The Influence of Social Determinants on Receiving Outpatient Treatment with Monoclonal Antibodies, Disease Risk, and Effectiveness for COVID-19.

BACKGROUND: Limited research has studied the influence of social determinants of health (SDoH) on the receipt, disease risk, and subsequent effectiveness of neutralizing monoclonal antibodies (nMAbs) for outpatient treatment of COVID-19. OBJECTIVE: To examine the influence of SDoH variables on receiving nMAb treatments and the risk of a poor COVID-19 outcome, as well as nMAb treatment effectiveness across SDoH subgroups. DESIGN: Retrospective observational study utilizing electronic health record data from four health systems. SDoH variables analyzed included race, ethnicity, insurance, marital status, Area Deprivation Index, and population density. PARTICIPANTS: COVID-19 patients who met at least one emergency use authorization criterion for nMAb treatment. MAIN MEASURE: We used binary logistic regression to examine the influence of SDoH variables on receiving nMAb treatments and risk of a poor outcome from COVID-19 and marginal structural models to study treatment effectiveness. RESULTS: The study population included 25,241 (15.1%) nMAb-treated and 141,942 (84.9%) non-treated patients. Black or African American patients were less likely to receive treatment than white non-Hispanic patients (adjusted odds ratio (OR) = 0.86; 95% CI = 0.82-0.91). Patients who were on Medicaid, divorced or widowed, living in rural areas, or living in areas with the highest Area Deprivation Index (most vulnerable) had lower odds of receiving nMAb treatment, but a higher risk of a poor outcome. For example, compared to patients on private insurance, Medicaid patients had 0.89 (95% CI = 0.84-0.93) times the odds of receiving nMAb treatment, but 1.18 (95% CI = 1.13-1.24) times the odds of a poor COVID-19 outcome. Age, comorbidities, and COVID-19 vaccination status had a stronger influence on risk of a poor outcome than SDoH variables. nMAb treatment benefited all SDoH subgroups with lower rates of 14-day hospitalization and 30-day mortality. CONCLUSION: Disparities existed in receiving nMAbs within SDoH subgroups despite the benefit of treatment across subgroups.

Neutralizing Monoclonal Antibody Use and COVID-19 Infection Outcomes.

Importance: Evidence on the effectiveness and safety of COVID-19 therapies across a diverse population with varied risk factors is needed to inform clinical practice. Objective: To assess the safety of neutralizing monoclonal antibodies (nMAbs) for the treatment of COVID-19 and their association with adverse outcomes. Design, Setting, and Participants: This retrospective cohort study included 167 183 patients from a consortium of 4 health care systems based in California, Minnesota, Texas, and Utah. The study included nonhospitalized patients 12 years and older with a positive COVID-19 laboratory test collected between November 9, 2020, and January 31, 2022, who met at least 1 emergency use authorization criterion for risk of a poor outcome. Exposure: Four nMAb products (bamlanivimab, bamlanivimab-etesevimab, casirivimab-imdevimab, and sotrovimab) administered in the outpatient setting. Main Outcomes and Measures: Clinical and SARS-CoV-2 genomic sequence data and propensity-adjusted marginal structural models were used to assess the association between treatment with nMAbs and 4 outcomes: all-cause emergency department (ED) visits, hospitalization, death, and a composite of hospitalization or death within 14 days and 30 days of the index date (defined as the date of the first positive COVID-19 test or the date of referral). Patient index dates were categorized into 4 variant epochs: pre-Delta (November 9, 2020, to June 30, 2021), Delta (July 1 to November 30, 2021), Delta and Omicron BA.1 (December 1 to 31, 2021), and Omicron BA.1 (January 1 to 31, 2022). Results: Among 167 183 patients, the mean (SD) age was 47.0 (18.5) years; 95 669 patients (57.2%) were female at birth, 139 379 (83.4%) were White, and 138 900 (83.1%) were non-Hispanic. A total of 25 241 patients received treatment with nMAbs. Treatment with nMAbs was associated with lower odds of ED visits within 14 days (odds ratio [OR], 0.76; 95% CI, 0.68-0.85), hospitalization within 14 days (OR, 0.52; 95% CI, 0.45-0.59), and death within 30 days (OR, 0.14; 95% CI, 0.10-0.20). The association between nMAbs and reduced risk of hospitalization was stronger in unvaccinated patients (14-day hospitalization: OR, 0.51; 95% CI, 0.44-0.59), and the associations with hospitalization and death were stronger in immunocompromised patients (hospitalization within 14 days: OR, 0.31 [95% CI, 0.24-0.41]; death within 30 days: OR, 0.13 [95% CI, 0.06-0.27]). The strength of associations of nMAbs increased incrementally among patients with a greater probability of poor outcomes; for example, the ORs for hospitalization within 14 days were 0.58 (95% CI, 0.48-0.72) among those in the third (moderate) risk stratum and 0.41 (95% CI, 0.32-0.53) among those in the fifth (highest) risk stratum. The association of nMAb treatment with reduced risk of hospitalizations within 14 days was strongest during the Delta variant epoch (OR, 0.37; 95% CI, 0.31-0.43) but not during the Omicron BA.1 epoch (OR, 1.29; 95% CI, 0.68-2.47). These findings were corroborated in the subset of patients with viral genomic data. Treatment with nMAbs was associated with a significant mortality benefit in all variant epochs (pre-Delta: OR, 0.16 [95% CI, 0.08-0.33]; Delta: OR, 0.14 [95% CI, 0.09-0.22]; Delta and Omicron BA.1: OR, 0.10 [95% CI, 0.03-0.35]; and Omicron BA.1: OR, 0.13 [95% CI, 0.02-0.93]). Potential adverse drug events were identified in 38 treated patients (0.2%). Conclusions and Relevance: In this study, nMAb treatment for COVID-19 was safe and associated with reductions in ED visits, hospitalization, and death, although it was not associated with reduced risk of hospitalization during the Omicron BA.1 epoch. These findings suggest that targeted risk stratification strategies may help optimize future nMAb treatment decisions.

The effect of time to amputation on medical costs accrued during the first twelve months after injury-A California workers' compensation claims study.

BACKGROUND: This study investigated whether the time to amputation (TtoA) after a work-related injury had a significant effect on the medical costs accrued in the first year after injury. DATA SOURCE: Six thousand nine hundred fifty-three person-level workers' compensation claims data from the state of California, USA, from 2007 to 2018. METHODS: Multiple quantile regression was used to assess the impact of TtoA on medical costs accrued during the first 12 months after injury. Three time intervals for TtoA were investigated: immediate (0, 1 days), short-delay (2-31 days), and long-delay (>31 days). RESULTS: The median (interquartile range) medical dollars paid per claim during the first 12 months for the study population was $12,414 ($6,324-$29,347). Amputations that occurred during the short-delay time interval resulted in significant ( p < 0.001) median (95% CI) savings of -$3,196 (-$3,968 to -$2,424) compared with the immediate amputation group. The long-delay time interval resulted in significantly ( p < 0.001) increased median (95% CI) spending of $5,613 ($4,675-$6,551) compared with the immediate amputation group. Covariates that significantly increased costs were medical intensity, medical complexity, use of a prosthesis, and if the injured worker pursued legal action in addition to a workers' compensation claim. CONCLUSIONS: This study presents the impact of TtoA on medical spending in the first year after a work-related injury that results in an amputation. Amputations that occurred within the first month after an injury resulted in reduced medical spending compared with immediate amputations, and amputations that occurred after the first month resulted in increased medical spending.

Occupational posttraumatic stress disorder and workplace violence in workers' compensation claims.

Acts of violence are the fifth leading cause of nonfatal occupational injuries in the United States. Experiencing a traumatic event at work can have serious mental health consequences, including the development of posttraumatic stress disorder (PTSD). This study aimed to quantify the prevalence of PTSD caused by workplace violence (WPV) in a statewide workers' compensation system and compare the outcomes and treatment of WPV cases versus those caused by other traumatic events. Using a retrospective cohort study design, workers who reported PTSD as the primary reason for a workers' compensation claim and had no coexisting physical injuries were found in California during 2009-2018. A total of 3,772 PTSD cases were identified, 48.9% of which were attributed to WPV. Demographic risk factors associated with WPV PTSD included lower income, younger age, female gender, and employment in retail or finance, p < .001-p = .007. For individuals who returned to work, claims due to WPV resulted in longer medically approved time away from work than non-WPV causes (Mdn = 132.5 days vs. Mdn = 91 days, respectively), p < .001. Three of the top 10 most frequently prescribed medications were administered against evidence-based guidelines. This study found that many treatments prescribed to PTSD patients are based on insufficient evidence, and the provision of existing empirically supported treatments is needed, particularly in generalized populations. The findings support the need for additional recognition of the cause of workplace PTSD to facilitate appropriate referrals to WPV or PTSD specialists to support return-to-work efforts.

Managing work disability to help patients return to the job.

Improving the timeliness and quality of your guidance on work disability lessens the impact of health problems on patients' lives and livelihoods.

Trends in incidence and correlation between medical costs and lost workdays for work-related amputations in the State of California from 2007 to 2018.

BACKGROUND: Detailed information regarding workers who experience an amputation in the workplace over the last decade is limited. To better understand the financial and functional impact of a work-related amputation, this study quantifies the incidence of work-related amputations in the California workforce from 2007 to 2018 as well as the relationship between medical costs and lost workdays as a function of amputation level. METHODS: Workers' compensation claims data from California spanning the years 2007 to 2018 were evaluated to describe trends in amputation incidence (N = 16 931). Quartile values for medical costs, indemnity costs, and lost workdays were reported as a function of amputation level. Correlations were performed between medical costs and lost workdays to examine their relationship. RESULTS: The average incidence from 2007 to 2018 was 8.9 (95% CI 8.5, 9.4) amputations per 100 000 workers. There was a significant spike in amputations in 2008. Partial-hand amputations were the most common with 73.3 (95% CI 69.2, 77.7) cases per 1 000 000 workers, and the industry with the highest incidence was construction with 26.0 (95% CI 22.4, 30.0) cases per 100 000 workers. Overall, medical costs were moderately correlated with lost workdays (Spearman's rho = 0.51), and that level of correlation remained relatively consistent across all levels of amputation (Spearman's rho = 0.48-0.62). CONCLUSIONS: Amputations represent high medical costs and number of lost workdays. Considering the type of amputation and the industry the injury occurred in is important in order to work toward returning this population to work. Our results present the status of amputations in the California workplace and establish a basis for using medical costs to infer lost work productivity for this population.

Occupational injuries in California's health care and social assistance industry, 2009 to 2018.

BACKGROUND AND AIM: The health care and social assistance industry has one of the highest rates of non-fatal occupational injuries and illnesses, both in California and nationally. In the coming years, the health care industry will face added pressure as both the population and workforce age. The aim of this study is to identify targeted populations that may benefit from interventions to prevent future injuries, keep the workforce healthy, and decrease injury-related costs. METHODS: This retrospective study analyzed California workers' compensation claims from 2009 to 2018 in the health care and social assistance industry. RESULTS: Across the four industry sub-groups, the highest number of claims came from hospitals (n = 243 605; 38.9%), followed by ambulatory care (n = 187 010; 29.9%), nursing/residential care (n = 133 206; 21.3%), and social assistance (n = 62 211; 9.9%). Nursing/residential care settings reported the highest proportion of both lifting injuries (15.8%) and low back injuries (16.9%) as compared to the other settings. Across all settings within California, nurses had the highest proportion of injuries (22.1%), followed by aides/assistants (20.4%), services staff (13.2%), administrative staff (11.0%), and technicians (10.3%). Thirty-five of California's counties had an increasing rate of population-adjusted claims during the study period. CONCLUSION: This study found that while hospitals have the highest number of injuries, ambulatory care employee injuries are increasing. Employees involved in non-patient care tasks, such as those working in facility service roles, would likely benefit from additional injury prevention interventions.

Guideline adherence and lost workdays for acute low back pain in the California workers' compensation system.

CONTEXT: The use of clinical-practice guidelines is a suggested method for improving health outcomes by the earlier provision of necessary and effective medical interventions. OBJECTIVE: To quantify the influence of adherence to guideline-recommended interventions in the first week of treatment for an initial low back pain (LBP) injury on lost workdays. METHODS: In a retrospective cohort of California's workers' compensation claims data from May 2009 to May 2018, 41 diagnostic and treatment interventions were abstracted from the medical claims for workers with acute LBP injuries and compared with guideline recommendations. Lost workdays within 1-year post-injury were compared by guideline adherence using quantile regressions. RESULTS: Of the 59,656 workers who met the study inclusion criteria, 66.1% were male and the average (SD) age was 41 (12) years. The median number (IQR) of lost workdays was 27 (6-146) days. In the first week of treatment, 14.2% of workers received only recommended interventions, 14.6% received only non-recommended interventions, and 51.1% received both recommended and non-recommended interventions. Opioid prescriptions fell 86% from 2009 to 2018. Workers who received only guideline-recommended interventions experienced significantly fewer lost workdays (11.5 days; 95% CI: -13.9, -9.1), a 29.3% reduction, than workers who received only non-recommended interventions. The percentage of workers receiving only recommended interventions increased from 10.3% to 18.2% over the 9 years. CONCLUSION AND RELEVANCE: When workers received guideline-recommended interventions, they typically returned to work in fewer days. The majority of workers received at least one non-recommended intervention, demonstrating the need for adherence to guideline recommendations. Fewer lost workdays and improved quality care are outcomes that strongly benefit injured workers.

Pre-Existing and New-Onset Depression and Anxiety Among Workers With Injury or Illness Work Leaves.

OBJECTIVES: To examine the influence of depression and/or anxiety on work leaves and the impact of work leaves on experiencing a new-onset depression and/or anxiety disorder. METHODS: IBM's MarketScan® research databases were linked to investigate depressive and anxiety disorders in workers with a work leave due to an injury or non-mental health illness (n = 467,930) and without a work leave (n = 2,764,447). RESULTS: The odds of a work leave within a year were 2.10 times higher (95%CI: 2.08-2.13) in individuals with depression and/or anxiety compared to those without. The odds of developing a new-onset depression and/or anxiety within a year was 4.21 times higher (95% CI: 4.14-4.27) in individuals with a work leave compared to those without. CONCLUSION: Depression and anxiety are both risk factors for and subsequent outcomes of injuries or illnesses that require a work leave.

Using low cost open-face passive samplers to sample PM concentration and elemental composition in childcare facilities.

Effective, low noise and low-cost samplers for airborne particulate matter (PM) in indoor environments are needed. In 15 northern California childcare facilities, we deployed open-faced polycarbonate substrate passive aerosol samplers and analyzed them using computer-controlled scanning electron microscopy to measure indoor PM particle size, number, and elemental concentration. Particle concentrations were compared to PM concentrations measured by filter-based active samplers. The PM mass concentrations measured after open-faced passive sampling were in good agreement with the PM concentrations obtained using co-located active samplers. The measured PM2.5 concentrations inside of the childcare facilities were in the range of 6-31 µg m-3, while the PM10 concentrations were in the range of 17-96 µg m-3. For PM10, 93.3% of the passive sampler results were within ±30% of those determined with the active sampler, and 67% of the PM2.5 results fell within ±30% of the active sampler measurements. The Pearson's correlation coefficient between PM mass concentrations estimated from the open-faced passive aerosol sampler (OPS) versus gravimetric (active sampler) methods was 0.77 for PM2.5 and 0.95 for PM10, respectively, indicating a strong correlation between the passive and active sampler results. PM and elemental composition varied by facility location and interior characteristics of the childcare facilities such as floor type, presence of combustion sources, occupant density, and the level of activity. The rich carbon content in the polycarbonate substrate produced positive bias in the carbon concentration analysis. Based on the carbon concentration, determined using a copper substrate, a correction factor was needed to determine the total carbon concentrations in the sampled PM for the polycarbonate substrate passive sampler. Overall, the results demonstrated that the OPS collected enough aerosol particles in one business day (6-8 hours) to assess PM levels.

The influence of antidepressant and psychotherapy treatment adherence on future work leaves for patients with major depressive disorder.

BACKGROUND: Depression is the greatest contributor to worldwide disability. The purpose of this study was to understand the influence of antidepressant and psychotherapy treatment adherence on future work leaves for patients with major depressive disorder. METHODS: Patients with a newly diagnosed major depressive disorder (n = 26,256) were identified in IBM® Watson™ MarketScan® medical and disability claims databases. Antidepressant and psychotherapy adherence metrics were evaluated in the acute phase of treatment, defined as the 114 days following the depression diagnosis. Multiple variable Cox proportional hazards regression models evaluated the influence of antidepressant and/or psychotherapy adherence on future injury or illness work leaves. RESULTS: The majority of work leaves in the 2-year follow-up period occurred in the acute phase of treatment (71.2%). Among patients without a work leave in the acute phase and who received antidepressants and/or psychotherapy (n = 19,994), those who were adherent to antidepressant or psychotherapy treatment in the acute phase had a 16% (HR = 0.84, 95% CI = 0.77-0.91) reduced risk of a future work leave compared to treatment non-adherent patients. Patients who were non-adherent or adherent to antidepressant treatment had a 22% (HR = 1.22, 95% CI = 1.11-1.35) and 13% (HR = 1.13, 95% CI = 1.01-1.27) greater risk of a future work leave, respectively, than patients not receiving antidepressant treatment. Conversely, patients who were non-adherent or adherent to psychotherapy treatment had a 9% (HR = 0.91, 95% CI = 0.81-1.02) and 28% (HR = 0.72, 95% CI = 0.64-0.82) reduced risk of a future work leave, respectively, than patients not receiving psychotherapy treatment. CONCLUSIONS: This analysis suggests that treatment adherence may reduce the likelihood of a future work leave for patients with newly diagnosed major depressive disorder. Psychotherapy appears more effective than antidepressants in reducing the risk of a future work leave.

Rates and Determinants of Use of Pharmacotherapy and Psychotherapy by Patients With Major Depressive Disorder.

OBJECTIVE: Rates and determinants of pharmacological and psychotherapy use were assessed after a major depressive disorder diagnosis. METHODS: In a retrospective claims study that included 2007-2016 records from the IBM MarketScan research databases, use of pharmacotherapy and psychotherapy was tracked in a population of 24,579 patients with a diagnosis of major depressive disorder. Univariate and multiple variable analyses were used to identify determinants of antidepressant adherence (proportion of days covered ≥.8) and intensive psychotherapy at the beginning of treatment (at least four psychotherapy visits in the first 4 weeks after initiating psychotherapy). RESULTS: In the 12 months following a diagnosis of major depressive disorder, most individuals received pharmacotherapy or psychotherapy (94.7%), and unimodal therapy was more common (58.5%) than bimodal therapy (36.2%). When antidepressants were initiated (N=13,524), 41.7% and 32.0% of patients were adherent in the acute and continuation phases, respectively. Initial antidepressant dosages were outside guideline recommendations for 34.5% of patients prescribed these medications. When psychotherapy was initiated, the median number of visits in the year after a patient's diagnosis was seven. Most patients (54.7%) did not continue to receive either antidepressant or psychotherapy treatment after month 5 following their diagnosis. A shorter time from diagnosis to treatment and a lower percentage of treatment costs paid by the patient were associated with increased antidepressant adherence and intensive psychotherapy use. CONCLUSIONS: Findings indicate that treatment guideline recommendations are not followed for a large proportion of patients with major depressive disorder and that improvement is needed in multiple areas to enhance effective treatment.

Associations of Maternal Exposure to Dichlorodiphenyltrichloroethane and Pyrethroids With Birth Outcomes Among Participants in the Venda Health Examination of Mothers, Babies and Their Environment Residing in an Area Sprayed for Malaria Control.

Although effective in controlling malaria, indoor residual spraying results in elevated exposure to insecticides such as dichlorodiphenyltrichloroethane (DDT) and pyrethroids. These chemicals cross the placenta, but no studies have examined their associations with birth outcomes in populations residing in indoor residual spraying areas. We investigated this question in the Venda Health Examination of Mothers, Babies and Their Environment (VHEMBE), a birth cohort study of 751 South African children born between 2012 and 2013. We measured maternal peripartum serum DDT and urine pyrethroid metabolite concentrations and collected data on birth weight, length, head circumference, and duration of gestation. We analyzed the data using marginal structural models with inverse-probability-of-treatment weights, generalized propensity scores, and standard conditional linear regression. Using all 3 analytical methods, p,p'-DDT, o,p'-DDT, and to a lesser extent p,p'-dichlorodiphenyldichloroethylene were related to elevated birth weight, birth length, and head circumference among girls. Changes in gestational duration did not mediate this relationship, suggesting that these exposures accelerate fetal growth, which is consistent with the known estrogenic properties of o,p'-DDT and p,p'-DDT. No associations with pyrethroid metabolites were found. Results suggest that prenatal exposure to DDT is related to elevated birth size. Further studies are needed to elucidate the implications of these findings.

Rates and predictors of recurrent work disability due to common mental health disorders in the United States.

CONTEXT: Despite the high prevalence of work disability due to common mental disorders (CMD), no information exists on the rates and predictors of recurrence in a United States population. OBJECTIVE: To estimate recurrent work disability statistics and evaluate factors associated with recurrence due to CMDs including adjustment, anxiety, bipolar, and depressive disorders. METHODS: Recurrent work disability statistics were calculated using a nationwide database of disability claims. For the CMDs, univariate and multiple variable analyses were used to examine demographic factors and comorbidities associated with the time to recurrence. RESULTS: Of the CMDs, cases with bipolar (n = 3,017) and depressive disorders (n = 20,058) had the highest recurrence densities, 98.7 and 70.9 per 1000 person-years, respectively. These rates were more than three times higher than recurrence rates for other chronic disorders (e.g., diabetes, asthma; n = 105,558) and non-chronic disorders (e.g., injury, acute illnesses; n = 153,786). Individuals with CMD were also more likely to have a subsequent disability distinct from their mental health condition. Risk factors for recurrent CMD disability included being younger, being an hourly employee, living in a geographic area with more college graduates, having more previous psychiatric visits, having a previous work leave, and the type of work industry. CONCLUSIONS: Results indicate that CMD patients may benefit from additional care and disability management both during and after their work absence to help prevent subsequent CMD and non-CMD related leaves.

Health Care Expenditures and Length of Disability Across Medical Conditions.

OBJECTIVE: To describe the relationship between the length of short-term disability (STD) and health care spending. METHODS: Medical claims for insured US employees on STD were evaluated to describe the distribution of disability durations and health expenditures across major diagnostic categories and common medical conditions. Correlations between health expenditures and disability durations were examined. RESULTS: The most expensive 10% of cases accounted for more than half of total health spending. The longest 10% of cases accounted for more than one-third of total disability time. Only one-third of the most expensive cases were also among the longest in duration. Disability durations were moderately correlated with medical spending and this relationship was modified by comorbid conditions and age. CONCLUSION: Psychosocial barriers, in addition to biomedical factors, should be considered to achieve optimal functional outcomes and well-being of patients.

Exposure to DDT and hypertensive disorders of pregnancy among South African women from an indoor residual spraying region: The VHEMBE study.

Indoor Residual Spraying (IRS), the use of insecticides inside residences for malaria control, may cause elevated exposure to insecticides such as dichlorodiphenyl trichloroethane (DDT). Evidence suggests that DDT exposure may increase blood pressure but no study has investigated associations with hypertensive disorders of pregnancy (HDP) in an IRS area. We measured the serum concentration of DDT and its breakdown product dichlorodiphenyl trichloroethylene (DDE) at the time of delivery among 733 rural South African women participating in the Venda Health Examination of Mothers, Babies and their Environment (VHEMBE). We also collected data on HDP diagnosis through questionnaires administered to participants and medical record abstraction. We used multiple logistic regression models to examine the relation between DDT/E and HDP. p,p'-DDT and p,p'-DDE serum concentrations were associated with HDP based on self-report (OR = 1.50; 95%CI = 1.10, 2.03 for p,p'-DDT and OR = 1.58; 95%CI = 1.09, 2.28 for p,p'-DDE) and medical records (OR = 1.32; 95%CI = 0.99, 1.75 for p,p'-DDT and OR = 1.47; 95%CI = 1.03, 2.09 for p,p'-DDE). p,p'-DDE was also associated with gestational hypertension (OR = 1.44; 95% CI = 1.00, 2.07). Exposure to DDT and DDE may be associated with elevated risks of HDP in South African women residing in an area sprayed for malaria control.

The Impact of the Glomerular Filtration Rate on the Human Plasma Proteome.

PURPOSE: The application of proteomics in chronic kidney disease (CKD) can potentially uncover biomarkers and pathways that are predictive of disease. EXPERIMENTAL DESIGN: Within this context, this study examines the relationship between the human plasma proteome and glomerular filtration rate (GFR) as measured by iohexol clearance in a cohort from Sweden (n = 389; GFR range: 8-100 mL min-1 /1.73 m2 ). A total of 2893 proteins are quantified using a modified aptamer assay. RESULTS: A large proportion of the proteome is associated with GFR, reinforcing the concept that CKD affects multiple physiological systems (individual protein-GFR correlations listed here). Of these, cystatin C shows the most significant correlation with GFR (rho = -0.85, p = 1.2 × 10-97 ), establishing strong validation for the use of this biomarker in CKD diagnostics. Among the other highly significant protein markers are insulin-like growth factor-binding protein 6, neuroblastoma suppressor of tumorigenicity 1, follistatin-related protein 3, trefoil factor 3, and beta-2 microglobulin. These proteins may indicate an imbalance in homeostasis across a variety of cellular processes, which may be underlying renal dysfunction. CONCLUSIONS AND CLINICAL RELEVANCE: Overall, this study represents the most extensive characterization of the plasma proteome and its relation to GFR to date, and suggests the diagnostic and prognostic value of proteomics for CKD across all stages.

Reducing Disability Durations and Medical Costs for Patients With a Carpal Tunnel Release Surgery Through the Use of Opioid Prescribing Guidelines.

OBJECTIVE: The impacts of compliance with opioid prescribing guidelines on disability durations and medical costs for carpal tunnel release (CTR) were examined. METHODS: Using a dataset of insured US employees, opioid prescriptions for 7840 short-term disability cases with a CTR procedure were identified. Opioids prescriptions were compared with the American College of Occupational and Environmental Medicine (ACOEM)'s opioid prescribing guidelines for postoperative, acute pain, which recommends no more than a 5-day supply, a maximum morphine equivalent dose of 50 mg/day, and only short-acting opioids. RESULTS: Most cases (70%) were prescribed an opioid and 29% were prescribed an opioid contrary to ACOEM's guidelines. Cases prescribed an opioid contrary to guidelines had disability durations 1.9 days longer and medical costs $422 higher than cases prescribed an opioid according to guidelines. CONCLUSIONS: The use of opioid prescribing guidelines may reduce CTR disability durations and medical costs.

Levels and Determinants of DDT and DDE Exposure in the VHEMBE Cohort.

BACKGROUND: Although indoor residual spraying (IRS) is an effective tool for malaria control, its use contributes to high insecticide exposure in sprayed communities and raises concerns about possible unintended health effects. OBJECTIVE: The Venda Health Examination of Mothers, Babies and their Environment (VHEMBE) is a birth cohort study initiated in 2012 to characterize prenatal exposure to IRS insecticides and exposures' impacts on child health and development in rural South Africa. METHODS: In this report, we describe the VHEMBE cohort and dichlorodiphenyltrichloroethane (DDT) and dichlorodiphenyldichloroethylene (DDE) serum concentrations measured in VHEMBE mothers when they presented for delivery. In addition, we applied a causal inference framework to estimate the potential reduction in population-level p,p'-DDT and p,p'-DDE serum concentrations under five hypothetical interventions. A total of 751 mothers were enrolled. RESULTS: Serum concentrations of p,p' isomers of DDT and DDE were above the limit of detection (LOD) in ≥98% of the samples, whereas the o,p' isomers were above the LOD in at least 80% of the samples. Median (interquartile range) p,p'-DDT and p,p'-DDE serum concentrations for VHEMBE cohort participants were 55.3 (19.0-259.3) and 242.2 (91.8-878.7) ng/g-lipid, respectively. Mothers reporting to have lived in a home sprayed with DDT for malaria control had ~5-7 times higher p,p'-DDT and p,p'-DDE serum concentrations than those who never lived in a home sprayed with DDT. Of the five potential interventions tested, we found increasing access to water significantly reduced p,p'-DDT exposure and increasing the frequency of household wet mopping significantly reduced p,p'-DDT and p,p'-DDE exposure. CONCLUSION: Our findings suggest that several intervention approaches may reduce DDT/DDE exposure in pregnant women living in IRS communities. https://doi.org/10.1289/EHP353.

Corrigendum to "Undisturbed dust as a metric of long-term indoor insecticide exposure: Residential DDT contamination from indoor residual spraying and its association with serum levels in the VHEMBE cohort" [Environ. Int. 85C (2015) 163-167].

Although approximately 123 million people may be exposed to high levels of insecticides through the use of indoor residual spraying (IRS) for malaria control, few studies exist on indoor insecticide contamination due to IRS and its relationship with human exposure. In the present study, we developed a sampling method to collect undisturbed dust from 50 homes in Limpopo, South Africa, a region where dichlorodiphenyltrichloroethane (DDT) has been used in IRS programs to prevent malaria for ~70years. We quantified DDT and its degradation products, dichlorodiphenyldichloroethylene (DDE), and dichlorodiphenyldichloroethane (DDD) in dust samples to determine dust loading levels and compared these levels to paired serum concentrations of p,p'-DDT and p,p'-DDE in women residents. p,p'-DDT and p,p'-DDE had the highest detection frequencies in both dust (58% and 34% detection, respectively) and serum samples (100% detection). Significantly higher detection frequencies for o,p'-DDT, p,p'-DDE, and p,p'-DDD were observed in dust samples collected in buildings that had been previously sprayed for malaria control. We also observed a significant, positive association between dust loading and serum concentrations of p,p'-DDT and p,p'-DDE (Spearman's rho=0.68 and 0.54, respectively). Despite the low detection frequency in dust, our results indicate that undisturbed dust may be a good metric to quantify long-term home exposure to DDT-related compounds and that contamination of the home environment may be an important determinant/source of DDT and DDE exposure.