Last data update: May 20, 2024. (Total: 46824 publications since 2009)
Records 1-30 (of 72 Records) |
Query Trace: Merritt R [original query] |
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Long-term cardiovascular disease outcomes in non-hospitalized medicare beneficiaries diagnosed with COVID-19: Population-based matched cohort study
Yang Q , Chang A , Tong X , Jackson SL , Merritt RK . PLoS One 2024 19 (5) e0302593 BACKGROUND: SARS-CoV2, the virus that causes coronavirus disease 2019 (COVID-19), can affect multiple human organs structurally and functionally, including the cardiovascular system and brain. Many studies focused on the acute effects of COVID-19 on risk of cardiovascular disease (CVD) and stroke especially among hospitalized patients with limited follow-up time. This study examined long-term mortality, hospitalization, CVD and stroke outcomes after non-hospitalized COVID-19 among Medicare fee-for-service (FFS) beneficiaries in the United States. METHODS: This retrospective matched cohort study included 944,371 FFS beneficiaries aged ≥66 years diagnosed with non-hospitalized COVID-19 from April 1, 2020, to April 30, 2021, and followed-up to May 31, 2022, and 944,371 propensity score matched FFS beneficiaries without COVID-19. Primary outcomes were all-cause mortality, hospitalization, and incidence of 15 CVD and stroke. Because most outcomes violated the proportional hazards assumption, we used restricted cubic splines to model non-proportional hazards in Cox models and presented time-varying hazard ratios (HRs) and Bonferroni corrected 95% confidence intervals (CI). RESULTS: The mean age was 75.3 years; 58.0% women and 82.6% non-Hispanic White. The median follow-up was 18.5 months (interquartile range 16.5 to 20.5). COVID-19 showed initial stronger effects on all-cause mortality, hospitalization and 12 incident CVD outcomes with adjusted HRs in 0-3 months ranging from 1.05 (95% CI 1.01-1.09) for mortality to 2.55 (2.26-2.87) for pulmonary embolism. The effects of COVID-19 on outcomes reduced significantly after 3-month follow-up. Risk of mortality, acute myocardial infarction, cardiomyopathy, deep vein thrombosis, and pulmonary embolism returned to baseline after 6-month follow-up. Patterns of initial stronger effects of COVID-19 were largely consistent across age groups, sex, and race/ethnicity. CONCLUSIONS: Our results showed a consistent time-varying effects of COVID-19 on mortality, hospitalization, and incident CVD among non-hospitalized COVID-19 survivors. |
Co-circulating monkeypox and swinepox viruses, democratic republic of the congo, 2022
Kalonji T , Malembi E , Matela JP , Likafi T , Kinganda-Lusamaki E , Vakaniaki EH , Hoff NA , Aziza A , Muyembe F , Kabamba J , Cooreman T , Nguete B , Witte D , Ayouba A , Fernandez-Nuñez N , Roge S , Peeters M , Merritt S , Ahuka-Mundeke S , Delaporte E , Pukuta E , Mariën J , Bangwen E , Lakin S , Lewis C , Doty JB , Liesenborghs L , Hensley LE , McCollum A , Rimoin AW , Muyembe-Tamfum JJ , Shongo R , Kaba D , Mbala-Kingebeni P . Emerg Infect Dis 2024 30 (4) 761-765 In September 2022, deaths of pigs manifesting pox-like lesions caused by swinepox virus were reported in Tshuapa Province, Democratic Republic of the Congo. Two human mpox cases were found concurrently in the surrounding community. Specific diagnostics and robust sequencing are needed to characterize multiple poxviruses and prevent potential poxvirus transmission. |
Hypertension in pregnancy: Current challenges and future opportunities for surveillance and research
Kuklina EV , Merritt RK , Wright JS , Vaughan AS , Coronado F . J Womens Health (Larchmt) 2024 Hypertension in pregnancy (HP) includes eclampsia/preeclampsia, chronic hypertension, superimposed preeclampsia, and gestational hypertension. In the United States, HP prevalence doubled over the last three decades, based on birth certificate data. In 2019, the estimated percent of births with a history of HP varied from 10.1% to 15.9% for birth certificate data and hospital discharge records, respectively. The use of electronic medical records may result in identifying an additional third to half of undiagnosed cases of HP. Individuals with gestational hypertension or preeclampsia are at 3.5 times higher risk of progressing to chronic hypertension and from 1.7 to 2.8 times higher risk of developing cardiovascular disease (CVD) after childbirth compared with individuals without these conditions. Interventions to identify and address CVD risk factors among individuals with HP are most effective if started during the first 6 weeks postpartum and implemented during the first year after childbirth. Providing access to affordable health care during the first 12 months after delivery may ensure healthy longevity for individuals with HP. Average attendance rates for postpartum visits in the United States are 72.1%, but the rates vary significantly (from 24.9% to 96.5%). Moreover, even among individuals with CVD risk factors who attend postpartum visits, approximately 40% do not receive counseling on a healthy lifestyle. In the United States, as of the end of September 2023, 38 states and the District of Columbia have extended Medicaid coverage eligibility, eight states plan to implement it, and two states proposed a limited coverage extension from 2 to 12 months after childbirth. Currently, data gaps exist in national health surveillance and health systems to identify and monitor HP. Using multiple data sources, incorporating electronic medical record data algorithms, and standardizing data definitions can improve surveillance, provide opportunities to better track progress, and may help in developing targeted policy recommendations. |
Fostering governance and information partnerships for chronic disease surveillance: The Multi-State EHR-Based Network for Disease Surveillance
Kraus EM , Saintus L , Martinez AK , Brand B , Begley E , Merritt RK , Hamilton A , Rubin R , Sullivan A , Karras BT , Grannis S , Brooks IM , Mui JY , Carton TW , Hohman KH , Klompas M , Dixon BE . J Public Health Manag Pract 2024 30 (2) 244-254 CONTEXT: Electronic health records (EHRs) are an emerging chronic disease surveillance data source and facilitating this data sharing is complex. PROGRAM: Using the experience of the Multi-State EHR-Based Network for Disease Surveillance (MENDS), this article describes implementation of a governance framework that aligns technical, statutory, and organizational requirements to facilitate EHR data sharing for chronic disease surveillance. IMPLEMENTATION: MENDS governance was cocreated with data contributors and health departments representing Texas, New Orleans, Louisiana, Chicago, Washington, and Indiana through engagement from 2020 to 2022. MENDS convened a governance body, executed data-sharing agreements, and developed a master governance document to codify policies and procedures. RESULTS: The MENDS governance committee meets regularly to develop policies and procedures on data use and access, timeliness and quality, validation, representativeness, analytics, security, small cell suppression, software implementation and maintenance, and privacy. Resultant policies are codified in a master governance document. DISCUSSION: The MENDS governance approach resulted in a transparent governance framework that cultivates trust across the network. MENDS's experience highlights the time and resources needed by EHR-based public health surveillance networks to establish effective governance. |
Bystander CPR and long-term survival in older adults with out-of-hospital cardiac arrest
Chan PS , Merritt R , McNally B , Chang A , Al-Araji R , Mawani M , Ahn KO , Girotra S . JACC Adv 2023 2 (8) BACKGROUND: Most studies on bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) have focused on in-hospital or short-term survival. OBJECTIVES: The purpose of this study was to examine the association between bystander CPR and long-term survival outcomes for OHCA. METHODS: Within the Cardiac Arrest Registry to Enhance Survival, we identified 152,653 patients with OHCA ≥65 years of age or older. Using multivariable hierarchical logistic regression, we first examined the association between bystander CPR and in-hospital survival. Then, among those surviving to discharge and linked to Medicare files, we evaluated the association between bystander CPR and long-term mortality over 5 years using multivariable Cox regression. RESULTS: Overall, 58,464 (38.3%) received bystander CPR. Patients receiving bystander CPR were more likely to have an OHCA that was witnessed, in a public location, and with an initial shockable rhythm. Bystander CPR was associated with a 24% higher likelihood of surviving to hospital discharge (10.2% vs 5.5%; adjusted relative risk: 1.24 [95% CI: 1.19-1.29]; P < 0.001), and this survival benefit was similar (interaction P = 0.24) for those who were 65 to 74, 75 to 84, and ≥85 years of age. Among patients surviving to hospital discharge (median follow-up of 31 months), bystander CPR was additionally associated with lower long-term mortality vs those without bystander CPR (adjusted hazard ratio: 0.78 [95% CI: 0.73-0.84]; P < 0.001), and this benefit was also consistent across age groups (interaction P = 0.13). CONCLUSIONS: In older adults with OHCA, bystander CPR was associated with higher rates of in-hospital survival. This survival benefit was not attenuated by competing mortality risks but increased in magnitude after hospital discharge. |
Advancing data capacity for economic outcomes in patient-centered outcomes research: Challenges and opportunities
Timbie JW , Reynolds KA , Evans EL , Brown DS , Cohen JW , Darien G , DeVoe JE , Grosse SD , Holve E , Meltzer DO , Merritt JG , Neumann PJ , Yabroff KR , Smith SR . Med Care 2023 61 S161-s165 The economic impacts of health care treatments and services on individuals and their families are central to many decisions people make about the use of health care. However, without the high-quality data needed to generate evidence on the clinical effectiveness and economic impacts of an intervention, decision-makers are generally limited in their ability to make informed health care decisions that reflect patient values and preferences. The importance of evidence on economic impacts, including nonmedical costs and work-related impacts, was recognized in the reauthorization of the Patient-centered Outcomes Research Trust Fund,1 which added economic outcomes to the range of outcomes that should be considered as part of patient-centered outcomes research (PCOR). |
Depressive symptoms and mortality among US adults
Zhang Z , Jackson SL , Gillespie C , Merritt R , Yang Q . JAMA Netw Open 2023 6 (10) e2337011 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. |
The American Heart Association 2030 Impact Goal: A Presidential Advisory From the American Heart Association
Angell SY , McConnell MV , Anderson CAM , Bibbins-Domingo K , Boyle DS , Capewell S , Ezzati M , de Ferranti S , Gaskin DJ , Goetzel RZ , Huffman MD , Jones M , Khan YM , Kim S , Kumanyika SK , McCray AT , Merritt RK , Milstein B , Mozaffarian D , Norris T , Roth GA , Sacco RL , Saucedo JF , Shay CM , Siedzik D , Saha S , Warner JJ . Circulation 2020 141 (9) e120-e138 Each decade, the American Heart Association (AHA) develops an Impact Goal to guide its overall strategic direction and investments in its research, quality improvement, advocacy, and public health programs. Guided by the AHA's new Mission Statement, to be a relentless force for a world of longer, healthier lives, the 2030 Impact Goal is anchored in an understanding that to achieve cardiovascular health for all, the AHA must include a broader vision of health and well-being and emphasize health equity. In the next decade, by 2030, the AHA will strive to equitably increase healthy life expectancy beyond current projections, with global and local collaborators, from 66 years of age to at least 68 years of age across the United States and from 64 years of age to at least 67 years of age worldwide. The AHA commits to developing additional targets for equity and well-being to accompany this overarching Impact Goal. To attain the 2030 Impact Goal, we recommend a thoughtful evaluation of interventions available to the public, patients, providers, healthcare delivery systems, communities, policy makers, and legislators. This presidential advisory summarizes the task force's main considerations in determining the 2030 Impact Goal and the metrics to monitor progress. It describes the aspiration that these goals will be achieved by working with a diverse community of volunteers, patients, scientists, healthcare professionals, and partner organizations needed to ensure success. |
Stroke mortality among Black and White adults aged 35 years before and during the COVID-19 pandemic - United States, 2015-2021
Yang Q , Tong X , Schieb L , Coronado F , Merritt R . MMWR Morb Mortal Wkly Rep 2023 72 (16) 431-436 Stroke is the fifth leading cause of death and a leading cause of long-term disability in the United States (1). Although stroke death rates have declined since the 1950s, age-adjusted rates remained higher among non-Hispanic Black or African American (Black) adults than among non-Hispanic White (White) adults (1,2). Despite intervention efforts to reduce racial disparities in stroke prevention and treatment through reducing stroke risk factors, increasing awareness of stroke symptoms, and improving access to treatment and care for stroke (1,3), Black adults were 45% more likely than were White adults to die from stroke in 2018.* In 2019, age-adjusted stroke death rates (AASDRs) (stroke deaths per 100,000 population) were 101.6 among Black adults and 69.1 among White adults aged ≥35 years. Stroke deaths increased during the early phase of the COVID-19 pandemic (March-August 2020), and minority populations experienced a disproportionate increase (4). The current study examined disparities in stroke mortality between Black and White adults before and during the COVID-19 pandemic. Analysts used National Vital Statistics System (NVSS) mortality data accessed via CDC WONDER(†) to calculate AASDRs among Black and White adults aged ≥35 years prepandemic (2015-2019) and during the pandemic (2020-2021). Compared with that during the prepandemic period, the absolute difference in AASDR between Black and White adults during the pandemic was 21.7% higher (31.3 per 100,000 versus 38.0). During the pandemic period, an estimated 3,835 excess stroke deaths occurred among Black adults (9.4% more than expected) and 15,125 among White adults (6.9% more than expected). These findings underscore the importance of identifying the major factors contributing to the widened disparities; implementing prevention efforts, including the management and control of hypertension, high blood cholesterol, and diabetes; and developing tailored interventions to reduce disparities and advance health equity in stroke mortality between Black and White adults. Stroke is a serious medical condition that requires emergency care. Warning signs of a stroke include sudden face drooping, arm weakness, and speech difficulty. Immediate notification of Emergency Medical Services by calling 9-1-1 is critical upon recognition of stroke signs and symptoms. |
Venous thromboembolism among Medicare acute ischaemic stroke patients with and without COVID-19.
Tong X , Yang Q , Asaithambi G , Merritt RK . Stroke Vasc Neurol 2022 8 (3) 259-262 BACKGROUND: COVID-19 is associated with an increased risk of venous thromboembolism (VTE). This study examined the prevalence of VTE among acute ischaemic stroke (AIS) patients with and without a history of COVID-19. METHODS: We identified AIS hospitalisations of Medicare fee-for-service (FFS) beneficiaries aged ≥65 years from 1 April 2020 to 31 March 2022. We compared the prevalence and adjusted prevalence ratio of VTE among AIS patients with and without a history of COVID-19. RESULTS: Among 283 034 Medicare FFS beneficiaries with AIS hospitalisations, the prevalence of VTE was 4.51%, 2.96% and 2.61% among those with a history of hospitalised COVID-19, non-hospitalised COVID-19 and without COVID-19, respectively. As compared with patients without a history of COVID-19, the prevalence of VTE among patients with a history of hospitalised or non-hospitalised COVID-19 were 1.62 (95% CI 1.54 to 1.70) and 1.13 (95% CI 1.03 to 1.23) times greater, respectively. CONCLUSIONS: There appeared to be a notably higher prevalence of VTE among Medicare beneficiaries with AIS accompanied by a current or prior COVID-19. Early recognition of coagulation abnormalities and appropriate interventions may help improve patients' clinical outcomes. |
Race and ethnicity data in the cardiac arrest registry to enhance survival: Insights from Medicare self-reported data
Chan PS , Merritt R , Chang A , Girotra S , Kotini-Shah P , Al-Araji R , McNally B . Resuscitation 2022 180 64-67 BACKGROUND: For out-of-hospital cardiac arrest (OHCA), assignment of race/ethnicity data can be challenging. Validation of race/ethnicity in registry data with patients' self-reported race/ethnicity would provide insights regarding misclassification. METHODS: Using recently linked 2013-2019 Cardiac Arrest Registry to Enhance Survival (CARES) data with Medicare files, we examined the concordance of race/ethnicity in CARES with self-reported race/ethnicity in Medicare. Among patients with unknown race/ethnicity in CARES, race/ethnicity data from Medicare files were reported. RESULTS: Of 26,875 patients in the linked data, 5757 (21.4%) had unknown race/ethnicity in CARES. Of the remaining 21,118 patients, 14,284 (67.6%) were identified in CARES as non-Hispanic White, 4771 (22.6%) as non-Hispanic Black, 1213 (5.7%) as Hispanic, 760 (3.6%) as Asian or Pacific Islander, and 90 (0.4%) as American Indian or Alaskan Native. The concordance rate for race/ethnicity between CARES and Medicare was 93.4% for patients reported as non-Hispanic White in CARES, 89.1% for non-Hispanic Blacks, 74.6% for Hispanics, 69.6% for Asians and Pacific Islanders, and 37.8% for American Indian or Alaskan Natives. For the 5757 patients with unknown race/ethnicity in CARES, 3973 (69.0%) self-reported in Medicare as non-Hispanic White, 617 (10.7%) as non-Hispanic Black, 425 (7.4%) as Hispanic, 491 (8.5%) as Asian or Pacific Islander, and 52 (0.9%) as American Indian or Alaskan Native. Race/ethnicity remained unknown in 199 (3.5%) of patients. CONCLUSION: Race/ethnicity in CARES was highly concordant with self-reported race/ethnicity in Medicare, especially for non-Hispanic White and Black individuals. For patients with unknown race/ethnicity data in CARES, the vast majority were of White race. |
Long-term outcomes for out-of-hospital cardiac arrest in elderly patients: An analysis of Cardiac Arrest Registry To Enhance Survival data linked to Medicare files
Chan PS , McNally B , Chang A , Girotra S , Al-Araji R , Mawani M , Ahn KO , Merritt R . Circ Cardiovasc Qual Outcomes 2022 15 (10) 101161circoutcomes122009042 BACKGROUND: Most studies on out-of-hospital cardiac arrest have primarily focused on in-hospital or short-term survival. Little is known about long-term outcomes and resource use among survivors of out-of-hospital cardiac arrest. METHODS: In this observationsl study, we describe overall long-term outcomes for patients from the national Cardiac Arrest Registry to Enhance Survival linked to Medicare files to create the Cardiac Arrest Registry to Enhance Survival: Mortality, Events, and Costs for Cardiac Arrest survivors dataset. Cardiac Arrest Registry to Enhance Survival data between 2013 and 2019 were linked to Medicare data using probabilistic matching algorithms. Overall long-term mortality, readmissions, and index hospitalization costs are reported for the overall cohort. RESULTS: Among 56 425 patients who were 65 years of age or older in Cardiac Arrest Registry to Enhance Survival who survived to hospital admission, 26 875 (47.6%) were successfully linked to Medicare files. Mean (+SD) cost of the index hospitalization was $23 262+$24 199 and the median cost was $14 636 (interquartile range, $9930-$30 033). Overall, 8676 (32.3%) survived to hospital discharge with 38.0% discharged home, 11.8% to hospice care, and the remaining 50.2% to other inpatient, skilled nursing care, or rehabilitation facilities. Mortality after discharge was initially high (27.0% at 3 months) and then increased gradually, with 1- and 3-year mortality of 37.1% and 50.1%, respectively. During the first year, 40.1% were readmitted at least once, with 19.7% readmitted on > 1 occasion. CONCLUSIONS: The Cardiac Arrest Registry to Enhance Survival: Mortality, Events, and Costs for Cardiac Arrest survivors registry includes rich data on postdischarge outcomes and resource utilization. Use of this dataset will enable future investigations on the long-term effectiveness, costs, and cost-effectiveness of various interventions for out-of-hospital cardiac arrest in elderly patients. |
Trends in EMS-attended out-of-hospital cardiac arrest survival, United States 2015-2019
Odom E , Nakajima Y , Vellano K , Al-Araji R , Coleman King S , Zhang Z , Merritt R , McNally B . Resuscitation 2022 179 88-93 AIM: Everyday, nearly 1000 U.S. adults experience out-of-hospital cardiac arrest (OHCA). Survival to hospital discharge varies across many factors, including sociodemographics, location of arrest, and whether bystander intervention was provided. The current study examines recent trends in OHCA survival by location of arrest using a cohort of emergency medical service (EMS) agencies that contributed data to the Cardiac Arrest Registry to Enhance Survival. METHODS: The 2015 CARES cohort (N=122,613) includes EMS agencies contributing data across five consecutive years, 2015-2019. We assessed trends in EMS-attended OHCA survival for the 2015 CARES cohort by location of arrest - public, residential, nursing home. Unadjusted and adjusted percentages were estimated using 3-level hierarchical logistic regression models among cases aged 18-65 years. RESULTS: Overall, survival from EMS-attended OHCA significantly increased from 12.5% in 2015 to 13.8% in 2019 (p=0.001). Survival from bystander witnessed arrests also increased significantly from 17.8% in 2015 to 19.7% in 2019 (p=0.004). The trend for survival increased overall and for bystander witnessed OHCAs occurring in public places and nursing homes. CONCLUSION: Increasing trends for EMS-attended OHCA survival were observed in the overall and bystander witnessed groups. No change in the trend for survival was observed among OHCAs in the groups most likely to have a desirable outcome - bystander witnessed, with a shockable rhythm, and receiving bystander intervention. Reporting and monitoring of OHCA may be an important first step in improving outcomes. Additional community interventions focused on bystander CPR and AED use may be warranted. |
COVID-19 and Risk of Acute Ischemic Stroke Among Medicare Beneficiaries Aged 65 Years or Older: Self-Controlled Case Series Study.
Yang Q , Tong X , George MG , Chang A , Merritt RK . Neurology 2022 98 (8) e778-e789 BACKGROUND AND OBJECTIVES: Findings of association between COVID-19 and stroke remain inconsistent, ranging from significant association, absence of association to less than expected ischemic stroke among hospitalized patients with COVID-19. The present study examined the association between COVID-19 and risk of acute ischemic stroke (AIS). METHODS: We included 37,379 Medicare fee-for-service (FFS) beneficiaries aged 65 years diagnosed with COVID-19 from April 1, 2020 through February 28, 2021 and AIS hospitalization from January 1, 2019 through February 28, 2021. We used a self-controlled case series design to examine the association between COVID-19 and AIS and estimated the incident rate ratios (IRR) by comparing incidence of AIS in risk periods (0-3, 4-7, 8-14, 15-28 days after diagnosis of COVID-19) vs. control periods. RESULTS: Among 37,379 Medicare FFS beneficiaries with COVID-19 and AIS, the median age at diagnosis of COVID-19 was 80.4 (interquartile range 73.5-87.1) years and 56.7% were women. When AIS at day of exposure (day=0) included in the risk periods, IRRs at 0-3, 4-7, 8-14, and 15-28 days following COVID-19 diagnosis were 10.3 (95% confidence interval 9.86-10.8), 1.61 (1.44-1.80), 1.44 (1.32-1.57), and 1.09 (1.02-1.18); when AIS at day 0 excluded in the risk periods, the corresponding IRRs were 1.77 (1.57-2.01) (day 1-3), 1.60 (1.43-1.79), 1.43 (1.31-1.56), and 1.09 (1.01-1.17), respectively. The association appeared to be stronger among younger beneficiaries and among beneficiaries without prior history of stroke but largely consistent across sex and race/ethnicities. DISCUSSION: Risk of AIS among Medicare FFS beneficiaries was ten times (day 0 cases in the risk period) as high during the first 3 days after diagnosis of COVID-19 as during the control period and the risk associated with COVID-19 appeared to be stronger among those aged 65-74 years and those without prior history of stroke. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that SARS-CoV-2 infection, the virus that causes COVID-19, is associated with increased risk of AIS in the first three days after diagnosis in Medicare FFS beneficiaries 65 years age. |
COVID-19 Pandemic and Quality of Care and Outcomes of Acute Stroke Hospitalizations: the Paul Coverdell National Acute Stroke Program.
Tong X , King SMC , Asaithambi G , Odom E , Yang Q , Yin X , Merritt RK . Prev Chronic Dis 2021 18 E82 INTRODUCTION: Studies documented significant reductions in emergency department visits and hospitalizations for acute stroke during the COVID-19 pandemic. A limited number of studies assessed the adherence to stroke performance measures during the pandemic. We examined rates of stroke hospitalization and adherence to stroke quality-of-care measures before and during the early phase of pandemic. METHODS: We identified hospitalizations with a clinical diagnosis of acute stroke or transient ischemic attack among 406 hospitals who contributed data to the Paul Coverdell National Acute Stroke Program. We used 10 performance measures to examine the effect of the pandemic on stroke quality of care. We compared data from 2 periods: pre-COVID-19 (week 11-24 in 2019) and COVID-19 (week 11-24 in 2020). We used χ(2) tests for differences in categorical variables and the Wilcoxon-Mann-Whitney rank test or Kruskal-Wallis test for continuous variables. RESULTS: We identified 64,461 hospitalizations. We observed a 20.2% reduction in stroke hospitalizations (from 35,851 to 28,610) from the pre-COVID-19 period to the COVID-19 period. Hospitalizations among patients aged 85 or older, women, and non-Hispanic White patients declined the most. A greater percentage of patients aged 18 to 64 were hospitalized with ischemic stroke during COVID-19 than during pre-COVID-19 (34.4% vs 32.5%, P < .001). Stroke severity was higher during COVID-19 than during pre-COVID-19 for both hemorrhagic stroke and ischemic stroke, and in-hospital death among patients with ischemic stroke increased from 4.3% to 5.0% (P = .003) during the study period. We found no differences in rates of receiving care across stroke type during the study period. CONCLUSION: Despite a significant reduction in stroke hospitalizations, more severe stroke among hospitalized patients, and an increase in in-hospital death during the pandemic period, we found no differences in adherence to quality of stroke care measures. |
Stroke Hospitalizations Before and During COVID-19 Pandemic Among Medicare Beneficiaries in the United States.
Yang Q , Tong X , Coleman King S , Olivari BS , Merritt RK . Stroke 2021 52 (11) 3586-3601 BACKGROUND AND PURPOSE: Emergency department visits and hospitalizations for stroke declined significantly following declaration of coronavirus disease 2019 (COVID-19) as a national emergency on March 13, 2020, in the United States. This study examined trends in hospitalizations for stroke among Medicare fee-for-service beneficiaries aged ≥65 years and compared characteristics of stroke patients during COVID-19 pandemic to comparable weeks in the preceding year (2019). METHODS: For trend analysis, we examined stroke hospitalizations from week 1 in 2019 through week 44 in 2020. For comparison of patient characteristics, we estimated percent reduction in weekly stroke hospitalizations from 2019 to 2020 during weeks 10 through 23 and during weeks 24 through 44 by age, sex, race/ethnicity, and state. RESULTS: Compared to weekly numbers of hospitalizations for stroke reported during 2019, stroke hospitalizations in 2020 decreased sharply during weeks 10 through 15 (March 1-April 11), began increasing during weeks 16 through 23, and remained at a level lower than the same weeks in 2019 from weeks 24 through 44 (June 7-October 31). During weeks 10 through 23, stroke hospitalizations decreased by 22.3% (95% CI, 21.4%-23.1%) in 2020 compared with same period in 2019; during weeks 24 through 44, they decreased by 12.1% (95% CI, 11.2%-12.9%). The magnitude of reduction increased with age but similar between men and women and among different race/ethnicity groups. Reductions in stroke hospitalizations between weeks 10 through 23 varied by state ranging from 0.0% (95% CI, -16.0%-1.7%) in New Hampshire to 36.2% (95% CI, 24.8%-46.7%) in Montana. CONCLUSIONS: One-in-5 fewer stroke hospitalizations among Medicare fee-for-service beneficiaries occurred during initial weeks of the COVID-19 pandemic (March 1-June 6) and weekly stroke hospitalizations remained at a lower than expected level from June 7 to October 31 in 2020 compared with 2019. Changes in stroke hospitalizations varied substantially by state. |
Herpes Zoster Vaccine Live and Risk of Stroke Among Medicare Beneficiaries: A Population-Based Cohort Study
Yang Q , Chang A , Tong X , Merritt R . Stroke 2021 52 (5) 1712-1721 BACKGROUND AND PURPOSE: Herpes zoster (HZ) is associated with increased risk of stroke, and zoster vaccine live (ZVL, Zostavax) reduces the risk of HZ. No study has examined the association between ZVL (Zostavax) and risk of stroke. Present study examined association between receipt of ZVL (Zostavax) and risk of stroke among older US population. METHODS: Our study included 1 603 406 US Medicare fee-for-service beneficiaries aged ≥66 years without a history of stroke and who received ZVL (Zostavax) during 2008 to 2014, and 1 603 406 propensity score-matched unvaccinated beneficiaries followed through to December 31, 2017. We used Cox proportional hazard models to examine association between ZVL (Zostavax) and composite fatal or nonfatal incident stroke outcomes. RESULTS: During a median of 5.1 years follow-up (interquartile range, 3.9-6.7), we documented 64 635 stroke events, including 43 954 acute ischemic strokes and 6727 hemorrhagic strokes, among vaccinated beneficiaries during 8 755 331 person-years. The corresponding numbers among unvaccinated beneficiaries were 73 023, 50 476, and 7276, respectively, during 8 517 322 person-years. Incidence comparing vaccinated to unvaccinated beneficiaries were 7.38 versus 8.57 per 1000 person-years for all stroke, 5.00 versus 5.90 for acute ischemic stroke, and 0.76 versus 0.84 for hemorrhagic stroke (P<0.001 for all difference). Adjusted hazard ratios comparing vaccinated to unvaccinated beneficiaries were 0.84 (95% CI, 0.83-0.85), 0.83 (0.82-0.84), and 0.88 (0.85-0.91) for all stroke, acute ischemic stroke, and hemorrhagic stroke, respectively. The association between ZVL (Zostavax) and risk of stroke appeared to be stronger among younger beneficiaries, beneficiaries who did not take antihypertensive or statin medications and who had fewer comorbid conditions (P<0.05 for interaction) but largely consistent across sex, low-income status, and racial groups. CONCLUSIONS: Among Medicare fee-for-service beneficiaries, receipt of ZVL (Zostavax) was associated with lower incidence of stroke. Our findings may encourage people to get vaccinated against HZ to reduce HZ and HZ-associated stroke risk. |
Racial/ethnic and geographic variations in long-term survival among Medicare beneficiaries after acute ischemic stroke
Tong X , Schieb L , George MG , Gillespie C , Merritt RK , Yang Q . Prev Chronic Dis 2021 18 E15 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. |
Association of usual sodium intake with obesity among US children and adolescents, NHANES 2009-2016
Zhao L , Ogden CL , Yang Q , Jackson SL , Loria CM , Galuska DA , Wiltz JL , Merritt R , Cogswell ME . Obesity (Silver Spring) 2021 29 (3) 587-594 OBJECTIVE: The purpose of this study was to investigate the association of sodium intake with obesity in US children and adolescents. METHODS: Cross-sectional data were analyzed for 9,026 children and adolescents in the National Health and Nutrition Examination Survey (NHANES) 2009-2016. Usual sodium intake was estimated from 24-hour dietary recalls using a measurement error model. Logistic regression was used to assess the association of sodium intake with overweight/obesity, obesity, and central obesity (waist to height ratio [WtHR] ≥ 0.5; waist circumferences (WC) ≥ age- and sex-specific 90th percentile). RESULTS: Mean (SE) sodium intake was 3,010 (9) and 3,404 (20) mg/d for children and adolescents, respectively. The adjusted odds ratio (AOR) comparing Q4 versus Q1 (87.5th vs. 12.5th percentile of sodium intake) among children was 1.98 (95% CI: 1.19-3.28) for overweight/obesity, 2.20 (1.30-3.73) for obesity, 2.10 (1.12-3.95) for WC ≥ 90th percentile, and 1.68 (0.95-2.97) for WtHR ≥ 0.5, adjusting for demographics, energy, and sugar-sweetened beverage intake. Among adolescents, AOR was 1.81 (0.98-3.37) for overweight/obesity, 1.71 (0.82-3.56) for obesity, 1.62 (0.71-3.66) for WC ≥ 90th percentile, and 1.73 (0.85-3.50) for WtHR ≥ 0.5. CONCLUSIONS: Sodium intake was positively associated with overweight/obesity, obesity, and central obesity among US children independent of energy and SSB intake, but the association did not reach significance among adolescents. |
Trends of risk profile among middle-aged adults hospitalized for acute ischemic stroke in United States 2006-2017
Tong X , Yang Q , George MG , Gillespie C , Merritt RK . Int J Stroke 2020 16 (7) 855-862 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. |
Serum sodium and potassium distribution and characteristics in the US Population, National Health and Nutrition Examination Survey 2009-2016
Overwyk KJ , Pfeiffer CM , Storandt RJ , Zhao L , Zhang Z , Campbell NRC , Wiltz JL , Merritt RK , Cogswell ME . J Appl Lab Med 2020 6 (1) 63-78 BACKGROUND: Concern has been expressed by some that sodium reduction could lead to increased prevalence of hyponatremia and hyperkalemia for specific population subgroups. Current concentrations of serum sodium and potassium in the US population can help address this concern. METHODS: We used data from the National Health and Nutrition Examination Survey 2009-2016 to examine mean and selected percentiles of serum sodium and potassium by sex and age group among 25 520 US participants aged 12 years or older. Logistic regression models with predicted residuals were used to examine the age-adjusted prevalence of low serum sodium and high serum potassium among adults aged 20 or older by selected sociodemographic characteristics and by health conditions or medication use. RESULTS: The distributions of serum sodium and potassium concentrations were within normal reference intervals overall and across Dietary Reference Intake life-stage groups, with a few exceptions. Overall, 2% of US adults had low serum sodium (<135 mmol/L) and 0.6% had high serum potassium (>5 mmol/L). Prevalence of low serum sodium and high serum potassium was higher among adults aged 71 or older (4.7 and 2.0%, respectively) and among adults with chronic kidney disease (3.4 and 1.9%), diabetes (5.0 and 1.1%), or using certain medications (which varied by condition), adjusted for age; whereas, prevalence was <1% among adults without these conditions or medications. CONCLUSIONS: Most of the US population has normal serum sodium and potassium concentrations; these data describe population subgroups at higher risk of low serum sodium and high serum potassium and can inform clinical care. |
Comparison of three devices for 24-hour ambulatory blood pressure monitoring in a nonclinical environment through a randomized trial
Nwankwo T , Coleman King SM , Ostchega Y , Zhang G , Loustalot F , Gillespie C , Chang TE , Begley EB , George MG , Shimbo D , Schwartz JE , Muntner P , Kronish IM , Hong Y , Merritt R . Am J Hypertens 2020 33 (11) 1021-1029 BACKGROUND: The U.S. Preventive Services Task Force recommends the use of 24-hour ambulatory blood pressure monitoring (ABPM) as part of screening and diagnosis of hypertension. The optimal ABPM device for population-based surveys is unknown. OBJECTIVE: Among three ABPM devices, we compared the proportion of valid BP readings, mean awake and asleep BP readings, differences between awake ABPM readings and initial standardized BP readings, and sleep experience. RESULTS: The proportions of valid blood pressure readings were not different among the three devices ( p > 0.45). Mean awake and asleep systolic BP were significantly higher for STO device (WA vs. STO vs. SL: 126.65 mmHg, 138.09 mmHg, 127.44 mmHg; 114.34 mmHg, 120.34 mmHg, 113.13 mmHg; p <0.0001 for both). The difference between the initial average standardized mercury systolic BP readings and the ABPM mean awake systolic BP was larger for STO device (WA vs. STO. vs. SL: -5.26 mmHg, -16.24 mmHg, -5.36 mmHg; p <0.0001); diastolic BP mean differences were ~ -6 mmHg for all three devices ( p =0.6). Approximately 55% of participants reported that the devices interfered with sleep; however, there were no sleep differences across the devices (p >0.4 for all). CONCLUSION: Most of the participants met the threshold of 70% valid readings over 24 hours. Sleep disturbance was common but did not interfere with completion of measurement in most of the participants. |
Effect of herpes zoster vaccine and antiviral treatment on risk of ischemic stroke
Yang Q , George MG , Chang A , Tong X , Merritt R , Hong Y . Neurology 2020 95 (6) e708-e717 OBJECTIVE: To determine whether increased risk of acute ischemic stroke (AIS) following herpes zoster (HZ) might be modified by the status of Zoster Vaccine Live (ZVL) vaccination and antiviral treatment following HZ. METHODS: We included 87,405 Medicare fee-for-service beneficiaries aged >/=66 years diagnosed with HZ and AIS from 2008-2017. We used a self-controlled case series design to examine the association between HZ and AIS, and estimated incident rate ratios (IRR) by comparing incidence of AIS in risk periods vs. control periods. To examine effect modification by ZVL and antiviral treatment, beneficiaries were classified into four mutually exclusive groups: (1) no vaccination and no antiviral treatment; (2) vaccination only; (3) antiviral treatment only; and (4) both vaccination and antiviral treatment. We tested for interaction to examine changes in IRRs across 4-groups. RESULTS: Among 87,405 beneficiaries with HZ and AIS, 22.0%, 2.0%, 70.1% and 5.8% were in groups 1 to 4, respectively. IRRs in 0-14, 15-30, 31-90, and 91-180 days following HZ were 1.89 (95% confidence interval [CI],1.77-2.02), 1.58 (95% CI,1.47-1.69), 1.36 (95% CI,1.31-1.42), and 1.19 (95% CI,1.15-1.23), respectively. There was no evidence of effect modification by ZVL and antiviral treatment on AIS (p=0.067 for interaction). The pattern of association between HZ and risk for AIS was largely consistent across age group, sex, and race. CONCLUSIONS: Risk of AIS increased significantly following HZ, and this increased risk was not modified by ZVL and antiviral treatment. Our findings suggest the importance of following recommended HZ vaccination in prevention of HZ and HZ-associated AIS. |
Dietary sodium intake and health indicators: A systematic review of published literature between January 2015 and December 2019
Overwyk KJ , Quader ZS , Maalouf J , Bates M , Webster J , George MG , Merritt RK , Cogswell ME . Adv Nutr 2020 11 (5) 1174-1200 As the science surrounding population sodium reduction evolves, monitoring and evaluating new studies on intake and health can help increase our understanding of the associated benefits and risks. Here we describe a systematic review of recent studies on sodium intake and health, examine the risk of bias (ROB) of selected studies, and provide direction for future research. Seven online databases were searched monthly from January 2015 to December 2019. We selected human studies that met specified population, intervention, comparison, outcome, time, setting/study design (PICOTS) criteria and abstracted attributes related to the study population, design, intervention, exposure, and outcomes, and evaluated ROB for the subset of studies on sodium intake and cardiovascular disease risks or indicators. Of 41,601 abstracts reviewed, 231 studies were identified that met the PICOTS criteria and ROB was assessed for 54 studies. One hundred and fifty-seven (68%) studies were observational and 161 (70%) focused on the general population. Five types of sodium interventions and a variety of urinary and dietary measurement methods were used to establish and quantify sodium intake. Five observational studies used multiple 24-h urine collections to assess sodium intake. Evidence mainly focused on cardiovascular-related indicators (48%) but encompassed an assortment of outcomes. Studies varied in ROB domains and 87% of studies evaluated were missing information on >/=1 domains. Two or more studies on each of 12 outcomes (e.g., cognition) not previously included in systematic reviews and 9 new studies at low ROB suggest the need for ongoing or updated systematic reviews of evidence on sodium intake and health. Summarizing evidence from assessments on sodium and health outcomes was limited by the various methods used to measure sodium intake and outcomes, as well as lack of details related to study design and conduct. In line with research recommendations identified by the National Academies of Science, future research is needed to identify and standardize methods for measuring sodium intake. |
Anti-PfGARP activates programmed cell death of parasites and reduces severe malaria.
Raj DK , Das Mohapatra A , Jnawali A , Zuromski J , Jha A , Cham-Kpu G , Sherman B , Rudlaff RM , Nixon CE , Hilton N , Oleinikov AV , Chesnokov O , Merritt J , Pond-Tor S , Burns L , Jolly G , Ben Mamoun C , Kabyemela E , Muehlenbachs A , Lambert L , Orr-Gonzalez S , Gnadig NF , Fidock DA , Park S , Dvorin JD , Pardi N , Weissman D , Mui BL , Tam YK , Friedman JF , Fried M , Duffy PE , Kurtis JD . Nature 2020 582 (7810) 104-108 Malaria caused by Plasmodium falciparum remains the leading single-agent cause of mortality in children1, yet the promise of an effective vaccine has not been fulfilled. Here, using our previously described differential screening method to analyse the proteome of blood-stage P. falciparum parasites2, we identify P. falciparum glutamic-acid-rich protein (PfGARP) as a parasite antigen that is recognized by antibodies in the plasma of children who are relatively resistant—but not those who are susceptible—to malaria caused by P. falciparum. PfGARP is a parasite antigen of 80 kDa that is expressed on the exofacial surface of erythrocytes infected by early-to-late-trophozoite-stage parasites. We demonstrate that antibodies against PfGARP kill trophozoite-infected erythrocytes in culture by inducing programmed cell death in the parasites, and that vaccinating non-human primates with PfGARP partially protects against a challenge with P. falciparum. Furthermore, our longitudinal cohort studies showed that, compared to individuals who had naturally occurring anti-PfGARP antibodies, Tanzanian children without anti-PfGARP antibodies had a 2.5-fold-higher risk of severe malaria and Kenyan adolescents and adults without these antibodies had a twofold-higher parasite density. By killing trophozoite-infected erythrocytes, PfGARP could synergize with other vaccines that target parasite invasion of hepatocytes or the invasion of and egress from erythrocytes. |
Lessons from the first 6 years of an intervention-based field epidemiology training programme in Papua New Guinea, 2013-2018
Ropa B , Flint J , O'Reilly M , Pavlin BI , Dagina R , Peni B , Bauri M , Pukienei A , Merritt T , Terrell-Perica S , Yamba A , Prybylski D , Collins J , Durrheim DN , Henderson A , Bieb S . BMJ Glob Health 2019 4 (6) e001969 Papua New Guinea (PNG) faces a critical shortage of human resources to address pressing public health challenges arising from an increasing burden of communicable and non-communicable diseases. PNG is an independent State in the Pacific and home to 8.2 million people. Resource and infrastructure constraints due to the country's challenging geography have made it difficult and expensive to deliver health services and implement health programmes. The National Department of Health and its partners developed a field epidemiology training programme of Papua New Guinea (FETPNG) to strengthen the country's public health workforce. The training programme covers field epidemiology competencies and includes the design, implementation and evaluation of evidence-based interventions by Fellows. From 2013 to 2018, FETPNG graduated 81 field epidemiologists. Most FETPNG graduates (84%) were from provincial or district health departments or organisations. Many of their intervention projects resulted in successful public health outcomes with tangible local impacts. Health challenges addressed included reducing the burden of multi-drug resistant-tuberculosis (TB), increasing immunisation coverage, screening and treating HIV/TB patients, and improving reproductive health outcomes. FETPNG Fellows and graduates have also evaluated disease surveillance systems and investigated disease outbreaks. Early and unwavering national ownership of FETPNG created a sustainable programme fitting the needs of this low-resource country. A focus on designing and implementing effective public health interventions not only provides useful skills to Fellows but also contributes to real-time, tangible and meaningful improvements in the health of the population. The graduates of FETPNG now provide a critical mass of public health practitioners across the country. Their skills in responding to outbreaks and public health emergencies, in collecting, analysing and interpreting data, and in designing, implementing and evaluating public health interventions continues to advance public health in PNG. |
Effect of a fruit and vegetable prescription program on children's fruit and vegetable consumption
Ridberg RA , Bell JF , Merritt KE , Harris DM , Young HM , Tancredi DJ . Prev Chronic Dis 2019 16 E73 INTRODUCTION: Most children in families with low income do not meet dietary guidance on fruit and vegetable consumption. Fruit and vegetable prescription programs improve access to and affordability of health-supporting foods for adults, but their effect on dietary behavior among children is not known. The objective of this study was to describe the extent to which exposure to a fruit and vegetable prescription program was associated with changes in consumption among participants aged 2 to 18. METHODS: We used data from a modified National Cancer Institute screener to calculate fruit and vegetable intake among 883 children who were overweight or had obesity and participated in a 4- to 6-month fruit and vegetable prescription program at federally qualified health centers during 4 years (2012-2015). Secondary analyses in 2017 included paired t tests to compare change in fruit and vegetable consumption (cups/day) between first and last visits and multivariable linear regressions, including propensity dose-adjusted models, to model this change as a function of sociodemographic and program-specific covariates, such as number of clinical visits and value of prescription redemption. RESULTS: We found a dose propensity-adjusted increase of 0.32 cups (95% confidence interval, 0.19-0.45 cups) for each additional visit while holding constant the predicted number of visits and site. An equal portion of the change-score increase was attributed to vegetable consumption and fruit consumption (beta = 0.16 for each). CONCLUSION: Fruit and vegetable prescription programs in clinical settings may increase fruit and vegetable consumption among children in low-income households. Future research should use a comparison group and consider including qualitative analysis of site-specific barriers and facilitators to success. |
The burden of cerebrovascular disease in the United States
Tong X , Yang Q , Ritchey MD , George MG , Jackson SL , Gillespie C , Merritt RK . Prev Chronic Dis 2019 16 E52 INTRODUCTION: Little is known about trends in the overall combined burden of fatal and nonfatal cerebrovascular disease events in the United States. Our objective was to describe the combined burden by age, sex, and region from 2006 through 2014. METHODS: We used data on adults aged 35 and older from 2006 through 2014 Nationwide Emergency Department Sample, National Inpatient Sample of the Healthcare Cost and Utilization Project, and the National Vital Statistics System. We calculated age-standardized cerebrovascular disease event rates by using the 2010 US Census population. Trends in rates were assessed by calculating the relative percentage change (RPC) between 2006 and 2014, and by using Joinpoint to obtain P values for overall trends. RESULTS: The age-standardized rate increased significantly for total cerebrovascular disease events (primary plus comorbid events) from 1,050 per 100,000 in 2006 to 1,147 per 100,000 in 2014 (P < .05 for trend). Treat-and-release emergency department visits with comorbid cerebrovascular disease events increased significantly, from 114 per 100,000 in 2006 to 213 per 100,000 in 2014 (RPC of 87%, P < .05 for trend). Significant rate increases were identified among adults aged 35 to 64 with an RPC of 19% in primary cerebrovascular disease events, 48% in comorbid cerebrovascular disease events, and 36% in total events. CONCLUSION: Our findings have important implications for the increasing cerebrovascular disease burden among adults aged 35 to 64. Focused prevention strategies should be implemented, especially among young adults who may be unaware of existing modifiable risk factors. |
Association between cardiovascular health metrics and depression among U.S. adults: National Health and Nutrition Examination Survey, 2007-2014
Zhang Z , Jackson S , Merritt R , Gillespie C , Yang Q . Ann Epidemiol 2019 31 49-56 e2 PURPOSE: The American Heart Association has identified seven modifiable cardiovascular health (CVH) metrics, including four health behaviors (body mass index, smoking, physical activity, and dietary intake) and three health factors (total cholesterol, blood pressure, and fasting glucose). We sought to examine the association between CVH metrics and depression. METHODS: We analyzed data on 14,561 adults aged 20 years or older from the National Health and Nutrition Examination Survey 2007-2014. Depressive symptoms were assessed using the Patient Health Questionnaire; a score of 0-4, 5-9, and 10 or higher represented no or minimal, mild, moderate or severe depressive symptoms, respectively. CVH was categorized as inadequate, average, or optimum. We used multinomial logistic regression to assess the association between CVH and depression, adjusted for age, gender, race or ethnicity, education, and alcohol use. RESULTS: Prevalence of inadequate, average, and optimum CVH were 6.1%, 59.7%, and 34.2%; 14.9% and 7.8% of adults had mild and moderate/severe depression, respectively. Compared with participants with optimum CVH, prevalence ratios for moderate or severe depression were 4.39 (95% confidence interval, 3.32-5.80) and 2.64 (2.15-3.24) for those with inadequate and average CVH, respectively. The corresponding prevalence ratios for mild depression were 2.11 (1.77-2.52) and 1.36 (1.19-1.55). The association appeared to be stronger for CVH behaviors. CONCLUSIONS: There was a graded association between CVH metrics, particularly for health behaviors, and mild and moderate/severe depression among U.S. adults. |
Association of usual 24-h sodium excretion with measures of adiposity among adults in the United States: NHANES, 2014
Zhao L , Cogswell ME , Yang Q , Zhang Z , Onufrak S , Jackson SL , Chen TC , Loria CM , Wang CY , Wright JD , Terry AL , Merritt R , Ogden CL . Am J Clin Nutr 2019 109 (1) 139-147 Background: Both excessive sodium intake and obesity are risk factors for hypertension and cardiovascular disease. The association between sodium intake and obesity is unclear, with few studies assessing sodium intake using 24-h urine collection. Objectives: Our objective was to assess the association between usual 24-h sodium excretion and measures of adiposity among US adults. Methods: Cross-sectional data were analyzed from a sample of 730 nonpregnant participants aged 20-69 y who provided up to 2 complete 24-h urine specimens in the NHANES 2014 and had data on overweight or obesity [body mass index (kg/m2) >/=25] and central adiposity [waist circumference (WC): >88 cm for women, >102 cm for men]. Measurement error models were used to estimate usual sodium excretion, and multiple linear and logistic regression models were used to assess its associations with measures of adiposity, adjusting for sociodemographic, health, and dietary variables [i.e., energy intake or sugar-sweetened beverage (SSB) intake]. All analyses accounted for the complex survey sample design. Results: Unadjusted mean +/- SE usual sodium excretion was 3727 +/- 43.5 mg/d and 3145 +/- 55.0 mg/d among participants with and without overweight/obesity and 3653 +/- 58.1 mg/d and 3443 +/- 35.3 mg/d among participants with or without central adiposity, respectively. A 1000-mg/d higher sodium excretion was significantly associated with 3.8-units higher BMI (95% CI: 2.8, 4.8) and a 9.2-cm greater WC (95% CI: 6.9, 11.5 cm) adjusted for covariates. Compared with participants in the lowest quartile of sodium excretion, the adjusted prevalence ratios in the highest quartile were 1.93 (95% CI: 1.69, 2.20) for overweight/obesity and 2.07 (95% CI: 1.74, 2.46) for central adiposity. The associations also were significant when adjusting for SSBs, instead of energy, in models. Conclusions: Higher usual sodium excretion is associated with overweight/obesity and central adiposity among US adults. |
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