1,721,114 research outputs found
Early Management of Community-Acquired Sepsis in a Regional Thai Referral Hospital: a Prospective Observational Study
Full text linkThesis (Master's)--University of Washington, 2017Purpose: The epidemiology and management of sepsis is poorly characterized in low- and middle-income countries. Methods: We performed a prospective observational cohort study of adults with community-acquired sepsis in a 1,420-bed regional referral hospital in northeast Thailand. Sepsis was defined as suspected infection plus organ dysfunction. Results: Between March 2013 and February 2014, 932 patients with sepsis were enrolled. Five hundred twelve (55%) were male and the mean age was 54 years. Eighty three percent of patients were transferred from other hospitals. Eighty four percent of patients were first evaluated in the Emergency Department, where median length of stay was 25 minutes. In the first day after presentation to the study hospital, the majority had blood cultures ordered (80%) and received antibiotics (84%). Most patients were admitted to the general medical wards; 15% were admitted to the intensive care unit (ICU) within the first hospital day. Patients admitted to the ICU had similar demographics and pre-existing co-morbidities but were more critically ill, and were and more likely to receive all measured sepsis management interventions. In-hospital mortality was 9% (87/932) and 28-day mortality was 22% (203/932). The 28-day mortality was significantly higher for patients admitted to the ICU on the first day (45% [63/139] vs. 18% [140/793], p<0.001). Conclusions: Sepsis in a regional referral hospital in rural Thailand, where some resources are limited, is commonly managed on general medical wards despite high rates of respiratory failure and shock. Twenty-eight-day mortality is comparable to some high-resource settings
Dietary Factors Associated with Hypertension in Nepal
No full textThesis (Master's)--University of Washington, 2012Hypertension is a major public health burden due to its causal association with cardiovascular disease morbidity, mortality, disability and economic costs. Diet has a major impact on hypertension. The aim of the study is to investigate the associations of diet score, dairy intake and animal protein intake with risk of hypertension in a sample of adults residing in central Nepal. This is a secondary data analysis of data collected by the University of Washington, Harvard and Shahid Gangalal National Heart Center, Nepal in 2009. Cross-sectional analyses were completed on selected variables collected during household interviews and examinations (n=200) in two regions of central Nepal: Kathmandu and Dhulikhel. Dietary information was collected via in-person interview using a food frequency questionnaire. The main models utilized logistic regression. The odds of having hypertension was 68% lower among those who eat low fat dairy daily (OR: 0.32, 95% CI: 0.07-1.29), 83% lower among those who eat 2-3 times a week (OR: 0.17, 95% CI: 0.03-0.89), 57% lower among those who eat once a week (OR:0.43, 95% CI: 0.06-2.55) and 60% lower among those who eat seldom or once a month (OR:0.40, 95% CI: 0.08-1.88) compared to those who never eat after adjusting for frequency of whole fat dairy consumption, frequency of animal protein consumption, demographic variables and traditional risk factors (p for trend=0.15). Compared to no consumption of whole fat dairy products, the odds ratio associated with daily consumption was 1.33 (95% CI: 0.38-3.38); 2-3 times per week consumption was 1.32 (95% CI: 0.08-23.37); once a week consumption was 4.08 (95% CI: 0.52-30.60) and seldom or once a month consumption was 1.85 (95% CI: 0.62-4.83) (p for trend=0.92). Compared to never consumption, the odds ratio associated with daily consumption of animal protein was 6.81 (95% CI: 0.31-150.47); 2-3 times per week consumption was 2.89 (95% CI: 0.70-11.81); once a week consumption was 1.29 (95% CI: 0.36-4.56) and seldom or once a month consumption was 1.43 (0.37- 5.45). (p for trend=0.11) The healthy eating pattern represented by diet score was non significantly protective (OR: 0.97, 95% CI: 0.93-1.02) (p for trend =0.414). In conclusion, the present study found a moderate but insignificant inverse association between low fat dairy intake and the risk of hypertension in the sample of middle and older age men and women. By contrast, whole-fat dairy intake and animal product intake was not related to the risk of hypertension. The higher diet score (representing healthy diet) was non-significantly protective for hypertension
Health Providers’ Perspectives on Incorporating the Chronic Care Model into the Management of Diabetes: Findings from a Community-based Hospital in Nepal
No full textThesis (Master's)--University of Washington, 2017-06Background: Nepal is not adequately prepared to tackle the increasing burden of diabetes, largely due to the lack of clarity on the integration of chronic disease management into health care delivery. Clear understanding of the opportunities and challenges of incorporating proven models of chronic disease care, such as the Chronic Care Model (CCM), into diabetes management is vital for any effort to improve diabetes care. Objectives: We aimed to: 1) describe the existing approach to diabetes management in Dhulikhel Hospital (DH), a community-based hospital in Dhulikhel, Nepal; 2) identify the opportunities and challenge of incorporating the components of the CCM into diabetes management at DH; and 3) develop a comprehensive plan for incorporating components of the CCM into diabetes management at DH. Methods: This cross-sectional mixed-methods study included qualitative and quantitative data collection strategies. We administered the Assessment of Chronic Illness Care Version 3.5 to obtain the perspectives of hospital leadership (n=2) and health providers (n=27) on the status of diabetes care at DH. Following a presentation of the CCM, we conducted in-depth interviews with hospital leadership (n=2) and health providers (n=8) to obtain their perspectives of the opportunities and challenges for incorporating CCM components into diabetes care. Findings were synthesized to develop a set of recommendations. Results: The overall score for the Assessment of Chronic Illness suggested stakeholders to perceive the presence of basic support for chronic disease (overall median program score of 5.4, IQ range: 2.8) at DH. There was consensus among the participants that CCM was highly relevant and important. Almost all of them said that the existing system addressed most of the components of CCM and believed that the ongoing activities and platform of DH provided opportunities for incorporating components of CCM into diabetes management. The components of delivery system design, decision support and organization of health care were considered already present in some form. However, there were concerns from the participants in the areas of community resources, self-management support and clinical information system. Conclusion: Recommendations based on data collected here provide feasible actions that may be taken at the leadership and provider level to improve diabetes care and management in Nepal. Many of these recommendations may be relevant to other low-income countries hoping to utilize the CCM for addressing the burden of diabetes and improving patient outcomes
Socioeconomic Status and Health Behavior in Nepal
No full textThesis (Master's)--University of Washington, 2016-07Background: Socioeconomic status (SES) is an important determinant of health outcomes, but more research is needed to improve our understanding of the relationship between SES, behavior and health, particularly in low- and middle-income countries (LMICs). Efforts to improve our understanding are limited by the difficulty of measuring economic status in low-resource settings where income may be seasonal and informal employment is common. The debate over how to accurately measure economic wellbeing is pertinent in Nepal, where more than 25% of the population lives in poverty and subsistence farming is an important source of livelihood. Additionally, studies suggest a growing burden of noncommunicable disease (NCDs) in Nepal, many of which are impacted by behavioral risk factors. Objectives: This study aimed to construct an asset-based wealth index to estimate household wealth; and to develop and test prediction models for tobacco use and physical activity in a community-based sample of adults in Dhulikhel, central Nepal. Methods: We conducted a cross-sectional study using data from 863 adult participants of the Dhulikhel Heart Study in Dhulikhel, Nepal. Household characteristics, individual sociodemographic characteristics and individual health behaviors were assessed using standard questionnaires completed during in-home interviews. The Demographic and Health Surveys (DHS) wealth index model was used to construct an asset-based measure of household wealth. The wealth index used information collected in the DHS, including access to utilities and infrastructure (e.g. source of drinking water), durable asset ownership, and housing characteristics (e.g. number of rooms for sleeping), to produce a measure household wealth. The wealth index was constructed using principal components analysis (PCA) of these measures. Backwards stepwise logistic regression was used to develop and test prediction models for tobacco use and physical activity using the developed wealth index and other SES variables. Tobacco use was categorized as ever (lifetime) or never. Participants were categorized as those who met the WHO guidelines for recommended level of physical activity (600 MET-minutes per week) and those who did not. Area under the Receiver Operating Characteristic curve (AUC) was used to assess the performance of the predictive models; an average AUC of 0.70 was considered acceptable. Results: Of 863 participants included in this study, 59% were female. The average age was 40.6 years and nearly a quarter of participants were in the highest quintile of household wealth. On average, study participants had 6.7 years of formal education; approximately one-third of the study population had no formal education. The first component of the PCA, designated as the wealth index, found that households with the following characteristics had higher loadings: use of liquid petroleum gas (LPG) as fuel for cooking; had a toilet that flushed to piped sewerage system; had drinking water piped into the dwelling; owned a TV; owned a nonmobile phone; owned a refrigerator; owned a table; owned a chair; owned a sofa; owned a cupboard; owned a computer; owned a clock; owned a fan; owned a bike or rickshaw; owned a motorcycle or scooter; had internet; had a bank account; had cement floors; and had a cement roof. The wealth index accounted for 17% of the variability across all wealth indicators. Approximately 32% of participants reported lifetime tobacco use, and 40% of participants did not meet the recommendation for physical activity. After adjustment for sociodemographic characteristics, males were found to have significantly higher odds of tobacco use (OR=6.22, 95%C CI: 3.7-10.45, p<0.001) compared to females. No significant differences in physical activity were seen by sex. The prediction model for tobacco use included sex, age, and education; wealth was not a significant covariate in this model. The average AUC associated with the performance of the model was 0.829. The prediction model for physical activity included age, education, wealth, ethnicity and work status in the past twelve months. The average AUC associated with the performance of the model was 0.649 which is below the cut-off of 0.70 traditionally used for evaluating such models
Physical Activity Program Participation and the Risk of Falls for Older Group Health Members
No full textThesis (Master's)--University of Washington, 2014Introduction: Falls are one of the biggest health concerns for aging adults. Despite evidence suggesting the importance of regular physical activity (PA) for reducing fall risk, few older adults engage in fall-prevention-oriented exercise. Regular PA through exercise programs offered as a Medicare or health-plan-covered benefit may be one method to increase PA and reduce fall risk. Here we investigate the effectiveness of participating in EnhanceFitness (EF) and Silver Sneakers (SS), two nationally-disseminated senior exercise programs, in reducing risk of falls resulting in medical care. Methods: A population-based, retrospective cohort study was conducted using data from Group Health Cooperative (GHC) members over age 65. Participants were classified as consistent users (having used EF/SS 2 or more times each year they were enrolled in GHC during the study period [2005-2011]); intermittent users (having used EF/SS two or more times in one or more years they were enrolled in GHC during the study period but not all years), or non-users of the EF/SS. A time-to-first fall requiring medical treatment (identified via ICD-9 code and E-codes in the medical record) analysis using Cox proportional hazards models was used for both programs to generate hazard ratios (HR) comparing consistent and intermittent users with non-users of either program. Hierarchical adjustment was used to address confounding by demographic characteristics and comorbidities (measured by ICD-9 codes in electronic health records). Results: In fully adjusted models, there was evidence of a dose-response relationship between EF participation and decreased fall risk compared to non-users (consistent EF user HR= 0.75, 95% CI = 0.64-0.89 and intermittent EF user HR = 0.87, 95% CI = 0.80-0.94). Participation in SS was not significantly associated with a decrease in risk for consistent users (HR= 0.97, 95% CI = 0.90-1.04), but a small significant reduction in risk was seen for intermittent users (HR= 0.93 95% CI= 0.90-0.97). Analyses evaluating effect modification showed that SS use was related to significantly lower fall risk among individuals over age 75 or with a BMI of 28 or below. Conclusion: Participation in EF provides a protective effect against falls resulting in medical care, with an indication of a dose-response relationship wherein this effect is strongest for consistent users. Results are less clear for SS participation, suggesting a small protective effect against medical falls for consistent and intermittent users that is potentially stronger for older and lower-BMI users
Associations of Air Pollution and Gait Speed in Older Adults
No full textThesis (Master's)--University of Washington, 2022Background: Air pollution is widely recognized as a threat to public health. The impact of long-term exposure to air pollution on gait speed trajectories over time have not been fully explored among US older adults. The specific aims of this study were to 1) examine the relationship between long-term exposure to air pollution and decline in gait speed among older adults, and 2) explore effect modification by cardiovascular disease status on the association.Methods: We analyzed data from 3,022 older adults in a prospective cohort study conducted from 2000 to 2008. Long term exposure to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) prior to study enrollment was estimated using state of the art prediction models. Gait speed at usual and rapid pace was assessed annually using a 15-feet timed walk test. Mixed effect models with random intercepts and slopes were fitted, adjusting for demographic and socioeconomic factors.
Results: Greater long-term PM2.5 exposure was related to faster gait speed decline at usual pace: one interquartile range higher 5-year average PM2.5 exposure was related to 0.048 m/s decline in gait speed (95% CI: -0.084, -0.024) over a 6-year study period adjusted for age, gender, race and ethnicity, education, smoking status, alcohol consumption, study site, and year since enrollment. Greater long-term NO2 exposure was associated with faster gait speed decline at both usual and rapid pace: one interquartile range higher 5-year average NO2 was associated with 0.078 m/s decline in usual pace gait (95% CI: -0.120, -0.042) and 0.042 m/s decline in rapid pace gait speed (95% CI: -0.078, -0.006) over 6-year period in adjusted models. The longitudinal association between air pollution and rapid gait speed decline was significant only in individuals with cardiovascular disease.
Conclusions: Long-term exposure to air pollution appears to be associated with faster progression in gait speed decline among older adults in four different locations in the US. Older adults with cardiovascular disease are more susceptible to the adverse effects of long-term exposure of air pollution and the progression in gait speed decline may be even faster among those with cardiovascular disease. Policies to reduce emission of air pollutants and interventions of avoid air pollution exposure or manage cardiovascular disease could contribute to the reduction in the burden of preventable institutionalization and hospitalization
Predisposing, Enabling and Reinforcing Factors Associated with the Use of Reproductive Cancer Screening among Peruvian Women
No full textThesis (Master's)--University of Washington, 2012Breast cancer is a major cause of death for women in Peru, and may soon surpass cervical cancer as the number one cause of cancer mortality among Peruvian women. Yet little is known about the determinants of reproductive cancer screening utilization in low and middle income countries. Data from a survey of risk factors for non-communicable diseases (FRENT), undertaken by the Ministry of Health in four Peruvian cities, was used to investigate variables representing three conceptual categories of barriers to obtaining mammograms, clinical breast exams, and pap smears based on a PRECEDE/PROCEED conceptual framework and previous qualitative work. Regression models revealed stress (predisposing), physician access and insurance (enabling), and marital status and previous child abuse (reinforcing) to be factors associated with screening, with some differences found across outcome and by age. Results provide evidence to direct interventions for increasing reproductive cancer screening in Peru
Plasma Amyloid, Inflammatory Markers, and Risk of Dementia in the Ginkgo Evaluation of Memory Study
No full textThesis (Master's)--University of Washington, 2019Most individuals with dementia have mixed neurodegenerative and vascular pathologies that may interact to accelerate cognitive decline. Prior studies have shown that two vascular inflammatory markers (pentraxin 3 and serum amyloid P) and plasma amyloid are associated with dementia, though results have been inconsistent. Using weighted Cox proportional hazards regression, we evaluated the joint associations of these inflammatory markers and plasma amyloid (Aβ1-42 and Aβ1-42/Aβ1-40 ratio) with risk of all-cause dementia. All four biomarkers were significantly associated with risk of dementia, and a composite of biomarker z-scores showed substantially higher risk for those with high levels of both inflammation and amyloid. Results for inflammatory markers and the composite z-score were stronger for individuals with MCI at baseline. Assessing inflammatory biomarkers in combination with plasma amyloid may lead to better prediction of symptomatic dementia onset than plasma amyloid alone
Repeat abortion and use of contraception among post-abortion women in Nepal – A prospective cohort study
Full text linkThesis (Master's)--University of Washington, 2015University of Washington Abstract Repeat abortion and use of contraceptive among post-abortion women in Nepal – A prospective cohort study Aradhana Thapa Chair of the Supervisory Committee: Research Professor, Annette L. Fitzpatrick Department of Family Medicine and Epidemiology Adjunct, Department of Global Health Aim: The study aims to identify the associated risk factors of repeat abortions and post-abortion contraceptive use among women in Pokhara city of Nepal. Background: Nepal legalized abortion in 2002 to promote safer motherhood (7). Safe abortion was attributed to be one of the contributing factors to a sharp decline of maternal mortality and morbidity in the country (9), however, abortion should not be considered an alternative to contraceptive use. Choosing abortions, repeatedly, can be detrimental to women and child health (11, 12). Post-abortion acceptance of contraception is low (41%) in the country and repeat abortion, high (33%) (8,11). Method: This is a prospective cohort study conducted among women who had just received an abortion procedure between January 2015 to April 2015 at three abortion clinics of Pokhara city in Nepal. We recruited 220 women immediately after their abortions to conduct a baseline interview and followed these in-person interviews with a telephone interview two months later to collect information on each woman’s current contraceptive method. Findings: The present study revealed that only half of the post-abortion women use effective contraception after abortion and there is a high prevalence of repeat abortion. The main factors positively influencing use of post-abortion contraception were presence of the woman’s husband in another country and choice of Tier II contraceptive methods. The main risk factors identified for repeat abortion were age and age at first pregnancy. Better educated women were less likely to adopt effective contraceptive measure after abortion. Conclusion: Considering low contraception use after abortion, increasing numbers of abortion, and high incidence of repeat abortion, a well targeted intervention may have substantial effect to reduce risk of unintended pregnancies
Making Sense of Brain Aging: Hearing and Visual Impairments, Ophthalmic Conditions, and Risk of Dementia in Older Adults
No full textThesis (Ph.D.)--University of Washington, 2020Background: Hearing and vision play an important role in physical, mental, and functional health. Less is known about the impact of deficits in hearing and vision, including dual sensory impairment (DSI), and causes of these sensory impairments on cognitive function. Objectives of this study were to examine risk of dementia associated with: (1) hearing and visual impairments in late-life; and (2) common ophthalmic conditions in older adults, such as cataracts, age-related macular degeneration (AMD), diabetic retinopathy (DR), and glaucoma. Methods: Participants from the Ginkgo Evaluation of Memory (GEM) Study and the Cardiovascular Health Study (CHS) who were dementia-free at baseline were included in the analyses. Information on hearing and visual impairments were based on self-report at baseline in the GEM Study and CHS. Additionally, in CHS, data on hearing and vision were collected at multiple follow-up visits. Medical histories collected by CHS and ICD-9 diagnostic codes from Medicare Part B claims data were used to ascertain diagnoses of specific ophthalmic conditions. Incident dementia, including major subtypes of Alzheimer’s disease (AD) and vascular dementia (VaD), was adjudicated by a consensus committee using standardized criteria. Multivariable Cox models were used to estimate risk of dementia, presented as hazard ratios (HRs) and 95% confidence intervals (CIs). Results: Greater number of sensory impairments was associated with increased risk of dementia in a graded fashion in both the GEM Study (P = 0.002) and CHS (P <0.001). DSI at baseline was associated with increased risk for all-cause dementia (HR = 1.86; 95% CI = 1.25 – 2.76) and AD (HR = 2.12; 95% CI = 1.34 – 3.36) in the GEM Study. Time-varying DSI was also associated with increased risk for all-cause dementia (HR = 2.60; 95% CI = 1.66 – 4.06) and AD (HR = 3.67; 95% CI = 2.04 – 6.60) in CHS. DSI severity at baseline in the GEM Study was associated with risk for all-cause dementia in a dose-dependent fashion (P = 0.02). Longer duration of DSI was associated with increased risk for all-cause dementia in CHS (P = 0.02). In CHS, increased risk for AD was associated with AMD (HR = 1.87; 95% CI = 1.13 – 3.09) and cataracts (HR = 1.34; 95% CI = 1.01 – 1.80). Increased risk for VaD was associated with DR (HR = 2.63; 95% CI = 1.10 – 6.27) and cataracts (HR = 1.41; 95% CI = 1.02 – 1.95). Conclusions: Older adults with hearing and visual impairments are at elevated risk of developing dementia. Differential associations between cataracts, AMD, DR, and incident dementia may reflect heterogeneous underlying neurodegenerative and vascular pathways shared between the eye and brain. Evaluation of hearing and vision, including common ophthalmic conditions associated with vision loss, may represent important areas for interventions in older adults to promote healthy cognitive aging
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