A Gene-Acculturation Study of Obesity Among US Hispanic/Latinos: The Hispanic Community Health Study/Study of Latinos.

OBJECTIVE: In the United States, Hispanic/Latino adults face a high burden of obesity; yet, not all individuals are equally affected, partly due in part to this ethnic group's marked sociocultural diversity. We sought to analyze the modification of body mass index (BMI) genetic effects in Hispanic/Latino adults by their level of acculturation, a complex biosocial phenomenon that remains understudied. METHODS: Among 11,747 Hispanic/Latinos adults in the Hispanic Community Health Study/Study of Latinos aged 18 to 76 years from four urban communities (2008-2011), we a) tested our hypothesis that the effect of a genetic risk score (GRS) for increased BMI may be exacerbated by higher levels of acculturation and b) examined if GRS acculturation interactions varied by gender or Hispanic/Latino background group. All genetic modeling controlled for relatedness, age, gender, principal components of ancestry, center, and complex study design within a generalized estimated equation framework. RESULTS: We observed a GRS increase of 0.34 kg/m 2 per risk allele in weighted mean BMI. The estimated main effect of GRS on BMI varied both across acculturation level and across gender. The difference between high and low acculturation ranged from 0.03 to 0.23 kg/m 2 per risk allele, but varied across acculturation measure and gender. CONCLUSIONS: These results suggest the presence of effect modification by acculturation, with stronger effects on BMI among highly acculturated individuals and female immigrants. Future studies of obesity in the Hispanic/Latino community should account for sociocultural environments and consider their intersection with gender to better target obesity interventions.

Evolution of healthcare costs for lower urinary tract symptoms associated with benign prostatic hyperplasia.

PURPOSE: With the ubiquity of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) in older men, costs related to this highly prevalent disease are likely significant but not well defined. With this study, we hoped to define costs related to LUTS/BPH care. METHODS: We utilized the Optum© de-identified Clinformatics® Data Mart Database (CDM) for privately insured male enrollees aged 40-64 years with LUTS/BPH (N ≈ 100,300 annually) and the Centers for Medicare and Medicaid Services Medicare 5% Sample for male beneficiaries aged 65 + years with LUTS/BPH (N ≈ 147,800 annually). Annual LUTS/BPH-related expenditures from 2004 to 2013 were age standardized and calculated overall and by age and service location. RESULTS: The Medicare cohort demonstrated a 23% increase in total costs over the study period with a 28% decrease in CDM costs. Decreases in inpatient hospital charges (45% for Medicare, 55% for CDM) were offset by increasing hospital-based outpatient fees (120% for Medicare, 87% for CDM). Overall, we estimated a total cost of at least $1.9 billion for treatment of men with LUTS/BPH for 2013. Per person expenditures increased with age within cohorts with an average per-person cost of $269 (CDM) and $248 (Medicare) in 2013. CONCLUSION: The distribution of healthcare expenditures for LUTS/BPH shifted across practice settings from 2004 to 2013, with increasing outpatient relative to inpatient expenditures. Total direct costs for LUTS/BPH in 2013 were at least $1.9 billion, not accounting for indirect costs or certain unmeasured populations.

Poor clinical guideline adherence and inappropriate testing for incident lower urinary tract symptoms associated with benign prostatic hyperplasia.

BACKGROUND: The American Urological Association makes recommendations for evaluation and testing for lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) to help primary care providers and specialists identify LUTS/BPH and harmful related conditions including urinary retention and prostate or bladder cancer. Our understanding of provider adherence to these Guidelines is limited to single-site or nonrepresentative settings. METHODS: We analyzed two insurance claims databases: the Optum® de-identified Clinformatics® Data Mart database for privately insured males aged 40-64 years (N ≈ 1,650,900 annually) and the Medicare 5% Sample for males aged ≥65 years (N ≈ 546,000 annually). We calculated the annual prevalence of LUTS/BPH and comorbid bladder cancer and bladder stones from 2004 to 2013. We additionally examined LUTS/BPH incidence and adherence to testing guidelines in a cohort of men newly diagnosed with LUTS/BPH in 2009. RESULTS: While LUTS/BPH prevalence and incidence increased with increasing age, evaluation testing became less common. Urinalysis was the most common testing type but was performed in <60% of incident patients. Serum prostate-specific antigen (PSA) was the second most common test across age groups (range: 15-34%). Prevalence of comorbid bladder cancer (range: 0-4%), but not bladder stones (range: 1-2%), increased with increasing age. CONCLUSIONS: Although older men were at greater risk of LUTS/BPH than younger men, they were less likely to undergo testing at diagnosis. Recommended testing with urinalysis was poor despite higher prevalence of bladder cancer in older men and a standard recommendation for urinalysis since 1994. Providers should be more cognizant of AUA Guidelines when assessing LUTS/BPH patients.

Intergenerational educational mobility and type 2 diabetes in the Sacramento Area Latino Study on Aging.

PURPOSE: United States (US) Latinos have the lowest educational attainment of any US racial/ethnic group, which may contribute to their disparate burden of Type 2 Diabetes. Herein, we aimed to examine the association between intergenerational educational mobility and Type 2 Diabetes among US Latino adults. METHODS: We used data from the Niños Lifestyle and Diabetes Study (2013-2014) and the Sacramento Area Latino Study on Aging (1998-1999) to link 616 adult Latino children to their parents. Model-based standardization and robust Poisson regression were used to estimate the prevalence of prediabetes, Type 2 Diabetes, treatment and glycemic control, and describe their associations with intergenerational educational mobility. RESULTS: Adult children with stable high intergenerational educational attainment had a higher prevalence of prediabetes (Prevalence Ratio, PR=1.58; 95% Confidence Interval, CI=1.08, 2.34) and lower prevalence of Type 2 Diabetes (PR=0.64, CI=0.41, 0.99), as compared to those who experienced low educational attainment across generations. Downward mobility was associated with a higher prevalence of prediabetes (PR=1.54, CI=1.06, 2.23) and worse glycemic control (PR=2.20, CI=1.13, 4.30), and upward mobility was associated with a lower prevalence of Type 2 Diabetes (PR=0.39, CI=0.22, 0.70). CONCLUSIONS: Our findings from a predominantly Mexican-heritage community suggest that higher education across generations may buffer individuals from glycemic dysregulation. As such, higher education may be a promising public health target to address the rising burden of Type 2 Diabetes in the US.

A prospective study of multiple sleep dimensions and hypertension risk among white, black and Hispanic/Latina women: findings from the Sister Study.

BACKGROUND: Poor sleep is associated with increased hypertension risk, but few studies have evaluated multiple sleep dimensions or investigated racial/ethnic disparities in this association among women. METHOD: We investigated multiple sleep dimensions (sleep duration, inconsistent weekly sleep patterns, sleep debt, frequent napping and difficulty falling or staying asleep) and hypertension risk among women, and determined modification by age, race/ethnicity and menopausal status. We used data from the Sister Study, a national cohort of 50 884 women who had sisters diagnosed with breast cancer in the United States enrolled in 2003-2009 and followed through September 2018. RESULTS: Of 33 497 women without diagnosed hypertension at baseline (mean age ±â€Šstandard deviation: 53.9 ±â€Š8.8 years; 88.7% White, 6.4% Black and 4.9% Hispanic/Latina), 23% (n = 7686) developed hypertension over a median follow-up of 10.1 years [interquartile range: 8.2-11.9 years]. Very short, short or long sleep duration, inconsistent weekly sleep patterns, sleep debt, frequent napping, insomnia, insomnia symptoms as well as short sleep and exploratory cumulative poor sleep score were associated with incident hypertension after adjustment for demographics factors. After additional adjustment for lifestyle and clinical factors, insomnia [hazard ratio = 1.09, 95% confidence interval (95% CI): 1.03-1.15] and insomnia symptoms plus short sleep (hazard ratio = 1.13, 95% CI: 1.05-1.21) remained associated with incident hypertension. These associations were stronger in younger (age<54 vs. ≥54 years) and premenopausal vs. postmenopausal women (all P-interaction < 0.05). Associations did not differ by race/ethnicity (all P-interaction > 0.05). CONCLUSION: Thus, screening for multiple sleep dimensions and prioritizing younger and premenopausal women may help identify individuals at high risk for hypertension.

Prevalence of Urinary Incontinence among a Nationally Representative Sample of Women, 2005-2016: Findings from the Urologic Diseases in America Project.

PURPOSE: Urinary incontinence is frequently underreported and underdiagnosed in the clinical setting. We analyzed 12 years of data from a large, nationally representative sample of women in the United States to assess the prevalence, severity, and daily impact of urinary incontinence and its subtypes at the population level. MATERIALS AND METHODS: We analyzed data from 15,003 women aged ≥20 years who participated in the 2005-2016 National Health and Nutrition Examination Survey. We estimated the prevalence of urinary incontinence in the prior year, overall and by subtype (stress, urgency or mixed). Among women with urinary incontinence, we additionally assessed symptom severity using the validated 4-level Incontinence Severity Index, as well as impact on daily activities. RESULTS: The 2005-2016 prevalence of any urinary incontinence was 53%; 16% of women had mixed urinary incontinence, 26% had stress only and 10% had urgency only. While urgency urinary incontinence and mixed urinary incontinence were highest among women aged ≥60 years, stress urinary incontinence was highest among women aged 40-59 years. NonHispanic Black women had higher prevalence of urgency urinary incontinence and lower prevalence of stress urinary incontinence compared to other racial/ethnic groups. Of women with urinary incontinence, 30% reported moderate or severe symptoms, which were more common among older than younger women. In addition, 24% of women with urinary incontinence reported that the condition affected their daily activities. CONCLUSIONS: Our study demonstrates a high prevalence of urinary incontinence among a nationally representative population of women in the United States, with many reporting that urinary incontinence affected their daily activities. Age and racial/ethnic trends varied by urinary incontinence subtype.

National Trends in Neuromodulation for Urinary Incontinence Among Insured Adult Women and Men, 2004-2013: The Urologic Diseases in America Project.

OBJECTIVE: To examine US trends in neuromodulation for urinary incontinence (UI) treatment from 2004 to 2013. METHODS: This study utilized 2 data sources: the Optum© de-identified Clinformatics® Data Mart Database for privately insured adults aged 18-64 years with a UI diagnosis (N≈40,000 women and men annually) and the Medicare 5% Sample for beneficiaries aged ≥65 years with a UI diagnosis (N≈65,000 women and men annually). We created annual cross-sectional cohorts and assessed prevalence of UI-related neuromodulation procedures among men and women separately from 2004 to 2013. Analyses were conducted overall and stratified by age, race/ethnicity, and geographic region. RESULTS: Nearly all neuromodulation procedures occurred in outpatient settings. Sacral neuromodulation (SNM) procedures for UI in both women and men grew steadily from 2004 to 2013, with more procedures performed in women than men. Among women with UI, SNM prevalence grew from 0.1%-0.2% in 2004 to 0.5%-0.6% in 2013. Posterior tibial nerve stimulation (PTNS) experienced growth from 2011 to 2013. Chemodenervation of the bladder with onabotulinumtoxinA (BTX) combined with other injectable procedures (including urethral bulking) remained stable over time. CONCLUSIONS: From 2004 to 2013, SNM procedures remained relatively uncommon but increased consistently. PTNS experienced growth starting in 2011 when PTNS-specific insurance claims became available. BTX trends remain unclear; future studies should assess it separately from other injectable procedures. Neuromodulation has a growing role in UI treatment, and ongoing trends will be important to examine.

Concomitant Use of Gabapentinoids with Opioids Is Associated with Increased Mortality and Morbidity among Dialysis Patients.

BACKGROUND: The opioid epidemic is a public health emergency and appropriate medication prescription for pain remains challenging. Physicians have increasingly prescribed gabapentinoids for pain despite limited evidence supporting their use. We determined the prevalence of concomitant gabapentinoid and opioid prescriptions and evaluated their associations with outcomes among dialysis patients. METHODS: We used the United States Renal Data System to identify patients treated with dialysis with Part A, B, and D coverage for all of 2010. Patients were grouped into 4 categories of drugs exposure status in 2010: (1) no prescriptions of either an opioid or gabapentinoid, (2) ≥1 prescription of an opioid and no prescriptions of gabapentinoids, (3) no prescriptions of an opioid and ≥1 prescription of gabapenbtinoids, (4) ≥1 prescription of both an opioid and gabapentinoid. Outcomes included 2-year all-cause death, dialysis discontinuation, and hospitalizations assessed in 2011 and 2012. RESULTS: The study population included 153,758 dialysis patients. Concomitant prescription of an opioid and gabapentin (15%) was more common than concomitant prescription of an opioid and pregabalin (4%). In adjusted analyses, concomitant prescription of an opioid and gabapentin compared to no prescription of either was associated with increased risk of death (hazard ratio [HR] 1.16, 95% CI 1.12-1.19), dialysis discontinuation (HR 1.14, 95% CI 1.03-1.27), and hospitalization (HR 1.33, 95% CI 1.31-1.36). Concomitant prescription of an opioid and pregabalin compared to no prescription of either was associated with increased mortality (HR 1.22, 95% CI 1.16-1.28) and hospitalization (HR 1.37, 95% CI 1.33-1.41), but not dialysis discontinuation (HR 1.13, 95% CI 0.95-1.35). Prescription of opioids and gabepentinoids compared to only being prescribed opioids was associated with higher risk of hospitalizations, but not mortality, or dialysis discontinuation. CONCLUSIONS: Concomitant prescription of opioids and gabapentinoids among US dialysis patients is common, and both drugs have independent effects on outcomes. Future research should prospectively investigate the potential harms of such drugs and identify safer alternatives for treatment of pain in end-stage renal disease patients.

Urinary phenols and parabens and diabetes among US adults, NHANES 2005-2014.

BACKGROUND AND AIMS: Phenols and parabens are ubiquitous and have been associated with markers of cardiovascular health. However, the literature lacks population-based studies examining the link between these endocrine disruptors and diabetes. We examined the association between paraben/phenol concentrations and diabetes among a nationally representative sample of US adults. METHODS AND RESULTS: We utilized data from the 2005-2014 National Health and Nutrition Examination Surveys (N = 8498). Total urinary concentrations of BPA, triclosan, BP-3, and propyl, butyl, ethyl, and methyl parabens were measured from urine specimens collected during the examination session. Diabetes status was based on self-report of a previous diagnosis or HbA1c≥6.5%. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CI) associated with the difference in log-transformed values of the 75th and 25th percentiles for each phenol/paraben, adjusting for potential confounders. The adjusted ORs (95% CI) of diabetes comparing the 75th to 25th percentiles of each paraben/phenol were 1.09 (0.96-1.23) for BPA, 0.84 (0.72-0.98) for triclosan, 0.69 (0.61-0.79) for BP-3, 0.71 (0.61-0.83) for propyl paraben, 0.66 (0.54-0.80) for butyl paraben, 0.60 (0.51-0.71) for ethyl paraben, and 0.79 (0.68-0.91) for methyl paraben. CONCLUSIONS: Higher concentrations of triclosan, BP-3, and propyl, butyl, ethyl, and methyl parabens were associated with lower odds of diabetes. These findings warrant further investigation into the potential mechanism behind the observed associations and the temporal direction of the associations, given that we cannot rule out reverse causation. Future studies of these endocrine disruptors may improve the understanding of their relationship with diabetes.

Racial/Ethnic Disparities in Atrial Fibrillation Treatment and Outcomes among Dialysis Patients in the United States.

BACKGROUND: Because stroke prevention is a major goal in the management of ESKD hemodialysis patients with atrial fibrillation, investigating racial/ethnic disparities in stroke among such patients is important to those who could benefit from strategies to maximize preventive measures. METHODS: We used the United States Renal Data System to identify ESKD patients who initiated hemodialysis from 2006 to 2013 and then identified those with a subsequent atrial fibrillation diagnosis and Medicare Part A/B/D. Patients were followed for 1 year for all-cause stroke, mortality, prescription medications, and cardiovascular disease procedures. The survival mediational g-formula quantified the percentage of excess strokes attributable to lower use of atrial fibrillation treatments by race/ethnicity. RESULTS: The study included 56,587 ESKD hemodialysis patients with atrial fibrillation. Black, white, Hispanic, and Asian patients accounted for 19%, 69%, 8%, and 3% of the population, respectively. Compared with white patients, black, Hispanic, or Asian patients were more likely to experience stroke (13%, 15%, and 16%, respectively) but less likely to fill a warfarin prescription (10%, 17%, and 28%, respectively). Warfarin prescription was associated with decreased stroke rates. Analyses suggested that equalizing the warfarin distribution to that in the white population would prevent 7%, 10%, and 12% of excess strokes among black, Hispanic, and Asian patients, respectively. We found no racial/ethnic disparities in all-cause mortality or use of cardiovascular disease procedures. CONCLUSIONS: Racial/ethnic disparities in all-cause stroke among hemodialysis patients with atrial fibrillation are partially mediated by lower use of anticoagulants among black, Hispanic, and Asian patients. The reasons for these disparities are unknown, but strategies to maximize stroke prevention in minority hemodialysis populations should be further investigated.

National Trends in the Surgical Management of Urinary Incontinence among Insured Women, 2004 to 2013: The Urologic Diseases in America Project.

PURPOSE: The objective of this study was to examine national trends in the surgical management of urinary incontinence in women in the United States from 2004 to 2013. MATERIALS AND METHODS: We analyzed the CDM (Optum® de-identified Clinformatics® Data Mart) for women 18 to 64 years old and the CMS (Centers for Medicare and Medicaid Services) Medicare 5% Sample for women 65 years old or older. We created annual cross-sectional cohorts and assessed trends in the annual prevalence of urinary incontinence related surgical procedures overall and by age, race/ethnicity and geographic region. RESULTS: We observed a decline in the percent of women with urinary incontinence who underwent surgical treatment according to the CMS (from 4.7% in 2004 to 2.7% in 2013) and the CDM (from 12.5% in 2004 to 9.1% in 2013). This trend persisted independently of age, race/ethnicity and geographic region. Slings were the most common procedure but started to decline in 2011, ultimately decreasing by about 50% during the study period. Compared to other groups the prevalence of urinary incontinence related surgical procedures, including slings, was highest among women 35 to 54 years old and White women, and lowest among women residing in the Northeast. These sociodemographic patterns persisted with time. During the study period injection procedures remained stable, sacral neuromodulation increased slightly but remained uncommon and suspension decreased to nearly 0% of all anti-incontinence procedures. CONCLUSIONS: Surgical management of female urinary incontinence experienced several shifts from 2004 to 2013, including a decline in sling procedures. Age, racial/ethnic and regional differences in treatment persisted with time. Improved understanding of the drivers of these trends may help direct future development of treatments of pelvic floor disorders.

Trends in Lower Urinary Tract Symptoms Associated with Benign Prostatic Hyperplasia, 2004 to 2013: the Urologic Diseases in America Project.

PURPOSE: Our current understanding of recent trends in the management of lower urinary tract symptoms associated with benign prostatic hyperplasia is incomplete, particularly in younger men. The 2018 Urologic Diseases in America Project attempted to fill this gap by analyzing multiple large administrative claims databases which include men of all ages and permit longitudinal followup. To our knowledge we report these findings for the first time in the scientific literature. MATERIALS AND METHODS: The 2 data sources used in this study included the de-identified Optum® Clinformatics® Data Mart database for men 40 to 64 years old and the Medicare 5% Sample for men 65 years old or older. To assess trends in lower urinary tract symptoms/benign prostatic hyperplasia related medication prescriptions and surgical procedures from 2004 to 2013 we created annual cross-sectional cohorts and a longitudinal cohort of patients with incident lower urinary tract symptoms/benign prostatic hyperplasia and 5 years of followup. RESULTS: The use of medications related to lower urinary tract symptoms/benign prostatic hyperplasia increased with age, particularly among men 40 to 60 years old. While medication use increased with time, surgical procedures decreased. Increasing age correlated with a higher rate of surgical procedures in the longitudinal cohort. Younger men were more likely to elect treatments of lower urinary tract symptoms/benign prostatic hyperplasia which reportedly optimize sexual function. CONCLUSIONS: Medication use increased and surgery decreased during the study period. Treatment approaches to lower urinary tract symptoms/benign prostatic hyperplasia varied greatly by patient age. While the minority of men in the fifth and sixth decades of life required treatment, a sharp increase in treatment use was seen between these decades. Younger men were more likely to elect less invasive surgical options. Future studies of lower urinary tract symptoms/benign prostatic hyperplasia should focus on age specific treatment selection.

Concordance between self-reported and actigraphy-assessed sleep duration among African-American adults: findings from the Jackson Heart Sleep Study.

STUDY OBJECTIVES: Most epidemiological studies assess sleep duration using questionnaires. Interpreting this information requires understanding the extent to which self-reported habitual sleep reflects objectively assessed sleep duration, particularly among African Americans, who disproportionately experience poor sleep health. METHODS: Among African-American participants of the Jackson Heart Sleep Study, we investigated differences in questionnaire-based self-assessed average sleep duration and self-assessed wake-bed time differences compared to actigraphy-based assessments of total sleep time (TST) and average time in bed (TIB). Linear regression models provided estimates of concordance between actigraphy-based and self-reported sleep duration. RESULTS: Among 821 adults, self-assessed average sleep duration was lower than self-assessed wake-bed time differences (6.4 ± 1.4 vs. 7.5 ± 1.7 h, p < 0.0001). Mean actigraphy-based TST was 6.6 ± 1.2 h, and actigraphy-based average TIB was 7.6 ± 1.2 h. Self-assessed average sleep duration and actigraphy-based TST were moderately correlated (r = 0.28, p < 0.0001). Self-assessed average sleep duration underestimated actigraphy-based TST by -30.7 min (95% confidence intervals [CI]: -36.5 to -24.9). In contrast, self-assessed wake-bed time differences overestimated actigraphy-based TST by 45.1 min (95% CI: 38.6-51.5). In subgroup analyses, self-assessed average sleep duration underestimated actigraphy-based measures most strongly among participants with insomnia symptoms. CONCLUSIONS: Among African Americans, self-assessed average sleep duration underestimated objectively measured sleep while self-assessed wake-bed time differences overestimated objectively measured sleep. Sleep measurement property differences should be considered when investigating disparities in sleep and evaluating their associations with health outcomes.

Epilepsy and antiseizure medications increase all-cause mortality in dialysis patients in the United States.

Seizures have been associated with uremia, but there are few data regarding the prevalence, treatment, and outcomes of patients with end-stage renal disease (ESRD) with epilepsy compared to those with ESRD without epilepsy. Here we conducted a retrospective cohort study using the United States Renal Data System to assess mortality and antiseizure medication prescriptions among patients with ESRD with and without a diagnosis of epilepsy. A modified Poisson regression with a robust variance was used to estimate the association between epilepsy status and mortality, and evaluate effect modification by neurology consultation. Additionally antiseizure medications were assessed in relation to mortality among those with epilepsy. Of 148,294 patients with ESRD in the cohort, 13,094 (8.8%) met a claims-based definition for epilepsy. Among those with epilepsy, 80.9% filled an anticonvulsant or hydantoin prescription in 2013-2014, compared to 33.3% without epilepsy. After adjustment for confounders, the mortality risk among those with epilepsy was 1.11 (95% confidence interval: 1.07, 1.14) times higher than those without. An epilepsy diagnosis was associated with a 15% increase in mortality risk among patients who did not have a neurology consultation (relative risk: 1.15 [95% confidence interval: 1.10, 1.20]), but this risk was attenuated among patients with a neurology consultation (1.07 [1.03, 1.11]). Prescription of gabapentin to patients with an epilepsy diagnosis compared to other antiseizure medications was associated with increased mortality (1.08 [1.01, 1.15]). Thus, patients with ESRD treated with dialysis have a high prevalence of epilepsy, which was associated with increased mortality risk compared to those without epilepsy. Hence, appropriate multidisciplinary care, treatment, and medication selection may reduce mortality among dialysis patients with epilepsy.

Pediatric Urinary Stone Disease in the United States: The Urologic Diseases in America Project.

OBJECTIVE: To examine the recent epidemiology of pediatric urinary stone disease (USD) in the United States. METHODS: We utilized the 2004-2016 Optum© Clinformatics® Data Mart database, a de-identified adjudicated administrative health claims database that includes 15-18 million individuals covered annually by commercial insurance in all 50 US states. The analysis included 12,739,125 children aged 0-18 years. We calculated annual rates of USD, ambulatory visits, and procedures, and the prevalence of prescription fills. RESULTS: The 2005-2016 USD rate was 59.5 cases per 100,000 person-years. The annual rate rose gradually from 2005 to a peak of 65.2 cases per 100,000 person-years in 2011. The USD rate increased with increasing age, and was highest among females compared to males, non-Hispanic Whites compared to other race/ethnic groups, and those residing in the South compared to other geographic regions. The overall 2005-2016 rate in the 120 days following a USD episode was 1.9 for ambulatory visits, 0.24 for surgical procedures, and 1.1 for imaging procedures. Ureteroscopy was the most common surgical procedure and CT scan was the most common imaging procedures, although ultrasound utilization increased over time. Medications were filled in 46.9% of cases, and use was lowest among males (43.1%), Asians (34.8%), and in the Northeast (34.3%). Opiate agonists were the most prevalent prescription (39.9%). CONCLUSION: Our study provides one of the most comprehensive examinations of pediatric USD to date, demonstrating shifting rates and treatment patterns over time, as well as differences by age, gender, race/ethnicity, and geographic region.

Perceived discrimination and depressive symptoms among US Latinos: the modifying role of educational attainment.

OBJECTIVE: Despite growing evidence that discrimination may contribute to poor mental health, few studies have assessed this association among US Latinos. Furthermore, the interaction between discrimination and educational attainment in shaping Latino mental health is virtually unexplored. This study aims to examine the association between perceived discrimination and depressive symptoms and the modifying role of education among a population of Mexican-origin adults. DESIGN: We utilized population-based data from 629 Mexican-origin adults (mean age = 52.8 years) participating the Niños Lifestyle and Diabetes Study (2013-2014). Perceived discrimination was defined as responding 'sometimes' or 'often' to at least one item on the 9-item Everyday Discrimination Scale. High depressive symptoms were defined as scoring ≥10 on the CESD-10. We used log-binomial and linear-binomial models to estimate prevalence ratios (PR) and prevalence differences (PD), respectively, of high depressive symptoms for levels of perceived discrimination. Final models were adjusted for age, sex, education, cultural orientation, and nativity. General estimating equations were employed to account for within-family clustering. RESULTS: Prevalence of perceived discrimination and high depressive symptoms were 49.5% and 29.2%, respectively. Participants experiencing discrimination had higher depressive symptom prevalence than those never or rarely experiencing discrimination [PR = 1.94, 95% confidence interval (CI): 1.46-2.58; PD = 0.19, 95% CI: 0.12-0.27]. The strength of this association varied by education level. The association between discrimination and depressive symptoms was stronger among those with >12 years of education (PR = 2.69; PD = 0.24) compared to those with ≤12 years of education (PR = 1.36; PD = 0.09). CONCLUSION: US Latinos suffer a high burden of depressive symptoms, and discrimination may be an important driver of this burden. Our results suggest that effortful coping strategies, such as achieving high education despite high perceived discrimination, may magnify discrimination's adverse effect on Latino mental health.

Spanish Language Use Across Generations and Depressive Symptoms Among US Latinos.

Acculturation markers, such as language use, have been associated with Latino depression. Language use may change between generations; however, few studies have collected intergenerational data to assess how language differences between generations impact depression. Using the Niños Lifestyle and Diabetes Study (2013-2014), we assessed how changes in Spanish language use across two generations of Mexican-origin participants in Sacramento, California, influenced offspring depressive symptoms (N = 603). High depressive symptoms were defined as CESD-10 scores ≥ 10. We used log-binomial and linear-binomial models to calculate prevalence ratios and differences, respectively, for depressive symptoms by language use, adjusting for identified confounders and within-family clustering. Decreased Spanish use and stable-equal English/Spanish use across generations protected against depressive symptoms, compared to stable-high Spanish use. Stable-low Spanish use was not associated with fewer depressive symptoms compared to stable-high Spanish use. Exposure to multiple languages cross-generationally may improve resource access and social networks that protect against depression.

How do we assess a racial disparity in health? Distribution, interaction, and interpretation in epidemiological studies.

Identifying the exposures or interventions that exacerbate or ameliorate racial health disparities is one of the fundamental goals of social epidemiology. Introducing an interaction term between race and an exposure into a statistical model is commonly used in the epidemiologic literature to assess racial health disparities and the potential viability of a targeted health intervention. However, researchers may attribute too much authority to the interaction term and inadvertently ignore other salient information regarding the health disparity. In this article, we highlight empirical examples from the literature demonstrating limitations of overreliance on interaction terms in health disparities research; we further suggest approaches for moving beyond interaction terms when assessing these disparities. We promote a comprehensive framework of three guiding questions for disparity investigation, suggesting examination of the group-specific differences in (1) outcome prevalence, (2) exposure prevalence, and (3) effect size. Our framework allows for better assessment of meaningful differences in population health and the resulting implications for interventions, demonstrating that interaction terms alone do not provide sufficient means for determining how disparities arise. The widespread adoption of this more comprehensive approach has the potential to dramatically enhance understanding of the patterning of health and disease and the drivers of health disparities.

Neighborhood language isolation and depressive symptoms among elderly U.S. Latinos.

PURPOSE: Neighborhood segregation related to cultural factors, such as language use, may influence elderly Latino depression. We examined the association between neighborhood-level Spanish language segregation and individual depressive symptoms among elderly Latinos. METHODS: We linked U.S. Census language use data with geocoded population-based data from 1789 elderly Latinos (mean age = 70.6 years) participating in the Sacramento Area Latino Study on Aging (1998-2008). Neighborhood language segregation was measured with the Index of Concentration at the Extremes, which demonstrates the extent to which residents are concentrated at extremes of deprivation and privilege. We fit two-level generalized linear-mixed models with random intercepts for census tracts to quantify the association between neighborhood-level language segregation and depressive symptoms, adjusting for identified confounders. RESULTS: After adjusting for age, sex, and nativity, residents of highly segregated Spanish-speaking neighborhoods had more depressive symptoms than those in highly segregated English-only-speaking neighborhoods (ß = -4.410; 95% confidence interval [CI] = -6.851 to -1.970). This association was largely attenuated upon adjustment for individual-level education (ß = -2.119; 95% CI = -4.650 to 0.413). CONCLUSIONS: Linguistically segregated communities may benefit from targeted outreach given the high depression prevalence in these neighborhoods. Furthermore, our findings suggest that limited access to fundamental social protections, such as education, may drive the segregation-depression association among U.S. Latinos.