Physiological Risk Research Articles

Evaluation of the Berlin polytrauma definition: A Dutch nationwide observational study.

The Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of ≥3 in ≥2 body regions (2AIS ≥3) combined with the presence of ≥1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR). The evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS ≥3, Injury Severity Score (ISS) of ≥16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS ≥3 patients were compared with those from the Deutsche Gesellschaft für Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS ≥3-DNTR patients and compared with those with an ISS of ≥16. The DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of ≥16, and 6,263 patients had suffered a 2AIS ≥3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS ≥3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS ≥3 and ISS ≥16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group. This study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS ≥16 and 2AIS ≥3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate. Epidemiological study, level III.

The origins of the 4 × 4 framework for noncommunicable disease at the World Health Organization.

This paper traces the history of noncommunicable disease public health research and programming at the World Health Organization. Specifically, it investigates the origins of the now pervasive 4 × 4 framework focusing on four sets of diseases (cardiovascular diseases, diabetes, chronic respiratory diseases, and cancers) caused by four behavioral risk factors (tobacco use, harmful use of alcohol, unhealthy diets, and physical inactivity). We have found that the 4 × 4 framework developed as a generalization from strategies to control epidemics of cardiovascular disease and stroke in high-income countries during the second half of the twentieth century. These strategies, which were narrowly focused on interventions to address behavioral “lifestyle” risk factors as well as pharmacotherapy for physiologic risk factors, were ultimately packaged as an integrated approach initially in high-income countries and subsequently extended to low- and middle-income countries, where they have failed to address much of the burden among very poor populations.

Thyroid storm, clouds and silver linings

J Oral Med Oral Surg 2021;27:35 Letter to the Editor Thyroid storm, clouds and silver linings John Laszlo* London, UK * Correspondence: jonlaszlo@hotmail.com Received: 9 April 2021 Accepted: 13 April 2021 Dear Editor, In addition to the use of personal protective equipment (PPE), significant interest has developed recommending topical application of Povidone Iodine (PVP-I) for pre-exposure prophylaxis (PEP) against COVID-19 transmission. PVP-I is safe, demonstrating a 99.9% reduction in MERS and SARS activity, far greater than chlorhexidine or benzalkonium-chloride [1]. As oral and nasal fluids contain greater than 107 COVID-19 viruses per mL, PVP-I is a theoretically useful PEP adjunct with PPE. However, the evidence for using PVP-I as PEP, is neither clear nor clinical, extrapolations were made assuming Covid-19 will be just as susceptible to PVP-I in-vivo, as MERS and SARS were in-vitro [1]. Placing those concerns aside, 15% of the population with Thyroid disease are excluded from PVP-I use, but a similar proportion, who are as yet undiagnosed for thyroid disease remain at physiological risk from inadvertent exposure to iodine in PVP-I [2]. In healthy patients, iodine exposure initiates the Wolff-Chaikoff effect;transiently reducing thyroid hormone levels and this is a valuable response to control hypermetabolic morbidity and mortality from the thyroid storm [3]. However, for patients with unrecognised thyroid dysfunction, iodine exposure can either lead to chronic hypothyroidism with no adaptation to Wolff-Chaikoff down-regulation, or it can lead to the Jos-Basedow phenomenon and critical thyroid storm initiation from a loss of negative feedback [3]. Therefore the 15% of patients excluded from PVP-I use are not placed at risk but those patients undiagnosed as yet not recognised as having a thyroid dysfunction will be placed at risk if exposed to PVP-I. If the bidirectional relationship between thyroid disease and kidney function is considered with regard to renal drug excretion;the association of cardiovascular and psychiatric illness with underlying and undiagnosed thyroid disease is problematic. With such patients, the risk of adverse pharmacokinetic drug interactions demands even closer attention if we are to use PVP-I for any patient. Given the positive relationship of thyroid function with RAAS (renin-angiotensin-aldosterone-system), the potential to amplify ACE 2 expression with PVP-Iodine exposure could increase COVID-19 infection risk as more ACE 2 receptors become activated and the potential for viral cellular entry increases [4]. Thyroid disease exhibits a 10:1 female to male predisposition [2], whereas the morbidity and mortality from COVID-19, with equal infectivity is predominantly male. Using PVP-I as PEP may be intuitive, but paradoxically counter-productive;as a greater risk of infection arises in patients more at risk from the effects of COVID-19 by using PVP-I. With 37 isotopes and as many molecular formulations, iodine has many benefits, for example;Silver-Iodide can precipitate rainfall and disinfect surfaces, but there are environmental and medical risks too. To realise the full PEP potential of PVP-I against COVID-19, the theoretical concerns outlined above require further analysis. Thyroid patients are not at increased risk of morbidity and mortality from COVID-19 [5] and this silver lining in a nebulous cloud of PEP should be recognised when considering measures that could potentially do more harm than good.

Fall-Related Physiological and Physical Risk Factors of Community-Dwelling Older Adults with Mild Cognitive Impairment: A Cross-Sectional Study

Fall-Related Physiological and Physical Risk Factors of Community-Dwelling Older Adults with Mild Cognitive Impairment: A Cross-Sectional Study

Perioperative oliguria: adequate physiological response or risk for acute kidney injury?

A injuria renal aguda (IRA) e uma complicacao grave no contexto cirurgico, associando-se a elevacao de custos e a desfechos clinicos adversos, em curto e longo prazos,. Ademais, sua etiologia multifacetada e fisiopatologia complexa desafia a adocao de medidas preventivas universais. A identificacao de fatores de riscos especificos para a IRA perioperatoria e essencial para o desenvolvimento de estrategias adequadas de prevencao e tratamento. Alguns fatores, como idade, raca, obesidade e doencas preexistentes, nao sao modificaveis. Outros, como tempo cirurgico [...]

Postural Discomfort and Musculoskeletal Disorders among Painters - An Analytical Study

Aim: The current investigation was to examine the intensity of body discomfort and various musculoskeletal disorders experienced by painter community due to their occupational habitat. Methods: A questionnaire was developed systematically with high competence with the current standard, which includes general profile sheet, occupational profile sheet and a modified Kromers body discomfort scale (Kroemer et al., 1987). These tools were used to gather information from the respondents. A sample of fifty two male painters aged between 19-75 years were interviewed randomly and mined various socio-demographic, socio-economic and health information. Data on occupational history, accidents, and leisure time activities were also collected. This paper focused on the intensity of pain due to prolonged standing and other postures during painting activities. Result: The prevalence of occupational health hazards has been reported to be high among painter community in India. The study revealed that the painters were engaged in rigorous hand-intensive jobs for many years, this subsistence activity led to rigorous and permanent discomforts in different parts of their body as an occupational health hazards. Conclusion: From the findings of the study, it can be concluded that painters faced many occupational health hazards. The current study focused on musculoskeletal disorder and uncertainties due to the nature of high risk associated painting jobs. The study revealed that the painter’s communities were highly susceptible to musculoskeletal disorders, especially severe leg pain. Most of the interviewed painters were highly concerned about high risk areas (activities on scaffoldings). So for safeguarding the painter communities from high potential professional, physical and physiological health risk, the government must entrust contractors for providing standard and modernized safe working environment, safeguarding tools and risk incentives.

Comparison of Familial, Polygenic and Biochemical Predictors of Mortality.

Mortality risk is known to be associated with many physiological or biochemical risk factors, and polygenic risk scores (PRSs) may offer an additional or alternative approach to risk stratification. We have compared the predictive value of common biochemical tests, PRSs and information on parental survival in a cohort of twins and their families. Common biochemical test results were available for up to 13,365 apparently healthy men and women, aged 17-93 years (mean 49.0, standard deviation [SD] 13.7) at blood collection. PRSs for longevity were available for 14,169 study participants and reported parental survival for 25,784 participants. A search for information on date and cause of death was conducted through the Australian National Death Index, with median follow-up of 11.3 years. Cox regression was used to evaluate associations with mortality from all causes, cancers, cardiovascular diseases and other causes. Linear relationships with all-cause mortality were strongest for C-reactive protein, gamma-glutamyl transferase, glucose and alkaline phosphatase, with hazard ratios (HRs) of 1.16 (95% CI [1.07, 1.24]), 1.15 (95% CI 1.04-1.21), 1.13 (95% CI [1.08, 1.19]) and 1.11 (95% CI [1.05, 1.88]) per SD difference, respectively. Significant nonlinear effects were found for urea, uric acid and butyrylcholinesterase. Lipid risk factors were not statistically significant for mortality in our cohort. Family history and PRS showed weaker but significant associations with survival, with HR in the range 1.05 to 1.09 per SD difference. In conclusion, biochemical tests currently predict long-term mortality more strongly than genetic scores based on genotyping or on reported parental survival.

Latent profiles of children's autonomic nervous system reactivity early in life predict later externalizing problems.

Prior researchers have observed relations between children's autonomic nervous system reactivity and externalizing behavior problems, but rarely considers the role of developmentally regulated changes in children's stress response systems. Using growth mixture modeling, the present study derived profiles of parasympathetic nervous system reactivity (as indicated by respiratory sinus arrhythmia (RSA)) and sympathetic nervous system reactivity (as indicated by pre-ejection period (PEP)) from low income, primarily Mexican American children measured repeatedly from infancy through age 5 (N=383) and investigated whether profiles were associated with externalizing problems at age 7. Analyses identified two profiles of RSA reactivity (reactive decreasing and U-shaped reactivity) and three profiles of PEP reactivity (blunted/anticipatory reactivity, reactive decreasing, non-reactive increasing). Compared to children with an RSA profile of reactive decreasing, those with an RSA profile of U-shaped reactivity had marginally higher externalizing problems, however, this difference was not statistically significant. Children who demonstrated a profile of blunted/anticipatory PEP reactivity had significantly higher externalizing problems compared to those with a profile of non-reactive increasing, likely related to the predominantly male composition of the former profile and predominantly female composition of the latter profile. Findings contribute to our understanding of developmental trajectories of ANS reactivity and highlight the utility of a longitudinal framework for understanding the effects of physiological risk factors on later behavior problems.

Association Between Perinatal Anemia and Postpartum Depression: A Prospective Cohort Study of Japanese Women

(Int J Gynecol Obstet. 2020;148:48–52) Anemia affects >40% of women in the world and can cause symptoms of fatigue, irritability, apathy, and depression. Because of these symptoms, anemia during pregnancy or the postpartum period has been identified as a possible physiological risk factor for postpartum depression (PPD). The aim of this study was to review the association between anemia and PPD in the second trimester, third trimester, and postpartum period.

Clinical, physical, physiological, and cardiovascular risk patterns of adults with schizophrenia: CORTEX-SP study: Characterization of adults with schizophrenia

Schizophrenia (SP) is a severe mental illness with high rates of premature morbidity and mortality, associated with an unhealthy lifestyle and the side effects of drug treatment. The aims of the study were: 1) to determine some key physical, physiological and biochemical markers of health status, including sleep quality, in adults (42±10 yr) with SP (n=126), 2) to estimate cardiovascular risk (CVR), and 3) to compare all studied variables with a healthy control (HC) population (n=30). Assessment was based on body composition, blood pressure, cardiorespiratory condition, sleep quality with triaxial accelerometry for eight days and biochemical analysis. Participants with SP showed a cardiovascular risk profile including “overweight metabolically abnormal”, low cardiorespiratory fitness, and impairment of ventilatory efficiency. Although individuals with SP slept more compared to HC, similar sleep efficiency was shown by both groups, but with significantly higher levels of wake after sleep onset by SP. The assessment of CVR revealed significantly higher values in SP (moderate risk) compared to HC (low risk) regardless of the estimation system. The identification of specific clinical, physical, and physiological CVR profiles in SP illness compared to healthy people strongly suggests targeting a comprehensive approach including non-pharmacological interventions.Clinical Trials.gov identifier, NCT03509597. Date of registration: April 26th, 2018

Abstract 16873: Association of Preoperative Cell-Free DNA Levels and Outcome Following Pediatric Cardiopulmonary Bypass

Introduction: Preoperative risk stratification in congenital cardiac surgery includes patient and procedure related factors, which may be used in clinical decision making as well program performance evaluation. Despite these tools, unidentified factors contribute to wide variation in outcomes both within and between centers. Identification of latent physiologic risk factors may strengthen predictive models. Hypothesis: Total cell-free DNA (TCF) functions as a biomarker for cellular injury as well as a pro-inflammatory cytokine. We hypothesized that elevated preoperative TCF would be associated with poor outcome following pediatric cardiac surgery requiring cardiopulmonary bypass (CPB). Methods: Prospective observational study of children age < 18 yr and wt > 3 kg undergoing planned CPB surgery. The Children’s Wisconsin Institutional Review Board approved the protocol . A serum TCF sample was obtained after induction of anesthesia prior to surgical incision. The primary outcome measure was a composite of postoperative cardiac arrest, ECMO, or death (CAED). Association of outcome to TCF was assessed by logistic regression with a cutpoint chosen by ROC curve exploration. Odds ratios with 95% CI were calculated. Results: Data were available in 117 patients, median age 0.9 years (range 0-17.4), median weight 7.8kg (range 3.2-98). The primary outcome (CAED) was met in 6/117 (5.1%). Table 1 summarizes characteristics of patients with and without CAED. Risk of CAED was 2% with TCF<20 ng/ml, and 27% with TCF>20 ng/ml (OR=18.2, CI 2.2- 212, p<0.01). Elevated TCF was associated to fewer hospital free days (GLM p<0.01). Data in table reported as median [IQR]. Conclusions: Preoperative TCF has an important association with postoperative cardiac arrest, ECMO, and death. Alternative or intensified treatment strategies could be considered in patients with elevated preoperative TCF.

Effects of prepartum stocking density and a blind on physiological biomarkers, health, and hygiene of transition Holstein dairy cows

Many dairy cows succumb to disease after calving. Disease risk may be affected by the cows' social environment and ability to perform maternal behaviors. In nature, cattle isolate from others and find seclusion to give birth; these behaviors may be limited in indoor group pens and could potentially affect the cows' ability to cope. The aim was to determine whether stocking density and a physical blind in prepartum bedded-pack group pens affected physiological biomarkers, disease risk, and hygiene of peripartum dairy cows. A randomized complete block designed with a 2 × 2 factorial arrangement of treatments was used. Approximately 3 wk before calving, 374 cows (primiparous = 127; multiparous = 247) were assigned randomly to 1 of 4 treatment pens with the following 2 factors: (1) high versus low stocking density (7.7 to 12.9 m2 vs. 15.4 to 25.8 m2 lying space per cow), and (2) presence or absence of a blind. The blind was created using plastic road barriers and plywood, a steel gate, and shade cloth. After calving, cows were moved into a freestall pen and milked 3 times per day. Blood was sampled on the day of enrollment (baseline; -24 d) and approximately -14, -7, 3, 7, 10, and 14 d relative to calving, to measure inflammatory (haptoglobin) and metabolic (nonesterified fatty acids and β-hydroxybutyrate) biomarkers. β-Hydroxybutyrate (≥1.2 mmol/L) was used to diagnose subclinical ketosis. Vaginal discharge was scored 3, 7, 10, and 14 d after calving, to diagnose metritis (none, mild, or severe). Hygiene was scored on -24, -14, and -7 d before calving. Before calving, haptoglobin was lower in pens with a blind. After calving, cows in pens with low stocking density before calving tended to be at greater odds of being diagnosed with metritis. Cows were more likely to have poorer hygiene scores in high stocking density pens. No treatment effects were detected for pre- and postpartum nonesterified fatty acids, β-hydroxybutyrate, postpartum haptoglobin, or subclinical ketosis. Results suggest that the provision of a blind and lower stocking density may be beneficial for reducing inflammation before calving. However, low prepartum stocking density might increase the odds of metritis after calving. Although the reason for this paradox is unclear, the effects of prepartum stocking density may require further exploration.

Racial and Ethnic Disparities in Systemic AL Amyloidosis: Examining Differences in Clinical Presentation and Outcomes

Background: Racial/ethnic minorities have been underrepresented in most population-based studies of AL amyloidosis published to date. This observation stands in marked contrast to multiple myeloma, a closely related disorder with a twofold higher incidence among blacks vs. whites. Given the scarcity of information about health disparities in AL amyloidosis, we aimed to characterize the clinical presentation and outcomes of this unique plasma cell disorder according to race/ethnicity. Methods: Data on consented patients with systemic AL amyloidosis seen at the Boston University Amyloidosis Center between 1990 and 2020 were obtained from a prospectively maintained database (ClinicalTrials.gov Identifier: NCT00898235). Sociodemographic factors, hematologic and organ disease markers, along with the use of high-dose melphalan and stem cell transplantation (HDM/SCT) were stratified by self-reported race/ethnicity. Groups included non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and non-Hispanic other (NHO). Differences were assessed by χ2 test for categorical variables and one-way ANOVA test for continuous variables. Multivariable logistic regression was used to determine the influence of variables on HDM/SCT utilization. The effect of race/ethnicity on mortality was estimated by multivariate Cox proportional hazards regression with adjustment for relevant confounders. Results: In a cohort of 2,416 patients, only 14% were underrepresented minorities (Figure 1A). At diagnosis, racial/ethnic minority groups were younger than NHWs by a median of 4-6 years. NHBs comprised 8% of the cohort and had higher-risk sociodemographic factors (e.g. educational attainment of high school level or less among 39% vs. 25% for NHWs; P < .001). Furthermore, there was an indication of more aggressive disease among NHBs with more patients having a difference between involved and uninvolved free light chains (dFLC) of > 180 mg/L (39% vs. 22-33%; P = .044). Hispanics comprised 4% of the cohort and presented with more advanced cardiac disease (i.e. median BNP of 1,041 pg/mL vs. 221-480 pg/mL; P = .001). Among a subcohort of 1,668 patients with available treatment data, 33% of Hispanics and 39% of NHBs were treated with HDM/SCT as compared to 47% of NHWs (P = .071). This treatment disparity was accounted for by sociodemographic (i.e. lower educational level) and physiologic risk factors (i.e. stage III cardiac involvement), rather than race/ethnicity itself. At data cutoff in March 2020, 1,622 (67%) patients were deceased. Compared with NHWs, the median survival for NHBs was shorter by nearly one year (Figure 1B) with an age/sex-adjusted HR for death of 1.24 (95% CI 1.03-1.49; P = .020). After further adjusting for disease and treatment variables, this survival difference was eliminated altogether (HR 0.82; 95% CI 0.50-1.34; P = .427). Conclusions: For the first time, this study shines a spotlight on racial/ethnic disparities in AL amyloidosis. Systematic underdetection, along with delayed diagnosis and referral, may explain why minority patients bear a disproportionate burden of late-stage cardiac involvement and high dFLC at the time of initial presentation. In turn, these factors contribute to underutilization of effective treatments such as HDM/SCT (particularly among Hispanics) and poorer survival (among NHBs) as observed in our study. The possibility of predisposing genetic and/or biological factors will need to be considered in future studies. Ultimately, greater awareness of AL amyloidosis within underrepresented communities, together with more widespread and accessible testing, are necessary to mitigate these health disparities. Figure 1: (A) The distribution of race/ethnicity in a large cohort of patients with AL amyloidosis and (B) Kaplan-Meier survival curves are shown. NHW indicates non-Hispanic white; NHB, non-Hispanic black; and NHO, non-Hispanic other. Figure 1 Disclosures Sanchorawala: Caleum: Other: advisory board; Proclara: Other: advisory board; Abbvie: Other: advisory board; UpToDate: Patents & Royalties; Regeneron: Other: advisory board; Janssen: Research Funding; Takeda: Research Funding; Celgene: Research Funding; Prothena: Research Funding; Caelum: Research Funding; Oncopeptide: Research Funding.

Pain Management in the Unstable Trauma Patient

Review the current literature regarding the optimal approach to pain control in unstable trauma patients, specifically focusing on the initial management of pain and rapid transition to multi-modal agents. There is a clear benefit to multi-modal analgesia instituted as rapidly as possible in trauma patients. While early management of pain depends upon the use of short-acting IV opioids, the rapid transition to adjunctive pain control strategies is optimal. The benefits include not only improved patient experience but also improved physiologic parameters and lower long-term risk of chronic pain and disability. The initial management of pain in unstable trauma patients is focused on titrating short-acting IV opioids to effect. Rapid institutions of multi-modal pain control, however, can improve short-term pain management while reducing the physiologic load imposed by uncontrolled pain and reduce the risk of long-term chronic pain and opioid misuse.

Sleep Disordered Breathing: An Epidemiological Study among Albanian Children and Adolescents.

Sleep Disordered Breathing (SDB) comprises a group of diseases characterized by alterations in the frequency and/or depth of breathing during sleep. The aim of this study was to investigate the frequency of SDB in a group of Albanian children and adolescents and to describe its social, physiological, psychological, sleep-related, and anthropometric risk factors, in relation to the sociodemographic situation. A total of 6087 participants (mean age: 10.42 years, range: 6 to 15 years, 52.3% females and 47.7% males) attending public schools all over Albania took part in the cross-sectional study. On a sample of 6087 questionnaires distributed, 4702 (77.25% of the original sample) were returned and included in the study. High risk status for SDB was assessed using the Paediatric Sleep Questionnaire (PSQ). The prevalence of SDB was 7.9%. No statistically significant difference was found for gender at high risk for SBD. Compared to participants living in urban aeras (7.3%), participants living in rural areas (10.4%) reported significantly higher SDB prevalence rates. No other significant correlations were detected between the high-risk subjects and the age. The prevalence of the subjects at high risk of SBD obese participants (20.8%) was statistically higher than among nonobese ones (6.3%). SDB is highly prevalent in Albanian growing population and further prevalence studies are recommended.

Discrepancies between Perceived and Physiological Fall Risks and Repeated Falls among Community-Dwelling Medicare Beneficiaries Aged 65 Years and Older

ABSTRACT Objectives This study examined the associations of discrepancies between perceived and physiological fall risks with repeated falls. Methods We analyzed the 2016 Medicare Current Beneficiary Survey of 2,487 Medicare beneficiaries aged ≥ 65 years with ≥ 1 fall. The outcome variable was repeated falls (≥ 2 falls), the key independent variable was a categorical variable of discrepancies between perceived (fear of falling) and physiological fall risks (physiological limitations), assessed using multivariate logistic regression. Results Among Medicare beneficiaries with ≥ 1 fall, 25.1% had low fear of falling but high physiological fall risk (Low Fear-High Physiological), 9.4% had high fear of falling but low physiological fall risk (High Fear-Low Physiological), 23.5% had low fear of falling and low physiological fall risks (Low Fear-Low Physiological), and 42.0% had high fear of falling and high physiological fall risks (High Fear-High Physiological). Having High Fear-High Physiological was associated with repeated falls (OR = 2.14; p < .001) compared to Low Fear-Low Physiological. Having Low Fear-High Physiological and High Fear-LowPhysiological were not associated with repeated falls. Conclusions Given that High Fear-High Physiological was associated with repeated falls and that many at-risk Medicare beneficiaries had High Fear-High Physiological, prevention efforts may consider targeting those most at-risk including Medicare beneficiaries with High Fear-High Physiological. Clinical Implications Assessing both perceived and physiological fall risks is clinically relevant, given it may inform targeted interventions for different at-risk Medicare beneficiaries among clinicians and other stakeholders.

The Iconographical Falls Efficacy Scale (IconFES) in community-dwelling older people-a longitudinal validation study.

This study aimed to develop cut-points for the 30-item and 10-item Iconographical Falls Efficacy Scale (IconFES) in community-dwelling older people and evaluate the psychometric properties, including construct and predictive validity with respect to falls and reduced physical activity over 1year. Eight hundred and one participants completed the IconFES and underwent physical, psychological and cognitive measures at baseline. Physical activity was recorded at baseline and 12months using an activity monitor, and 1-year fall incidence was collected using monthly falls calendars. Using receiver-operating characteristic curves and the Youden's index for history of falls, physiological fall risk and depressive symptoms, cut-points were defined to differentiate between low and high concern about falling (30-item: <53; 10-item: <19). For the 30-item IconFES, we additionally defined cut-points for low (≤40), moderate (41-58) and high (≥59) concern about falling. Groups based on these cut-points differed significantly: low coordinated stability, executive function and amount of daily walking, and high level of disability (30-item version) and female gender (low/high 30-item version). Although there were some inconsistencies across IconFES classifications, high concern about falling predicted having had multiple falls or multiple/injurious falls, low amount of daily walking and low movement intensity at 12months. The developed IconFES cut-points were sensitive to variables associated with concern about falling and predicted fall incidence and physical activity restriction after 12months. Applying these cut-points appears useful to identify older people with high concern about falling, who are at higher risk of falls and activity curtailment.

Life in the army reserves – the balance of work, training and physical activity: an ethnographic study

ABSTRACT Physiological, psychological and social risk factors influence the health and wellbeing of military personnel and units. Whilst evidence has investigated employment within the regular military, the same cannot be said for reserve personnel. Reservists negotiate civilian employment whilst balancing the rigours of military life. Little is known about the lives and experiences of these individuals despite their reliance within the military. The current study sought to understand the health, lives and experiences of reservists through an ethnography consisting of observations, lived experience, conversations and semi-structured interviews. Forty personnel participated in the study which took place in one combat unit of the British Army. Data were collected across training exercises and weekly meetings. In total 300 hours of data were analysed using an iterative process. ‘Life as a reservist’, ‘the risk factors and implications for health and wellbeing’ and ‘the critical promotion of physical activity and health within the Army’ were identified within the data. While the training the Army Reserves undertake is supportive of health and wellbeing, the structure within the Army reduces choice and control. Enriching training and social support can mitigate these antecedents of ill-being. Further effective training can provide a setting to foster resilience and prepare personnel for deployment. The study highlights the differences and similarities between full-time personnel and the experiences of reservists, both in terms of health, wellbeing and the training undertaken. Future research may seek to understand the differences in theatres of operation, and attitudes of those responsible for promoting health and wellbeing.

Anemic Women are More at Risk of Injectable Contraceptive Discontinuation Due to Side-Effects in Ethiopia

Background: This paper investigates the importance of women’s physiological condition for predicting the risk of discontinuing using the injectable contraceptive due to side-effects in Ethiopia, where unmet need for family planning is substantial. Methods: Contraceptive calendar data from the 2016 Ethiopian Demographic and Health Survey were analyzed. Women aged 15-49 who had initiated the injectable contraceptive in the two years prior to interview were included in the analysis (N=1,513). After checking for reverse causality, the associations between physiological risk factors and discontinuation of the injectable contraceptive due to either side-effects (DSE) or other reasons (DOR) were estimated using multivariate Cox proportional regression analyses. Findings: In 2016, 10% of women had initiated the injectable in the last two years, and 1 in 4 had discontinued use by the time of the interview. Of these, 1 in 5 discontinued due to side-effects. Women with anemia were twice more at risk of DSE compared with non-anemic women, while anemia status was not associated with DOR. The association between anemia and the experience of side-effects is likely driven by iron-deficiency anemia: having not taken iron supplements during last pregnancy increased the risk of DSE. Sociocultural factors including religion, wealth and relationship status were significant predictors for DOR, but not for DSE. Interpretation: Accounting for diversity in physiological condition is key for understanding contraceptive discontinuation due to side-effects. To reduce side-effects and thereby unmet needs, family planning programs might benefit from providing hormonal contraception as part of an integrated package addressing anemia. Funding Statement: No specific funding was obtained for this research. RS is undertaking graduate study, funded by both an Economic and Social Research Council studentship and a Clarendon scholarship, as part of which, she conducted this research. Declaration of Interests: There are no conflict of interests. Ethics Approval Statement: Procedures and questionnaires for standard DHS surveys have been approved by the ICF Institutional Review Broad (IRB) and the specific Ethiopian protocol by IRBs in Ethiopia.

Carotid endarterectomy remains safe in high-risk patients

ObjectiveCarotid endarterectomy (CEA) is a proven intervention for stroke risk reduction in symptomatic and asymptomatic patients. High-risk patients are often offered carotid stenting to minimize the risk and optimize the outcomes. As a referral center for high-risk patients, we evaluated and analyzed our experience with high-risk CEA patients. MethodsWe retrospectively reviewed consecutive patients who had undergone CEA at a tertiary referral center. The demographics, indications for surgery, physiologic and anatomic risk factors, intraoperative surgical management, perioperative complications, morbidity, and mortality were analyzed. The high-risk physiologic factors identified included an ejection fraction <30%, positive preoperative stress test results, and compromised pulmonary function test results. The high-risk patients included those requiring home oxygen, those with a partial pressure of oxygen of <60 mm Hg, and patients with a forced expiratory volume in 1 second of <30%. The high-risk anatomic factors identified included previous head and/or neck radiation, a history of ipsilateral neck surgery, contralateral nerve palsy, redo CEA, previous ipsilateral stenting, contralateral occlusion, contralateral CEA, nasotracheal intubation, and digastric muscle division. After propensity score matching, patients with and without high-risk physiologic and anatomic factors were compared. The primary outcomes were a composite of stroke, myocardial infarction, and 30-day mortality. The secondary outcomes were cranial injury and surgical site infection. ResultsDuring a 10-year period, 1347 patients had undergone CEA at the Cleveland Clinic main campus. Of the 1347 patients, 1152 met the criteria for analysis. Propensity score matching found adequate matches for 424 high-risk patients, with 173 patients having at least one physiologic high-risk factor and 293 at least one anatomic high-risk factor. No significant differences were found in the primary composite outcome or any of its components. Overall, the stroke rate for the standard-risk and high-risk patients was 1.9% and 1.4%, respectively. The high-risk patients were significantly more likely to have experienced a cranial nerve injury, although most were temporary. When patients with one or multiple risk factors were analyzed, no significant difference was found in the primary composite outcome or any of its components. Patients with two or more risk factors were significantly more likely to have experienced a cranial nerve injury, with most being temporary. ConclusionsIn our large series, CEA remained a viable and safe surgical solution for patients with high-risk anatomic and physiologic risk factors, with acceptable stroke, myocardial infarction, and 30-day mortality rates.