Comparison of 2-Hour Oral Glucose Tolerance Test and Hemoglobin A1C in the Identification of Pre-Diabetes in Women with Infertility and Recurrent Pregnancy Loss.

RESEARCH QUESTION: Does hemoglobin A1C (HbA1C) predict pre-diabetes (pre-DM) in a population of women with infertility and/or recurrent pregnancy loss (RPL), when considering the 75 g, 2-hour oral glucose tolerance test (2h GTT) as the gold standard? DESIGN: Retrospective study of 242 patients with infertility or RPL presenting to a university-affiliated reproductive endocrinology and infertility clinic between January 2012 and December 2016 who underwent screening for disorders of glucose metabolism with a 2h GTT. The prevalence of pre-DM as defined by HbA1C 5.7% to 6.4% and 2h GTT values of 140-199 mg/dL, and predictive values of HbA1C for the identification of pre-DM when compared with 2h GTT, were calculated and compared. RESULTS: Of 242 patients, 188 (77.7%) women had both HbA1C and 2h GTT performed. Of these, 89 (47.3%) tested positive for pre-DM by one or both methods. Of 89 patients, 14 (15.7%) had both an abnormal 2h GTT and an abnormal HbA1C. Only 6 out of 89 (6.7%) patients tested positive for pre-DM by an abnormal 2h GTT in the setting of a normal HbA1C result. Conversely, 69 of these 89 patients (77.5%) tested positive for pre-DM by an abnormal HbA1C in the setting of a normal 2h GTT. The prevalence of pre-DM, as defined by 2h GTT, was 10.6% (20/188) (95% CI, 6.6-16.0), compared with a prevalence of 44.1% (83/188) (95% CI, 36.9-51.6) when pre-DM was defined by HbA1C alone. When the 2h GTT was considered the gold standard for the identification of pre-DM, the negative predictive value (NPV) of HbA1C compared with 2h GTT was 94.3% (95% CI, 88.0-97.9), whereas the positive predictive value (PPV) of HbA1C compared with 2h GTT was only 16.9% (95% CI, 9.5-26.7). CONCLUSIONS: Although a normal HbA1C was highly predictive of a normal 2h GTT, the two tests demonstrate poor agreement in the identification of pre-DM in women with infertility and/or RPL. Hemoglobin A1C is superior to the 2h GTT as an initial screening test for pre-DM in this population, since it identified a substantial number of women who would otherwise remain undiagnosed in the setting for a normal 2h GTT alone. However, the long-term clinical relevance of an elevated HbA1C in this population needs to be better defined.

Per and polyfluoroalkyl substances (PFAS) blood levels after contamination of a community water supply and comparison with 2013-2014 NHANES.

INTRODUCTION: Per and polyfluoroalkyl substances (PFAS), including perfluorononanoic acid (PFNA) and perfluorooctanoic acid (PFOA), were detected in the community water supply of Paulsboro New Jersey in 2009. METHODS: A cross-sectional study enrolled 192 claimants from a class-action lawsuit, not affiliated with this study, who had been awarded a blood test for 13 PFAS. Study participants provided their blood test results and completed a survey about demographics; 105 participants also completed a health survey. Geometric means, 25th, 50th, 75th, and 95th percentiles of exposure of PFNA blood serum concentrations were compared to that of the 2013-2014 NHANES, adjusted for reporting level. Associations between PFNA, PFOA, PFOS, and PFHxS and self-reported health outcomes were assessed using logistic regression. RESULTS: PFNA serum levels were 285% higher in Paulsboro compared with U.S. residents. PFNA serum levels were higher among older compared with younger, and male compared to female, Paulsboro residents. After adjustment for potential confounding, there was a significant association between increased serum PFNA levels and self-reported high cholesterol (OR: 1.15, 95% CI: 1.02, 1.29). DISCUSSION/CONCLUSION: Further investigation into possible health effects of PFAS exposure in Paulsboro and other community settings is warranted. Since exposure has ceased, toxicokinetics of PFAS elimination should be explored.

Ongoing barriers to immediate postpartum long-acting reversible contraception: a physician survey.

BACKGROUND: Postpartum women are at risk for unintended pregnancy. Access to immediate long-acting reversible contraception (LARC) may help decrease this risk, but it is unclear how many providers in the United States routinely offer this to their patients and what obstacles they face. Our primary objective was to determine the proportion of United States obstetric providers that offer immediate postpartum LARC to their obstetric patients. METHODS: We surveyed practicing Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (ACOG) about their use of immediate postpartum LARC. These members are demographically representative of ACOG members as a whole and represent all of the ACOG districts. Half of these Fellows were also part of the Collaborative Ambulatory Research Network (CARN), a group of ACOG members who voluntarily participate in research. We asked about their experience with and barriers to immediate placement of intrauterine devices and contraceptive implants after delivery. RESULTS: There were a total of 108 out of 600 responses (18%). Participants practiced in a total of 36 states and/or US territories and their median age was 52 years. Only 26.9% of providers surveyed offered their patients immediate postpartum LARC, and of these providers, 60.7% work in a university-based practice. There was a statistically significant association between offering immediate postpartum LARC and practice type, with the majority of providers working at a university-based practice (p < 0.001). Multiple obstacles were identified, including cost or reimbursement, device availability, and provider training on device placement in the immediate postpartum period. CONCLUSION: The majority of obstetricians surveyed do not offer immediate postpartum long-acting reversible contraception to patients in the United States. This is secondary to multiple obstacles faced by providers.

Improved outcomes after blastocyst-stage frozen-thawed embryo transfers compared with cleavage stage: a Society for Assisted Reproductive Technologies Clinical Outcomes Reporting System study.

OBJECTIVE: To investigate whether there is a difference in obstetrical and perinatal outcomes in blastocyst frozen-thawed embryo transfers (FETs) compared with cleavage-stage FET. DESIGN: A retrospective cohort study. SETTING: Not applicable. PATIENT(S): Women undergoing autologous FETs at either the blastocyst stage (n = 118,572) or the cleavage stage (n = 117,619) reported to the Society for Assisted Reproductive Technology in the years 2004-2013. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Live birth, gestational age, birth weight, miscarriage. RESULT(S): After controlling for confounders, there were a 49% increased odds of live birth after blastocyst-stage FET compared with cleavage-stage FET (odds ratio [OR] = 1.49; 95% confidence interval [CI], 1.44, 1.54). Additionally, blastocyst FET was associated with a 68% (OR = 1.68; 95% CI, 1.63, 1.74) increased odds of clinical pregnancy and an 7% (OR = 0.93; 95% CI, 0.88, 0.92) decreased odds of miscarriage. There was also a 16% increased odds of preterm delivery (OR = 1.16; 95% CI, 1.06, 1.27) after blastocyst FET but no difference in birth weights. CONCLUSION(S): In patients undergoing FET, blastocyst-stage transfer is associated with higher live-birth rates when compared with cleavage-stage transfers. Furthermore, perinatal outcomes are similar between the groups.

Substance abuse treatment as HIV prevention: more questions than answers.

This report examines associations between the availability of human immunodeficiency virus (HIV)-related health services in substance abuse treatment programs and characteristics of the programs and the patients they serve. In a cross-sectional, descriptive design and via a validated survey, program administrators within the National Drug Abuse Treatment Clinical Trials Network provided information on program characteristics, patient characteristics (rates of risky sexual and drug behaviors and HIV infection), and the availability of 31 different HIV-related health services. Of 319 programs, 84% submitted surveys. Service availability rates ranged from: 10% (pneumococcal vaccination) to 86% (drug testing) for the 6 HIV-related services offered to all patients, 13% (Pap smear for women) to 54% (tuberculin skin testing) for the 6 services offered to new patients, 2% (sterile injection equipment) to 64% (male condoms) for the 4 risk-reduction services, 37% (Pap smear for women) to 61% (tuberculin skin testing) for the 11 biological assessments offered to HIV-positive patients, and 33% (medical treatments) to 52% (counseling) for the 4 other services offered to HIV-positive patients. The availability of these HIV-related services was associated with clinical settings, the types of addiction treatment services, the rates of risky drug and sexual behaviors, and HIV infection rates among patients. Availability of such services was below published guidelines. While the results provide another basis for the infection-related prevention benefits of substance abuse treatment, the variability in the availability of HIV-related health care deserves further study and has health policy implications in determining how to utilize substance abuse treatment in reducing drug-related HIV transmission.

Substance abuse treatment clinician opinions and infectious disease service delivery.

Substance abuse treatment programs are an important platform for delivery of services for infectious diseases associated with drug and alcohol use. However, important components of infectious disease care are not universally provided. Clinician training often focuses on information about infectious diseases and less attention is paid to provider opinions and attitudes that may be barriers to providing infectious diseases services. In a national multi-site trial conducted by the National Drug Abuse Treatment Clinical Trials Network (CTN), we investigated the relationship between clinician opinions and the delivery of services for human immunodeficiency virus, hepatitis C virus, and sexually transmitted infections in substance abuse treatment settings. Survey data were collected from 1,723 clinicians at 269 CTN treatment programs. Clinician opinion was found to be significantly related to infectious disease service delivery. Implications for training are discussed.

Disparities in Health Services for HIV/AIDS, Hepatitis C Virus, and Sexually Transmitted Infections: Role of Substance Abuse Treatment Programs.

OBJECTIVES: This report focused upon the availability of infection-related health services in substance abuse treatment programs with and without addiction services tailored for special populations (women and non-white populations). METHODS: In a cross-sectional, descriptive design, treatment program administrators across the United States within the National Drug Abuse Treatment Clinical Trials Network provided information on program characteristics, the availability of infection-related services (four medical services and three non-medical services for HIV, HCV, and STI), and barriers to providing infection-related services. RESULTS: Of 319 programs, 269 submitted surveys (84% response rate). Of these, 80% provided addiction services for special populations. Programs providing addiction services designed for at least one special population, were more likely to provide infection-related health services, especially HIV-related education (94% versus 85%, p = 0.05) and patient counseling (76% versus 60%, p = 0.03) and were more likely to include outpatient addiction services (86% versus 57%, p<0.001) and outreach and support services (92% versus 70%, p=0.01). Barriers to providing infection-related services included funding (cited by 48.3% to 74.7% of programs), health insurance (cited by 28.9% to 60.8% of programs), and patient acceptance (cited by 23.2% to 54.3% of programs). CONCLUSIONS: Despite many barriers, infection-related healthcare is available in programs with addiction treatment services tailored for special populations, especially for African Americans and Latino Americans. Tailoring substance abuse treatment along with reducing barriers to infection-related care represent public health interventions with potential to reduce the burdens and disparities associated with these infections.

Cannabis withdrawal in the United States: results from NESARC.

OBJECTIVE: Although cannabis is the most widely abused illicit drug, little is known about the prevalence of cannabis withdrawal and its factor structure, clinical validity, and psychiatric correlates in the general population. METHOD: National Epidemiologic Survey on Alcohol and Related Conditions participants were assessed, in 2001-2002, with structured in-person interviews covering substance history, DSM-IV Axis I and II disorders, and withdrawal symptoms after cessation of use. Of these, 2613 had been frequent cannabis users (> or = 3 times/week), and a "cannabis-only" subset (N = 1119) never binge-drank or used other drugs > or = 3 times/week. RESULTS: In the full sample and subset, 44.3% (SE = 1.19) and 44.2% (SE = 1.75), respectively, experienced > or = 2 cannabis withdrawal symptoms, while 34.4% (SE = 1.21) and 34.1% (SE = 1.76), respectively, experienced > or = 3 symptoms. The symptoms formed 2 factors, one characterized by weakness, hypersomnia, and psychomotor retardation and the second by anxiety, restlessness, depression, and insomnia. Both symptom types were associated with significant distress/impairment (p < .01), substance use to relieve/avoid cannabis withdrawal symptoms (p <.01), and quantity of cannabis use (among the cannabis-only users p < .05). Panic (p < .01) and personality (p > .01) disorders were associated with anxiety symptoms in both samples, family history of drug problems was associated with weakness symptoms in the subset (p = .01), and depression was associated with both sets of symptoms in the subset (p < or = .05). CONCLUSION: Cannabis withdrawal was prevalent and clinically significant among a representative sample of frequent cannabis users. Similar results in the subset without polysubstance abuse confirmed the specificity of symptoms to cannabis. Cannabis withdrawal should be added to DSM-V, and the etiology and treatment implications of cannabis withdrawal symptoms should be investigated.

States and substance abuse treatment programs: funding and guidelines for infection-related services.

Community-based substance abuse treatment programs provide HIV, hepatitis C virus, and sexually transmitted infection services. To explore how state funding and guidelines affect practice, we surveyed state agency administrators and substance abuse treatment program administrators and clinicians regarding 8 infection-related services. Although state funding for infection-related services is widely available, substance abuse treatment programs do not always access it. Substance abuse treatment program guidelines are clearer in states that have written guidelines. Improved communication between state agencies and substance abuse treatment programs may enhance service.

Alcohol consumption and posttraumatic stress after exposure to terrorism: effects of proximity, loss, and psychiatric history.

OBJECTIVES: We examined the effects of exposure to or interpersonal loss resulting from a terrorist attack on posttraumatic stress and alcohol consumption after we controlled for psychiatric history assessed before the attack. METHODS: At baseline (1991-1992) and at 1- and 10-year follow-ups, an adult community sample of drinkers living approximately 12 mi (19.2 km) from the World Trade Center were evaluated for alcohol dependence and major depression. Of this group, 82.2% were assessed regarding the impact of the September 11, 2001, attacks, including proximity to the World Trade Center, interpersonal loss, posttraumatic stress, and alcohol consumption. RESULTS: In regression models, interpersonal loss and past major depression, but not proximity to the World Trade Center, predicted posttraumatic stress symptoms. Proximity and past alcohol dependence, but not interpersonal loss, predicted high levels of post-September 11 alcohol consumption. Past alcohol dependence did not modify the proximity-drinking relationship, and past major depression did not modify the loss-posttraumatic stress relationship. CONCLUSIONS: Participants' responses to September 11 were specific to their type of exposure and not predetermined by their psychiatric history. A better understanding of responses to traumatic events should assist more-effective prevention and intervention efforts.

Health services for HIV/AIDS, HCV, and sexually transmitted infections in substance abuse treatment programs.

The National Drug Abuse Treatment Clinical Trials Network conducted this study to determine the availability of and factors associated with infection-related health services in substance abuse treatment settings. In a cross-sectional descriptive design, state policies, reimbursement for providers, state level of priority, and treatment program characteristics were studied via written surveys of administrators of substance abuse treatment programs and of state health and substance abuse departments. Data from health departments and substance abuse agencies of 48 states and from 269 substance abuse treatment programs revealed that human immunodeficiency virus/acquired immunodeficiency syndrome-related services are more frequent than hepatitis C virus or sexually transmitted infection-related services, and that nonmedical services are more frequent than medical services. While the availability of infection-related health services is associated with medical staffing patterns, addiction pharmacotherapy services, and state priorities, reimbursement was the most significant determining factor. These findings suggest that greater funding of these health services in substance abuse treatment settings, facilitated by supportive state policies, represents an effective response to the excess morbidity and mortality of these substance use-related infections.

Effect of ADH1B genotype on alcohol consumption in young Israeli Jews.

BACKGROUND: The alcohol dehydrogenase 1B (ADH1B) genotype affects the risk for alcoholism, with elevated prevalence of a protective allele in Jews. Alcohol consumption is increasing among younger Israeli Jews, reflecting environmental influences. We investigated whether the relationship of ADH1B genotype with alcohol consumption differed between younger and older adult Israelis. METHODS: Israeli community residents aged 22 to 65 participated in a structured interview that included questions on the maximum number of drinks on an occasion (Maxdrinks). The ADH1B genotype was determined for 68 participants and dichotomized into nonprotective (ADH1B(*)1/1) and protective (ADH1B(*)1/2 or ADH1B(*)2/2) genotypes. Using Maxdrinks as the dependent variable, Poisson's regression was used to test an age x genotype interaction. RESULTS: The ADH1B genotype interacted significantly with age (p=0.01) in a Poisson's model with Maxdrinks as the outcome. Among participants >or=33 years, Maxdrinks was low and unrelated to the ADH1B genotype. Among participants <33 years with ADH1B(*)1/2 or ADH1B(*)2/2, Maxdrinks was also low (mean, 2.6 drinks) but among those with ADH1B(*)1/1, Maxdrinks was substantially higher (mean, 6.2 drinks). CONCLUSION: Maximum lifetime drinking among younger adult Israelis without genetic protection exceeded thresholds for risky and unsafe drinking (>or=5 drinks). Environmental influences promoting greater drinking among younger Israelis may particularly affect those with the nonprotective, more common ADH1B genotype.

Changes in the prevalence of non-medical prescription drug use and drug use disorders in the United States: 1991-1992 and 2001-2002.

OBJECTIVE: To examine changes in the prevalence of non-medical prescription drug use and DSM-IV non-medical prescription abuse and dependence in the United States between 1991-1992 and 2001-2002. METHOD: Comparison of the prevalence of past-year non-medical prescription drug use and drug use disorders in the total sample and among lifetime non-medical users in two large national surveys conducted 10 years apart. RESULTS: From 1991-1992 to 2001-2002, the prevalence of DSM-IV non-medical prescription drug use increased by 53%, from 1.5% to 2.3% (p<0.001), and the prevalence of drug use disorders increased by 67% from 0.3% to 0.5% (p<0.001). The conditional prevalence of a disorder among users increased numerically from 19.9% to 23.6%, but this increase was not statistically significant (p=0.15). CONCLUSIONS: There have been substantial increases in the prevalence of prescription drug non-medical use and prescription drug use disorders in the United States. Given the clinical utility of prescription drugs, urgent action is needed to find approaches that balance the need for access to these medications among those who need them, against their potential for abuse and dependence in subgroups of vulnerable individuals.

DSM-IV alcohol dependence: a categorical or dimensional phenotype?

BACKGROUND: Etiologic research on complex disorders including alcohol dependence requires informative phenotypes. Information is lost when categorical variables represent inherently dimensional conditions. We investigated the validity of DSM-IV alcohol dependence as a dimensional phenotype by examining evidence for linearity and thresholds in associations with validating variables. METHOD: Current drinkers in the National Longitudinal Alcohol Epidemiologic Survey (NLAES) (n=18352) and National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) (n=20836) were analyzed. Validating variables included family alcoholism, early-onset drinking, and alcohol treatment. Logistic or Poisson regression modeled the relationships between the validating variables and dependence in categorical, dimensional or hybrid forms, with severity defined as number of current DSM-IV alcohol-dependence criteria. Wald tests assessed differences between models. RESULTS: No evidence was found for boundaries between categories. Instead, the association of alcohol dependence with the validating variables generally increased in linear fashion as the number of alcohol-dependence criteria increased. For NLAES models of family alcoholism, early-onset drinking and treatment, the lines had zero intercepts, with slopes of 0.18, 0.27, 0.70, respectively. For NESARC models of family history and early-onset drinking, the zero intercept lines had slopes of 0.20, 0.33, and 0.77, respectively. Wald tests indicated that models representing alcohol dependence as a dimensional linear predictor best described the association between dependence criteria and the validating variables. CONCLUSIONS: The sample sizes allowed strong tests. Diagnoses are necessary for clinical decision-making, but a dimensional alcohol-dependence indicator should provide more information for research purposes.