Malathion exposure may increase infertility risk among US Adults: Results from the 2015-2016 NHANES.

BACKGROUND AND PURPOSE: Organophosphate pesticides such as malathion are the most widely used pesticides. Despite endocrine-disrupting effects, there is a paucity of information regarding chronic exposure to non-persistent organopesticides such as malathion. The purpose of this study is to describe the exposure burden among U.S. residents as well as possible impacts on fertility. METHODS: Population-based data collected by the National Health and Nutrition Examination Survey (NHANES) between 2015 and 2016 were used to perform a retrospective analysis on urinary concentrations of malathion diacid. Samples were assessed from 1703 adult participants, statistically weighted to represent over 231 million individuals. General linear models were used to examine associations between exposure and reproductive health measures among pre-menopausal women. RESULTS: Detectable concentrations of malathion diacid were identified in 16.1 % (n = 254) of samples. Concentrations were higher among women who reported seeing a physician due to difficulties becoming pregnant (P < 0.001; r2 = 0.12) as well as among women who reported trying for at least a year to become pregnant (P < 0.001; r2 = 0.06). CONCLUSIONS: Exposure to malathion is associated with a history of reproductive health challenges among women.

Human epididymis protein 4: Analysis of national health and nutrition examination survey data.

BACKGROUND: Human epididymis protein 4 (HE4) is a tumor marker overexpressed in ovarian cancer and is commonly utilized to aid with diagnosis of an adnexal mass. HE4 levels vary based on pregnancy, age, menopausal status, and tobacco use. OBJECTIVE(S): The objective of this study was to evaluate population-based data to examine factors that affect HE4 among adult women in the United States and stratify levels of HE4 by demographic and gynecologic factors. STUDY DESIGN: A retrospective analysis was conducted using data from 2,480 women aged 20 + who participated in the National Health and Nutrition Examination Survey (2001-2002). From these cross-sectional data, serum HE4 and cotinine, a marker of tobacco exposure, were combined with demographic and interview data. Estimated glomerular filtration rates (eGFR) were based on serum creatinine, age, sex, and race. Other variables of interest included menopausal status, pregnancy, and various gynecologic factors. Summary HE4 data are provided as geometric means with associated 95 % confidence intervals. RESULTS: HE4 levels were independently associated with age, renal function, and nicotine use, all p < 0.001. Pre-menopausal women with a history of endometriosis were found to have elevated HE4 levels compared to those without, p < 0.01; however, we found no such difference among post-menopausal women. Adjusting for age, no differences in HE4 were found based on race/ethnicity, p = 0.29. HE4 levels showed statistically significant associations with income level; however, these were small and clinically irrelevant. CONCLUSION: This study provides evaluation of HE4 levels among a data set representative of 98.5 million non-institutionalized women in the United States and gives insight into extraneous factors that may influence these levels.

Normative Values for Serum Neurofilament Light Chain in US Adults.

BACKGROUND AND PURPOSE: Neurofilament light chain (NfL) levels serve as a marker of neuroaxonal injury and can be measured in both cerebrospinal fluid and serum. Although serum NfL (sNfL) levels have been shown to increase with the progression of various neurological conditions, normative values for healthy individuals have not yet been established. This study was undertaken to determine age-specific normative values for sNfL and evaluate the associations between sNfL and sociodemographic characteristics. METHODS: A retrospective analysis was conducted using population-based data collected by the National Health and Nutrition Examination Survey between 2013 and 2014. The sera of 2071 adult participants were collected. General linear models were used to examine the associations between sNfL levels and sample characteristics. RESULTS: The data analysis revealed a significant positive association between age and sNfL levels (p<0.001). Sex was also associated with sNfL levels (p=0.04) after controlling for age. The mean sNfL levels for males and females were 17.99 pg/mL (95% confidence interval [CI]=15.43-20.17) and 15.78 pg/mL (95% CI=13.00-18.55) respectively, after controlling for age. CONCLUSIONS: These results suggest that sNfL levels increase with age and are affected by sex. The findings of this study provide a useful baseline for comparing sNfL levels in clinical practice and future research.

Attention deficit hyperactivity disorder medications and bone mineral density of adults in the United States.

Introduction: Several medications used to treat attention deficit hyperactivity disorder (ADHD) have been associated with diminished bone mineral density (BMD) in children. The objective of this study was to determine if evidence exists for a similar association among adults. Materials and methods: A retrospective cross-sectional analysis was conducted using data collected by the National Health Nutrition Examination Survey 2013-2018. Data from 7961 individuals aged 18 to 50, 79 of whom were taking medications to treat ADHD. Dual-energy X-ray absorptiometry scans provided measure of body composition. Linear regression models were used to examine associations between ADHD medication use and body composition. Results: Stimulant ADHD medication usage was found to be associated with decreased BMD in both the skull (-6.6%; 95% CI 5.9-7.2) (P < 0.05) and thoracic spine (-6.0%; 95% CI 5.1-7.0) (P < 0.05). No difference in BMD was seen in any other skeletal region based on stimulant ADHD medication use (P > 0.05). We found no evidence to suggest that duration of use affected the observed decreases in BMD, P > 0.05. Conclusion: This study using a nationally representative sample assessed whether stimulant medication use in adults with ADHD was associated with decreased BMD. The overall results are inconclusive. Further study is needed to better evaluate if ADHD and/or stimulant medication use is independently associated with bone health.

Prevalence of Hepatic Steatosis and Fibrosis in the United States.

Introduction: Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in the world. We evaluated vibration-controlled transient elastography (VCTE) data to determine the prevalence of two principle manifestations of NAFLD, hepatic steatosis and hepatic fibrosis. Methods: Data were sourced from the 2017 to 2018 National Health and Nutrition Examination Survey, which provides a representative cross-section of the noninstitutionalized U.S. population. Participants 18 years of age and older were examined using sera and VCTE. Sociodemographic and medical history information were gathered through self-report. Logistic regression models assessed relationships between steatosis, fibrosis, and variables of interest. Prevalence estimates are reported as weighted percentages with 95% Wald confidence intervals (CIs). Results: A total of 4083 participants representing 187 million U.S. adults were included in our analysis. We estimate the prevalence of steatosis (controlled attenuation parameter ≥302 dB/m, ≥S1) at 27.3% (95% CI: 25.3-29.4) and significant fibrosis (liver stiffness ≥8.2 kPa, ≥F2) at 7.7% (95% CI: 6.1-9.6). Both were independently associated with age, gender, body mass index (BMI), and diabetes (all P < 0.05). The greatest predictor of both steatosis and fibrosis was BMI. Steatosis was present in 3.6%, 18.7%, and 49.4% of those in the normal or underweight, overweight, or obese categories, respectively. Significant fibrosis was present in 2.1%, 3.2%, and 14.7% of those in the normal or underweight, overweight, or obese categories, respectively. Conclusions: Clinically significant steatosis and/or fibrosis are highly prevalent among the U.S. adult population. The greatest predictor of both steatosis and fibrosis is obesity.

Normative formaldehyde-hemoglobin adduct levels among the US Population: Analysis of the 2013-2016 National Health and Nutrition Examination Survey.

INTRODUCTION: Formaldehyde (FA) is currently classified as a known carcinogen. In addition to being a ubiquitous compound with many common exogenous exposure sources, it is also part of multiple metabolic pathways and present in every living cell. The objectives of this study were to determine normative levels of FA as measured by FA-Hemoglobin (Hb) adducts in the United States (US) and to determine if FA-Hb levels differ based on a variety of demographic factors. METHODS: Data collected between 2013 and 2016 by the National Health and Nutrition Examination Survey were assessed from 4521 participants representing approximately 244 million individuals living in the US. General linear models were used to examine associations between FA-Hb adducts and sample characteristics. FA-Hb levels were summarized using geometric mean concentrations (GMC) and associated 95% confidence intervals (CI). RESULTS: The overall GMC was 131.10 nmol/g Hb (95% CI 129.39-132.83). Analyses revealed no evidence to support associations between FA-Hb levels and age, gender, income, or nicotine use. Among adults, non-Hispanic Black race was associated with lower FA-Hb levels compared to all other race/ethnicity groups, P < 0.01. CONCLUSION: The study provides the first normative values for FA in adults and children. These data could be a tool to assess the body's response to acute and chronic exposure.

Prevalence and risk factors for Trichomonas vaginalis infection among adults in the U.S., 2013-2014.

OBJECTIVE: Trichomonas vaginalis (TV) infection is common, curable, and associated with significant reproductive morbidity and risk for HIV infection. This analysis updates estimates of the prevalence of asymptomatic TV infection, and its associated risk factors, in the non-institutionalized U.S. population. METHODS: We analyzed data from 4057 individuals who participated in the National Health and Nutrition Examination Survey (NHANES) 2013-2014 data collection cycle. Participant interviews ascertained demographic characteristics, self-reported tobacco use, and sexual history. Self-collected urine specimens from participants aged 18 to 59 years were tested for TV infection using the Gen-Probe Aptima TV assay. Cotinine was assayed from serum to provide a biomarker of recent tobacco exposure. Weighted percentages are provided to account for unequal selection probabilities among participants and adjustments for non-response. RESULTS: Our sample included 1942 men (49.2%, 95% Confidence Interval [CI] 48.0-50.5) and 2115 women (50.8%, 95%CI 49.5-52.0). The infection prevalence among men was 0.5% (n = 16; 95%CI 0.2-1.0) and 1.8% (n = 55; 95%CI 1.1-3.1) in women. After controlling for participant characteristics associated with TV infection, females had a 5.2-fold increased odds of being infected compared to men (adjusted odds ratio (aOR) 5.2, 95% CI 2.4-11.4). Non-Hispanic blacks were more likely to be infected compared to non-Hispanic whites (aOR 11.2, 95% CI 4.6-27.2). Individuals below the federal poverty level were more likely to be infected compared to those earning >3 times the federal poverty level (aOR 6.7, 95% CI 1.7-26.6), and active smokers were more likely to be infected compared to participants with no nicotine exposure (aOR 8.7, 95% CI 4.1-18.2). CONCLUSION: Trichomonas vaginalis infection continues to be relatively common, especially in women, smokers, non-Hispanic blacks, and in groups of lower socioeconomic status. Identifying the demographic characteristics of populations in the United States disproportionately affected by TV could impact screening and treatment of this infection in clinical practice. Further research on whether screening and treating for asymptomatic TV infection in high-risk populations improves risk for reproductive morbidity and HIV infection is warranted.

Differentiating between smokers and nonsmokers using serum cotinine.

Aim: Our goal is to evaluate implications of cotinine cut points in subgroups of smokers and nonsmokers. Materials & methods: Data were assessed from 13,357 adult participants and collected over a period of 6 years by the National Health and Nutrition Examination Survey (2009-2014). Receiver operating characteristic curve analysis was used to identify optimal cut points. Rao-Scott χ2 tests measured associations between group characteristics. Results: The optimal serum cotinine cut point adult cigarette smokers was 3.63 ng/ml (sensitivity of 96.7%; specificity of 93.0%). This cut point differed by gender as well as race/ethnicity. Conclusion: There are notable differences in subgroup cut points compared with previous research. Use of gender or race/ethnicity specific cut points is more appropriate when feasible and may help clinician recommendations.

Evaluation of Clinical Nurse Transition Program at US Army Hospitals.

INTRODUCTION: The purpose of this evaluation was to determine the effectiveness of the clinical nurse transition program (CNTP) for newly commissioned Army nurses. This is one of the first evaluations conducted to document the outcomes of the Army Nurse Corps (ANC) transition-to practice residency program. MATERIALS AND METHODS: This project was a prospective pre-test/post-test design evaluation of newly licensed registered nurses (RNs) entering the military health system from Fall 2017 to Fall 2018 using Casey-Fink Readiness for Practice Survey and the New Graduate RN Transition Program Competency Assessment Tool. Data were analyzed using SAS 9.4. All tests were two-tailed as applicable and p-values less than 0.05 were considered significant. Missing data were treated as missing for individual items; their values were not imputed. No participant was excluded due to missing items. This evaluation was determined to be exempt from human subject protection regulations by the Human Protections Administrator at Womack Army Medical Center. RESULTS: A total of 92 pre-test surveys were sent to the nine CNTP training sites which actively trained RNs during the study timeframe. Due to a shipping error, 6 of the 92 completed pre-test surveys from one CNTP site were not received, for an overall response rate of 93.4% (86/92), from eight CNTP sites. Of the 86 participants from whom pre-tests were received, all 86 successfully returned their post-test survey, for a 100% response rate pre- to post- survey. The participants were predominately white (73.3%) and female (70.9%) with a median age of 23 years (IQR: 22-24 years) and an undergraduate GPA of 3.5 (IQR: 3.4-3.7, Table II). Quantitative data analysis revealed that after the training, all participants reported a significant improvement in providing safe (p < 0.0001) and quality care (p < 0.0001) for an average workload of in-patient patients. It also showed a significant improvement in team leading (p < 0.0001), effective decision making (p < 0.0001), incorporating evidence into practice (p < 0.0001), and demonstrated professionalism (p < 0.0001). The overall clinical competence and readiness to practice (p < 0.0001) also improved. Data shows that participants perceive significant improvement in all the objectives set by the ANC for the transition program. CONCLUSION: The results of this program evaluation provide evidence that the CNTP has been a success in meeting the intended objectives. Participants showed a significant improvement in their perceived readiness and level of competency in clinical, technical, and leadership skills performance at the end of the program, as well as improved communication and teamwork. The CNTP experience provides an effective means to facilitate the development of newly licensed Army nurses' clinical competence and confidence in practice. The study limitation includes the Casey-Fink Readiness for Practice Survey had relatively low reliability, but it was chosen as it was better aligned to the specified CNTP objectives. And also, with any self-reported evaluation, there is potential bias regarding the accuracy of participants' self-perception. Follow-up study may include examining the demographics of the incoming nurses, such as their source of commission. To determine if and how the comfort and confidence self-reported by the new graduate nurses is reflective of actual ability, nurse preceptors may be asked to complete skills assessments or simulations with objective measurements may be used.

An Association Between Herpes Zoster Vaccination and Stroke Reduction Among Elderly Individuals.

Herpes zoster (HZ, shingles) affects individuals (60+ years) by reactivation of varicella virus from primary infection. Approximately one-third of the general population will develop HZ and are at increased risk of stroke. Our objective was describing possible associations between self-reported HZ vaccination and stroke with the Centers for Disease Control and Prevention's Behavioral Risk Factors Surveillance System, a cross-sectional nationwide telephone survey. Non-institutionalized U.S. adults answered items concerning health risk behaviors. 2014 survey data were from 265,568 adults 50-79 years old. Multivariable Cox regressions adjusted for standard demographics, body mass index, and coronary heart disease showed that HZ-vaccinated individuals had lower risk of reporting stroke those not vaccinated (hazard ratio [HR] = 1.73). After stratification of participants into six 5-year age groups, adjusted weighted binary logistic regressions were conducted for each age group with stroke as outcome. The HZ-vaccinated group aged 65-69 years reported stroke approximately 50% less than those unvaccinated (adjusted Odds Ratio [aOR] = 1.51; 99% confidence interval [CI]:1.21,1.88). Secondary analyses indicated that this benefit was among HZ-vaccinated whites (aOR = 1.6, 95%CI:1.4,2.0), but not African Americans or Hispanics. These possible protective effects are not detected 10 years after recommended vaccine uptake. Limitations include not following participants longitudinally and that time between stroke and vaccination could not be determined.

Tobacco Use and Prevalence of Human Papillomavirus in Self-Collected Cervicovaginal Swabs Between 2009 and 2014.

OBJECTIVE: To evaluate relationships between an objective biomarker of current tobacco exposure and high-risk genital human papillomavirus (HPV) prevalence among adult women in the United States. METHODS: We performed a retrospective analysis of adult women (aged 18-59 years) using three consecutive 2-year cycles (2009-2014) from the cross-sectional National Health and Nutrition Examination Surveys. Women who provided self-collected cervicovaginal swabs and serum were included. Human papillomavirus genotyping was conducted on cervicovaginal samples with a Linear Array HPV assay. Cotinine, a major metabolite of nicotine, was assayed from serum to provide a biomarker of recent tobacco exposure. Participants were stratified into three levels of tobacco exposure (nonsmokers, secondhand smoke exposure, and smokers) based on serum cotinine concentration levels using previously published ethnic-specific cut points. Weighted percentages are provided to account for unequal selection probabilities among participants and adjustments for nonresponse. RESULTS: Among the 5,158 women analyzed, 2,778 were classified as nonsmokers (57.1%, 95% CI 54.5-59.6%), 1,109 classified as having secondhand smoke exposure (18.4%, 95% CI 16.5-20.3%), and 1,271 classified as smokers (24.6%, 95% CI 22.8-26.5%) using serum cotinine concentration levels. Prevalence of HPV infection differed between nicotine exposure groups (P<.001): 441 smokers (32.1%, 95% CI 29.6-34.7%), 322 women with secondhand smoke exposure (26.1%, 95% CI 22.7-29.7%), and 451 nonsmokers (15.1%, 95% CI 13.3-17.1%) had a high-risk genital HPV infection. Controlling for demographics and number of lifetime sexual partners, the risks compared with nonsmokers for infection with a high-risk HPV genotype for smokers (adjusted odds ratio [OR] 1.7, 95% CI 1.4-22) and secondhand smokers (adjusted OR 1.4, 95% CI 1.1-1.8) are similarly increased (P<.001). CONCLUSION: In this large cross-sectional, population-based study, we show a relationship between an objective biomarker of current tobacco use and genital HPV infection. Cigarette smoking and exposure to secondhand smoke are associated with increased odds of infection with high-risk genital HPV independent of lifetime number of sexual partners.

Validation of Visual Objective Biomarkers for Acute Concussion.

Objective: Despite an increase in the awareness and diagnosis of mild traumatic brain injury (mTBI), there remains a paucity of data examining the comparative efficacy of available assessments. This study aims to validate visual functions as potential biomarkers for mTBI. Methods: This case-control correlational design utilizes military personnel diagnosed with acute (≤72 h post-injury) mTBI (n = 100) and age-matched controls (n = 100) to examine the relative effectiveness of the pupillary light reflex (PLR), near point of convergence (NPC) break, King-Devick (KD) test time, and Convergence Insufficiency Symptom Survey (CISS) score to discriminate between participants with mTBI. Results: Three of the eight PLR parameters (i.e., average constriction velocity (ACV), average dilation velocity (ADV), and 75% re-dilation time; all p < 0.001) were affected in mTBI participants. Similarly, NPC break, KD test time, and CISS scores showed a statistically significant difference between groups (all p < 0.001). Area under the curve showed that ADV (0.82) and NPC (0.74) have the higher predictive values of all objective parameters. Conclusions: ADV, ACV, and NPC break are objective visual functions markedly affected in the acute mTBI group compared with controls; therefore, we proposed that they could be used as biomarkers for acute mTBI.

Regenerative Endodontic Procedures among Endodontists: A Web-based Survey.

INTRODUCTION: The protocols that endodontists implement for regenerative endodontic procedures (REPs) are unknown. The aim of this study was to examine current REP protocols among practicing endodontists in the United States. METHODS: A Web-based survey was sent to 4060 active members of the American Association of Endodontists (AAE). A total of 850 participants completed the survey, representing a 20.9% response rate. RESULTS: Responses indicated 60% reported having performed REPs; most performed 1 to 3 per year. The most commonly selected source (60.8%) for the clinical protocol was the "AAE Clinical Considerations for a Regenerative Procedure." Time constraints were the most common reason why 92.4% of respondents did not report their REP cases to the AAE.org database; additionally, 15.5% were unaware of it. Almost half (49.8%) of the participants reported they would attempt an REP on a patient of any age. The most commonly used irrigants were >3% sodium hypochlorite at the first appointment and EDTA at the scaffold formation appointment. As the intracanal medicament, 52.2% used calcium hydroxide, whereas 23.5% used triple antibiotic paste. At the scaffold formation appointment, 77.1% used a local anesthetic without a vasoconstrictor, and 94.3% used a blood clot as the scaffold. Mineral trioxide aggregate was the coronal barrier most often selected. Considering factors most likely to encourage the use of REPs in the future, 79.8% reported the availability of good candidates followed by 40.1% who desired better evidence. CONCLUSIONS: Based on the results of this survey, REP protocols appear to be heterogeneous and do not strictly conform to the "AAE Clinical Considerations for a Regenerative Procedure."