Factors Associated with Confirmed and Unconfirmed Autism Spectrum Disorder Diagnosis in Children Volunteering for Research.

PURPOSE: Diagnostic accuracy of autism spectrum disorder (ASD) is crucial to track and characterize ASD, as well as to guide appropriate interventions at the individual level. However, under-diagnosis, over-diagnosis, and misdiagnosis of ASD are still prevalent. METHODS: We describe 232 children (MAge = 10.71 years; 19% female) with community-based diagnoses of ASD referred for research participation. Extensive assessment procedures were employed to confirm ASD diagnosis before study inclusion. The sample was subsequently divided into two groups with either confirmed ASD diagnoses (ASD+) or unconfirmed/inaccurate diagnoses (ASD-). Clinical characteristics differentiating the groups were further analyzed. RESULTS: 47% of children with community-based ASD diagnoses did not meet ASD criteria by expert consensus. ASD + and ASD- groups did not differ in age, gender, ethnicity, or racial make-up. The ASD + group was more likely to have a history of early language delays compared to the ASD- group; however, no group differences in current functional language use were reported by caregivers. The ASD + group scored significantly higher on ADI-R scores and on the ADOS-2 algorithm composite scores and calibrated severity scores (CSSs). The ASD- group attained higher estimated IQ scores and higher rates of psychiatric disorders, including anxiety disorder, disruptive behavior, and mood disorder diagnoses. Broadly, caregiver questionnaires (SRS-2, CCC-2) did not differentiate groups. CONCLUSION: Increased reported psychiatric disorders in the ASD- group suggests psychiatric complexity may contribute to community misdiagnosis and possible overdiagnosis of ASD. Clinician-mediated tools (ADI-R, ADOS-2) differentiated ASD + versus ASD- groups, whereas caregiver-reported questionnaires did not.

Executive function and preterm birth: A longitudinal study.

Infants born low birth weight (LBW) and preterm are at risk for developmental delay and cognitive deficits. These deficits can lead to lifelong learning difficulties and high-risk behaviors. Preterm (PT) and full-term (FT) groups were compared across infant and toddler measures of behavior and development to extract early indicators of executive function (EF). The goal was to extract indicators of EF from standardized infant assessments. PT (<2500 grams and <37 weeks) and FT (> 2500 grams and >37 weeks) were compared across assessment and EF components were identified from the BSID-III. A multivariate linear model was used to examine group differences. All children (99 PT and 46 FT) were administered the Bayley III and the DMQ assessments for session 1 (6-8 months). During session 2, N=78 PT and 37 FT (18-20 months), the CBCL was added to previous assessments, and the BRIEF-P was added to previous assessments in session 3, N= 52 PT and 36 FT for session 3 (See Table 1). Significant change scores were found on BSID-III subtests and EF components across all 3 sessions. The PT group also showed significantly more behavioral concerns on the CBCL at 18 months and 36 months and had lower scores on the BRIEF-P than their FT peers. The number of children born PT (N = 27, 52%) who were in Early Intervention (EI) increased across the 3 sessions. Examining early indicators of EFs supported the development of early identification that could lead to decrease adverse outcomes often associated with preterm birth.

Prevalence of pulmonary artery dilation in non-cystic fibrosis bronchiectasis: a computed tomography analysis from a cohort of the US Bronchiectasis and Nontuberculous Mycobacteria Research Registry.

Although pulmonary artery (PA) dilation is independently associated with significant morbidity and mortality in patients with pulmonary diseases irrespective of diagnosed pulmonary hypertension, its relationship with nontuberculous mycobacteria (NTM) is unknown. The Bronchiectasis and NTM Research Registry is a multicenter registry created to foster research in non-cystic fibrosis (CF) bronchiectasis and NTM lung disease. The majority of patients with non-CF bronchiectasis at Oregon Health & Science University have NTM infections. To determine the prevalence of PA dilation in these patients and its association with supplemental oxygen use, severity of bronchiectasis, tobacco use, and NTM in the sputum culture, we evaluated the chest computed tomography (CT) scans from 321 patients in a cross-sectional analysis. We measured the severity of bronchiectasis by applying modified Reiff criteria and measured the diameters of the PA and aorta (Ao), with PA dilation defined as a PA:Ao ratio >0.9. In our cohort, the mean age was 67.3 years and 83.2% were female. The mean modified Reiff score was 7.1, indicating moderate disease severity. Forty-two patients (13.1%) were found to have PA dilation. PA dilation was positively associated with the use of supplemental oxygen (P<0.001), but there was no association between PA dilation and NTM infection.

Multimorbidity and Functional Disability among Older Adults: The Role of Inflammation and Glycemic Status - An Observational Longitudinal Study.

INTRODUCTION: Specific multimorbidity combinations, in particular those including arthritis, stroke, and cognitive impairment, have been associated with high burden of activities of daily living (ADL)-instrumental activities of daily living (IADL) disability in older adults. The biologic underpinnings of these associations are still unclear. METHODS: Observational longitudinal study using data from the Health and Retirement Study (N = 8,618, mean age = 74 years, 58% female, 25% non-white) and negative binomial regression models stratified by sex to evaluate the role of inflammatory and glycemic biomarkers (high-sensitivity C-reactive protein (hs-CRP) and HbA1c) in the association between specific multimorbidity combinations (grouped around one of eight index diseases: arthritis, cancer, cognitive impairment, diabetes, heart disease, hypertension, lung disease, and stroke; assessed between 2006 and 2014) and prospective ADL-IADL disability (2 years later, 2008-2016). Results were adjusted for sociodemographic characteristics, body mass index, number of coexisting diseases, and baseline ADL-IADL score. RESULTS: Multimorbidity combinations indexed by arthritis (IRR = 1.1, 95% CI = 1.01-1.20), diabetes (IRR = 1.19, 95% CI = 1.09-1.30), and cognitive impairment (IRR = 1.11, 95% CI = 1.01-1.23) among men and diabetes-indexed multimorbidity combinations (IRR = 1.07, 95% CI = 1.01-1.14) among women were associated with higher ADL-IADL scores at increasing levels of HbA1c. Across higher levels of hs-CRP, multimorbidity combinations indexed by arthritis (IRR = 1.06, 95% CI = 1.02-1.11), hypertension (IRR = 1.06, 95% CI = 1.02-1.11), heart disease (IRR = 1.06, 95% CI = 1.01-1.12), and lung disease (IRR = 1.14, 95% CI = 1.07-1.23) were associated with higher ADL-IADL scores among women, while there were no significant associations among men. CONCLUSION: The findings suggest potential for anti-inflammatory management among older women and optimal glycemic control among older men with these particular multimorbidity combinations as focus for therapeutic/preventive options for maintaining functional health.

Prevalence of pulmonary artery dilation in non-cystic fibrosis bronchiectasis: A CT analysis from a cohort of the US Bronchiectasis and Nontuberculous Mycobacteria Research Registry.

Although pulmonary artery (PA) dilation is independently associated with significant morbidity and mortality in patients with pulmonary diseases irrespective of diagnosed pulmonary hypertension, its relationship to nontuberculous mycobacteria (NTM) is unknown. To determine the prevalence of PA dilation in patients with NTM-predominant non-CF bronchiectasis, we evaluated the chest computed tomography (CT) scans from 321 patient in the United States based Bronchiectasis and NTM Research Registry. The majority of our cohort had NTM infection. We measured the severity of bronchiectasis using modified Reiff criteria and measured the diameters of the PA and aorta (Ao), with PA dilation defined as a PA:Ao ratio > 0.9. Forty-two patients (13%) were found to have PA dilation. PA dilation was positively associated with the use of supplemental oxygen (p < 0.001), but there was no association between PA dilation and NTM infection.

Are We on the Same Page? A Cross-Sectional Study of Patient-Clinician Goal Concordance in Rheumatoid Arthritis.

OBJECTIVE: Patient-clinician goal concordance is associated with improved outcomes in certain chronic diseases but not explored in rheumatoid arthritis (RA). We examined goal concordance, correlates of concordance, and the association of concordance with health outcomes. METHODS: Adult patients with RA seen at least 1 time in the prior 12 months at 1 of 2 rheumatology clinics participated. Patients and their clinicians independently ranked top 3 goals for RA treatment from 8 options before a routine visit. Patients completed postvisit surveys on health, demographic information, health literacy, and adherence. Goal concordance was defined as the patient's number 1 goal being among the clinician's top 3 goals for that patient. Bivariable and multivariable logistic regression models were used to examine correlates of concordance. RESULTS: Patients were 58% female and 16% Spanish-speaking, and 29% had limited health literacy. Among 204 patient-clinician dyads, 20% were goal-discordant. "Have less pain" was selected by both patient and clinician in 81% of dyads, followed by "have fewer problems doing daily activities" by 63%. Otherwise, clinicians prioritized avoiding side effects, whereas patients ranked improved sleep, fatigue, and mood. Longer disease duration was associated with discordance (median 13.3 years, interquartile range [IQR] 5.2-20 among discordant vs. 7 years, IQR 4-14; P = 0.039); higher depressive symptoms were associated with concordance (8.1% vs. 24%; P = 0.04). Goal concordance was associated with higher medication adherence (adjusted odds ratio 2.76 [95% confidence interval 1.01, 7.56]). CONCLUSION: One in 5 patient-clinician dyads had discordant treatment goals. Goal concordance was associated with higher medication adherence. Studies to improve goal elicitation and communication of patients with RA's priorities are needed.

Association between treatment setting and outcomes among oregon medicaid patients with opioid use disorder: a retrospective cohort study.

BACKGROUND: Residential treatment is a common approach for treating opioid use disorder (OUD), however, few studies have directly compared it to outpatient treatment. The objective of this study was to compare OUD outcomes among individuals receiving residential and outpatient treatment. METHODS: A retrospective cohort study used linked data from a state Medicaid program, vital statistics, and the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episodes Dataset (TEDS) to compare OUD-related health outcomes among individuals treated in a residential or outpatient setting between 2014 and 2017. Multivariable Cox proportional hazards and logistic regression models examined the association between treatment setting and outcomes (i.e., opioid overdose, non-overdose opioid-related and all-cause emergency department (ED) visits, hospital admissions, and treatment retention) controlling for patient characteristics, co-morbidities, and use of medications for opioid use disorders (MOUD). Interaction models evaluated how MOUD use modified associations between treatment setting and outcomes. RESULTS: Of 3293 individuals treated for OUD, 957 (29%) received treatment in a residential facility. MOUD use was higher among those treated as an outpatient (43%) compared to residential (19%). The risk of opioid overdose (aHR 1.39; 95% CI 0.73-2.64) or an opioid-related emergency department encounter or admission (aHR 1.02; 95% CI 0.80-1.29) did not differ between treatment settings. Independent of setting, MOUD use was associated with a significant reduction in overdose risk (aHR 0.45; 95% CI 0.23-0.89). Residential care was associated with greater odds of retention at 6-months (aOR 1.71; 95% CI 1.32-2.21) but not 1-year. Residential treatment was only associated with improved retention for individuals not receiving MOUD (6-month aOR 2.05; 95% CI 1.56-2.71) with no benefit observed in those who received MOUD (aOR 0.75; 95% CI 0.46-1.29; interaction p = 0.001). CONCLUSIONS: Relative to outpatient treatment, residential treatment was not associated with reductions in opioid overdose or opioid-related ED encounters/hospitalizations. Regardless of setting, MOUD use was associated with a significant reduction in opioid overdose risk.

Recognizing Pediatric ARDS: Provider Use of the PALICC Recommendations in a Tertiary Pediatric ICU.

BACKGROUND: For almost 50 years, pediatricians used adult guidelines to diagnose ARDS. In 2015, specific criteria for pediatric ARDS were defined. However, it remains unclear how frequently providers recognize pediatric ARDS and whether recognition affects adherence to consensus recommendations. METHODS: This was a mixed-method, retrospective study of mechanically ventilated pediatric subjects after the release of the pediatric ARDS recommendation statement. Pediatric ARDS cases were identified according to the new criteria. Provider recognition was defined by documentation in the medical record. Pediatric ARDS subjects with and without provider recognition were compared quantitatively according to clinical characteristics, adherence to lung-protective ventilation (LPV), adjunctive therapies, and outcomes. A qualitative document analysis (QDA) was performed to evaluate knowledge and beliefs surrounding the Pediatric Acute Lung Injury Consensus Conference recommendations. RESULTS: Of 1,983 subject encounters, pediatric ARDS was identified in 321 (16%). Provider recognition was present in 97 (30%) cases and occurred more often in subjects who were older, had worse oxygenation deficits, or were bone marrow transplant recipients. Recognition rates increased each studied year. LPV practices did not differ based on provider recognition; however, subjects who received it were more likely to experience permissive hypoxemia and adherence to extrapulmonary recommendations. Ultimately, there was no differences in outcomes between the provider recognition and non-provider recognition groups. Three themes emerged from the QDA: (1) pediatric ARDS presents within a complex, multidimensional context, with potentially competing organ system failures; (2) similar to historical conceptualizations, pediatric ARDS was often considered a visual diagnosis, with measures of oxygenation unreferenced; and (3) emphasis was placed on non-evidence-based interventions, such as pulmonary clearance techniques, rather than on consensus recommendations. CONCLUSIONS: Among mechanically ventilated children, pediatric ARDS was common but recognized in a minority of cases. Potential opportunities, such as an opt-out approach to LPV, may exist for improved dissemination and implementation of recommended best practices.

Cardiovascular Outcomes in Aortopathy: GenTAC Registry of Genetically Triggered Aortic Aneurysms and Related Conditions.

BACKGROUND: The GenTAC (Genetically Triggered Thoracic Aortic Aneurysm and Cardiovascular Conditions) Registry enrolled patients with genetic aortopathies between 2007 and 2016. OBJECTIVES: The purpose of this study was to compare age distribution and probability of elective surgery for proximal aortic aneurysm, any dissection surgery, and cardiovascular mortality among aortopathy etiologies. METHODS: The GenTAC study had a retrospective/prospective design. Participants with bicuspid aortic valve (BAV) with aneurysm (n = 879), Marfan syndrome (MFS) (n = 861), nonsyndromic heritable thoracic aortic disease (nsHTAD) (n = 378), Turner syndrome (TS) (n = 298), vascular Ehlers-Danlos syndrome (vEDS) (n = 149), and Loeys-Dietz syndrome (LDS) (n = 121) were analyzed. RESULTS: The 25% probability of elective proximal aortic aneurysm surgery was 30 years for LDS (95% CI: 18-37 years), followed by MFS (34 years; 95% CI: 32-36 years), nsHTAD (52 years; 95% CI: 48-56 years), and BAV (55 years; 95% CI: 53-58 years). Any dissection surgery 25% probability was highest in LDS (38 years; 95% CI: 33-53 years) followed by MFS (51 years; 95% CI: 46-57 years) and nsHTAD (54 years; 95% CI: 51-61 years). BAV experienced the largest relative frequency of elective surgery to any dissection surgery (254/33 = 7.7), compared with MFS (273/112 = 2.4), LDS (35/16 = 2.2), or nsHTAD (82/76 = 1.1). With MFS as the reference population, risk of any dissection surgery or cardiovascular mortality was lowest in BAV patients (HR: 0.13; 95% CI: 0.08-0.18; HR: 0.13; 95%: CI: 0.06-0.27, respectively). The greatest risk of mortality was seen in patients with vEDS. CONCLUSIONS: Marfan and LDS cohorts demonstrate age and event profiles congruent with the current understanding of syndromic aortopathies. BAV events weigh toward elective replacement with relatively few dissection surgeries. Nonsyndromic HTAD patients experience near equal probability of dissection vs prophylactic surgery, possibly because of failure of early diagnosis.

The impact of CARA mandates on nurse practitioner controlled substance prescribing in Oregon: a cohort study.

BACKGROUND: In 2017, the United States Comprehensive Addiction and Recovery Act (CARA) expanded authorization to prescribe buprenorphine for opioid use disorder (OUD) to nurse practitioners (NPs). Compared to physicians, NPs were required to complete 16 additional hours of training on controlled substance prescribing before a buprenorphine waiver application. As this differential additional education mandate was seen as a potential barrier, we evaluated the impact of this requirement on both NP waiver acquisition and prescribing of controlled substances, comparing NPs who obtained waivers to those who had not. METHODS: Through 2016-2018 Oregon Prescription Drug Monitoring Program and linked NP licensure data, we identified factors associated with waiver acquisition at baseline (2016) and evaluated changes in controlled substance prescribing before (2016) and after waiver acquisition (2018). Using chi-square and Mann-Whitney U testing, we calculated and described controlled substance prescribing types, rates, and patient level quantities including co-prescribing of benzodiazepines and opioids by NPs. Multivariable linear regression compared prescribing by waivered and non-waivered NPs for significant changes in non-buprenorphine controlled substance prescribing. RESULTS: Waivered NPs were more likely to have a psychiatric certification, have prior disciplinary action, and have generally higher levels of non-buprenorphine controlled substance prescribing than their non-waivered counterparts. While there was a significant increase in opioid prescriptions per patient among waivered NPs, following CARA implementation, co-prescribing of benzodiazepines and opioids significantly declined among waivered NPs relative to non-waivered NPs. CONCLUSIONS: Although educational requirements were rescinded in 2021 for most applicants, enhanced opioid prescribing training should be incorporated into professional educational offerings regardless of regulatory mandate. We recommended continued focus on education regarding avoidance of high risk prescribing such as co-prescribing of opioids and benzodiazepines. NPs who acquire waivers may take on higher risk patients already using opioids, and these findings may represent transitions in practice and patient setting.

Multimorbidity Accumulation Among Middle-Aged Americans: Differences by Race/Ethnicity and Body Mass Index.

BACKGROUND: Obesity and multimorbidity are more prevalent among U.S. racial/ethnic minority groups. Evaluating racial/ethnic disparities in disease accumulation according to body mass index (BMI) may guide interventions to reduce multimorbidity burden in vulnerable racial/ethnic groups. METHOD: We used data from the 1998-2016 Health and Retirement Study on 8 106 participants aged 51-55 at baseline. Disease burden and multimorbidity (≥2 co-occurring diseases) were assessed using 7 chronic diseases: arthritis, cancer, heart disease, diabetes, hypertension, lung disease, and stroke. Four BMI categories were defined per convention: normal, overweight, obese class 1, and obese class 2/3. Generalized estimating equations models with inverse probability weights estimated the accumulation of chronic diseases. RESULTS: Overweight and obesity were more prevalent in non-Hispanic Black (82.3%) and Hispanic (78.9%) than non-Hispanic White (70.9 %) participants at baseline. The baseline burden of disease was similar across BMI categories, but disease accumulation was faster in the obese class 2/3 and marginally in the obese class 1 categories compared with normal BMI. Black participants across BMI categories had a higher initial burden and faster accumulation of disease over time, while Hispanics had a lower initial burden and similar rate of accumulation, compared with Whites. Black participants, including those with normal BMI, reach the multimorbidity threshold 5-6 years earlier compared with White participants. CONCLUSIONS: Controlling weight and reducing obesity early in the lifecourse may slow the progression of multimorbidity in later life. Further investigations are needed to identify the factors responsible for the early and progressing nature of multimorbidity in Blacks of nonobese weight.

Are there sex differences in potentially inappropriate prescribing in adults with multimorbidity?

BACKGROUND/OBJECTIVES: Limited knowledge exists regarding sex differences in prescribing potentially inappropriate medications (PIMs) for various multimorbidity patterns. This study sought to determine sex differences in PIM prescribing in older adults with cardiovascular-metabolic patterns. DESIGN: Retrospective cohort study. SETTING: Health and Retirement Study (HRS) 2004-2014 interview data, linked to HRS-Medicare claims data annualized for 2005-2014. STUDY SAMPLE: Six thousand three-hundred and forty-one HRS participants aged 65 and older with two and more chronic conditions. MEASUREMENTS: PIM events were calculated using 2015 American Geriatrics Society Beers Criteria. Multimorbidity patterns included: "cardiovascular-metabolic only," "cardiovascular-metabolic plus other physical conditions," "cardiovascular-metabolic plus mental conditions," and "no cardiovascular-metabolic disease" patterns. Logistic regression models were used to determine the association between PIM and sex, including interaction between sex and multimorbidity categories in the model, for PIM overall and for each PIM drug class. RESULTS: Women were prescribed PIMs more often than men (39.4% vs 32.8%). Overall, women had increased odds of PIM (Adj. odds ratio [OR] = 1.30, 95% confidence interval [CI]: 1.16-1.46). Women had higher odds of PIM than men with cardiovascular-metabolic plus physical patterns (Adj. OR = 1.25, 95% CI: 1.07-1.45) and cardiovascular-metabolic plus mental patterns (Adj. OR = 1.25, 95% CI: 1.06-1.48), and there were no sex differences in adults with a cardiovascular-metabolic only patterns (Adj. OR = 1.13, 95% CI: 0.79-1.62). Women had greater odds of being prescribed the following PIMs: anticholinergics, antidepressants, antispasmodics, benzodiazepines, skeletal muscle relaxants, and had lower odds of being prescribed pain drugs and sulfonylureas compared with men. CONCLUSION: This study evaluated sex differences in PIM prescribing among adults with complex cardiovascular-metabolic multimorbidity patterns. The effect of sex varied across multimorbidity patterns and by different PIM drug classes. This study identified important opportunities for future interventions to improve medication prescribing among older adults at risk for PIM.

Racial and Ethnic Differences in Multimorbidity Changes Over Time.

BACKGROUND: Our understanding of how multimorbidity progresses and changes is nascent. OBJECTIVES: Assess multimorbidity changes among racially/ethnically diverse middle-aged and older adults. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study using latent class analysis to identify multimorbidity combinations over 16 years, and multinomial logistic models to assess change relative to baseline class membership. Health and Retirement Study respondents (age 51 y and above) in 1998 and followed through 2014 (N=17,297). MEASURES: Multimorbidity latent classes of: hypertension, heart disease, lung disease, diabetes, cancer, arthritis, stroke, high depressive symptoms. RESULTS: Three latent classes were identified in 1998: minimal disease (45.8% of participants), cardiovascular-musculoskeletal (34.6%), cardiovascular-musculoskeletal-mental (19.6%); and 3 in 2014: cardiovascular-musculoskeletal (13%), cardiovascular-musculoskeletal-metabolic (12%), multisystem multimorbidity (15%). Remaining participants were deceased (48%) or lost to follow-up (12%) by 2014. Compared with minimal disease, individuals in cardiovascular-musculoskeletal in 1998 were more likely to be in multisystem multimorbidity in 2014 [odds ratio (OR)=1.78, P<0.001], and individuals in cardiovascular-musculoskeletal-mental in 1998 were more likely to be deceased (OR=2.45, P<0.001) or lost to follow-up (OR=3.08, P<0.001). Hispanic and Black Americans were more likely than White Americans to be in multisystem multimorbidity in 2014 (OR=1.67, P=0.042; OR=2.60, P<0.001, respectively). Black compared with White Americans were more likely to be deceased (OR=1.62, P=0.01) or lost to follow-up (OR=2.11, P<0.001) by 2014. CONCLUSIONS AND RELEVANCE: Racial/ethnic older adults are more likely to accumulate morbidity and die compared with White peers, and should be the focus of targeted and enhanced efforts to prevent and/or delay progression to more complex multimorbidity patterns.

Evaluation of rescue oral glucocorticoid therapy during inpatient cystic fibrosis exacerbations.

An acute pulmonary exacerbation (APE) in cystic fibrosis (CF) is characterized by increased pulmonary symptoms attributed to bacterial colonization, neutrophil recruitment, and inflammation. Antimicrobials, airway clearance, and nutrition are the mainstay of therapy. However, when patients fail to improve, corticosteroids have been added to therapy. We retrospectively examined the use of rescue steroids in a children's hospital from 2013 to 2017 during CF APE treatment following at least 1 week of inpatient therapy without expected clinical improvement. In total, 106 encounters of 53 unique patients, aged 6-20 years, who had FEV1 percent predicted (FEV1pp) data at baseline, admission, midpoint, and discharge, and had admission duration of at least 12 days were studied. Encounters treated with steroids had less improvement at midpoint percent change from admission in FEV1pp (4.9 ± 11.3) than nonsteroid group change in FEV1pp (20.1 ± 24.6; p < .001). Failure to improve as expected was the rationale for steroid use. At discharge, there was no difference in mean FEV1pp (p = .76). Delays in steroid therapy by waiting until the end of the second week increased the total length of stay (LOS). Propensity matching, comparing outcomes in patients without midpoint improvement in FEV1pp, was also evaluated. There was no difference in admission or discharge FEV1pp between groups. Equally, no difference in FEV1pp at follow-up visit or in time until the next APE was detected. Secondary analysis for associations including gender, genotype, fungal colonization, or inhaled antimicrobials was nonsignificant. These data suggest rescue use of corticosteroids during APE does not predictably impact important outcome measures during CF APE treatment.

Annual Wellness Visits and Influenza Vaccinations among Older Adults in the US.

OBJECTIVES: Investigate whether combinations of sociodemographic factors, chronic conditions, and other health indicators pose barriers for older adults to access Annual Wellness Visits (AWVs) and influenza vaccinations. METHODS: Data on 4999 individuals aged ≥65 years from the 2012 wave of the Health and Retirement Study linked with Medicare claims were analyzed. Conditional Inference Tree (CIT) and Random Forest (CIRF) analyses identified the most important predictors of AWVs and influenza vaccinations. Multivariable logistic regression (MLR) was used to quantify the associations. RESULTS: Two-year uptake was 22.8% for AWVs and 65.9% for influenza vaccinations. For AWVs, geographical region and wealth emerged as the most important predictors. For influenza vaccinations, number of somatic conditions, race/ethnicity, education, and wealth were the most important predictors. CONCLUSIONS: The importance of geographic region for AWV utilization suggests that this service was unequally adopted. Non-Hispanic black participants and/or those with functional limitations were less likely to receive influenza vaccination.

Healthcare-associated urinary tract infections with onset post hospital discharge.

OBJECTIVE: Current surveillance for healthcare-associated (HA) urinary tract infection (UTI) is focused on catheter-associated infection with hospital onset (HO-CAUTI), yet this surveillance does not represent the full burden of HA-UTI to patients. Our objective was to measure the incidence of potentially HA, community-onset (CO) UTI in a retrospective cohort of hospitalized patients. DESIGN: Retrospective cohort study. SETTING: Academic, quaternary care, referral center. PATIENTS: Hospitalized adults at risk for HA-UTI from May 2009 to December 2011 were included. METHODS: Patients who did not experience a UTI during the index hospitalization were followed for 30 days post discharge to identify cases of potentially HA-CO UTI. RESULTS: We identified 3,273 patients at risk for potentially HA-CO UTI. The incidence of HA-CO UTI in the 30 days post discharge was 29.8 per 1,000 patients. Independent risk factors of HA-CO UTI included paraplegia or quadriplegia (adjusted odds ratio [aOR], 4.6; 95% confidence interval [CI], 1.2-18.0), indwelling catheter during index hospitalization (aOR, 1.5; 95% CI, 1.0-2.3), prior piperacillin-tazobactam prescription (aOR, 2.3; 95% CI, 1.1-4.5), prior penicillin class prescription (aOR, 1.7; 95% CI, 1.0-2.8), and private insurance (aOR, 0.6; 95% CI, 0.4-0.9). CONCLUSIONS: HA-CO UTI may be common within 30 days following hospital discharge. These data suggest that surveillance efforts may need to be expanded to capture the full burden to patients and better inform antibiotic prescribing decisions for patients with a history of hospitalization.

Racial/ethnic differences in multimorbidity development and chronic disease accumulation for middle-aged adults.

BACKGROUND: Multimorbidity-having two or more coexisting chronic conditions-is highly prevalent, costly, and disabling to older adults. Questions remain regarding chronic diseases accumulation over time and whether this differs by racial and ethnic background. Answering this knowledge gap, this study identifies differences in rates of chronic disease accumulation and multimorbidity development among non-Hispanic white, non-Hispanic black, and Hispanic study participants starting in middle-age and followed up to 16 years. METHODS AND FINDINGS: We analyzed data from the Health and Retirement Study (HRS), a biennial, ongoing, publicly-available, longitudinal nationally-representative study of middle-aged and older adults in the United States. We assessed the change in chronic disease burden among 8,872 non-Hispanic black, non-Hispanic white, and Hispanic participants who were 51-55 years of age at their first interview any time during the study period (1998-2014) and all subsequent follow-up observations until 2014. Multimorbidity was defined as having two or more of seven somatic chronic diseases: arthritis, cancer, heart disease (myocardial infarction, coronary heart disease, angina, congestive heart failure, or other heart problems), diabetes, hypertension, lung disease, and stroke. We used negative binomial generalized estimating equation models to assess the trajectories of multimorbidity burden over time for non-Hispanic black, non-Hispanic white, and Hispanic participants. In covariate-adjusted models non-Hispanic black respondents had initial chronic disease counts that were 28% higher than non-Hispanic white respondents (IRR 1.279, 95% CI 1.201, 1.361), while Hispanic respondents had initial chronic disease counts that were 15% lower than non-Hispanic white respondents (IRR 0.852, 95% CI 0.775, 0.938). Non-Hispanic black respondents had rates of chronic disease accumulation that were 1.1% slower than non-Hispanic whites (IRR 0.989, 95% CI 0.981, 0.998) and Hispanic respondents had rates of chronic disease accumulation that were 1.5% faster than non-Hispanic white respondents (IRR 1.015, 95% CI 1.002, 1.028). Using marginal effects commands, this translates to predicted values of chronic disease for white respondents who begin the study period with 0.98 chronic diseases and end with 2.8 chronic diseases; black respondents who begin the study period with 1.3 chronic diseases and end with 3.3 chronic diseases; and Hispanic respondents who begin the study period with 0.84 chronic diseases and end with 2.7 chronic diseases. CONCLUSIONS: Middle-aged non-Hispanic black adults start at a higher level of chronic disease burden and develop multimorbidity at an earlier age, on average, than their non-Hispanic white counterparts. Hispanics, on the other hand, accumulate chronic disease at a faster rate relative to non-Hispanic white adults. Our findings have important implications for improving primary and secondary chronic disease prevention efforts among non-Hispanic black and Hispanic Americans to stave off greater multimorbidity-related health impacts.

Diabetes-Multimorbidity Combinations and Disability Among Middle-aged and Older Adults.

BACKGROUND: Older adults with diabetes rarely have only one chronic disease. As a result, there is a need to re-conceptualize research and clinical practice to address the growing number of older Americans with diabetes and concurrent chronic diseases (diabetes-multimorbidity). OBJECTIVE: To identify prevalent multimorbidity combinations and examine their association with poor functional status among a nationally representative sample of middle-aged and older adults with diabetes. DESIGN: A prospective cohort study of the 2012-2014 Health and Retirement Study (HRS) data. We identified the most prevalent diabetes-multimorbidity combinations and estimated negative binomial models of diabetes-multimorbidity on prospective disability. PARTICIPANTS: Analytic sample included 3841 HRS participants with diabetes, aged 51 years and older. MAIN MEASURES: The main outcome measure was the combined activities of daily living (ADL)-instrumental activities of daily living (IADL) index (range 0-11; higher index denotes higher disability). The main independent variables were diabetes-multimorbidity combination groups, defined as the co-occurrence of diabetes and at least one of six somatic chronic diseases (hypertension, cardiovascular disease, lung disease, cancer, arthritis, and stroke) and/or two mental chronic conditions (cognitive impairment and high depressive symptoms (CESD score ≥ 4). KEY RESULTS: The three most prevalent multimorbidity combinations were, in rank-order diabetes-arthritis-hypertension (n = 694, 18.1%); diabetes-hypertension (n = 481, 12.5%); and diabetes-arthritis-hypertension-heart disease (n = 383, 10%). Diabetes-multimorbidity combinations that included high depressive symptoms or stroke had significantly higher counts of ADL-IADL limitations compared with diabetes-only. In head-to-head comparisons of diabetes-multimorbidity combinations, high depressive symptoms or stroke added to somatic multimorbidity combinations was associated with a higher count of ADL-IADL limitations (diabetes-arthritis-hypertension-high depressive symptoms vs. diabetes-arthritis-hypertension: IRR = 1.95 [1.13, 3.38]; diabetes-arthritis-hypertension-stroke vs. diabetes-arthritis-hypertension: IRR = 2.09 [1.15, 3.82]) even after adjusting for age, gender, education, race/ethnicity, BMI, baseline ADL-IADL, and diabetes duration. Coefficients were robust to further adjustment for diabetes treatment. CONCLUSIONS: Depressive symptoms or stroke added onto other multimorbidity combinations may pose a substantial functional burden for middle-aged and older adults with diabetes.

Health-related quality of life in Veterans with epileptic and psychogenic nonepileptic seizures.

RATIONALE: Health-related quality of life (HRQoL) is compromised in civilians with epileptic seizures (ES) or psychogenic nonepileptic seizures (PNES). U.S. Veterans are a distinct patient group with regard to gender, age, and background. We studied HRQoL in Veterans and asked the following: (1) Is there a difference in HRQoL in Veterans with ES vs. PNES?; (2) What factors influence HRQoL in each group?; (3) What factors influenced the difference between seizure groups? METHODS: We studied consecutive Veterans entering the epilepsy monitoring units (EMUs) of three VA Epilepsy Centers of Excellence. Patients underwent continuous video-EEG monitoring. Seizure diagnoses followed established criteria. Health-related quality of life was measured with the Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Evaluations included the Structured Clinical Interview for Diagnostic and Statistical Manual-IV (DSM IV), the posttraumatic stress disorder (PTSD) Checklist (PCL), the Beck Depression Inventory II (BDI-II), and the Minnesota Multiphasic Personality Inventory-2 Restructured form (MMPI-2RF). Between-group differences were tested with Wilcoxon tests. Nested regression analysis was used to evaluate the influence of demographic, social, military, seizure-related, and psychological factors on QOLIE-31 scores. RESULTS: The median QOLIE-31 total score was 14 points lower in Veterans with PNES vs. ES (p < 0.001; Cohen's d = 0.73). Within each seizure group, psychological factors accounted for ≥50% of the variance in QOLIE scores while combined demographic, social, and seizure-related factors accounted for 18% (group with ES) and 7% (PNES). Psychological measures, particularly PCL and the BDI-II scores, accounted for all of the difference in QOLIE-31 total scores between Veterans with ES and those with PNES. CONCLUSIONS: Health-related quality of life as measured by the QOLIE-31 is worse in Veterans with PNES as compared with those with ES. Psychological factors account for the most of the variance in QOLIE-31 scores regardless of seizure type and also account for the difference between groups with PNES and ES. Demographic, military, social, and seizure-related factors have minimal influence on HRQoL. These results in U.S. Veterans are similar to those found in civilians despite differences in patient age, gender, and background.

Trends In Coverage For Disease-Modifying Therapies For Multiple Sclerosis In Medicare Part D.

The high cost of multiple sclerosis (MS) disease-modifying therapies can negatively affect access for patients through increased payer restrictions and higher out-of-pocket spending. Our objective was to describe changes in pharmacy benefit coverage and cost-sharing amounts for MS disease-modifying therapies in the Medicare Part D program, using enrollment-weighted Prescription Drug Plan Formulary files for the period 2007-16. Among therapies available throughout the study period, the rate of prior authorization use increased from 61-66 percent of plans to 84-90 percent. The share of plans with at least one therapy available without limitations declined from 39 percent to 17 percent. The projected cumulative out-of-pocket spending for 2019 was $6,894. The therapy with the highest out-of-pocket spending was generic glatiramer acetate. Policy makers need to consider both access restrictions and a growing cost-sharing burden as potential consequences of high and rising drug prices for people with MS.