County Demographics and COVID-19 Death Rates: Comparison of relationship in the first and current stage of the pandemic in the United States of America

Previous studies have discovered disparity in death rates associated with SARS-CoV-2 infection in the United States during the initial stages of the pandemic. Specifically, the death rates were higher in the population in poverty and communities of color across the United States. In the current study, we perform the secondary analysis of death rates due to COVID-19 data, obtained from the Center for Disease Control and Prevention (CDC). Results indicate that in the first phase of the pandemic (February 1 to August 1, 2020), counties with higher percentage of White, Native Hawaiian and other Pacific Islanders, and two or more races populations were found to have lower per-capita COVID-19 death rate. Whereas counties with population having higher percentage of females, Black or African American people, and persons in poverty had higher death rates. Analysis of the death rates from August 1 to September 10, 2020, indicate that disparity continues with counties having higher population of Black or African American people and female having higher death rates. Poverty is not a significant variable in determining the death rates due to COVID-19. Based on the current data and lack of detailed molecular mechanism of the disease, we suggest that more resources must be diverted to counties with higher percentages of Black or African American and female populations.

Safety and efficacy of a pharmaco-invasive reperfusion strategy in rural ST-elevation myocardial infarction patients with expected delays due to long-distance transfers.

AIMS: To determine the safety and efficacy of a pharmaco-invasive reperfusion strategy utilizing half-dose fibrinolysis combined with transfer for immediate percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients presenting to remote rural hospitals. Primary PCI is preferred for STEMI if performed in a timely manner. However, <20% of STEMI patients transferred for PCI in the USA have door-to-balloon times <2 h. METHODS AND RESULTS: Prospective data from the Level 1 MI programme were analysed. All STEMI patients presenting to the Minneapolis Heart Institute or 31 referral hospitals received aspirin, clopidogrel, and unfractionated heparin (UFH) at the presenting hospital and those presenting to hospitals ≥60 miles away also received half-dose fibrinolytic with transfer for immediate PCI. From April 2003 through December 2009, we enrolled 2634 consecutive STEMI patients in the Level 1 MI database including 660 transferred from remote hospitals utilizing pharmaco-invasive therapy and 600 patients who presented directly to the PCI centre. There were no significant differences in 30-day mortality (5.5 vs. 5.6%; P= 0.94), stroke (1.1 vs. 1.3%; P= 0.66) or major bleeding (1.5 vs. 1.8%; P= 0.65), or re-infarction/ischaemia (1.2 vs. 2.5%; P= 0.088) in patients receiving a pharmaco-invasive strategy compared with patients presenting directly to the PCI centre, despite a significantly longer door-to-balloon time. CONCLUSION: Within a regional STEMI system of care, half-dose fibrinolysis combined with immediate transfer for PCI may be a safe and effective option for STEMI patients with expected delays due to long-distance transfer.

Evolution of hemodialysis access resistance: a longitudinal 5-year model using functional principal components analysis.

PURPOSE: Arteriovenous fistulae (AVF) and grafts (AVG) are the preferred accesses in hemodialysis (HD). By monitoring access resistance (AR) one can potentially identify problems with an established HD access, but little is known about how these changes in AR occur, or the variations between the two access types as they mature longitudinally. We postulated that AR evolves differentially between AVF and AVG, a critical aspect to further understanding of the natural history of HD accesses. To describe these changes, we applied a novel statistical methodology of functional principal component (FPC) analysis. METHODS: Using ultrasound dilution flow studies, we retrospectively studied 479 functional HD accesses in which a total of 4573 assessments were made. Accounting for patient factors of age, race, gender and diabetes mellitus (DM) status, we employed a multivariate, mixed-effects model. Using the mean effects of those covariates, we then applied FPC analyses to assess the longitudinal, timedependent changes between AVFs and AVGs over a 5-year period. RESULTS: Both types of upper-arm access were associated with a lower initial AR. Older age and DM were associated with a higher AR. Longitudinal AR varied significantly for both AVF and AVG, between the upper arm and lower arm. As a function of time, AVG was associated with an increasing AR. Conversely, AVF, especially upper-arm ones, demonstrated a longitudinal drop in AR. CONCLUSIONS: Evolutionally, AR can be predicted not only by the type of access, but also by the location along the arm of that access and by clinical patient factors. Longitudinal change in AR does differ between AVG and AVF. Our report provides the foundation of observed changes over time and provides insight as to how these variations are affected. We endorse ongoing surveillance to screen for clinical sequelae, even years from initial placement.

A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior to fibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. METHODS AND RESULTS: We developed a standardized PCI-based treatment system for STEMI patients from 30 hospitals up to 210 miles from a PCI center. From March 2003 to November 2006, 1345 consecutive STEMI patients were treated, including 1048 patients transferred from non-PCI hospitals. The median first door-to-balloon time for patients <60 miles (zone 1) and 60 to 210 miles (zone 2) from the PCI center was 95 minutes (25th and 75th percentiles, 82 and 116 minutes) and 120 minutes (25th and 75th percentiles, 100 and 145 minutes), respectively. Despite the high-risk unselected patient population (cardiogenic shock, 12.3%; cardiac arrest, 10.8%; and elderly [> or =80 years of age], 14.6%), in-hospital mortality was 4.2%, and median length of stay was 3 days. CONCLUSIONS: Rapid transfer of STEMI patients from community hospitals up to 210 miles from a PCI center is safe and feasible using a standardized protocol with an integrated transfer system.

Risperidone monotherapy for post-traumatic stress disorder related to sexual assault and domestic abuse in women.

Post-traumatic stress disorder is a common, chronic, and often disabling mental illness. Selective serotonin reuptake inhibitors are the usual first-line treatment for post-traumatic stress disorder, but many patients fail to respond adequately. Thus, other treatment options, including the atypical antipsychotics such as risperidone, need to be tested. Women between the ages of 19 and 64 years with post-traumatic stress disorder were enrolled. Symptom severity was rated at baseline using the Treatment Outcomes Post-traumatic Stress Disorder Scale-8, Hamilton Rating Scale for Anxiety, Hamilton Rating Scale for Depression, and Clinician Administered Post-traumatic Stress Disorder Scale. After washout from other psychotropic medications, 20 participants were randomized to either risperidone or placebo. Total score on the Treatment Outcomes Post-traumatic Stress Disorder Scale-8 served as the primary outcome measure. Repeated-measures analysis of variance was followed by Newman-Keuls tests. A significant main effect exists for visits using the Treatment Outcomes Post-traumatic Stress Disorder Scale-8 raw score. For the treatment group, the difference between baseline Treatment Outcomes Post-traumatic Stress Disorder Scale-8 scores and treatment visit scores was significant beginning at visit 6 and continued through visit 11. No significant difference observed between baseline and any treatment visit for the placebo group. The Clinician Administered Post-traumatic Stress Disorder Scale, Hamilton Rating Scale for Anxiety, and Hamilton Rating Scale for Depression data revealed a similar pattern. In this small pilot study, risperidone monotherapy was more effective than placebo in the treatment of post-traumatic stress disorder.

Radiation following percutaneous balloon aortic valvuloplasty to prevent restenosis (RADAR pilot trial).

OBJECTIVES: We wished to determine the feasibility and early safety of external beam radiation therapy (EBRT) used following balloon aortic valvuloplasty (BAV) to prevent restenosis. BACKGROUND: BAV for calcific aortic stenosis (AS) has been largely abandoned because of high restenosis rates, i.e., > 80% at 1 year. Radiation therapy is useful in preventing restenosis following vascular interventions and treating other benign noncardiovascular disorders. METHODS: We conducted a 20-patient, pilot study evaluating EBRT to prevent restenosis following BAV in elderly patients with calcific AS. Total doses ranging from 12-18 Gy were delivered in fractions over a 3-5 day post-op period to the aortic valve. Echocardiography was performed pre and 2 days post-op, 1, 6, and 12 months following BAV. RESULTS: One-year follow-up is completed (age 89 +/- 4). There were no complications related to EBRT. Eight patients died prior to 1 year; 5 of 10 (50%) in the low-dose (12 Gy) group and 3 of 10 (30%) in the high-dose (15-18 Gy) group. None of these 8 patients had restenosis, i.e., > 50% loss of the initial AVA gain, and only three deaths were cardiac in origin. One patient underwent aortic valve replacement and none repeated BAV. By 1 year, 3 of the initial 10 (30%) in the low-dose group and 1 of 9 (11%) in the high-dose group demonstrated restenosis (21% overall). CONCLUSIONS: EBRT following BAV in elderly patients with AS is feasible, free of early complications, and holds promise in reducing the 1 year restenosis rate in a dose-dependent fashion.

Limited flow reserve in non-obstructed bypass grafts supplying infarcted myocardium: implications for cardiovascular magnetic resonance imaging protocols.

We evaluated flow reserve in non-obstructed bypass grafts supplying infarcted and noninfarcted myocardium. Bypass grafts were examined by phase-contrast flow measurements and myocardial viability was assessed with late enhancement technique. Flow reserve was higher in bypasses supplying normal myocardium compared to those supplying infarcted myocardium (2.9 vs. 1.5, p<.0001). This difference remained significant after adjusting for co-variables. Bypass grafts supplying infarcted myocardium were more likely to have lower flow reserve than those supplying normal myocardium (flow reserve < or =2, 84% vs 18%, p = .0003). Flow reserve is reduced in non-stenosed bypasses supplying infarcted myocardium, likely due to altered microcirculation. Thus, cardiovascular magnetic resonance based bypass assessment must include myocardial viability testing.

Proteinuria and risk for stroke and coronary heart disease during 27 years of follow-up: the Honolulu Heart Program.

BACKGROUND: Urinary protein excretion has been linked to coronary heart disease (CHD); the relationship to stroke is less clear. We assessed whether urine dipstick screening for protein predicted stroke and CHD in the Honolulu Heart Program cohort. METHODS: Prospective, observational study of 6252 Japanese American men in Honolulu aged 45 to 68 years. Proteinuria was detected by means of urine dipstick screening during the first and third examinations. Subjects were classified as having no proteinuria if results were negative at both examinations, transient proteinuria if results were positive at 1 examination, and persistent proteinuria if results were positive at both examinations. Relative risk was derived using those subjects with no proteinuria as the reference. Outcomes were assessed through 27 years. RESULTS: No proteinuria was found in 92.8% of subjects, transient proteinuria in 6.1%, and persistent proteinuria in 1.1%. The age-adjusted incident stroke rates were 3.7, 7.3, and 11.8 per 1000 person-years in subjects with no, transient, or persistent proteinuria, respectively (P<.001). Age-adjusted rates of incident CHD were 9.4, 15.8, and 35.2 events per 1000 person-years, respectively (P<.001). Using Cox proportional hazards models, adjusting for age, body mass index, physical activity, smoking status, cholesterol level, presence of hypertension or diabetes mellitus, and alcohol consumption, the relative risk for 27-year incident stroke was 1.66 (95% confidence interval, 1.21-2.30; P = .002) with transient proteinuria and 2.84 (95% confidence interval, 1.51-5.34; P = .001) with persistent proteinuria, and relative risk for 27-year incident CHD was 1.48 (95% confidence interval, 1.19-1.83; P<.001) with transient proteinuria and 3.72 (95% confidence interval, 2.62-5.27; P<.001) with persistent proteinuria. CONCLUSION: Proteinuria detected at urine dipstick screening independently predicted increased risk for incident stroke and incident CHD over 27 years in this cohort.

Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention.

BACKGROUND: Direct percutaneous coronary intervention (PCI) is the preferred method of reperfusion for ST-elevation myocardial infarction (STEMI). Transfer from community hospitals to PCI centers increases availability for direct PCI, which improves outcomes compared to fibrinolysis in Europe. It has been difficult to achieve similar door-to-balloon times for transfer patients in the United States. METHODS: We designed a standardized protocol and integrated system of transfer for patients with STEMI. We report the door-to-balloon times for the pre- and postpilot patients in the index hospital and describe the details of the current Level 1 MI Program. RESULTS: In the 15 months before the pilot project, the door-to-balloon time for patients receiving ad hoc transfer for direct PCI was 192 minutes, similar to the national average. The door-to-balloon time for the patients receiving rescue PCI after failed thrombolysis was 221 minutes. The standardized protocol decreased door-to-balloon time to 98 minutes in the pilot trial (P < .01) and has now been applied successfully in 29 community hospitals. CONCLUSIONS: Rapid transfer of patients with STEMI is feasible in the United States using a standardized protocol and integrated transfer system. This requires a team approach with cooperation between cardiologists, emergency physicians, nurses, and the emergency medical system as well as various health care organizations.

New ACGME work-hour guidelines and their impact on current residency training practices.

OBJECTIVE: Accreditation Council for Graduate Medical Education (ACGME) has introduced new work-hour guidelines for residents in ACGME accredited programs that were implemented in July 2003. The new ACGME policies impact several practices in various psychiatry residency programs across the U.S., even though psychiatry has not been at the forefront of the debate regarding work hours. METHODS: The authors surveyed all psychiatry residency programs in the U.S. and identified several current practices that may infringe on the new ACGME work-hour guidelines. CONCLUSION: Further interpretation of the new guidelines is needed.

Addiction training scale: pilot study of a self-report evaluation tool for psychiatry residents.

OBJECTIVE: Alcohol and drug dependence disorders have become common public health hazards. Psychiatrists encounter these problems in a major portion of their patients. However, recent data suggest that their training does not provide them the confidence to treat these disorders. Current methods of evaluating residents fail to adequately ascertain the lack of confidence in substance abuse training. Here, we present the Addiction Training Scale (ATS) that we developed to help trainers identify deficits in residents' substance abuse training. METHOD: We developed the ATS and conducted a pilot study with the psychiatry residents at the Creighton University Department of Psychiatry, to test the validity of the ATS as a self-report evaluation tool to measure the level of psychiatry residents' preparedness in treating substance abuse disorders. RESULTS: Our results suggest that the ATS is related to the confidence and preparedness that residents express in their ability to treat substance abuse problems. CONCLUSION: The ATS may be beneficial in assessing psychiatry residents' substance abuse training and identifying deficits, which may be addressed during training.

Patient and physician attitudes to using medications with religiously forbidden ingredients.

BACKGROUND: Over 1000 medications contain pork- and/or beef-derived gelatin and stearic acid as inert ingredients. Use of these medications in patients with religious beliefs against consumption of these ingredients might constitute an ethical conflict. OBJECTIVE: To assess patients' and physicians' attitudes about using medications with religiously prohibited ingredients derived from pork and/or beef. METHODS: In this pilot study, 100 patients and 100 physicians completed a survey designed to assess their knowledge and opinion on using medications that might contain inert ingredients derived from animals whose consumption offends followers of certain religions. RESULTS: Of the 100 patients surveyed, most (84%) reported that they were not aware that several medications contained ingredients derived from pork and/or beef. About 63% of the patients wanted their physicians, and 35% of the patients wanted their non-physician healthcare providers (pharmacists, nurses), to inform them when using such medications. Thirteen percent of the patients shared religious reasons for not consuming pork and/or beef products. Approximately 70% of physicians were unaware that several medications contain ingredients that might be against their patients' religion, and most (70%) thought that it was important to inform their patients if such drugs were prescribed. CONCLUSIONS: This pilot study suggests that both patients and physicians think that patients should be informed whenever medications that contain pork- and/or beef-derived products are prescribed. The use of medications with these ingredients is an ethical issue. Informing patients about this issue promotes respect for their religious beliefs and may promote therapeutic alliance; therefore, this might have public health implications and needs further research.

Image guided I125 prostate brachytherapy with Hybrid Interactive Mick technique in the community setting: How does it compare?

The aim of this study is to evaluate the target coverage, procedural techniques, and merits of Hybrid Interactive Mick (HIM) I125 transperineal permanent implantation (TPPI) of the prostate performed with 10 urologists in a community hospital. Detailed day 0 post-implant dosimetric evaluations of TPPI procedures were performed on 333 consecutive monotherapy patients treated between September 2000 and November 2003 at a single institution. All patients underwent TPPI with HIM. Pelvic and CXR films were obtained for a manual seed count at day 0 and again > day 90 on 175 patients. The HIM-prostate brachytherapy performed in a community hospital provided median D(90), V100, and V150 values of 157Gy, 94%, and 42.3%, respectively. 18% of patients had seed migration to the lungs while 2% had seed migration to the bladder. Only 7 patients (4%) had 2 or more seeds migrate to the lungs. Procedure times average 38 minutes and number of needles used averaged 18. The post-implant urinary retention rate was 2.1% Use of HIM-prostate brachytherapy in the community setting with multiple urologists reproducibly maintained excellent and consistent dosimetric coverage. Procedure times and number of needles used were minimized, and with careful attention to image-guided technique, seed migration to bladder and lung was also minimized.

The validity of subjective measures of body image disturbance.

OBJECTIVE: We examined weight dissatisfaction (actual weight minus self-stated ideal weight) and weight goal (normative weight minus self-stated ideal weight) subjective indices in a large clinical sample to determine how the indices discriminate between diagnostic categories and relate to other measures of body image disturbance. METHOD: Approximately 200 anorexic, bulimic, and eating disorder not otherwise specified (NOS) participants reported their self-stated ideal weight and completed the Mizes Anorectic Cognitions (MAC) Questionnaire, Eating Disorders Inventory (EDI), and Restraint Scale-Revised. RESULTS: Compared with bulimic and NOS participants, anorexics reported less weight dissatisfaction but had an ideal weight that is farthest from normative weight. The weight dissatisfaction measure correlates well with other measures of body image disturbance, and both measures show evidence of discriminant validity. DISCUSSION: These two measures highlight the substantial differences in the nature of body image disturbance between the eating disorder diagnostic groups. Theoretical, clinical, and practical implications are discussed.

Infective endocarditis in patients with end-stage renal disease: clinical presentation and outcome.

BACKGROUND: Infective endocarditis is a common complication of vascular access in patients undergoing long-term hemodialysis. However, available data are either dated or gathered from small samples. The goal of this study was to investigate the clinical characteristics and outcome of infective endocarditis occurring in patients with end-stage renal disease. METHODS: Patients were identified by computerized discharge diagnosis and manual chart review at 3 major hospitals in Honolulu, Hawaii. The search covered an 11-year period, through December 2001. Modified Duke criteria were retrospectively applied. Patients fulfilling criteria for definite endocarditis were included in this study. RESULTS: Forty patients were identified. Average age was 59.4 years, and average duration of hemodialysis before endocarditis was 3.3 years; arteriovenous fistulas were the most commonly used access sites. Predominant organism was Staphylococcus aureus in 20 (50%) of the 40 cases. The mitral valve was affected in 29 cases (73%); aortic and mitral valve endocarditis was seen in 8 cases (20%). Overall in-hospital mortality was 52% (21/40). Patients with an unfavorable outcome more often had fever on admission, fewer negative blood cultures, and bivalvular infective endocarditis, and more often underwent valve replacement surgery. The perioperative mortality in patients undergoing valve replacement was 73% (11/15). CONCLUSIONS: Mortality of infective endocarditis in patients with end-stage renal disease remains high and has been essentially unchanged during the past decade. If patients require valve replacement surgery, mortality is even higher. A randomized, controlled trial is needed to clarify whether the increased mortality is due solely to more severe disease in patients requiring valve replacement surgery.

Management of patients with chronic kidney disease presenting with acute coronary syndrome.

We evaluated the treatment pattern of patients with chronic kidney disease presenting with acute coronary syndromes. In a retrospective chart review of 400 patients with and without kidney disease presenting with angina pectoris we found that patients with chronic kidney disease have longer hospital stays, receive fewer diagnostic angiographies, and have a delay in therapy.

Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes.

We assessed the influence of CKD on bleeding in 200 patients with ACS via retrospective chart analysis. Using K/DOQI guidelines to stratify patients based on GFR, no differences in documented bleeding or antithrombotic utilization were observed among the groups. Due to increased mortality risk of patients with CKD from cardiovascular disease, assessing benefit-to-risk ratios of various medical interventions is crucial.

Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease.

We examined treatment patterns of female pts with CKD admitted for ACS. In this retrospective review of 200 patients with chronic kidney disease presenting with acute coronary syndrome, we found that females patients were less likely to receive aspirin and ACE-inhibitors and there was a trend towards less frequent use of coronary angiography

Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes.

A retrospective review of 200 patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) was compared to 200 patients without CKD to investigate the incidence of bleeding. Logistic regression analysis identified CKD as an independent risk factor for bleeding (OR 1.82, 95% CI 1.02 - 3.25). CKD patients with ACS appear to have more bleeding complications.