Predictors of Discharge Disposition in Older Adults With Burns: A Study of the Burn Model Systems.

Older patients with burn injury have a greater likelihood for discharge to nursing facilities. Recent research indicates that older patients discharged to nursing facilities are two to three times as likely to die within a 3-year period relative to those discharged to home. In light of these poor long-term outcomes, we conducted this study to identify predictors for discharge to independent vs nonindependent living status in older patients hospitalized for burns. We retrospectively reviewed all older adults (age ≥ 55 years) who were prospectively enrolled in a longitudinal multicenter study of outcomes from 1993 to 2011. Patient, injury, and treatment outcomes data were analyzed. Recognizing that transfer to inpatient rehabilitation may have impacted final hospital discharge disposition: we assessed the likelihood of inpatient rehabilitation stay, based on identified predictors of inpatient rehabilitation. We subsequently performed a logistic regression analysis on the clustered, propensity-matched cohort to assess associations of burn and injury characteristics on the primary outcome of final discharge status. A total of 591 patients aged ≥55 years were treated and discharged alive from three participating U.S. burn centers during the study period. Mean burn size was 14.8% (SD 11.2%) and mean age was 66.7 years (SD 9.3 years). Ninety-three patients had an inpatient rehabilitation stay before discharge (15.7%). Significant factors predictive of inpatient rehabilitation included a burn >20% TBSA, mechanical ventilation, older age, range of motion deficits at acute care discharge, and study site. These factors were included in the propensity model. Four hundred seventy-one patients (80%) were discharged to independent living status. By matched propensity analysis, older age was significantly associated with a higher likelihood of discharge to nonindependent living (P < .01 in both the 65-74 age group and the oldest age group when compared with the 55-64 age group). Comorbidity (P < .01) and history of alcohol abuse (P < 0.01) were also predictive patient factors. Furthermore, clinical practice variations among the three study sites also constituted a significant factor in discharge disposition (both P < .01 when compared with the index study site). Older age remains an important risk factor for discharge to nonindependent living status, even after accounting for inpatient rehabilitation stay. This analysis, however, reveals significant variations in discharge disposition practices among the three participating study sites. We believe that these variations among burn centers need to be elucidated to better understand discharge disposition status in older patients with burns.

The effect of race/ethnicity on gestational weight gain.

Minority women are gaining more weight than recommended during pregnancy. This study aimed to determine the risk of excessive gestational weight gain (GWG) in Hispanic and Black women compared to non-Hispanic women in Colorado. A retrospective cohort study of all birth records from 2007 to 2010 in Colorado was conducted. The primary outcome was GWG, and the exposure was race/ethnicity. Covariates were marital status, education, intensity of prenatal care, age, parity, tobacco use, alcohol use and years in the US. Chi square and multiple logistic regression was performed. 230,698 records were analyzed. Half of the Hispanic and Black women began their pregnancy overweight or obese. Hispanic women had a 0.84 (95% CI 0.8-0.9) and Black women had a 0.95 (95% CI 0.9-1.0) risk of excessive GWG than NHW women. Pre-pregnancy weight is an independent risk for adverse outcomes. The study findings provide healthcare providers focal points in preconception health care and programming.

Sensitivity of systemic inflammatory response syndrome for critical illness among ED patients.

BACKGROUND: Little is known about the diagnostic accuracy of systemic inflammatory response syndrome (SIRS) criteria for critical illness among emergency department (ED) patients with and without infection. Our objective was to assess the diagnostic accuracy of SIRS criteria for critical illness in ED patients. METHODS: This was a retrospective cohort study of ED patients at an urban academic hospital. Standardized chart abstraction was performed on a random sample of all adult ED medical patients admitted to the hospital during a 1-year period, excluding repeat visits, transfers, ED deaths, and primary surgical or psychiatric admissions. The binary composite outcome of critical illness was defined as 24 hours or longer in intensive care or inhospital death. Presumed infection was defined as receiving antibiotics within 48 hours of admission. Systemic inflammatory response syndrome criteria were calculated using ED triage vital signs and initial white blood cell count. RESULTS: We studied 1152 patients; 39% had SIRS, 27% had presumed infection, and 23% had critical illness (2% had inhospital mortality, and 22% had ≥24 hours in intensive care). Of patients with SIRS, 38% had presumed infection. Of patients without SIRS, 21% had presumed infection. The sensitivity of SIRS criteria for critical illness was 52% (95% confidence interval [CI], 46%-58%) in all patients, 66% (95% CI, 56%-75%) in patients with presumed infection, and 43% (95% CI, 36%-51%) in patients without presumed infection. CONCLUSIONS: Systemic inflammatory response syndrome at ED triage, as currently defined, has poor sensitivity for critical illness in medical patients admitted from the ED.

Church-based social marketing to motivate older adults to take balance classes for fall prevention: cluster randomized controlled trial.

OBJECTIVE: Determine whether a church-based social marketing program increases older adults' participation in balance classes for fall prevention. METHODS: In 2009-10, 51 churches (7101 total members aged ≥ 60) in Colorado, U.S.A. were randomized to receive no intervention or a social marketing program. The program highlighted benefits of class participation (staying independent, building relationships), reduced potential barriers (providing convenient, subsidized classes), and communicated marketing messages through church leaders, trained "messengers," printed materials and church-based communication channels. Between-group differences in balance class enrollment and marketing message recall among congregants were compared using Wilcoxon Two-Sample Test and regression models. RESULTS: Compared to 25 control churches, 26 churches receiving the social marketing program had a higher median proportion (9.8% vs. 0.3%; p<0.001) and mean number (7.0 vs. 0.5; IRR=11.2 [95%CI: 7.5, 16.8]) of older adult congregants who joined balance classes. Intervention church members were also more likely to recall information about preventing falls with balance classes (AOR=6.2; 95% CI: 2.6, 14.8) and availability of classes locally (AOR=7.7; 95% CI: 2.6, 22.9). CONCLUSIONS: Church-based social marketing effectively disseminated messages about preventing falls through balance classes and, by emphasizing benefits and reducing barriers and costs of participation, successfully motivated older adults to enroll in the classes.

Validation of a method for quantifying carotid artery calcification from panoramic radiographs.

OBJECTIVE: Carotid artery calcification can be visualized on panoramic radiographs. Incidental observation of these calcifications could identify patients in need of further screening. The purpose of this study was to validate the assessment and quantification of calcification on panoramic radiographs with the stenosis and the calculated resistive index (RI) from Doppler ultrasonography. STUDY DESIGN: Digital panoramic radiographs were used to assess the area of carotid artery calcification using tools available in NIH's ImageJ. Inpatient and outpatient discharge records were reviewed to identify subjects with a completed carotid Doppler ultrasound exam (n = 122). RESULTS: The quantification of carotid artery calcification was found to correlate well with the degree of stenosis (area under the curve [AUC] 0.81 [95% confidence interval [CI] 0.64, 0.98]) and the RI of the common carotid artery (AUC 0.79 [95% CI 0.59, 0.98]). CONCLUSION: This method for quantification of carotid artery calcification could identify patients in need of further evaluation.

Quality-of-life loss of people admitted to burn centers, United States.

PURPOSE: To estimate quality-of-life loss per serious burn survivor in a large U.S. cohort. METHODS: Longitudinal functional assessments of all 1,587 people receiving primary treatment in 5 burn centers between 2000 and 2009 included pre-burn (retrospective), at time of discharge, and 6, 12, and 24 months post-injury. We assessed adults with RAND Short Form (SF) 12 and children with SF-10 or Child Health Questionnaire, the child surveys scored using standard norms-based scoring. A literature review identified 20 quality-adjusted life year utility scorings for SF-12 and 27 scorings for EQ-5d response distributions predicted from SF-12 scores. We computed composite scores for each patient and time period by applying 32 scorings that met quality/non-duplication criteria. RESULTS: Mean quality-of-life scores were 0.805 4 weeks pre-burn, 0.562 at discharge, rebounded through 1 year, and stabilized at 0.735 (0.750 for TBSA burned below 25 %, 0.722 for TBSA burned of 25-50 %, and 0.695 for larger burns). As a percentage of initial levels, burns reduced short-term quality of life by 30 %. Long-term loss averaged 11 %, ranging from 9 % for TBSA burned below 25-13 % for TBSA burned above 50 %. Children recovered faster and more fully. CONCLUSION: Burns cause substantial losses in quality of life, with long-term losses comparable to traumatic brain injury.

Performance of 3-dimensional echocardiography in measuring left ventricular volumes and ejection fraction: a systematic review and meta-analysis.

OBJECTIVES: The primary aim of this systematic review is to objectively evaluate the test performance characteristics of three-dimensional echocardiography (3DE) in measuring left ventricular (LV) volumes and ejection fraction (EF). BACKGROUND: Despite its growing use in clinical laboratories, the accuracy of 3DE has not been studied on a large scale. It is unclear if this technology offers an advantage over traditional two-dimensional (2D) methods. METHODS: We searched for studies that compared LV volumes and EF measured by 3DE and cardiac magnetic resonance (CMR) imaging. A subset of those also compared standard 2D methods with CMR. We used meta-analyses to determine the overall bias and limits of agreement of LV end-diastolic volume (EDV), end-systolic volume (ESV), and EF measured by 3DE and 2D echocardiography (2DE). RESULTS: Twenty-three studies (1,638 echocardiograms) were included. The pooled biases ± 2 SDs for 3DE were -19.1 ± 34.2 ml, -10.1 ± 29.7 ml, and - 0.6 ± 11.8% for EDV, ESV, and EF, respectively. Nine studies also included data from 2DE, where the pooled biases were -48.2 ± 55.9 ml, -27.7 ± 45.7 ml, and 0.1 ± 13.9% for EDV, ESV, and EF, respectively. In this subset, the difference in bias between 3DE and 2D volumes was statistically significant (p = 0.01 for both EDV and ESV). The difference in variance was statistically significant (p < 0.001) for all 3 measurements. CONCLUSIONS: Three-dimensional echocardiography underestimates volumes and has wide limits of agreement, but compared with traditional 2D methods in these carefully performed studies, 3DE is more accurate for volumes and more precise in all 3 measurements.

Observational studies of patients in the emergency department: a comparison of 4 sampling methods.

STUDY OBJECTIVE: We evaluate the ability of 4 sampling methods to generate representative samples of the emergency department (ED) population. METHODS: We analyzed the electronic records of 21,662 consecutive patient visits at an urban, academic ED. From this population, we simulated different models of study recruitment in the ED by using 2 sample sizes (n=200 and n=400) and 4 sampling methods: true random, random 4-hour time blocks by exact sample size, random 4-hour time blocks by a predetermined number of blocks, and convenience or "business hours." For each method and sample size, we obtained 1,000 samples from the population. Using χ(2) tests, we measured the number of statistically significant differences between the sample and the population for 8 variables (age, sex, race/ethnicity, language, triage acuity, arrival mode, disposition, and payer source). Then, for each variable, method, and sample size, we compared the proportion of the 1,000 samples that differed from the overall ED population to the expected proportion (5%). RESULTS: Only the true random samples represented the population with respect to sex, race/ethnicity, triage acuity, mode of arrival, language, and payer source in at least 95% of the samples. Patient samples obtained using random 4-hour time blocks and business hours sampling systematically differed from the overall ED patient population for several important demographic and clinical variables. However, the magnitude of these differences was not large. CONCLUSION: Common sampling strategies selected for ED-based studies may affect parameter estimates for several representative population variables. However, the potential for bias for these variables appears small.

Longitudinal changes in Scores on the Autism Diagnostic Interview--Revised (ADI-R) in pre-school children with autism: Implications for diagnostic classification and symptom stability.

We prospectively examined mean changes in Autism Diagnostic Interview-Revised (ADI-R) Total and Domains scores and stability of the ADI-R diagnostic classification in 28 children with autism initially assessed at age 2-4 years and reassessed 2 years later. Mean Total, Social Interaction, and Communication scores decreased significantly from Time 1 to Time 2 Restricted/repetitive Domain mean scores did not change over time. The ADI-R diagnostic classification was stable in 67% of children using the current published criteria. The stability increased to 78% when a modified criterion was used in the Restricted/repetitive Domain and to 88% when the broader ASD criteria were used. Among pre-schoolers with autism, parent-reported symptoms decreased significantly at two-year follow-up in Social and Communication Domains but not in the Restricted/repetitive Domain. However, ADI-R diagnostic classification remained relatively stable over time. Revising ADI-R diagnostic criteria in the Restricted/repetitive Domain or including the broader ASD criteria may improve its sensitivity and diagnostic stability in younger children.

Loss of alveolar bone due to periodontal disease exhibits a threshold on the association with coronary heart disease.

BACKGROUND: A number of epidemiologic studies were published that looked at the association between coronary heart disease (CHD) and periodontal disease. However, debate exists about whether this association is a true relationship or simply an example of an uncontrolled confounder. This retrospective cohort study examines the relationship between periodontal disease and CHD. METHODS: Digital panoramic radiographs were used to assess alveolar bone loss (ABL) using a Schei ruler. Participants consisted of Veterans Administration (VA) patients who were eligible for dental benefits and had a digital panoramic radiograph taken at the VA Medical Center, Denver, Colorado. Information on CHD and other important clinical variables were obtained from electronic medical records. RESULTS: The examination of the relationship between ABL and CHD revealed a significant non-linear relationship with a threshold at ≈ 20% bone loss with a doubling of the probability ratios of CHD compared to those at 7.5% bone loss. CONCLUSIONS: To our knowledge, this is the first study to demonstrate a non-linear relationship between ABL and CHD. A significant positive association between ABL and CHD was found at even low levels of bone loss between 10% and 20%.

Functional and psychosocial outcomes of older adults after burn injury: results from a multicenter database of severe burn injury.

A number of factors increase the susceptibility of older adults to burn injury. The majority of studies of older adults have focused on patient and injury factors related to mortality risk. However, little is known about the long-term functional and psychological outcomes of older adults after severe burn. The purpose of this study is to examine the long-term outcomes of older adults after burn injury. The authors performed an analysis of the outcomes of older adults (age 55 years or older) enrolled in a prospective study of burn injury outcomes. Change in living situation as well as distress, functional impairment, and quality of life were examined at discharge and at 6, 12, and 24 months after hospital discharge. Mixed effects modeling was performed to compare differences across age groups and time as well as to account for missing data. A total of 737 patients aged 55 years or older were enrolled and followed in the National Institute on Disability and Rehabilitation Research burn program. Patients in all age groups had significant deficits in Short Form-36, Functional Independence Measure, and Brief Symptom Inventory scores at time of discharge. Recovery of physical and psychosocial functioning was greatest from discharge to 6 months in patients aged 55 to 74 years and greatest at 1 year for patients aged 75 years or older. This study confirms that severe burn injury significantly impacts both functional outcome and psychosocial quality of life in older adults. However, the impact seems to be age related as are recovery trajectories. Rehabilitation programs lasting up to 1 year after injury could be of tremendous benefit in helping older adults achieve maximal potential recovery.

Effect of maternal birthplace on gestational diabetes prevalence in Colorado Hispanics.

(1) Describe gestational diabetes mellitus (GDM) prevalence time trends in USborn (USWH) and Mexico-born (MWH), white Hispanic Colorado women and (2) Determine effect of maternal birthplace on GDM prevalence. Retrospective population-based study of 1995-2004 Colorado birth certificate data for live, singleton births to white, Hispanic mothers estimated prevalence, trends, and association of GDM and maternal birthplace. Univariate, bivariate and logistic regression analyses were conducted. GDM prevalence in 154,957 births increased in both USWH (1.77-2.53%, P < 0.0001) and MWH (2.38-3.08%, P < 0.0001). Over study years, MWH had higher crude odds (OR = 1.30; 95% CI = 1.22-1.38) for developing GDM than USWH. Adjustment for maternal age and maternal education reduced GDM risk by birth country (OR = 1.05; 95% CI = 0.98-1.13, P = ns). GDM prevalence increased in both US-born and Mexico-born, white, Hispanic Colorado women. Mexico-born immigrant women may have increased risk for GDM compared with their USborn counterparts. Lower education attainment may be determinant of disease risk.

Pre-pandemic planning survey of healthcare workers at a tertiary care children's hospital: ethical and workforce issues.

BACKGROUND: Prior to the development of written policies and procedures for pandemic influenza, worker perceptions of ethical and workforce issues must be identified. OBJECTIVE: To determine the relationship between healthcare worker (HCW) reporting willingness to work during a pandemic and perception of job importance, belief that one will be asked to work, and sense of professionalism and to assess HCW's opinions regarding specific policy issues as well as barriers and motivators to work during a pandemic. METHODS: A survey was conducted in HCWs at The Children's Hospital in Denver, Colorado, from February to June 2007. Characteristics of workers reporting willingness to work during a pandemic were compared with those who were unwilling or unsure. Importance of barriers and motivators was compared by gender and willingness to work. RESULTS: Sixty percent of respondents reported willingness to work (overall response rate of 31%). Belief one will be asked to work (OR 4.6, P < 0.0001) and having a high level of professionalism (OR 8.6, P < 0.0001) were associated with reporting willingness to work. Hospital infrastructure support staffs were less likely to report willingness to work during a pandemic than clinical healthcare professionals (OR 0.39, P < 0.001). Concern for personal safety, concern for safety of family, family's concern for safety, and childcare issues were all important barriers to coming to work. CONCLUSIONS: Educational programs should focus on professional responsibility and the importance of staying home when ill. Targeted programs toward hospital infrastructure support and patient and family support staff stressing the essential nature of these jobs may improve willingness to work.

Perceptions regarding workplace hazards at a veterinary teaching hospital.

OBJECTIVE: To assess perceptions of personnel working at a veterinary teaching hospital regarding risks of occupational hazards and compare those perceptions with assessments made by occupational safety experts. DESIGN: Cross-sectional study. STUDY POPULATION: A representative sample of personnel (n = 90) working at the veterinary teaching hospital at Colorado State University and a panel of 3 occupational safety experts. PROCEDURES: Hospital personnel ranked perceptions of 14 physical, chemical, and biological workplace hazards and listed the injuries, illnesses, and near misses they had experienced. The expert panel provided consensus rankings of the same 14 hazards for 9 sections of the facility. Risk perceptions provided by the 2 sources were compared. RESULTS: Risk perceptions did not differ significantly between hospital personnel and the expert panel for most of the site-specific comparisons (94/126 [75%]). Personnel perceived greater risks for some physical hazards (loud noises, sharps injuries, and ionizing radiation) and some chemical or materials exposures (insecticides or pesticides and tissue digester emissions). In contrast, the expert panel perceived greater risks for physical hazards (bite or crush and restraining and moving animals), chemical exposures (anesthetic waste gas), and biological exposures (Toxoplasma gondii, antimicrobial-resistant bacteria, and allergens). CONCLUSIONS AND CLINICAL RELEVANCE: Participants and safety experts had similar perceptions about occupational risks, but there were important differences where hospital personnel apparently overestimated or underappreciated the risks for workplace hazards. This type of study may be useful in guiding development of optimal workplace safety programs for veterinary hospitals.

The effect of virtual reality on pain and range of motion in adults with burn injuries.

Few studies have empirically investigated the effects of immersive virtual reality (VR) on postburn physical therapy pain control and range of motion (ROM). We performed a prospective, randomized controlled study of the effects of adding VR to standard therapy in adults receiving active-assisted ROM physical therapy, by assessing pain scores and maximal joint ROM immediately before and after therapy on two consecutive days. Thirty-nine inpatients, aged 21 to 57 years (mean 35 years), with a mean TBSA burn of 18% (range, 3-60%) were studied using a within-subject, crossover design. All patients received their regular pretherapy pharmacologic analgesia regimen. During physical therapy sessions on two consecutive days (VR one day and no VR the other day; order randomized), each patient participated in active-assisted ROM exercises with an occupational or physical therapist. At the conclusion of each session, patients provided 0 to 100 Graphic Rating Scale measurements of pain after each 10-minute treatment condition. On the day with VR, patients wore a head-position-tracked, medical care environment-excluding VR helmet with stereophonic sound and interacted in a virtual environment conducive to burn care. ROM measurements for each joint exercised were recorded before and after each therapy session. Because of nonsignificant carryover and order effects, the data were analyzed using simple paired t-tests. VR reduced all Graphic Rating Scale pain scores (worst pain, time spent thinking about the pain, and pain unpleasantness by 27, 37, and 31% respectively), relative to the no VR condition. Average ROM improvement was slightly greater with the VR condition; however, this difference failed to reach clinical or statistical significance (P = .243). Ninety-seven percent of patients reported zero to mild nausea after the VR session. Immersive VR effectively reduced pain and did not impair ROM during postburn physical therapy. VR is easily used in the hospital setting and offers a safe, nonpharmacologic adjunctive analgesic treatment.

Case-based surveillance of influenza hospitalizations during 2004-2008, Colorado, USA.

Colorado became the first state to make laboratory-confirmed influenza-associated hospitalizations a case-based reportable condition in 2004. We summarized surveillance for influenza hospitalizations in Colorado during the first 4 recorded influenza seasons (2004-2008). We highlight the similarities and differences among influenza seasons; no 2 seasons were entirely the same. The 2005-06 influenza season had 2 distinct waves of activity (types A and B), the 2006-07 season was substantially later and milder, and 2007-08 had substantially greater influenza B activity. The case-based surveillance for influenza hospitalizations provides information regarding the time course of seasonal influenza activity, reported case numbers and population-based rates by age group and influenza virus type, and a measure of relative severity. Influenza hospitalization surveillance provides more information about seasonal influenza activity than any other surveillance measure (e.g., surveillance for influenza-like illness) currently in widespread use among states. More states should consider implementing case-based surveillance for influenza hospitalizations.

Neonatal outcomes after elective cesarean delivery.

OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC. METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity. RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P=.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use). CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay. LEVEL OF EVIDENCE: II.

Ethnicity, body size, and estrogen levels in postmenopausal Hispanic and non-Hispanic white women.

BACKGROUND: Hispanic women are at lower risk for incident breast cancer, but the reasons for this lower risk are unknown. Among postmenopausal women, breast cancer risk is inversely associated with circulating levels of 2-hydroxyestrone but directly associated with levels of 16alpha-hydroxyestrone, according to most studies. Likewise, according to most research, the ratio of 2-hydroxyestrone/16alpha-hydroxyestrone is, therefore, inversely associated with breast cancer risk. METHODS: We measured levels of these two circulating estrones as well as estradiol in 40 Hispanic women and 40 non-Hispanic white women who were all postmenopausal and not taking hormones. RESULTS: Compared with non-Hispanic white women, Hispanic women had 69% higher circulating levels of 2-hydroxyestrone (p = 0.04), and 10% lower levels of 16alpha-hydroxyestrone (p = 0.09). Consequentially, Hispanic women had more favorable estrogen profiles than non-Hispanic white women, with an 89% higher 2:16 ratio (p = 0.01). This finding was not substantially affected by adjustment for other breast cancer risk factors, including matching on body mass index (BMI). CONCLUSIONS: This ethnic difference in estrogen profile requires further research to establish whether there is a causal relationship to breast cancer risk that may, at least partially, explain why postmenopausal Hispanic women have a lower incidence of breast cancer.

Plasma 25,OH vitamin D concentrations are not associated with rheumatoid arthritis (RA)-related autoantibodies in individuals at elevated risk for RA.

OBJECTIVE: To evaluate the association between rheumatoid arthritis (RA)-related autoantibodies and plasma 25,OH vitamin D in subjects at risk for RA. METHODS: In 1210 subjects without RA, 76 were positive for anti-cyclic citrullinated peptide antibodies or for at least 2 rheumatoid factors (RF; by nephelometry: RF-IgM, RF-IgG, RF-IgA). 25,OH vitamin D was measured in these cases and 154 autoantibody-negative controls from this cohort. RESULTS: 25,OH vitamin D levels did not differ between cases and controls (adjusted OR 1.23, 95% CI 0.93-1.63). CONCLUSION: Vitamin D concentrations are not associated with RA-related autoimmunity in unaffected subjects at increased risk for RA.

Age at menarche and first pregnancy among psychosocially at-risk adolescents.

We sought to determine which factors influence the association between menarche and conception among adolescent study participants (n = 1030), who demonstrated an earlier age of menarche than did national samples. Age at first sexual intercourse (coitarche) mediated the relationship between age at menarche and first pregnancy among White girls, whereas gynecologic age at coitarche (age at coitarche minus age at menarche) and age at menarche explained the timing of the first pregnancy among Black and Hispanic girls. Pregnancy prevention interventions to delay coitarche should also include reproductive education and contraception.