Characteristics of Adults With Congenital Heart Defects in the United States.

BACKGROUND: In the United States, >1 million adults are living with congenital heart defects (CHDs), but gaps exist in understanding the health care needs of this growing population. OBJECTIVES: This study assessed the demographics, comorbidities, and health care use of adults ages 20 to 64 years with CHDs. METHODS: Adults with International Classification of Disease-9th Revision-Clinical Modification CHD-coded health care encounters between January 1, 2008 (January 1, 2009 for Massachusetts) and December 31, 2010 were identified from multiple data sources at 3 U.S. sites: Emory University (EU) in Atlanta, Georgia (5 counties), Massachusetts Department of Public Health (statewide), and New York State Department of Health (11 counties). Demographics, insurance type, comorbidities, and encounter data were collected. CHDs were categorized as severe or not severe, excluding cases with isolated atrial septal defect and/or patent foramen ovale. RESULTS: CHD severity and comorbidities varied across sites, with up to 20% of adults having severe CHD and >50% having ≥1 additional cardiovascular comorbidity. Most adults had ≥1 outpatient encounters (80% EU, 90% Massachusetts, and 53% New York). Insurance type differed across sites, with Massachusetts having a large proportion of Medicaid (75%) and EU and New York having large proportions of private insurance (44% EU, 67% New York). Estimated proportions of adults with CHD-coded health care encounters varied greatly by location, with 1.2 (EU), 10 (Massachusetts), and 0.6 (New York) per 1,000 adults based on 2010 census data. CONCLUSIONS: This was the first surveillance effort of adults with CHD-coded inpatient and outpatient health care encounters in 3 U.S. geographic locations using both administrative and clinical data sources. This information will provide a clearer understanding of health care use in this growing population.

Assessing Pregnancy, Gestational Complications, and Co-morbidities in Women With Congenital Heart Defects (Data from ICD-9-CM Codes in 3 US Surveillance Sites).

Improved treatment of congenital heart defects (CHDs) has resulted in women with CHDs living to childbearing age. However, no US population-based systems exist to estimate pregnancy frequency or complications among women with CHDs. Cases were identified in multiple data sources from 3 surveillance sites: Emory University (EU) whose catchment area included 5 metropolitan Atlanta counties; Massachusetts Department of Public Health (MA) whose catchment area was statewide; and New York State Department of Health (NY) whose catchment area included 11 counties. Cases were categorized into one of 5 mutually exclusive CHD severity groups collapsed to severe versus not severe; specific ICD-9-CM codes were used to capture pregnancy, gestational complications, and nongestational co-morbidities in women, age 11 to 50 years, with a CHD-related ICD-9-CM code. Pregnancy, CHD severity, demographics, gestational complications, co-morbidities, and insurance status were evaluated. ICD-9-CM codes identified 26,655 women with CHDs, of whom 5,672 (21.3%, range: 12.8% in NY to 22.5% in MA) had codes indicating a pregnancy. Over 3 years, age-adjusted proportion pregnancy rates among women with severe CHDs ranged from 10.0% to 24.6%, and 14.2% to 21.7% for women with nonsevere CHDs. Pregnant women with CHDs of any severity, compared with nonpregnant women with CHDs, reported more noncardiovascular co-morbidities. Insurance type varied by site and pregnancy status. These US population-based, multisite estimates of pregnancy among women with CHD indicate a substantial number of women with CHDs may be experiencing pregnancy and complications. In conclusion, given the growing adult population with CHDs, reproductive health of women with CHD is an important public health issue.

Surveillance of Congenital Heart Defects among Adolescents at Three U.S. Sites.

The prevalence, co-morbidities, and healthcare utilization in adolescents with congenital heart defects (CHDs) is not well understood. Adolescents (11 to 19 years old) with a healthcare encounter between January 1, 2008 (January 1, 2009 for MA) and December 31, 2010 with a CHD diagnosis code were identified from multiple administrative data sources compiled at 3 US sites: Emory University, Atlanta, Georgia (EU); Massachusetts Department of Public Health (MA); and New York State Department of Health (NY). The estimated prevalence for any CHD was 4.77 (EU), 17.29 (MA), and 4.22 (NY) and for severe CHDs was 1.34 (EU), 3.04 (MA), and 0.88 (NY) per 1,000 adolescents. Private or commercial insurance was the most common insurance type for EU and NY, and Medicaid for MA. Inpatient encounters were more frequent in severe CHDs. Cardiac co-morbidities included rhythm and conduction disorders at 20% (EU), 46% (MA), and 9% (NY) as well as heart failure at 3% (EU), 15% (MA), and 2% (NY). Leading noncardiac co-morbidities were respiratory/pulmonary (22% EU, 34% MA, 16% NY), infectious disease (17% EU, 22% MA, 20% NY), non-CHD birth defects (12% EU, 23% MA, 14% NY), gastrointestinal (10% EU, 28% MA, 13% NY), musculoskeletal (10% EU, 32% MA, 11% NY), and mental health (9% EU, 30% MA, 11% NY). In conclusion, this study used a novel approach of uniform CHD definition and variable selection across administrative data sources in 3 sites for the first population-based CHD surveillance of adolescents in the United States. High resource utilization and co-morbidities illustrate ongoing significant burden of disease in this vulnerable population.

Population-based surveillance of congenital heart defects among adolescents and adults: surveillance methodology.

BACKGROUND: Improved treatment of congenital heart defects (CHDs) has increased survival of persons with CHDs; however, no U.S. population-based systems exist to assess prevalence, healthcare utilization, or longer-term outcomes among adolescents and adults with CHDs. METHODS: Novel approaches identified individuals aged 11-64 years who received healthcare with ICD-9-CM codes for CHDs at three sites: Emory University in Atlanta, Georgia (EU), Massachusetts Department of Public Health (MA), New York State Department of Health (NY) between January 1, 2008 (2009 for MA) and December 31, 2010. Case-finding sources included outpatient clinics; Medicaid and other claims data; and hospital inpatient, outpatient, and emergency visit data. Supplemental information came from state vital records (EU, MA), and birth defects registries (EU, NY). Demographics and diagnostic and procedural codes were linked, de-duplicated, and shared in a de-identified dataset. Cases were categorized into one of five mutually exclusive CHD severity groups; non-cardiac comorbidity codes were grouped into broad categories. RESULTS: 73,112 individuals with CHD codes in healthcare encounters were identified. Primary data source type varied: clinics (EU, NY for adolescents), claims (MA), hospital (NY for adults). There was a high rate of missing data for some variables and data varied in format and quality. Some diagnostic codes had poor specificity for CHD ascertainment. CONCLUSIONS: To our knowledge, this is the first population-based, multi-site CHD surveillance among adolescents and adults in the U.S. Identification of people living with CHDs through healthcare encounters using multiple data sources was feasible, though data quality varied and linkage/de-duplication was labor-intensive.

Baseline Prevalence of Birth Defects Associated with Congenital Zika Virus Infection - Massachusetts, North Carolina, and Atlanta, Georgia, 2013-2014.

Zika virus infection during pregnancy can cause serious brain abnormalities, but the full range of adverse outcomes is unknown (1). To better understand the impact of birth defects resulting from Zika virus infection, the CDC surveillance case definition established in 2016 for birth defects potentially related to Zika virus infection* (2) was retrospectively applied to population-based birth defects surveillance data collected during 2013-2014 in three areas before the introduction of Zika virus (the pre-Zika years) into the World Health Organization's Region of the Americas (Americas) (3). These data, from Massachusetts (2013), North Carolina (2013), and Atlanta, Georgia (2013-2014), included 747 infants and fetuses with one or more of the birth defects meeting the case definition (pre-Zika prevalence = 2.86 per 1,000 live births). Brain abnormalities or microcephaly were the most frequently recorded (1.50 per 1,000), followed by neural tube defects and other early brain malformations† (0.88), eye abnormalities without mention of a brain abnormality (0.31), and other consequences of central nervous system (CNS) dysfunction without mention of brain or eye abnormalities (0.17). During January 15-September 22, 2016, the U.S. Zika Pregnancy Registry (USZPR) reported 26 infants and fetuses with these same defects among 442 completed pregnancies (58.8 per 1,000) born to mothers with laboratory evidence of possible Zika virus infection during pregnancy (2). Although the ascertainment methods differed, this finding was approximately 20 times higher than the proportion of one or more of the same birth defects among pregnancies during the pre-Zika years. These data demonstrate the importance of population-based surveillance for interpreting data about birth defects potentially related to Zika virus infection.

Lessons from an acupuncture teaching clinic: patient characteristics and pain management effectiveness.

OBJECTIVES: To understand the following about patients using an acupuncture teaching clinic: (1) sociodemographic characteristics and main complaints and (2) self-reported level of patient-centered outcomes regarding pain management. METHODS/DESIGN: Retrospective chart review. SUBJECTS: A total of 458 new patients at NESA clinic during October 1, 2009 to July 31, 2010 were enrolled in the study. INTERVENTIONS: A variety of styles of Oriental medicine, primarily Chinese and Japanese style acupuncture and also heat treatments (MOXA or heat lamps) and Tui Na (Asia bodywork). RESULTS: Results from Objective 1 were descriptive (n = 421). Objective 2 focused on the 59 patients from the larger sample who completed both an initial and a follow-up Measure Your Medical Outcome Profile (MYMOP) form and who used acupuncture for pain management of (1) diseases of the musculoskeletal system and/or connective tissue or (2) migraine/headache. Both the symptom severity and activity of daily living/well-being scales of the MYMOP showed over 15.8% improvement from baseline to at least six weeks of treatment: 28.6% for Symptom 1, 19.4% for Symptom 2, 35.7% for activities of daily living, and 25.0% for well-being. The relative majority for each sociodemographic trait investigated were as follows: female, about 40 years old, white, not Hispanic or Latino, married, highly educated, and employed. Most patients were confident in acupuncture treatment. Out of the 421 acupuncture patients, 68.2% wanted acupuncture in order to manage pain. Overall, 20.6% of the patients (59, N = 287) who used acupuncture for pain management for diseases of the musculoskeletal system and/or connective tissue or migraine or headache completed the sixth-week follow-up MYMOP form. Of these patients, 57.6% (34, N = 59) returned during week 6 of the semester for acupuncture treatment and reported clinical improvement in at least one MYMOP severity score, and no score got worse. CONCLUSIONS: The information about sociodemographic characteristic and patient-centered outcomes of pain management can be used for service provision, future study planning, and marketing. Future studies should address the low follow-up rate, the quality of self-reported clinic data, and the reasons that patients chose acupuncture treatments and teaching clinics.

The Feasibility and Effects of Acupuncture on Quality of Life Scores During Chemotherapy in Ovarian Cancer: Results from a Pilot, Randomized Sham-Controlled Trial.

BACKGROUND: Within a pilot trial regarding chemotherapy-induced neutropenia, the secondary aim of the main study was explored. This involved measuring the effects-as shown on two key measurement scales reflecting quality of life (QoL)-of verum versus sham acupuncture on patients with ovarian cancer during chemotherapy. OBJECTIVE: The aim of this substudy was to determine the feasibility of determining the effects of verum acupuncture versus sham acupuncture on QoL in patients with ovarian cancer during chemotherapy. DESIGN: This was a randomized, sham-controlled trial. SETTING: The trial was conducted at two cancer centers. PATIENTS: Patients with ovarian cancer (N=21) who were receiving chemotherapy-primarily intravenous carboplatin and paclitaxel-participated in this substudy. INTERVENTION: The participants were given either active or sham acupuncture 1 week prior to cycle 2 of chemotherapy. There were ten sessions of acupuncture, with manual and electro-stimulation over a 4-week period. MAIN OUTCOME MEASURES: The European Organization for Research and Treatment of Cancer-Quality-of-Life Questionnaire-Core 30 Item (EORTC-QLQ-C30) and the Quality of Life Questionnaire-Ovarian Cancer Module-28 Item (QLQ-OV28) were administered to the patients at baseline and at the end of their acupuncture sessions. RESULTS: Of the original 21, 15 patients (71%) completed the study, and 93% of them completed the questionnaires. The EORTC-QLQ-C30 subscores were improved in the acupuncture arm, including the mean scores of social function (SF), pain, and insomnia (p=0.05). However, after adjusting for baseline differences, only the SF score was significantly higher in the active acupuncture arm, compared with the sham acupuncture arm (p=0.03). CONCLUSIONS: It appears feasible to conduct a randomized sham-controlled acupuncture trial measuring QoL for patients with ovarian cancer who are undergoing chemotherapy. Acupuncture may have a role in improving QoL during chemotherapy.

The Cognitive Change in Women study (CCW): informant ratings of cognitive change but not self-ratings are associated with neuropsychological performance over 3 years.

The value of self-reported memory complaints for identifying or predicting future cognitive decline or dementia is controversial, but observations from a third party, or "informant," may prove more useful. The relationship between Informant and Self-ratings of cognitive status and neuropsychological test scores was examined in a cohort of 384 nondemented, community-dwelling women, aged 60 years and older, participating in a single-site Women's Health Initiative ancillary study. Each participant and her respective informant separately completed the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Participants also underwent neuropsychological testing and responded to questionnaires on depression and functioning in complex activities of daily living. All neuropsychological test scores were significantly correlated (P values <0.05 to <0.01) with IQCODE ratings whereas Self-ratings overestimated cognitive functioning in some domains. Furthermore, the Self and Informant ratings were both positively correlated with depression and negatively correlated with participants' activity level. Therefore, informant judgments of functional abilities are robust predictors of cognitive status in high functioning nondemented women. These results suggest that informants may be sensitive to changes that are not clinically significant but that may represent an incipient trend for decline.

Monounsaturated, trans, and saturated Fatty acids and cognitive decline in women.

OBJECTIVES: To prospectively assess effects of select dietary fats on cognitive decline. DESIGN: Prospective observational; 3-year follow-up. SETTING: Northwestern University. PARTICIPANTS: Four hundred eighty-two women aged 60 and older who participated in the Women's Health Initiative (WHI) Observational Study or in the control group of the WHI Diet Modification arm. MEASUREMENTS: Dietary intake from a validated food frequency questionnaire (FFQ) administered twice (mean 2.7 years apart) before baseline cognitive assessment (mean 2.9 years after second FFQ) was averaged. Testing of memory, vision, executive function, language, and attention was performed twice, 3 years apart. A global Z-score was created for both time points by averaging all Z-scores for each participant, and global cognitive change was defined as the difference between follow-up and baseline Z-scores. RESULTS: Median intake of saturated fat (SFA), trans-fat, (TFA), dietary cholesterol (DC), and monounsaturated fat (MUFA) was 18.53, 3.45, 0.201, and 19.39 g/d, respectively. There were no associations between degree of cognitive decline and intake of SFA (P=.69), TFA (P=.54), or DC (P=.64) after adjusting for baseline cognition, total energy intake, age, education, reading ability, apolipoprotein E ɛ4 allele, body mass index, estrogen and beta-blocker use, and intake of caffeine and other fatty acids. In contrast, MUFA intake was associated with lower cognitive decline in fully adjusted linear regression models, with mean decline (standard error) of 0.21 (0.05) in the lowest and 0.05 (0.05) in the highest quartiles (P=.02). This effect of MUFA intake was primarily in the visual and memory domains (P=.03 for both). CONCLUSION: Greater intake of SFA, TFA, and DC was not associated with cognitive decline, whereas greater MUFA intake was associated with less cognitive decline.

Scalp hair and urine mercury content of children in the Northeast United States: the New England Children's Amalgam Trial.

UNLABELLED: Children may be at particular risk from toxic effects of mercury (Hg). Previous studies of hair (organic) and urine (inorganic) Hg levels in US children were unable to assess Hg levels while accounting for exposure to amalgam dental restorations. This analysis describes, over a 5-year period, levels and correlates/predictors of scalp hair (H-Hg) and urinary (U-Hg) mercury in 534 New England Children's Amalgam Trial (NECAT) participants, aged 6-10 years and without exposure to dental amalgam at baseline. RESULTS: Mean H-Hg levels were between 0.3 and 0.4 microg/g over 5 years. 17-29% of children had H-Hg levels > or = 0.5 microg/g, and 5.0 to 8.5% of children had levels > or = 1 microg/g, in any given study year. In adjusted models, fish consumption frequency was the most robust predictor of high H-Hg. U-Hg mean levels were between 0.7 and 0.9 microg/g creatinine over two years. The percentage of those with U-Hg > or 2.3 microg/g creatinine ranged from 4% to 6%. Number of amalgam restorations had a significant dose-response relationship with U-Hg level. Daily gum chewing in the presence of amalgam was associated with high U-Hg.

Serum alpha-tocopherol, concurrent and past vitamin E intake, and mild cognitive impairment.

OBJECTIVES: Associations of past dietary vitamin E intake, past and current vitamin E supplement use, and current serum alpha-tocopherol levels, with memory (amnestic) and mixed-domain cognitive impairment in older women, ascertained from an in-depth neuropsychological assessment, were explored. METHODS: This analysis used baseline data from 526 participants in a single-site ancillary study to the Women's Health Initiative, the Cognitive Change in Women study. RESULTS: In bivariate analyses, neither past dietary vitamin E intake (<8 mg/day vs more) nor current vitamin E supplement use was associated with impairment. Women who did not use vitamin E supplements at Women's Health Initiative baseline had an increased risk of mixed-domain impairment (odds ratio [OR] 1.88; 95% CI 1.09 to 3.23). This association lost significance when adjusting for age, education, American National Adult Reading Test (ANART) score, and time between measurement of past vitamin E use and cognitive testing. Concurrent serum alpha-tocopherol had significant cross-sectional associations with both memory and mixed impairments, with women in the lowest quartile of serum alpha-tocopherol nearly twice as likely to show signs of memory (1.92; 1.24 to 2.97) and mixed-domain (2.01; 1.13 to 3.57) impairments. In multivariable models adjusting for age, education, and ANART score, the lowest quartile of serum alpha-tocopherol was associated with increased odds of memory impairment (OR 2.02; 1.27 to 3.20) and mixed impairments (OR 2.00; 1.04 to 3.85). Additional adjustment for APOE e4 did not affect these results. CONCLUSION: There was weak or no evidence of a protective effect of previous vitamin E intake on cognitive function. However, the association of low concurrent serum alpha-tocopherol with memory and mixed impairment merits further exploration.

Are foot disorders associated with functional limitation and disability among community-dwelling older adults?

The objectives of this study are to examine whether specific foot disorders and ankle weakness and foot pain are related to functional limitations or disabilities in elders. Community-dwelling adults 65 and older were enrolled in a population-based, cross-sectional study of foot disorders and health outcomes. Demographics, health status, comorbidities, self-reported foot and knee pain, function and disability, and observed structural foot disorders, body mass index, and ankle muscle strength were assessed on 717 participants. The associations of foot disorders, foot pain, and ankle muscle weakness with function and disability were examined with regression analyses. Foot disorders were not associated with functional outcomes or disability. Ankle weakness was associated with performance-based function (p = .005), self-report function (p lesser than .001), and disability (p = .009). Foot pain was associated with self-report function (p = .01) and disability (p = .007). Foot pain and ankle weakness seem to be related to important health outcomes among older adults.

Foot musculoskeletal disorders, pain, and foot-related functional limitation in older persons.

OBJECTIVES: To examine whether common musculoskeletal disorders of feet are associated with pain and foot-related functional limitation. DESIGN: A cross-sectional study using stratified random sampling. SETTING: A residential community. PARTICIPANTS: Ethnically diverse sample of elderly persons (n=784). MEASUREMENTS: Foot disorders (hallux valgus/bunion, pes planus (flat foot), pes cavus (high arch), hammertoe, mallet toe, claw toe, overlapping toes, bunionette, and plantar fasciitis), foot pain, the foot health functional status (FHFS, range 0-100, 100=no problems) scale, and walk time score (range 0-4, 4=fastest). RESULTS: Most commonly assessed musculoskeletal disorders, including hallux valgus and toe deformities, were not associated with pain or function limitation. Plantar fasciitis and, to a lesser extent, pes cavus were associated with worse FHFS scores; foot pain partially explained this association. Neither foot disorders nor foot pain were significantly associated with slower walk times. CONCLUSION: Many foot disorders had little relationship with foot pain or function and may not require clinical attention when asymptomatic. Risk factors and preventive and therapeutic interventions for plantar fasciitis require further longitudinal investigation.