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Abstract Background Hypertension is one of the most prevalent chronic diseases in the United States and can increase a person’s risk of stroke and other cardiovascular complications. Yet only 1 in 4 people with high blood pressure in the United States have their blood pressure managed. To improve hypertension control, we supported 9 health centers in Texas with the implementation of the Healthy Heart Ambassador Blood Pressure Self-Monitoring (HHA) Program. Methods We provided health center training using the HHA Program Facilitation Training Guide, recorded barriers to implementing the HHA program, and employed strategies to overcome those barriers. Results There were 68 staff members from the health centers trained to deliver the HHA program. Three health centers successfully implemented all three major components of HHA, three were able to implement two components, two adopted two components, and one withdrew due to insufficient capacity. Capability, technology infrastructure, and motivation were among the barriers most referenced. Conclusion Clinic non-physician team members delivering the HHA program will need training and ongoing technical assistance to overcome implementation barriers.

Abstract Background Coronavirus 2019 (COVID-19) pandemic has claimed over six million lives and infected more than 650 million people globally. Public health agencies have deployed several strategies, including rolling out vaccination campaigns to curb the pandemic, yet a significant proportion of the global population has not received the COVID-19 vaccine. We assessed differences in COVID-19 vaccination coverage by Gross National Income (GNI) per capita of WHO members (i.e., countries, areas, and territories, n = 192) and by WHO member regions (n = 6). Methods Using an ecological study design, we analyzed publicly available data from the WHO website merged with the World Bank’s GNI per capita data. We included a total of 192 WHO members and six WHO regions in the analysis. We utilized negative binomial regression to assess the associations between the GNI per capita and COVID-19 vaccination coverage (cumulative number of persons fully vaccinated and/or received at least one dose of the vaccine per 100 population), and ANOVA test to assess the differences in vaccination coverage per WHO regions. Results Low GNI per capita WHO members had significantly lower full vaccination coverage (aRR 0.30, 95% CI 0.22—0.40) compared to high GNI per capita WHO members. These members were also 66% less likely to receive at least one dose of the vaccine (aRR 0.34, 0.26—0.44) relative to high GNI per capita WHO members. Africa region had a significantly lower fully vaccination coverage (aRR 0.71, 95% CI 0.36—0.54) and received at least one dose of the COVID-19 vaccine (aRR 0.78, 95% CI 0.62—0.99) than Europe region. Conversely, the Western Pacific region had significantly higher fully vaccination coverage (aRR 1.40 95% CI 1.12—1.74) and received at least one dose of COVID-19 vaccines (aRR 1.40 95% CI 1.14—1.73) relative to European region. Conclusion WHO members with low GNI per capita and the African region reported significantly lower COVID-19 vaccination coverage than those with high GNI per capita or other regions. Efforts to strengthen and promote COVID-19 vaccination in low-income WHO countries and African region should be scaled up.

BackgroundDiabetes is considered one of the most prevalent and preventable chronic health conditions in the United States. Research has shown that evidence-based prevention measures and lifestyle changes can help lower the risk of developing diabetes. The National Diabetes Prevention Program (National DPP) is an evidence-based program recognized by the Centers for Disease Control and Prevention; it is designed to reduce diabetes risk through intensive group counseling in nutrition, physical activity, and behavioral management. Factors known to influence this program’s implementation, especially in primary care settings, have included limited awareness of the program, lack of standard clinical processes to facilitate referrals, and limited reimbursement incentives to support program delivery. A framework or approach that can address these and other barriers of practice is needed.ObjectiveWe used Implementation Mapping, a systematic planning framework, to plan for the adoption, implementation, and maintenance of the National DPP in primary care clinics in the Greater Houston area. We followed the framework’s five iterative tasks to develop strategies that helped to increase awareness and adoption of the National DPP and facilitate program implementation.MethodsWe conducted a needs assessment survey and interviews with participating clinics. We identified clinic personnel who were responsible for program use, including adopters, implementers, maintainers, and potential facilitators and barriers to program implementation. The performance objectives, or sub-behaviors necessary to achieve each clinic’s goals, were identified for each stage of implementation. We used classic behavioral science theory and dissemination and implementation models and frameworks to identify the determinants of program adoption, implementation, and maintenance. Evidence- and theory-based methods were selected and operationalized into tailored strategies that were executed in the four participating clinic sites. Implementation outcomes are being measured by several different approaches. Electronic Health Records (EHR) will measure referral rates to the National DPP. Surveys will be used to assess the level of the clinic providers and staff’s acceptability, appropriateness of use, feasibility, and usefulness of the National DPP, and aggregate biometric data will measure the level of the clinic’s disease management of prediabetes and diabetes.ResultsParticipating clinics included a Federally Qualified Health Center, a rural health center, and two private practices. Most personnel, including the leadership at the four clinic sites, were not aware of the National DPP. Steps for planning implementation strategies included the development of performance objectives (implementation actions) and identifying psychosocial and contextual implementation determinants. Implementation strategies included provider-to-provider education, electronic health record optimization, and the development of implementation protocols and materials (e.g., clinic project plan, policies).ConclusionThe National DPP has been shown to help prevent or delay the development of diabetes among at-risk patients. Yet, there remain many challenges to program implementation. The Implementation Mapping framework helped to systematically identify implementation barriers and facilitators and to design strategies to address them. To further advance diabetes prevention, future program, and research efforts should examine and promote other strategies such as increased reimbursement or use of incentives and a better billing infrastructure to assist in the scale and spread of the National DPP across the U.S.

Background: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract (GIT) that represent approximately 1 to 2 percent of primary gastrointestinal (GI) cancers. Owing to their rarity, very little is known about their overall epidemiology, and the prognostic factors of their pathology. The current study aimed to evaluate the independent determinants of mortality in patients diagnosed with GISTs over the past decade. Methods: Our study comprised 2374 patients diagnosed with GISTs from 2000 to 2017 from the Surveillance, Epidemiology, and End Results (SEER) database. We analyzed the baseline characteristics, and overall mortality (OM), as well as the cancer-specific mortality (CSM) of GISTs. Variables with a p value < 0.01 in the univariate Cox regression were incorporated into the multivariate Cox model, to determine the independent prognostic factors. Results: Multivariate Cox proportional hazard regression analyses of factors affecting the all-cause mortality and GIST-related mortality among US patients between 2010 and 2017 revealed a higher overall mortality in non-Hispanic Black patients (HR = 1.516, 95% CI 1.172–1.961, p = 0.002), patients aged 80+ (HR = 9.783, 95% CI 4.185–22.868, p = 0), followed by those aged 60–79 (HR = 3.408, 95% CI 1.488–7.807, p = 0.004); male patients (HR = 1.795, 95% CI 1.461–2.206, p < 0.001); patients with advanced disease with distant metastasis (HR = 3.865, 95% CI 2.977–5.019, p < 0.001), followed by cases with regional involvement via both direct extension and lymph node involvement (HR = 3.853, 95% CI 1.551–9.57, p = 0.004); and widowed patients (HR = 1.975, 95% CI 1.494–2.61, p < 0.001), followed by single patients (HR = 1.53, 95% CI 1.154–2.028, p = 0.003). The highest CSM was observed in the same groups, except widowed patients and patients aged 60–79. The highest CSM was also observed among patients that underwent chemotherapy (HR = 1.687, 95% CI 1.19–2.392, p = 0.003). Conclusion: In this updated study on the outcomes of patients with GISTs, we found that non-Hispanic Black patients, male patients, and patients older than 60 years have a higher mortality with GISTs. Furthermore, patients who have received chemotherapy have a higher GIST-specific mortality, and married patients have a lower mortality. However, we do not know to what extent these independent prognostic factors interact with each other to influence mortality. This study paves the way for future studies addressing these interactions. The results of this study may help treating clinicians to identify patient populations associated with a dismal prognosis, as those may require closer follow-up and more intensive therapy; furthermore, with married patients having a better survival rate, we hope to encourage clinicians to involve family members of the affected patients early in the disease course, as the social support might impact the prognosis.

Background: Suicide is a leading but preventable cause of death and is preceded by domains of thoughts, plans, and attempts. We assessed the prevalence of suicidality domains and determined the association of suicidality domains with sexual identity, mental health disorder symptoms, and sociodemographic characteristics. Methods: We used the 2019 National Survey on Drug Use and Health (NSDUH) data to perform weighted multivariable logistic regression and margins analyses to examine between and within-group differences in suicidality by sexual identity among adults aged ≥ 18 years. Results: About 4.89%, 1.37%, and 0.56% of the population experienced suicidal thoughts, plans, and attempts, respectively. Those aged 18–25 years old had a higher odds of suicidality compared to those aged 26 years or older. Compared to those who reported having no alcohol use dependence, illicit drug use dependence, and major depressive episodes (MDEs), those who reported alcohol use dependence, illicit drug use dependence, and MDE had higher odds of suicidal thoughts, plans, and attempts. Between all sexual identity groups, bisexuals who experienced MDEs had the highest probability of having suicidal thoughts while lesbians and gays who experienced MDE showed a higher probability of suicidal plans and attempts compared to heterosexuals. Within each sexual identity group, the probability of having suicidal thoughts, suicidal plans, and suicidal attempts was higher for those who had experienced MDEs compared to those who had not experienced MDEs. Conclusion: Substance use disorder and MDE symptoms were associated with increased suicidality, especially among young adults and sexual minority people. This disparity underscores the need for tailored interventions and policies to enhance the provision of prompt mental health screening, diagnosis, and linkage to care for mental health services, particularly among the most vulnerable in the population.

Background: Primary cardiac sarcomas (PCS) are extremely rare malignant tumors involving the heart. Only isolated case reports have been described in the literature over different periods of time. This pathology has been associated with a dismal prognosis and given its rarity; treatment options are very limited. Furthermore, there are contrasting data about the effectiveness of current treatment modalities in improving the survival of patients with PCS, including surgical resection which is the mainstay of therapy. There is a paucity of data on the epidemiological characteristics of PCS. This study has the objective of investigating the epidemiologic characteristics, survival outcomes, and independent prognostic factors of PCS. Methods: A total of 362 patients were ultimately registered in our study from the Surveillance, Epidemiology, and End Results (SEER) database. The study period was from 2000 to 2017. Demographics such as clinical characteristics, overall mortality (OM), and PCS-specific mortality (CSM) were taken into account. A p value of p < 0.001), followed by age 60–79 (HR = 1.429, 95% CI 1.028–1.986, p = 0.033); and PCS with distant metastases (HR = 1.888, 95% CI 1.389–2.566, p < 0.001). Patients that underwent surgical resection of the primary tumor and patients with malignant fibrous histiocytomas (HR = 0.657, 95% CI 0.455–0.95, p = 0.025) had a better OM (HR = 0.606, 95% CI 0.465–0.791, p < 0.001). The highest cancer-specific mortality was observed in age 80+ (HR = 5.037, 95% CI 2.606–9.736, p < 0.001) and patients with distant metastases (HR = 1.953, 95% CI 1.396–2.733, p < 0.001). Patients with malignant fibrous histiocytomas (HR = 0.572, 95% CI 0.378–0.865, p = 0.008) and those who underwent surgery (HR = 0.581, 95% CI 0.436–0.774, p < 0.001) had a lower CSM. Patients in the age range 80+ (HR = 13.261, 95% CI 5.839–30.119, p < 0.001) and advanced disease with distant metastases (HR = 2.013, 95% CI 1.355–2.99, p = 0.001) were found to have a higher OM in the multivariate analyses adjusting for covariates). Lower OM was found in patients with rhabdomyosarcoma (HR = 0.364, 95% CI 0.154–0.86, p = 0.021) and widowed patients (HR = 0.506, 95% CI 0.263–0.977, p = 0.042). Multivariate cox proportional hazard regression analyses of CSM also revealed higher mortality of the same groups, and lower mortality in patients with Rhabdomyosarcoma. Conclusion: In this United States population-based retrospective cohort study using the SEER database, we found that cardiac rhabdomyosarcoma was associated with the lowest CSM and OM. Furthermore, as expected, age and advanced disease at diagnosis were independent factors predicting poor prognosis. Surgical resection of the primary tumor showed lower CSM and OM in the crude analysis but when adjusted for covariates in the multivariate analysis, it did not significantly impact the overall mortality or the cancer-specific mortality. These findings allow for treating clinicians to recognize patients that should be referred to palliative/hospice care at the time of diagnosis and avoid any surgical interventions as they did not show any differences in mortality. Surgical resection, adjuvant chemotherapy, and/or radiation in patients with poor prognoses should be reserved as palliative measures rather than an attempt to cure the disease.

Background: Primary malignant melanomas of the Gastrointestinal mucosa are uncommon. Most cases of gastrointestinal (GI) melanomas are secondary, arising from metastasis at distant sites. The purpose of this study is to assess to what extent the interaction between independent prognostic factors (age and tumor site) of primary GI melanoma influence survival. Furthermore, we also aimed to investigate the clinical characteristics, survival outcomes, and independent prognostic factors of patients with primary GI melanoma in the past decade. Methods: A total of 399 patients diagnosed with primary GI melanoma, between 2008 and 2017, were enrolled in our study by retrieving data from the Surveillance, Epidemiology, and End Results (SEER) database. We analyzed demographics, clinical characteristics, and overall mortality (OM) as well as cancer-specific mortality (CSM) of primary GI melanoma. Variables with a p value < 0.1 in the univariate Cox regression were incorporated into the multivariate Cox model (model 1) to determine the independent prognostic factors, with a hazard ratio (HR) of greater than 1 representing adverse prognostic factors. Furthermore, we analyzed the effect of the interaction between age and primary location on mortality (model 2). Results: Multivariate cox proportional hazard regression analyses revealed higher OM in age group 80+ (HR = 5.653, 95% CI 2.212–14.445, p = 0), stomach location of the tumor (HR = 2.821, 95% CI 1.265–6.292, p = 0.011), regional lymph node involvement only (HR = 1.664, 95% CI 1.051–2.635, p < 0.05), regional involvement by both direct extension and lymph node involvement (HR = 1.755, 95% CI 1.047–2.943, p < 0.05) and distant metastases (HR = 4.491, 95% CI 3.115–6.476, p = 0), whereas the lowest OM was observed in patients with small intestine melanoma (HR = 0.383, 95% CI 0.173–0.846, p < 0.05). Multivariate cox proportional hazard regression analyses of CSM also revealed higher mortality of the same groups and lower CSM in small intestine and colon melanoma excluding the rectum. For model 2, considering the interaction between age and primary site on mortality, higher OM was found in age group 80+, followed by age group 40–59 then age group 60–79, regional lymph node involvement only, regional involvement by both direct extension and lymph node involvement and distant metastases. The small intestine had a lower OM. The rectum as primary location and the age range 40–59 interacted to lower the OM (HR = 0.14, 95% CI 0.02–0.89, p = 0.038). Age and primary gastric location did not interact to affect the OM. For the CSM, taking into account the interaction between age and the primary location, higher mortality was found in the same groups and the colon location. The primary colon location also interacted with the age group 40–59 to increase the CSM (HR = 1.38 × 109, 95% CI 7.80 × 107–2.45 × 1010, p = 0). Conclusions: In this United States population-based retrospective cohort study using the SEER database, we found that only the age range 40–59 interacted with the rectum and colon to lower and increase mortality respectively. Primary gastric location, which was the single most important location to affect mortality, did not interact with any age range to influence mortality. With those results, we hope to shed some light on this rare pathology with a very dismal prognosis.