Although links between adverse childhood experiences (ACEs) and problems in adulthood are wellestablished, less is known regarding links between exposure to trauma during childhood and adolescence and high-risk behavior in adolescence. We tested the hypothesis that cumulative exposure to up to 20 different types of trauma and bereavement/loss incrementally predicts high-risk adolescent behavior beyond demographic variables. Adolescents reporting exposure to at least 1 type of trauma (n ϭ 3,785; mean age ϭ 15.3 years; 62.7% girls) were selected from the National Child Traumatic Stress Network Core Data Set (CDS). Logistic regression analyses tested associations among both demographic variables and number of types of trauma and loss exposure as predictors, and 9 types of high-risk adolescent behavior and functional impairment (attachment difficulties, skipping school, running away from home, substance abuse, suicidality, criminality, self-injury, alcohol use, and victim of sexual exploitation) as criterion variables. As hypothesized, hierarchical logistic regression analyses revealed that each additional type of trauma exposure significantly increased the odds ratios for each problem behavior (range ϭ 1.06 -1.22) after accounting for demographic variables. Some demographic variables (female gender, public insurance eligibility, and older age) were also associated with increased likelihood for some outcomes. Study findings extend previously identified links between childhood trauma and problems later in life to include high-risk behavior and functional impairment during adolescence. The findings underscore the need for a trauma-informed public health approach to systematic screening, prevention, and early intervention for traumatized and bereaved youth in child service systems.

Aims  Clinical trials have demonstrated that a reduction in low-density lipoprotein cholesterol (LDL-C) reduces cardiovascular (CV) events. This has, however, not yet been shown in a real-world setting. We aimed to investigate the association between LDL-C changes and statin intensity with prognosis after a myocardial infarction (MI). Methods and results  Patients admitted with MI were followed for mortality and major CV events. Changes in LDL-C between the MI and a 6- to 10-week follow-up visit were analysed. The associations between quartiles of LDL-C change and statin intensity with outcomes were assessed using adjusted Cox regression analyses. A total of 40 607 patients were followed for a median of 3.78 years. The median change in LDL-C was a 1.20 mmol/L reduction. Patients with larger LDL-C reduction (1.85 mmol/L, 75th percentile) compared with a smaller reduction (0.36 mmol/L, 25th percentile) had lower hazard ratios (HR) for all outcomes (95% confidence interval): composite of CV mortality, MI, and ischaemic stroke 0.77 (0.70–0.84); all-cause mortality 0.71 (0.63–0.80); CV mortality 0.68 (0.57–0.81); MI 0.81 (0.73–0.91); ischaemic stroke 0.76 (0.62–0.93); heart failure hospitalization 0.73 (0.63–0.85), and coronary artery revascularization 0.86 (0.79–0.94). Patients with ≥50% LDL-C reduction using high-intensity statins at discharge had a lower incidence of all outcomes compared with those using a lower intensity statin. Conclusions  Larger early LDL-C reduction and more intensive statin therapy after MI were associated with a reduced hazard of all CV outcomes and all-cause mortality. This supports clinical trial data suggesting that earlier lowering of LDL-C after an MI confers the greatest benefit.

Background Trends in acute myocardial infarction (AMI) incidence rates for diverse races/ethnicities are largely unknown, presenting barriers to understanding the role of race/ethnicity in AMI occurrence. Methods and Results We identified AMI hospitalizations for Kaiser Permanente Southern California members, aged ≥35 years, during 2000 to 2014 using discharge diagnostic codes. We excluded hospitalizations with missing race/ethnicity information. We calculated annual incidence rates (age and sex standardized to the 2010 US census population) for AMI, ST‐segment–elevation myocardial infarction, and non–ST‐segment–elevation myocardial infarction by race/ethnicity (Hispanic and non‐Hispanic racial groups: Asian or Pacific Islander, black, and white). Using Poisson regression, we estimated annual percentage change in AMI, non–ST‐segment–elevation myocardial infarction, and ST‐segment–elevation myocardial infarction incidence by race/ethnicity and AMI incidence rate ratios between race/ethnicity pairs, adjusting for age and sex. We included 18 630 776 person‐years of observation and identified 44 142 AMI hospitalizations. During 2000 to 2014, declines in AMI, non–ST‐segment–elevation myocardial infarction, and ST‐segment–elevation myocardial infarction were 48.7%, 34.2%, and 69.8%, respectively. Age‐ and sex‐standardized AMI hospitalization rates/100 000 person‐years declined for Hispanics (from 307 to 162), Asians or Pacific Islanders (from 271 to 158), blacks (from 347 to 199), and whites (from 376 to 189). Annual percentage changes ranged from −2.99% to −4.75%, except for blacks, whose annual percentage change was −5.32% during 2000 to 2009 and −1.03% during 2010 to 2014. Conclusions During 2000 to 2014, AMI, non–ST‐segment–elevation myocardial infarction, and ST‐segment–elevation myocardial infarction hospitalization incidence rates declined substantially for each race/ethnic group. Despite narrowing rates among races/ethnicities, differences persist. Understanding these differences can help identify unmet needs in AMI prevention and management to guide targeted interventions.

BackgroundAtrial fibrillation (AF) is the most common clinically significant arrhythmia in adults and a major risk factor for ischemic stroke. Nonetheless, previous research suggests that many individuals diagnosed with AF lack awareness about their diagnosis and inadequate health literacy may be an important contributing factor to this finding.Methods and ResultsWe examined the association between health literacy and awareness of an AF diagnosis in a large, ethnically diverse cohort of Kaiser Permanente Northern and Southern California adults diagnosed with AF between January 1, 2006 and June 30, 2009. Using self‐reported questionnaire data completed between May 1, 2010 and September 30, 2010, awareness of an AF diagnosis was evaluated using the question “Have you ever been told by a doctor or other health professional that you have a heart rhythm problem called atrial fibrillation or atrial flutter?” and health literacy was assessed using a validated 3‐item instrument examining problems because of reading, understanding, and filling out medical forms. Of the 12 517 patients diagnosed with AF, 14.5% were not aware of their AF diagnosis and 20.4% had inadequate health literacy. Patients with inadequate health literacy were less likely to be aware of their AF diagnosis compared with patients with adequate health literacy (prevalence ratio=0.96; 95% CI [0.94, 0.98]), adjusting for sociodemographics, health behaviors, and clinical characteristics.ConclusionsLower health literacy is independently associated with less awareness of AF diagnosis. Strategies designed to increase patient awareness of AF and its complications are warranted among individuals with limited health literacy.