Background: Annually, over 150,000 cardiovascular events occur among individuals ,65 years old in the United States, including asymptomatic ones. Coronary artery calcium (CAC), a subclinical marker of coronary artery disease (CAD), enhances risk stratification among asymptomatic individuals. This study assessed the prevalence of CAC in a rural population and determined relationships between traditional risk factors for CAD and CAC scores. Methods: During January 2011 to December 2012, asymptomatic individuals from central Appalachia were screened for CAC in the largest tertiary cardiovascular institute. Based on Agatston scale, participants were grouped into 4 CAC scores: zero (CAC 5 0), mild (CAC 5 1-99), moderate (CAC 5 100-399) and severe (CAC $ 400). Multinomial logistic regression was used to examine associations between potential risk factors of CAD and CAC score. Results: Of 1,674 participants, 55.4% had positive CAC score (CAC . 0). Increasing age and being male were positively associated with higher CAC scores. Although there was significant association between mild CAC and hypertension and family history of CAD, moderate CAC was positively associated with smoking status. Except hypercholesterolemia and sedentary lifestyle, severe CAC was significantly associated with major health conditions (obesity, diabetes and hypertension), lifestyle (smoking) and family history of CAD. Conclusions: More than half of participants in the CAC screening had subclinical CAD (CAC score . 0). The association between CAC score and CAD risk factors suggests that education about subclinical atherosclerosis among asymptomatic individuals in this region with high cardiovascular disease prevalence is needed because CAC improves CAD risk stratification, and the knowledge of CAC enhances medication adherence and motivates individuals towards beneficial behavioral/lifestyle modification.

In May 2010, the United Nations (UN) General Assembly unanimously adopted a resolution on non-communicable diseases (NCDs) that called for high-level meetings to address the global burden of NCDs. This paper highlights the growing global burden of NCDs (cardiovascular diseases, cancer, chronic obstructive pulmonary diseases and diabetes), provides a brief historical background on the adoption of the UN NCDs resolution and argues that the resolution provides a remarkable new opportunity for improved international collaboration to address NCDs. Additionally, the paper argues that while the existing World Health Organisation programme on NCDs be continued and expanded, the UN can provide the expanded political leadership that is necessary for multi-sectoral collaboration and can serve as a respected forum for dealing with the issue across numerous key UN agencies.

Objective: Capacity building and training to improve contraceptive care is essential for patient-centered care and reproductive autonomy. This study assessed the feasibility of translating the knowledge and skills gained from contraception trainings into improvements in practice. Study Design: Participants completed surveys following contraceptive care trainings provided to family planning clinic and hospital obstetric providers and staff as a part of the Choose Well contraceptive access initiative in South Carolina. Surveys assessed participants’ intent to change their practice post-training and anticipated barriers to implementing change. A mixed-methods approach was utilized including descriptive analysis of Likert scale responses and thematic content analysis to synthesize open-ended, qualitative responses. Results: Data were collected from 160 contraceptive training sessions provided to 4814 clinical and administrative staff between 2017 and 2019. Post-training surveys were completed by 3464 participants (72%), and of these, 2978 answered questions related to the study outcomes. Most respondents (n = 2390; 80.7%) indicated intent to change their practice and 35.5% (n = 1044) anticipated barriers to implementing intended changes. Across all training categories, organizational factors (time constraints, policies and practices, infrastructure/resources) were the most frequently perceived barrier to improving contraceptive services. Structural factors related to cost for patients were also identified as barriers to IUD and implant provision. Conclusion: The trainings were successful in influencing family planning staff and providers’ intent to improve their contraceptive practices, yet some anticipated barriers in translating training into practice. Improvements in organizational and structural policies are critical to realizing the benefits of trainings in advancing quality contraceptive care. Implications: In addition to training, coordinated efforts to address organizational practices and resources, coupled with system-level policy changes are essential to facilitate the delivery and sustainability of patient-centered contraceptive care.

Background: Effects of cardiovascular (CV) risk factors on the diameter of the thoracic aorta have not been fully studied. This study examined the associations between CV risk factors and diameter of thoracic aorta. Materials and Methods: Study population comprised of 1273 asymptomatic adults aged ≥18 years from Central Appalachia region of the United States who participated in a coronary artery screening between January 2014 and December 2016. Descriptive statistics and multiple linear regression analyses were performed to examine associations between multiple CV risk factors and diameters of the thoracic aorta. Results: Mean (±SD) age of participants was 57.9±9.7 years; that of body mass index (BMI) was 29.4±5.9. The mean aortic sinus, ascending aorta, and descending aorta diameter were 34.1±4.4 mm, 33.8±4.4 mm, and 26.0±3.6 mm, respectively. Increasing age, being male, and having a higher BMI were associated with wider aortic sinus, ascending aorta, and descending aorta diameters. Hypertension (p < 0.05) and obesity (p < 0.0001) were significantly associated with wider diameter for all measured aortic diameters. Participants with diabetes had wider descending aorta compared to those without (26.6±3.9 mm vs. 25.9±3.5 mm, P = 0.012). Participants who had ever smoked a cigarette had significantly wider descending aorta diameter compared to never smokers (26.3±3.6 mm vs. 25.9±3.5 mm, p = 0.031). Conclusions: The study results suggest that decreasing BMI and management of CV risk factors such as hypertension and modifying behavioral risk factors such as smoking are likely to be emphasized in order to decrease the rate of aortic dilatation and subsequent aortic dissection, if aortic dilatation is detected during a CT scan.

This chapter will address the issue of risk for HIV-associated neurocognitive disorder (HAND), focusing on HIV-associated dementia (HAD), among persons living with HIV in relationship to the risk for other dementias. Advances in effective antiretroviral therapy (ART) have led to an increase in the prevalence of older persons surviving with HIV – in addition to older persons who become infected by HIV later in life. Hence, HIV is no longer a disease of younger persons, and additional attention has been brought to bear against the plight of older persons living with HIV – not only as it pertains to treatment but also to prevention. The additional risk caused by aging among older persons living with HIV is complex to asses, and HIV infection is a research area that requires a robust approach to multiple other factors causing neurocognitive impairment with older age. The long-term and potentially neurotoxic exposure to ART and the deleterious consequences of chronic infection with HIV and its associated neuro-inflammation have been described for health. This aids in the understanding of dementia risk factors in this patient population, but the comorbidities (HIV- and non-HIV-associated) occurring among older persons living with HIV must also be addressed to properly assess the overall impact on dementia risk in this group. This need also warrants our examination of the risk factors for other dementias (and comorbid dementias) in persons living with HIV versus the general population through the assessment and quantification of modifiable and non-modifiable risk factors identified as major contributors toward dementia.

Objective. To examine alternative tobacco product (ATP) use and associated factors among middle school students in Appalachian Tennessee. Method. Data (2015– 2016; N=573) from school-based tobacco surveys in 11 middle schools in Appalachian Tennessee were analyzed. Multiple logistic regression model described factors associated with ATP use. Results. More than one-tenth (13.2%) of participants have ever used ATPs. Approximately 9%, 7%, 6%, and 2% of participants have ever used e-cigarettes, cigarettes, smokeless tobacco, and little cigars or cigarillos, respectively. The following were significantly associated with ever use of ATPs: believing tobacco users have more friends, owning tobacco-branded item(s), living with a tobacco user, having ever smoked cigarettes, and living in homes where smoking is allowed. Conclusion. More than one in 10 of participants have ever used at least one ATP, and association with desirable objects and situations may promote ATP use. Interventions should seek to reduce these positive images and make all tobacco products unappealing.

Background: Pulmonary artery (PA) diameter may be altered in association with cardiovascular (CV) risk factors as noted in aorta in systemic hypertension. The flow of blood from the right ventricle to the PA and all the way to the capillary level depends on the pulmonary vascular resistance and to a lesser extent compliance and impedance of the PA, which are the fundamental conduit for maintenance of the right heart hemodynamics. Our objective is to determine the association between CV risk factors and the main pulmonary artery (MPA) diameter. Methods: The study population are asymptomatic individuals with no known diagnosis of CV diseases in central Appalachia (n=1,282). Adults aged 18 years or older were eligible for the screening if they were referred by a physician. For self-referral, only males aged ≥45 years and females aged ≥55 years were eligible. Unadjusted and adjusted linear regression analyses were performed. Results: The mean MPA diameter was significantly higher among males compared to females (27.19±4.20 vs. 24.99±3.91 mm, P<0.0001). Participants with diabetes also had wider MPA diameter (26.79±4.56 mm) compared to those without diabetes (25.93±4.11 mm) (P=0.015). Further, hypertensive (26.42±4.15 vs. 25.71±4.21 mm, P=0.002) and obese (27.25±4.11 vs. 25.28±4.07 mm, P<0.0001) participants had significantly wider MPA diameter compared to non-hypertensive and non-obese participants, respectively. Multivariable model showed that age, sex and body mass index (BMI) were significantly associated with MPA diameter. A 1-year increase in age increased MPA diameter by 0.046 mm (P<0.0001). The diameter of MPA was wider among males by 2.16 mm compared to females (P<0.0001). Finally, with one unit increase in BMI, the MPA diameter increased by 0.16 mm (P<0.0001). Conclusions: MPA diameter was significantly associated with age, sex, and BMI. Further prospective studies are needed to correlate computed tomography (CT) measurement of MPA diameter with pulmonary pressure as assessed by echocardiogram to diagnose pulmonary hypertension (PH).

Purpose of Review: To review the landmark studies in predicting obstructive coronary artery disease (CAD) in symptomatic patients with stable chest pain and identify better prediction tools and propose a simplified algorithm to guide the health care providers in identifying low risk patients to defer further testing. Recent Findings: There are a few risk prediction models described for stable chest pain patients including Diamond-Forrester (DF), Duke Clinical Score (DCS), CAD Consortium Basic, Clinical, and Extended models. The CAD Consortium models demonstrated that DF and DCS models overestimate the probability of CAD. All CAD Consortium models performed well in the contemporary population. PROMISE trial secondary data results showed that a clinical tool using readily available ten very low-risk pre-test variables could discriminate low-risk patients to defer further testing safely. Summary: In the contemporary population, CAD Consortium Basic or Clinical model could be used with more confidence. Our proposed simple algorithm would guide the physicians in selecting low risk patients who can be managed conservatively with deferred testing strategy. Future research is needed to validate our proposed algorithm to identify the low-risk patients with stable chest pain for whom further testing may not be warranted.

E-cigarette use among youth in the United States (U.S.) continues to increase. In the rural Northeast Tennessee, where prevalence of tobacco use is higher than national and state averages, there is no literature on e-cigarette use to inform policies and programs. This study aimed to estimate the prevalence of e-cigarette use and examine association of e-cigarette use with two tobacco products among school-going adolescents. Data from 894 participants of a school-based survey conducted in 2016 in Northeast Tennessee were analyzed. Descriptive statistics and logistic regression analyses were conducted to estimate the prevalence and delineate the associations between e-cigarette use and other tobacco products. Approximately 11% of the participants currently used e-cigarettes, and 35% had ever used e-cigarettes. About 6% of the participants were current users of both e-cigarettes and cigarettes; 4% were current users of e-cigarettes and smokeless tobacco; 3% were current users of all three products, and 15% had ever tried all three products. More than one-half of current e-cigarette users (52%) also smoked cigarettes. Adjusting for covariates, current e-cigarette use was positively associated with cigarette smoking [Odds Ratio (OR) 27.32, 95% confidence interval (CI) 14.4–51.7] and smokeless tobacco use [OR 7.92, 95% CI 3.8–16.5]. E-cigarette use was more common among the high school students than cigarette and smokeless tobacco use, and a significant proportion of users either smoked cigarettes, used smokeless tobacco, or both. Thus, there is a critical need for preventive policies and programs to address dual and poly-use of these products.

The objective of this study is to determine the diagnostic performance of computed tomography perfusion (CTP) with and without computed tomography angiography (CTA) in assessment of hemodynamically significant coronary artery lesions in comparison to invasive fractional flow reserve (FFR). Materials and Methods PubMed and Cochrane Center Register of Controlled Trials from January 2010 searched through December 2014. Nine original studies were selected evaluating the diagnostic performance of CTP with and without CTA to invasive coronary angiography in evaluation of hemodynamic significance of coronary lesions (n = 951). Results The sensitivity, specificity, LR+ and LR- and DOR of CTA+CTP were 0.85 [95% confidence interval (CI: 0.79-0.89)] 0.94 (CI: 0.91-0.97), 15.8 (CI: 7.99-31.39), 0.146 (CI: 0.08-0.26), and 147.2 (CI: 69.77-310.66). Summary Receiver Operating Characteristics (SROC) results showed area under the curve (AUC) of 0.97 indicating that CTA+CTP may detect hemodynamically significant coronary artery lesions with high accuracy. The sensitivity, specificity, LR+ and LR- and DOR of CTP were 0.83 (CI: 0.78-0.87), 0.84 (CI: 0.80-0.87) 5.26 (CI: 2.93-9.43), 0.209 (CI: 0.12-0.36), and 31.97 (CI: 11.59-88.20). Conclusions This result suggests that CTP with CTA significantly improves diagnostic performance of coronary artery lesions compared to CTA alone and closely comparable with invasive FFR.