Background Despite a recent American Heart Association (AHA) consensus statement emphasizing the importance of resistant hypertension, the incidence and prognosis of this condition is largely unknown. Methods and Results This retrospective cohort study in two integrated health plans included patients with incident hypertension started on treatment from 2002–2006. Patients were followed for the development of resistant hypertension based on AHA criteria of uncontrolled blood pressure despite use of three or more antihypertensive medications using medication fill and blood pressure measurement data. We determined incident cardiovascular events (death or incident myocardial infarction, heart failure, stroke or chronic kidney disease) in patients with and without resistant hypertension adjusting for patient and clinical characteristics. Among 205,750 patients with incident hypertension, 1.9% developed resistant hypertension within a median 1.5 years from initial treatment, or 0.7 cases per 100 person-years of follow-up. These patients were more often men, older, and had higher rates of diabetes compared with nonresistant patients. Over 3.8 years of median follow-up, cardiovascular event rates were significantly higher in those with resistant hypertension (unadjusted: 18.0% vs. 13.5%, p<0.001). After adjusting for patient and clinical characteristics, resistant hypertension was associated with a higher risk of cardiovascular events (HR 1.47, 95% CI 1.33–1.62). Conclusions Among patients with incident hypertension started on treatment, 1 in 50 patients developed resistant hypertension. Resistant hypertension patients had an increased risk of cardiovascular events supporting the need for greater efforts toward improving hypertension outcomes in this population.

In this large, multisite cohort of patients with severe obesity, bariatric surgery was associated with a lower risk of incident cancer, particularly obesity-associated cancers, such as postmenopausal breast cancer, endometrial cancer, and colon cancer. More research is needed to clarify the specific mechanisms through which bariatric surgery lowers cancer risk.

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Having online access to medical records and clinicians was associated with increased use of clinical services compared with group members who did not have online access.

Objective Depression among pregnant women is a prevalent public health problem associated with poor maternal and offspring development. Behavioral Activation (BA) is a scalable intervention aligned with pregnant women’s preference for non-pharmacological depression care. This is the first test of the effectiveness of BA for depression among pregnant women, which aimed to evaluate the effectiveness of BA as compared with treatment as usual (TAU). Method Pregnant women (mean age = 28.75; SD = 5.67) with depression symptoms were randomly assigned to BA (n = 86) or TAU (n = 77). Exclusion criteria included known bipolar or psychotic disorder or immediate self-harm risk. Follow-up assessment occurred 5 and 10 weeks post-randomization and 3 months postpartum using self-report measures of primary and secondary outcomes and putative targets. Results Compared with TAU, BA was associated with significantly lower depressive symptoms (d = 0.34, p = .04) and higher remission (56.3% vs. 30.3%, p = .003). BA also demonstrated significant advantage on anxiety and perceived stress. Participants attended most BA sessions and reported high satisfaction. Participants in BA reported significantly higher levels of behavioral activation (d = 0.69, p <.0002) and environmental reward (d = 0.54, p < .003) than those who received TAU, and early change in both of these putative targets significantly mediated subsequent depression outcomes. Conclusions BA is effective for pregnant women, offering significant depression, anxiety, and stress related benefits, with mediation analyses supporting the importance of putative targets of activation and environmental reward.

Patients with resistant hypertension are at risk for poor outcomes. Medication adherence and intensification improve blood pressure control; however, little is known about these processes or their association with outcomes in resistant hypertension. This retrospective study included patients from 2002-2006 with incident hypertension from two health systems who developed resistant hypertension, or uncontrolled blood pressure despite adherence to ≥3 antihypertensive medications. Patterns of hypertension treatment, medication adherence (percentage of days covered) and treatment intensification (increase in medication class or dose) were described in the year after resistant hypertension identification. Then, the association between medication adherence and intensification with 1-year blood pressure control was assessed controlling for patient characteristics. Of the 3,550 patients with resistant hypertension, 49% were male and mean age 60. One year after resistance hypertension determination, fewer patients were taking diuretics (77.7% vs. 92.2%, p<0.01), beta blockers (71.2% vs. 79.4%, p<0.01) and ACE/ARB (64.8% vs. 70.1%, p<0.01) compared to baseline. Rates of blood pressure control improved over 1-year (22% vs. 55%, p=<0.01). During this year, adherence was not associated with 1-year blood pressure control (adjusted OR 1.18, 0.94-1.47). Treatment was intensified in 21.6% of visits with elevated blood pressure. Increasing treatment intensity was associated with 1-year blood pressure control (adjusted OR 1.64; 95% CI 1.58-1.71). In this cohort of patients with resistant hypertension, treatment intensification but not medication adherence was significantly associated with 1-year blood pressure control. These findings highlight the need to investigate why patients with uncontrolled blood pressure do not receive treatment intensification.

Objective: This retrospective cohort study examined whether bariatric surgery is associated with reduced risk of breast cancer among pre- and postmenopausal women. Background: Obesity is associated with increased risk of breast cancer, but the impact of weight loss on breast cancer risk has been difficult to quantify. Methods: The cohort included obese (body mass index ≥35 kg/m2) patients enrolled in an integrated health care delivery system between 2005 and 2012 (with follow-up through 2014). Female bariatric surgery patients (N = 17,998) were matched on body mass index, age, study site, and comorbidity index to 53,889 women with no bariatric surgery. Kaplan–Meier curves and Cox proportional hazards models were used to examine incident breast cancer up to 10 years after bariatric surgery. Pre- and postmenopausal women were examined separately, and further classified by estrogen receptor (ER) status. Results: The analysis included 301 premenopausal and 399 postmenopausal breast cancer cases. In multivariable adjusted models, bariatric surgery was associated with a reduced risk of both premenopausal (HR = 0.72, 95% CI, 0.54–0.94) and postmenopausal (HR = 0.55, 95% CI, 0.42–0.72) breast cancer. Among premenopausal women, the effect of bariatric surgery was more pronounced among ER-negative cases (HR = 0.36, 95% CI, 0.16–0.79). Among postmenopausal women, the effect was more pronounced in ER-positive cases (HR = 0.52, 95% CI, 0.39–0.70). Conclusions: Bariatric surgery was associated with a reduced risk of breast cancer among severely obese women. These findings have significant public health relevance because the prevalence of obesity continues to rise, and few modifiable breast cancer risk factors have been identified, especially for premenopausal women.

ObjectiveThe goal of this study was to determine whether the reduction in cancer risk after bariatric surgery is due to weight loss.MethodsWe conducted a retrospective matched cohort study of patients undergoing bariatric surgery using data from a large integrated health insurance and care delivery system with five sites in four states. The study included 18,355 bariatric surgery subjects and 40,524 non-surgical subjects matched on age, sex, BMI, site and Elixhauser comorbidity index. Multivariable Cox proportional hazards models examined the relationship between weight loss at 1 year and incident cancer up to 10 years follow-up.ResultsWe identified 1,196 incident cancers. The average one year post-surgical weight loss was 27% among patients undergoing bariatric surgery vs 1% in matched non-surgical patients. Percent weight loss at one year was significantly associated with a reduced risk of any cancer in adjusted models (HR 0.897, 95% CI 0.832–0.968, p=0.005 for every 10% weight loss) while bariatric surgery was not a significant independent predictor of cancer incidence.ConclusionsWeight loss after bariatric surgery was associated with a lower risk of incident cancer. There was no apparent independent effect of the bariatric surgery itself on cancer risk that was independent of weight loss.