Stimulant Patterns, Alone or with Other Psychotropic Classes, in Medicaid-Insured Youth Continuously Enrolled for 3-8 Years.

Objective: Little U.S. pharmacoepidemiologic study is based on treatment during continuous enrollment for periods more than a year. This study aims to show pediatric patterns of stimulant use (alone or with other psychotropic classes) from Medicaid administrative claims data for stimulant patterns of 3- to 8-year continuous enrollees. Methods: A retrospective cohort study was derived from Medicaid enrollment, pharmacy, and diagnosis claims data (2007-2014) in a mid-Atlantic state. Youth aged 2-17 years with 3-8 years of continuous enrollment treated with stimulants were compared with a date-matched comparison group treated without stimulants. Major outcomes include prevalence and duration of stimulant use and patterns of stimulant polypharmacy across relatively long enrollments (3-8 years). Results: Among 264,518 unique 2- to 17-year olds with 3-8 years of continuous enrollment, 16.5% had stimulant prescription dispensings, doubling the annual national prevalence of 8.1%. Subgroup analysis showed that the highest prevalence of stimulant use was for 6- to 11-year olds (20.4%), foster care eligible youth (42.3%), and those with 7-8 years of continuous enrollment (20.1%). Externalizing psychiatric disorders were far more common in those treated with stimulants than in those treated without stimulants. The duration of stimulant exposure overall was a median of 487 days, half that of foster care stimulant users. Stimulant polypharmacy with two or more psychotropic classes concomitantly characterized 29.8% of stimulant users. Among those with three or four or more class polypharmacy, 85% and 88%, respectively, had concomitant stimulant and antipsychotic use. The adjusted odds ratio (AOR) of three or more class polypharmacy significantly increased in 12- to 17-year-old age group (AOR = 1.8), foster care eligibility (AOR = 4.5), and among those with the longest enrollment (AOR = 1.7). Conclusions and Relevance: Stimulant prevalence in Medicaid-insured youth with continuous enrollment of 3-8 years was twice as common as in annual data sets. Future research should investigate three to five interclass stimulant polypharmacy effectiveness in reliably diagnosed community populations.

Effects of Low-Calorie Sweetener Restriction on Glycemic Variability and Cardiometabolic Health in Children with Type 1 Diabetes: Findings of a Pilot and Feasibility Study.

Low-calorie sweeteners (LCS) are commonly consumed by children with type 1 diabetes (T1D), yet their role in cardiometabolic health is unclear. This study examined the feasibility, acceptability, and preliminary effects of 12 weeks of LCS restriction among children with T1D. Children (n = 31) with T1D completed a two-week run-in (n = 28) and were randomly assigned to avoid LCS (LCS restriction, n = 15) or continue their usual LCS intake (n = 13). Feasibility was assessed using recruitment, retention, and adherence rates percentages. Acceptability was assessed through parents completing a qualitative interview (subset, n = 15) and a satisfaction survey at follow-up. Preliminary outcomes were between-group differences in change in average daily time-in-range (TIR) over 12 weeks (primary), and other measures of glycemic variability, lipids, inflammatory biomarkers, visceral adiposity, and dietary intake (secondary). Linear regression, unadjusted and adjusted for age, sex, race, and change in BMI, was used to compare mean changes in all outcomes between groups. LCS restriction was feasible and acceptable. No between-group differences in change in TIR or other measures of glycemic variability were observed. However, significant decreases in TNF-alpha (-0.23 ± 0.08 pg/mL) and improvements in cholesterol (-0.31 ± 0.18 mmol/L) and LDL (-0.60 ± 0.39 mmol/L) were observed with usual LCS intake, compared with LCS restriction. Those randomized to LCS restriction did not report increases in total or added sugar intake, and lower energy intake was reported in both groups (-190.8 ± 106.40 kcal LCS restriction, -245.3 ± 112.90 kcal usual LCS intake group). Decreases in percent energy from carbohydrates (-8.5 ± 2.61) and increases in percent energy from protein (3.2 ± 1.16) and fat (5.2 ± 2.02) were reported with usual LCS intake compared with LCS restriction. Twelve weeks of LCS restriction did not compromise glycemic variability or cardiometabolic outcomes in this small sample of youth with T1D. Further examination of LCS restriction among children with T1D is warranted.

Social Determinants of Health Influence Future Health Care Costs in the Medicaid Cohort of the District of Columbia Study.

Policy Points Social determinants of health are an important predictor of future health care costs. Medicaid must partner with other sectors to address the underlying causes of its beneficiaries' poor health and high health care spending. CONTEXT: Social determinants of health are an important predictor of future health care costs but little is known about their impact on Medicaid spending. This study analyzes the role of social determinants of health (SDH) in predicting future health care costs for adult Medicaid beneficiaries with similar past morbidity burdens and past costs. METHODS: We enrolled into a prospective cohort study 8,892 adult Medicaid beneficiaries who presented for treatment at an emergency department or clinic affiliated with two hospitals in Washington, DC, between September 2017 and December 31, 2018. We used SDH information measured at enrollment to categorize our participants into four social risk classes of increasing severity. We used Medicaid claims for a 2-year period; 12 months pre- and post-study enrollment to measure past and future morbidity burden according to the Adjusted Clinical Groups system. We also used the Medicaid claims data to characterize total annual Medicaid costs one year prior to and one year after study enrollment. RESULTS: The 8,892 participants were primarily female (66%) and Black (91%). For persons with similar past morbidity burdens and past costs (p < 0.01), the future morbidity burden was significantly higher in the upper two social risk classes (1.15 and 2.04, respectively) compared with the lowest one. Mean future health care spending was significantly higher in the upper social risk classes compared with the lowest one ($2,713, $11,010, and $17,710, respectively) and remained significantly higher for the two highest social risk classes ($1,426 and $3,581, respectively), given past morbidity burden and past costs (p < 0.01). When we controlled for future morbidity burden (measured concurrently with future costs), social risk class was no longer a significant predictor of future health care costs. CONCLUSIONS: SDH are statistically significant predictors of future morbidity burden and future costs controlling for past morbidity burden and past costs. Further research is needed to determine whether current payment systems adequately account for differences in the care needs of highly medically and socially complex patients.

Predictors of electronic nicotine product quit attempts and cessation: Analysis of waves 3 and 4 of the PATH study.

INTRODUCTION: Identifying theory-based predictors of electronic nicotine product (ENP) quit attempts and cessation can guide the development of effective vaping cessation interventions, which are currently limited. This study examined predictors of ENP quit attempts and cessation among adult ENP users. METHODS: Using data from wave 3 (W3; 2015-2016) current established ENP users in the Population Assessment of Tobacco and Health study, we used multivariable logistic regression to identify predictors of (i) wave 4 (W4; 2016-2018) quit attempts (unweighted n = 1,135); and (ii) W4 cessation among those who made a quit attempt (unweighted n = 610). Predictors included Social Cognitive Theory (SCT)-based cognitive (interest in quitting, self-efficacy to quit, outcome expectancies, risk perception), behavioral (smoking status, and use of combustibles, non-combustibles, cannabis, and alcohol), and socio-environmental (perceived disapproval, household rules, exposure to advertising) factors. RESULTS: Between W3 and W4, 51.7% of W3 ENP users made a quit attempt. Among those who tried quitting, 68.4% stopped using ENPs. SCT-based predictors of ENP quit attempts included higher interest in quitting ENPs (aOR = 1.18), greater self-efficacy to quit ENPs (aOR = 1.31), and currently using cigarettes (vs non-smoker; aOR = 1.71), non-combustibles (aOR = 2.25), and cannabis (aOR = 1.80). Predictors of ENP cessation included greater self-efficacy to quit ENPs (aOR = 1.33), greater perceived risk of ENPs (aOR = 1.35), and being a current smoker (vs non-smoker; aOR = 3.28). CONCLUSIONS: ENP cessation interventions should address cognitive factors, particularly self-efficacy, as it predicted quit attempts and cessation. Cigarette smoking among dual users should be monitored and addressed to ensure that those who quit using ENPs do not maintain cigarette use.

Associations between college/university campus characteristics and student body mass index.

BACKGROUND: Campus environments are associated with undergraduate weight. However, few studies have examined campus type and geographic location in relation to student weight. This article aimed to identify college/university students with elevated BMIs by campus type and region. METHODS: Linear mixed effects regression models were fit to data from the American College Health Association-National College Health Assessment II. Analyses tested associations between campus type/region and student self-reported BMI. RESULTS: The sample included 404,987 students from 445 schools with mean BMI 24.9 ± 5.8. Across all school types/regions, BMI confidence intervals included overweight values. Two-year and public school students had higher BMIs compared to four-year and private school students, respectively. Students in the Midwest had higher BMIs compared to students in the Northeast. In the South only, Minority Serving Institution (MSI) students had higher BMIs compared to non-MSI students. CONCLUSION: Healthy weight maintenance programs should be made available to undergraduate students.

Relationship Between Social Determinants of Health and Antihypertensive Medication Adherence in a Medicaid Cohort.

BACKGROUND: Little is known about the relationship between social determinants of health (SDH) and medication adherence among Medicaid beneficiaries with hypertension. METHODS: We conducted a posthoc subgroup analysis of 3044 adult Medicaid beneficiaries who enrolled in a parent prospective cohort study and had a diagnosis of hypertension based on their Medicaid claims during a 24-month period before study enrollment. We calculated the proportion of days covered by at least one antihypertensive medication during the first 12 months after study enrollment using the prescription claims data. We measured numerous SDH at the time of study enrollment and we categorized our hypertension cohort into 4 social risk groups based on their response profiles to the SDH variables. We compared the mean proportion of days covered by the different levels of the SDH factors. We modeled the odds of being covered by an antihypertensive medication daily throughout the follow-up period by social risk group, adjusted for age, sex, and disease severity using a generalized linear model. RESULTS: The nonrandom sample was predominately Black (93%), female (62%) and had completed high school (77%). The mean proportion of days covered varied significantly by different SDH, such as food insecurity (49%-56%), length of time living at present place (47%-57%), smoking status (50%-56%), etc. Social risk group was a significant predictor of medication adherence. Participants in the 2 groups with the most social risks were 36% (adjusted odds ratio=0.64 [95% CI, 0.53-0.78]) and 20% (adjusted odds ratio=0.80 [95% CI, 0.70-0.93]) less adherent to their hypertension therapy compared with participants in the group with the fewest social risks. CONCLUSIONS: Social risks are associated with lower antihypertensive medication adherence in the Medicaid population.

Determinants of lower-extremity injury severity and recovery in U.S. High School Soccer Players.

Lower-extremity injuries are common among soccer players, yet few studies have attempted to identify determinants of lower-extremity injury severity and recovery within this group. We aim to identify determinants of lower-extremity injury severity and recovery among high school (HS) soccer players in the US. We used soccer-related injury observations recorded within the NATION-SP during 2011/12-2013/14. Odds of a season-ending game-related injury were higher than a season-ending practice-related injury (Adj. OR = 2.64, 95% CI = [1.39, 5.01]). Gender, setting, and playing surface emerged as significant determinants of any time loss following lower-extremity injuries in multivariable logistic regression models, and multivariable random effects Poisson regression models also revealed significant differences in recovery durations across levels of these variables for "similarly severe" injuries. Findings suggest that gender, injury setting, playing surface contribute to injury corollaries differently. Similar multi-method approaches are needed to identify determinants of injury severity and recovery in this group.

Trajectories of ENDS and cigarette use among dual users: analysis of waves 1 to 5 of the PATH Study.

INTRODUCTION: Concurrent electronic nicotine delivery system (ENDS) and cigarette (dual) use is harmful. Identifying longitudinal trajectories of ENDS and cigarette use among dual users can help to determine the public health impact of ENDS and inform tobacco control policies and interventions. OBJECTIVES: (1) To identify independent and joint trajectories of ENDS and cigarette use among wave (W) 1 adult dual users across W1 to W5 of the Population Assessment of Tobacco and Health (PATH) Study; and (2) identify W1 predictors of ENDS and cigarette joint trajectory group membership. METHODS: We used group-based trajectory modelling to estimate independent and joint trajectories of ENDS and cigarette use from wave 1 (W1; 2013-2014) to wave 5 (W5; 2018-2019) among W1 adult established dual users of ENDS and cigarettes (n=545) from the PATH Study. We used multinomial logistic regression to identify W1 predictors of joint trajectories. RESULTS: Two ENDS (early quitters=66.0%, stable users=34.0%) and three cigarette (stable users=55.2%, gradual quitters=27.3%, early quitters=17.5%) trajectories of W1 were identified. In joint trajectory analysis, 41.6% of participants were early ENDS quitters and stable cigarette users; 14.8% early ENDS quitters and gradual cigarette quitters; 14.6% stable ENDS users and stable cigarette users; 11.2% stable ENDS users and gradual cigarette quitters; 10.3% early ENDS quitters and early cigarette quitters; and 7.4% stable ENDS users and early cigarette quitters. Cigarette and ENDS use frequency, nicotine dependence, cannabis use and other non-combusted tobacco product use predicted trajectory group membership (p values <0.05). CONCLUSIONS: Most dual users maintained long-term cigarette smoking or dual use, highlighting the need to address cessation of both products. Continued monitoring of trajectories and their predictors is needed, given ongoing changes to the ENDS marketplace.

Rationale and design of DRINK-T1D: A randomized clinical trial of effects of low-calorie sweetener restriction in children with type 1 diabetes.

BACKGROUND: Low-calorie sweeteners (LCSs) provide sweetness without sugar or calories and are used to replace added sugars by many children with type 1 diabetes (T1D). However, the role of LCSs in diabetes management and cardiometabolic health is unclear. OBJECTIVE: The Diabetes Research in Kids Study (DRINK-T1D) aims to investigate effects of LCS restriction on glycemic variability, visceral adiposity, lipid profiles, and systemic inflammation among children 6-12 years old with T1D. METHODS: Children with T1D, who report habitual consumption of foods and beverages containing LCSs, are recruited from the Washington Nationals Diabetes Care Complex (DCC) at Children's National Hospital (CNH) in Washington, DC. Following a phone screening and two-week run-in period involving continuation of usual LCS intake, children are randomized to 12 weeks of LCS restriction (replacement of diet beverages with still or sparkling water and avoidance of other sources of LCSs) or continued usual LCS intake (control). The primary outcome is the difference in change in glycemic variability in the LCS restriction group versus the control group. Change in glycemic variability will be assessed as the difference in daily average time-in-range (TIR), measured using continuous glucose monitoring (CGM) during two weeks at the end of the 12-week intervention, compared with during the two-week run-in period prior to randomization. Participants also complete a variety of anthropometric, metabolic, dietary, and behavioral assessments throughout the 14-week study. CONCLUSIONS: DRINK-T1D is an innovative, randomized controlled trial, evaluating effects of LCS restriction on glycemic variability and cardiometabolic health in children with T1D. Findings of DRINK-T1D will support or challenge the common practice of recommending LCS use in this patient population and will have clinically relevant implications for pediatric T1D management. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04385888.

The Influence of Social Determinants of Health on Emergency Departments Visits in a Medicaid Sample.

STUDY OBJECTIVE: We evaluate the relationship between social determinants of health and emergency department (ED) visits in the Medicaid Cohort of the District of Columbia. METHODS: We conducted a retrospective cohort analysis of 8,943 adult Medicaid beneficiaries who completed a social determinants of health survey at study enrollment. We merged the social determinants of health data with participants' Medicaid claims data for up to 24 months before enrollment. Using latent class analysis, we grouped our participants into 4 distinct social risk classes based on similar responses to the social determinants of health questions. We classified ED visits as primary care treatable or ED care needed, using the Minnesota algorithm. We calculated the adjusted log relative primary care treatable and ED care needed visit rates among the social risk classes by using generalized linear mixed-effects models. RESULTS: The majority (71%) of the 49,111 ED visits made by the 8,943 participants were ED care needed. The adjusted log relative rate of both primary care treatable and ED care needed visit rates increased with each higher (worse) social risk class compared with the lowest class. Participants in the highest social risk class (ie, unemployed and many social risks) had a log relative primary care treatable and ED care needed rate of 39% (range 28% to 50%) and 29% (range 21% to 38%), respectively, adjusted for age, sex, and illness severity. CONCLUSION: There is a strong relationship between social determinants of health and ED utilization in this Medicaid sample that is worth investigating in other Medicaid samples and patient populations.

Hepatitis B birth dose vaccination patterns in the military health System, 2014-2018.

BACKGROUND: Since 2005, the universal hepatitis B (HepB) birth dose has been recommended for all medically stable infants weighing ≥2,000 g at birth. The timing of the birth dose provides a critical safeguard and prevents infection among infants born to HBsAg-positive mothers not identified prenatally. We assess infant HepB vaccination in the U.S. Department of Defense's Military Health System (MHS) to identify trends in vaccination coverage and sociodemographic factors associated with non-receipt of the birth dose, receiving the first HepB vaccine >3 days of life, and not receiving any HepB vaccine in the first 18 months of life utilizing parental refusal codes. To our knowledge, this is one of the first studies assessing trends in parental refusal of the HepB birth dose utilizing administrative claims parental refusal codes. METHODS: We conducted a retrospective cohort analysis of MHS live births from January 1, 2014 through December 31, 2018 utilizing administrative claims data. Data were included from 44 hospitals in 24 unique states, territories, or countries. We analyzed diagnosis codes for vaccine refusal and vaccination and current procedural terminology (CPT) codes to identify vaccination patterns. Generalized linear mixed effects models with a logit link were used to assess factors associated with vaccination patterns. RESULTS: HepB birth dose vaccination coverage increased from 79.6% in 2014 to 88.1% in 2018 (p < .0001). Refusal rates also increased from 3.7% in 2014 to 4.5% in 2018 (p < .0001). The percentage of patients with missing diagnosis codes for vaccine refusal or vaccination decreased from 16.7% in 2014 to 7.4% in 2018. Factors associated with non-receipt of the birth dose included earlier year of birth, white maternal race, higher maternal age, higher birth order, and longer infant length of stay in hospital. CONCLUSION: Vaccination coverage for HepB birth dose is high in the MHS and increased over time; concurrently, refusal rates also increased over time. Utilizing administrative claims data has the benefit of differentiating reasons for non-receipt of the birth dose over time.

Latent Class Analysis to Represent Social Determinant of Health Risk Groups in the Medicaid Cohort of the District of Columbia.

OBJECTIVE: To develop distinct social risk profiles based on social determinants of health (SDH) information and to determine whether these social risk groups varied in terms of health, health care utilization, and costs. METHODS: We prospectively enrolled 8943 beneficiaries insured by the District of Columbia Medicaid program between September 2017 and December 2018. Participants completed a SDH survey and we obtained their Medicaid claims data for a 2-year period before study enrollment. We used latent class analysis (LCA) to identify distinct social risk profiles based on their SDH responses. We assessed the relationship among different SDH as well as the relationship among the social risk classes and health, health care use and costs. RESULTS: The majority of SDH were moderately to strongly correlated with one another. LCA yielded 4 distinct social risk groups. Group 1 reported the least social risks with the most employed. Group 2 was distinguished by financial strain and housing instability with fewer employed. Group 3 were mostly unemployed with limited car and internet access. Group 4 had the most social risks and most unemployed. The social risk groups demonstrated meaningful differences in health, acute care utilization, and health care costs with group 1 having the best health outcomes and group 4 the worst (P<0.05). CONCLUSIONS: LCA is a practical method of aggregating correlated SDH data into a finite number of distinct social risk groups. Understanding the constellation of social challenges that patients face is critical when attempting to address their social needs and improve health outcomes.

Determinants of concussion diagnosis, symptomology, and resolution time in U.S. high school soccer players.

Determinants of concussion diagnosis, symptomology, and other sequelae have not been examined in high school soccer players. Using a sample of soccer-related head/neck injuries from the NATION Surveillance Program, we evaluated potential determinants (sex, injury history, injury mechanism, setting) of concussion characteristics. A total of 378 head/neck injuries were recorded, and 189 (50.0%) injuries from this sample, resulted in a concussion diagnosis. Odds of concussion diagnosis were 84% higher among female players compared with their male counterparts, and over two-fold higher in game settings compared with practice settings. We also observed several significant symptom dependencies, such as higher odds of difficulty concentrating (OR = 5.84, 95% CI = [2.99, 11.42]) given concurrent light sensitivity. Furthermore, we identified injury mechanism as a determinant of concussion symptom resolution time. Our results suggest that determinants of soccer-related concussions and their sequelae are multifactorial, and extend the existing literature with the potential to inform clinical practice.

Maternal Serum Lipid Trajectories and Association with Pregnancy Loss and Length of Gestation.

OBJECTIVE: We characterized lipid trajectories and investigated lipids and rate of pregnancy lipid change with the risk of pregnancy loss or preterm delivery <37 weeks. STUDY DESIGN: In a secondary analysis of 337 women with one to two prior losses assigned to placebo in a randomized controlled trial at four centers (2007-2012), cholesterol, low- and high-density lipoprotein cholesterol (HDL-C), and triglycerides were measured up to 6 months prepregnancy (time 0) and pregnancy up to 7 visits. Trajectories were created using linear mixed models. Multivariable logistic regression with adjustment for maternal characteristics and cholesterol was performed. RESULTS: Lipids decreased from prepregnancy to 4 to 5 weeks, followed by an increase, and were biphasic or triphasic depending on the lipid component. Between 4 and 8 weeks, for every 1-unit increase in HDL-C, there was a 22% decreased odds of loss <14 weeks (odds ratio: 0.78; 95% confidence interval: 0.60, 0.99) and 24% decreased odds of loss or preterm delivery 14 to <37 weeks (odds ratio: 0.76; 95% confidence interval: 0.60, 0.96). CONCLUSION: There were no associations with other lipid components or other time points. An impaired rise of HDL-C early in pregnancy may signal maladaptation to pregnancy that is associated with pregnancy loss or preterm delivery.

Association between persistent endocrine-disrupting chemicals (PBDEs, OH-PBDEs, PCBs, and PFASs) and biomarkers of inflammation and cellular aging during pregnancy and postpartum.

BACKGROUND: Endocrine-disrupting chemicals (EDCs) can target immune and metabolic pathways. However, few epidemiologic studies have examined the influence of EDCs on measures of inflammation and cellular aging during pregnancy and postpartum. OBJECTIVE: We investigated associations between prenatal exposures to polybrominated diphenyl ethers (PBDEs), hydroxylated PBDE metabolites (OH-PBDEs), polychlorinated biphenyls (PCBs), and per- and polyfluorochemicals (PFASs) with repeated biomarker measurements of inflammation and cellular aging in women during pregnancy and the postpartum period. METHODOLOGY: Overweight or obese pregnant women were recruited from the San Francisco Bay area (n = 103) during their first or second trimester of pregnancy. Blood samples were collected from participants at baseline (median 16 weeks gestation) and at three and nine months postpartum. Serum concentrations of PBDEs, OH-PBDEs, PCBs, and PFASs were measured at baseline. Inflammation biomarkers (interleukin 6 [IL-6], interleukin 10 [IL-10], and tumor necrosis factor [TNF-α]) and leukocyte telomere length (LTL), a biomarker of cellular aging, were measured at all three time points. Associations between serum chemical concentrations and repeated measures of IL-6, IL-10, TNF-α, and LTL were examined using linear mixed models. We also examined the potential for effect modification by time (visit) and obesity. RESULTS: In adjusted models, we observed positive relationships between PBDEs and pro-inflammatory cytokines (IL-6 and TNF-α). A doubling in ∑PBDEs was associated with a 15.26% (95% CI 1.24, 31.22) and 3.74% (95% CI -0.19, 7.82) increase in IL-6 and TNF-α, respectively. Positive associations were also observed for PFASs and IL-6. A two-fold increase in ∑PFASs was associated with a 20.87% (95% CI 3.46, 41.22) increase in IL-6. 5-OHBDE-47 was inversely associated with anti-inflammatory cytokine IL-10. Some EDC-outcome associations, including those of PBDEs with TNF-α, were stronger during pregnancy (compared to three or nine months postpartum) and among obese (compared to overweight) women (p-interaction <0.05). CONCLUSIONS: These findings suggest that exposure to specific EDCs is associated with increased inflammation among women during pregnancy and the postpartum period. Future studies should replicate these findings in additional study populations and examine the implications of these associations for maternal and child health.

An approximate joint model for multiple paired longitudinal outcomes and time-to-event data.

Joint modeling of multivariate paired longitudinal data and time-to-event data presents computational challenges that supersede full likelihood estimation due to the large dimensional random effects vector needed to capture correlation due to clustering with respect to pairs, subjects, and outcomes. We propose an alternative, computationally simpler approach to estimation of complex shared parameter models where missing data is imputed based on the Posterior Predictive Distribution from a Conditional Linear Model (CLM) approximation. Existing methods for complete data are then implemented to obtain estimates of the event time model parameters. Our method is applied to examine the effects of discordant growth in anthropometric measures of longitudinal fetal growth in twin fetuses and the timing of birth. Simulation results are presented to show that our method performs relatively well with moderate measurement errors under certain CLM approximations.

Left ventricular assist device outcomes based on flow configuration and pre-operative left ventricular dimension: An Interagency Registry for Mechanically Assisted Circulatory Support Analysis.

BACKGROUND: Axial configuration (AC) and centrifugal configuration (CC) left ventricular assist devices (LVAD) have different flow characteristics, and whether the interaction between device flow configuration and the pre-operative left ventricular internal diastolic diameter (LVIDD) mediates adverse events after LVAD implantation is unknown. METHODS: We queried 9,424 continuous-flow LVAD recipients who received LVADs from April 2008 to June of 2015 in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). The pre-operative LVIDD * flow configuration interaction term was tested in multivariable models to determine its relationship to adverse events. RESULTS: The pre-operative LVIDD * flow configuration interaction was a significant predictor of device thrombosis. As the LVIDD increased, the risk of AC device thrombosis increased compared with CC devices (p = 0.0099). At 7.0 cm, the hazard ratio (HR) for AC device thrombosis compared with the CC device was 1.61 (95% confidence interval [CI], 1.17-2.22; p = 0.004) and continued to rise as the LVIDD increased. The LVIDD * flow configuration interaction did not predict stroke, gastrointestinal bleeding, or patient survival. In multivariable models, the hazard of stroke was higher with the CC device regardless of the LVIDD (HR, 1.96; 95% CI, 1.64-2.36; p < 0.0001). Adjusted analyses showed LVAD implantation into a larger left ventricle was associated with a lower risk of death (HR, 0.90; 95% CI, 0.85-0.95; p = 0.0004) per centimeter of LVIDD. CONCLUSIONS: Our study suggests that the pre-operative LVIDD, flow configuration, and interaction terms should be considered individually when choosing the appropriate LVAD to mitigate the rates of device thrombosis, stroke, and death.

Consumer Product Chemicals in Indoor Dust: A Quantitative Meta-analysis of U.S. Studies.

Indoor dust is a reservoir for commercial consumer product chemicals, including many compounds with known or suspected health effects. However, most dust exposure studies measure few chemicals in small samples. We systematically searched the U.S. indoor dust literature on phthalates, replacement flame retardants (RFRs), perfluoroalkyl substances (PFASs), synthetic fragrances, and environmental phenols and estimated pooled geometric means (GMs) and 95% confidence intervals for 45 chemicals measured in ≥3 data sets. In order to rank and contextualize these results, we used the pooled GMs to calculate residential intake from dust ingestion, inhalation, and dermal uptake from air, and then identified hazard traits from the Safer Consumer Products Candidate Chemical List. Our results indicate that U.S. indoor dust consistently contains chemicals from multiple classes. Phthalates occurred in the highest concentrations, followed by phenols, RFRs, fragrance, and PFASs. Several phthalates and RFRs had the highest residential intakes. We also found that many chemicals in dust share hazard traits such as reproductive and endocrine toxicity. We offer recommendations to maximize comparability of studies and advance indoor exposure science. This information is critical in shaping future exposure and health studies, especially related to cumulative exposures, and in providing evidence for intervention development and public policy.

Risk Factors for Melanoma Among Survivors of Non-Hodgkin Lymphoma.

PURPOSE: Previous studies have reported that survivors of non-Hodgkin lymphoma (NHL) have an increased risk of developing cutaneous melanoma; however, risks associated with specific treatments and immune-related risk factors have not been quantified. PATIENTS AND METHODS: We evaluated second melanoma risk among 44,870 1-year survivors of first primary NHL diagnosed at age 66 to 83 years from 1992 to 2009 and included in the Surveillance, Epidemiology, and End Results-Medicare database. Information on NHL treatments, autoimmune diseases, and infections was derived from Medicare claims. RESULTS: A total of 202 second melanoma cases occurred among survivors of NHL, including 91 after chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and 111 after other NHL subtypes (cumulative incidence by age 85 years: CLL/SLL, 1.37%; other NHL subtypes, 0.78%). Melanoma risk after CLL/SLL was significantly increased among patients who received infused fludarabine-containing chemotherapy with or without rituximab (n=18: hazard ratio [HR], 1.92; 95% CI, 1.09 to 3.40; n=10: HR, 2.92; 95% CI, 1.42 to 6.01, respectively). Significantly elevated risks also were associated with T-cell activating autoimmune diseases diagnosed before CLL/SLL (n=36: HR, 2.27; 95% CI, 1.34 to 3.84) or after CLL/SLL (n=49: HR, 2.92; 95% CI, 1.66 to 5.12). In contrast, among patients with other NHL subtypes, melanoma risk was not associated with specific treatments or with T-cell/B-cell immune conditions. Generally, infections were not associated with melanoma risk, except for urinary tract infections (CLL/SLL), localized scleroderma, pneumonia, and gastrohepatic infections (other NHLs). CONCLUSION: Our findings suggest immune perturbation may contribute to the development of melanoma after CLL/SLL. Increased vigilance is warranted among survivors of NHL to maximize opportunities for early detection of melanoma.