3%, respectively, whereas the other sleep problems remained relatively stable. All sleep problems, except inadequate sleep, were more common during the study period among adults with CKD than without CKD (40% versus 21% for nocturia; 5% versus 2% for excessive sleep; 30% versus 25% for trouble sleeping; 12% versus 8% for sleep disorder). Both eGFR <30 ml/min per 1.73 m(2) and albuminuria were positively associated with nocturia and excessive sleep. Excessive sleep and nocturia were also associated with higher mortality (adjusted hazard ratio for >9 versus 7-9 hours/night=1.7; 95% CI, 1.3 to 2.1; and for nocturia=1.2; 95% CI, 1.1 to 1.4). CONCLUSIONS: The high prevalence of sleep problems among persons with CKD and their associations with mortality suggest their potential importance to clinical practice. Future work could examine the health effects of identifying and treating sleep problems in patients with CKD.

Stroke is the fifth leading cause of death in the United States (1). In 2017, on average, a stroke-related death occurred every 3 minutes and 35 seconds in the United States, and stroke is a leading cause of long-term disability (1). To prevent mortality or long-term disability, strokes require rapid recognition and early medical intervention (2,3). Common stroke signs and symptoms include sudden numbness or weakness of the face, arm, or leg, especially on one side; sudden confusion or trouble speaking; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, or loss of balance; and a sudden severe headache with no known cause. Recommended action at the first sign of a suspected stroke is to quickly request emergency services (i.e., calling 9-1-1) (2). Public education campaigns have emphasized recognizing stroke signs and symptoms and the importance of calling 9-1-1, and stroke knowledge increased 14.7 percentage points from 2009 to 2014 (4). However, disparities in stroke awareness have been reported (4,5). Knowledge of the five signs and symptoms of stroke and the immediate need to call emergency medical services (9-1-1), collectively referred to as "recommended stroke knowledge," was assessed among 26,076 adults aged ≥20 years as part of the 2017 National Health Interview Survey (NHIS). The prevalence of recommended stroke knowledge among U.S. adults was 67.5%. Stroke knowledge differed significantly by race and Hispanic origin (p<0.001). The prevalence of recommended stroke knowledge was highest among non-Hispanic White adults (71.3%), followed by non-Hispanic Black adults (64.0%) and Hispanic adults (57.8%). Stroke knowledge also differed significantly by sex, age, education, and urbanicity. After multivariable adjustment, these differences remained significant. Increasing awareness of the signs and symptoms of stroke continues to be a national priority. Estimates from this report can inform public health strategies for increasing awareness of stroke signs and symptoms.

BACKGROUND: Higher intake of ultraprocessed foods (UPFs) might be associated with increased risk of cardiovascular disease. OBJECTIVES: Our objective was to examine the association between usual percentage of calories (%kcal) from UPFs and the American Heart Association's "Life's Simple 7" cardiovascular health (CVH) metrics in US adults. METHODS: We analyzed data from 11,246 adults aged ≥20 y from the NHANES 2011-2016 (a cross-sectional, nationally representative survey). UPF designation was assigned on the basis of the NOVA classification system, according to the extent and purpose of food processing. Each CVH metric was given a score of 0, 1, or 2 representing poor, intermediate, or ideal health, respectively. Scores of the 6 metrics (excluding diet) were summed, and CVH was categorized as inadequate (0-4), average (5-8), or optimum (9-12). We used the National Cancer Institute's methods to estimate the usual %kcal from UPFs, and multivariable linear and multinomial logistic regression to assess the association between UPFs and CVH, adjusted for age, sex, race and Hispanic origin, education, and poverty. RESULTS: The weighted prevalence of inadequate, average, and optimum CVH was 8.0%, 51.7%, and 40.3%, respectively. The mean usual %kcal from UPFs was 55.4%, and midpoint of quartiles of intake ranged from 40.4% (quartile 1) to 70.5% (quartile 4). Every 5% increase in calories from UPFs was associated with 0.14 points lower CVH score (P < 0.001). The adjusted ORs for inadequate CVH were 1.40 (95% CI: 1.23, 1.60), 1.82 (1.45, 2.29), and 2.57 (1.79, 3.70), respectively, comparing quartiles 2, 3, and 4 with quartile 1 of UPF intake. The pattern of association was largely consistent across subgroups. CONCLUSIONS: Usual %kcal from UPFs represented more than half of total calorie intake in US adults. A graded inverse association between %kcal from UPFs and CVH was observed.

OBJECTIVES: Multiple early childhood screenings are recommended, but gaps persist in implementation. Our aim for this project was to improve screening, discussion, referral, and follow-up of development, autism spectrum disorder (ASD), maternal depression, and social determinants of health (SDoH) to 90% by July 2018. METHODS: This 1-year national quality improvement collaborative involved 19 pediatric primary care practices. Supported by virtual and in-person learning opportunities, practice teams implemented changes to early childhood screening. Monthly chart reviews were used to assess screening, discussion, referral, and follow-up for development, ASD, maternal depression, and SDoH. Parent surveys were used to assess parent-reported screening and referral and/or resource provision. Practice self-ratings and team surveys were used to assess practice-level changes. RESULTS: Participating practices included independent, academic, hospital-affiliated, and multispecialty group practices and community health centers in 12 states. The collaborative met development and ASD screening goals of >90%. Largest increases in screening occurred for maternal depression (27% to 87%; +222%; P < .001) and SDoH (26% to 76%; +231%; P < .001). Statistically significant increases in discussion of results occurred for all screening areas. For referral, significant increases were seen for development (53% to 86%; P < .001) and maternal depression (23% to 100%; P = .008). Parents also reported increased screening and referral and/or resource provision. Practice-level changes included improved systems to support screening. CONCLUSIONS: Practices successfully implemented multiple screenings and demonstrated improvement in subsequent discussion, referral, and follow-up steps. Continued advocacy for adequate resources to support referral and follow-up is needed to translate increased screening into improved health outcomes.