Faculty Bibliography

BACKGROUND:Ineffective referral networks in low- and middle-income countries hinders access to evidence-based therapies by hypertensive patients, leading to high cardiovascular mortality and morbidity. The STRENGTHS (Strengthening Referral Networks for Management of Hypertension Across Health Systems) study evaluates strategies to improve referral processes utilizing the International Association of Public Participation framework to engage stakeholders. OBJECTIVES/OBJECTIVE:This study sought to identify and engage key stakeholders involved in referral of patients in the Ministry of Health, western Kenya. METHODS:Key stakeholders involved in policy formulation, provision, or consumption of public health care service were mapped out and contacted by phone, letters, and emissaries to schedule meetings, explain research objectives, and obtain feedback. RESULTS:Key stakeholders identified were the Ministry of Health, the Academic Model Providing Access to Healthcare, health professionals, communities and their leadership, and patients. Engaging them resulted in permission to contact research in their areas of jurisdiction and enabled collaboration in updating care protocols with emphasis on timely and appropriate referrals. CONCLUSIONS:Early stakeholder identification and engagement using the International Association of Public Participation model eased explanation of research objectives, building consensus, and shaping the interventions to improve the referral process.

Background: Sodium bicarbonate therapy (SBT) has a variety of ED indications but its use is controversial. Some authors recommend SBT for drug overdoses involving salicylates and sodium channel antagonists such as tricyclics (TCA). Due to its effect on serum potassium, we hypothesized that SBT may prolong the QTc and increase risk for adverse cardiovascular events (ACVE). Our purpose was to evaluate SBT dose and duration in ED patients with drug overdose for an association with ACVE.
Method(s): We prospectively analyzed consecutive ED patients with acute drug overdose who were given SBT at two urban teaching hospitals from 2015-present. Data included SBT indication, dose, duration, and QTc (initial/peak from computer generated Bazett correction) during hospital stay. We used median values to dichotomize total dose (high/low) and total duration (long/short) of SBT. Patients were prospectively followed to hospital discharge for the occurrence of the primary outcome: ACVE and/or mortality. The previously validated definition of ACVE was used for in-hospital occurrence of any of these: ventricular dysrhythmia, myocardial infarction, shock requiring vasopressors, and cardiac arrest. Severe QTc prolongation was defined using the validated cutoff >=500ms. Ventricular dysrhythmias were adjudicated by a blinded cardiologist.
Result(s): Indications for SBT in 30 patients analyzed were: salicylism (5), sodium channel antagonist (6 TCA, 5 other), wide QRS in absence of known drug (9), acidosis or cardiac arrest (3), and unknown (2). After SBT, severe QTc prolongation occurred in 6 (20%), ACVE in 17 (57%), and 6 (20%) died. There was a significant association between severe QTc prolongation in-hospital for both high dose and long duration groups (p<0.05 for both). There was a significant correlation between both SBT dose (83% high, 38% low, p < .05) and SBT duration (100% long, 25% short, p < .05) with the primary outcome.
Conclusion(s): ED patients with acute drug overdose receiving SBT had very high rates of mortality and ACVE, which were strongly associated with higher dose and longer duration of SBT. Severity of overdose was a limitation to interpretation as a potential confounder. Overall, these results are consistent with the hypothesis that SBT prolongs the QTc and increases risk for ACVE, validating previous safety concerns regarding the administration of SBT for drug overdose

BACKGROUND:Preschool-based interventions offer promise to instill healthy behaviors in children, which can be a strategy to reduce the burden of cardiovascular disease later. However, their efficacy in underserved communities is not well established. OBJECTIVES/OBJECTIVE:The purpose of this study was to assess the impact of a preschool-based health promotion educational intervention in an underserved community. METHODS:This cluster-randomized controlled study involved 15 Head Start preschools in Harlem, New York. Schools and their children were randomized 3:2 to receive either a 4-month (50 h) educational intervention to instill healthy behaviors in relation to diet, physical activity, body/heart awareness, and emotion management; or their standard curriculum (control). The primary outcome was the change from baseline in the overall knowledge, attitudes, and habits (KAH) score of the children at 5 months. As secondary outcomes, we evaluated the changes in KAH subcomponents and emotion comprehension. Linear mixed-effects models were used to test for intervention effects. RESULTS:The authors enrolled 562 preschool children age 3 to 5 years, 51% female, 54% Hispanic/Latino, and 37% African-American. Compared with the control group, the mean relative change from baseline in the overall KAH score was ∼2.2 fold higher in the intervention group (average absolute difference of 2.86 points; 95% confidence interval: 0.58 to 5.14; p = 0.014). The maximal effect was observed in children who received >75% of the curriculum. Physical activity and body/heart awareness components, and knowledge and attitudes domains, were the main drivers of the effect (p values <0.05). Changes in emotion comprehension trended toward favoring intervened children. CONCLUSIONS:This multidimensional school-based educational intervention may be an effective strategy for establishing healthy behaviors among preschoolers from a diverse and socioeconomically disadvantaged community. Early primordial prevention strategies may contribute to reducing the global burden of cardiovascular disease. (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health [FAMILIA]; NCT02343341).

Elevated blood pressure is the leading cause of death worldwide; however, treatment and control rates for hypertension are low. Here, we analyze the relationship between physician and nurse density and hypertension treatment rates worldwide. Data on hypertension treatment rates were collected from the STEPwise approach to Surveillance country reports, individual studies resulting from a PubMed search for articles published between 1990 and 2010, and manual search of the reference lists of extracted studies. Data on health care worker density were obtained from the Global Atlas of the Health Workforce. We controlled for a variety of variables related to population characteristics and access to health care, data obtained from the World Bank, World Development Indicators, United Nations, and World Health Organization. We used clustering of SEs at the country level. Full data were available for 154 hypertension treatment rate values representing 68 countries between 1990 and 2010. Hypertension treatment rate ranged from 3.4% to 82.5%, with higher treatment rates associated with higher income classification. Physician and nurse/midwife generally increased with income classification. Total healthcare worker density was significantly associated with hypertension treatment rate in the unadjusted model ( P<0.001); however, only nurse density remained significant in the fully adjusted model ( P=0.050). These analyses suggest that nurse density, not physician density, explains most of the relationship with hypertension treatment rate and remains significant even after adjusting for other independent variables. These results have important implications for health policy, health system design, and program implementation.

INTRODUCTION/BACKGROUND:Understanding context and how this can be systematically assessed and incorporated is crucial to successful implementation. We describe how context has been assessed (including exploration or evaluation) in Global Alliance for Chronic Diseases (GACD) implementation research projects focused on improving health in people with or at risk of chronic disease and how contextual lessons were incorporated into the intervention or the implementation process. METHODS:Using a web-based semi-structured questionnaire, we conducted a cross-sectional survey to collect quantitative and qualitative data across GACD projects (n = 20) focusing on hypertension, diabetes and lung diseases. The use of context-specific data from project planning to evaluation was analyzed using mixed methods and a multi-layered context framework across five levels; 1) individual and family, 2) community, 3) healthcare setting, 4) local or district level, and 5) state or national level. RESULTS:Project teams used both qualitative and mixed methods to assess multiple levels of context (avg. = 4). Methodological approaches to assess context were identified as formal and informal assessments, engagement of stakeholders, use of locally adapted resources and materials, and use of diverse data sources. Contextual lessons were incorporated directly into the intervention by informing or adapting the intervention, improving intervention participation or improving communication with participants/stakeholders. Provision of services, equipment or information, continuous engagement with stakeholders, feedback for personnel to address gaps, and promoting institutionalization were themes identified to describe how contextual lessons are incorporated into the implementation process. CONCLUSIONS:Context is regarded as critical and influenced the design and implementation of the GACD funded chronic disease interventions. There are different approaches to assess and incorporate context as demonstrated by this study and further research is required to systematically evaluate contextual approaches in terms of how they contribute to effectiveness or implementation outcomes.

Objective: Sodium bicarbonate therapy (SBT) is provided in the emergency department (ED) for a variety of indications but its use is controversial. Some authors recommend SBT for overdoses of salicylates and sodium channel antagonists (e.g. tricyclic antidepressants [TCAs]). Due to its effect in lowering serum potassium, however, SBT administration may prolong the QTc interval and potentially cause increased rates of adverse cardiovascular events (ACVE), such as ventricular dysrhythmias. To quantify this risk, we evaluated an emergency department (ED) overdose patient population for the association between SBT and ACVE.
Method(s): We prospectively analyzed consecutive ED patients with acute drug overdose who were given SBT at two urban teaching hospitals from 2015-present. Data included SBT indication, dose, duration, and QTc (initial/peak from computer generated Bazett correction) during hospital stay. We used median values to dichotomize total dose (high/low) and total duration (long/short) of SBT. Patients were prospectively followed to hospital discharge for the occurrence of the primary outcome: ACVE and/or mortality. The previously validated definition of ACVE was used for in-hospital occurrence of any of the following: ventricular dysrhythmia, myocardial infarction, shock requiring vasopressors, and cardiac arrest [1]. Severe QTc prolongation was defined as previously validated using the cut off >=500ms. Occurrence of ventricular dysrhythmia was adjudicated by a blinded cardiologist.
Result(s): Indications for SBT in 30 patients analyzed were: salicylism (n= 5), sodium channel antagonist (6 TCA, 5 other), wide QRS in absence of known drug (n= 9), acidosis or cardiac arrest (n= 3), and unknown (n= 2). After SBT, severe QTc prolongation occurred in 6 (20%), ACVE in 17 (57%), and 6 patients (20%) died. There was a significant association between severe QTc prolongation in-hospital for both high dose and long duration groups (p < 0.05 for both). There was a significant correlation between both SBT dose (83% high, 38% low, p < 0.05) and SBT duration (100% long, 25% short, p < 0.05) with the primary outcome.
Conclusion(s): ED patients with acute drug overdose receiving SBT had very high rates of mortality and ACVE, which were strongly associated with higher dose and longer duration of SBT. Severity of overdose may represent a limitation to interpretation as a potential confounder. Overall, these results are consistent with the hypothesis that SBT may cause unintended ACVE, and validates previous safety concerns regarding the administration of SBT to overdose patients

Background: In ED patients who present with acute drug overdose, severe QTc prolongation (>500 ms) has been shown to be a predictor of adverse cardiovascular events (ACVE). However, it is unclear what clinical factors are associated with delayed severe QTc prolongation (dsQTp), and it is unknown whether dsQTp can predict ACVE. This study aims to: (1) Define clinical factors associated with dsQTp, and (2) test whether dsQTp is an independent predictor for ACVE.
Method(s): This was a prospective cohort study at 2 urban tertiary care EDs. Data was collected by trained research assistants, and included demographics, drug exposure, medication administration, initial and repeat ECG data, lab data, and outcome measures. dsQTp was defined as presence of initial QTc 499. The primary study outcome was the composite of ACVE defined as in-hospital occurrence of any of the following: MI, shock, ventricular dysrhythmia, and cardiac arrest. Univariate statistics and multivariable logistic regression calculations were made using SPSS version 24. With a fixed sample size of 1670, we calculated that we would have 99% power to show a 3-fold increase in risk with 0.05 alpha.
Result(s): Out of 2311 patients screened, 641 were excluded (age 500) leaving 1670 patients for analysis. The dsQTp group (N = 27) was found to be older than the control group (N = 1643)(40.1 vs 51.6, P
Conclusion(s): This cohort study reveals a subset of ED patients who are at greater risk of overdose-related ACVE but not immediately apparent by the initial ECG. Further study is needed to identify which patients are at risk for dsQTp, as they may require prolonged observation and repeated ECGs. Limitations include missing repeat QTc measurements, and inability to control for overdose severity as a surrogate for repeat ECGs. Future study is warranted to further characterize patients at risk for dsQTp to evaluate other exposure-related factors as yet undiscovered