Diabetes mellitus and hard braking events in older adult drivers.

BACKGROUND: Diabetes mellitus (DM) can impair driving safety due to hypoglycemia, hyperglycemia, diabetic peripheral neuropathy, and diabetic eye diseases. However, few studies have examined the association between DM and driving safety in older adults based on naturalistic driving data. METHODS: Data for this study came from a multisite naturalistic driving study of drivers aged 65-79 years at baseline. Driving data for the study participants were recorded by in-vehicle recording devices for up to 44 months. We used multivariable negative binomial modeling to estimate adjusted incidence rate ratios (aIRRs) and 95% confidence intervals (CIs) of hard braking events (HBEs, defined as maneuvers with deceleration rates ≥ 0.4 g) associated with DM. RESULTS: Of the 2856 study participants eligible for this analysis, 482 (16.9%) reported having DM at baseline, including 354 (12.4%) insulin non-users and 128 (4.5%) insulin users. The incidence rates of HBEs per 1000 miles were 1.13 for drivers without DM, 1.15 for drivers with DM not using insulin, and 1.77 for drivers with DM using insulin. Compared to drivers without DM, the risk of HBEs was 48% higher for drivers with DM using insulin (aIRR 1.48; 95% CI: 1.43, 1.53). CONCLUSION: Older adult drivers with DM using insulin appear to be at increased proneness to vehicular crashes. Driving safety should be taken into consideration in DM care and management.

Association between polypharmacy and hard braking events in older adult drivers.

BACKGROUND: Polypharmacy (i.e., simultaneous use of two or more medications) poses a serious safety concern for older drivers. This study assesses the association between polypharmacy and hard braking events in older adult drivers. METHODS: Data for this study came from a naturalistic driving study of 2990 older adults. Information about medications was collected through the "brown-bag review" method. Primary vehicles of the study participants were instrumented with data recording devices for up to 44 months. Multivariable negative binomial model was used to estimate the adjusted incidence rate ratios (aIRRs) and 95 % confidence intervals (CIs) of hard-braking events (i.e., maneuvers with linear deceleration rates ≥0.4 g) associated with polypharmacy. RESULTS: Of the 2990 participants, 2872 (96.1 %) were eligible for this analysis. At the time of enrollment, 157 (5.5 %) drivers were taking fewer than two medications, 904 (31.5 %) were taking 2-5 medications, 895 (31.2 %) were taking 6-9 medications, 571 (19.9 %) were taking 10-13 medications, and 345 (12.0 %) were taking 14 or more medications. Compared to drivers using fewer than two medications, the risk of hard-braking events increased 8 % (aIRR 1.08, 95 % CI 1.04, 1.13) for users of 2-5 medications, 12 % (aIRR 1.12, 95 % CI 1.08, 1.16) for users of 6-9 medications, 19 % (aIRR 1.19, 95 % CI 1.15, 1.24) for users of 10-13 medications, and 34 % (aIRR 1.34, 95 % CI 1.29, 1.40) for users of 14 or more medications. CONCLUSIONS: Polypharmacy in older adult drivers is associated with significantly increased incidence of hard-braking events in a dose-response fashion. Effective interventions to reduce polypharmacy use may help improve driving safety in older adults.

State cannabis laws and cannabis positivity among fatally injured drivers.

BACKGROUND: As of November 8, 2023, 24 states and the District of Columbia have legalized cannabis for both recreational and medical use (RMCL-states), 14 states have legalized cannabis for medical use only (MCL-states) and 12 states have no comprehensive cannabis legislation (NoCL-states). As more states legalize cannabis for recreational use, it is critical to understand the impact of such policies on driving safety. METHODS: Using the 2019 and 2020 Fatality Analysis Reporting System data, we performed multivariable logistic regression modeling to explore the association between state level legalization status and cannabis positivity using toxicological testing data for 14,079 fatally injured drivers. We performed a sensitivity analysis by including multiply imputed toxicological testing data for the 14,876 eligible drivers with missing toxicological testing data. RESULTS: Overall, 4702 (33.4%) of the 14,079 fatally injured drivers tested positive for cannabis use. The prevalence of cannabis positivity was 30.7% in NoCL-states, 32.8% in MCL-states, and 38.2% in RMCL-states (p < 0.001). Compared to drivers fatally injured in NoCL-states, the adjusted odds ratios of testing positive for cannabis were 1.09 (95% confidence interval: 0.99, 1.19) for those fatally injured in MCL-states and 1.54 (95% confidence interval: 1.34, 1.77) for those fatally injured in RMCL-states. Sensitivity analysis yielded similar results. CONCLUSIONS: Over one-third of fatally injured drivers tested positive for cannabis use. Drivers fatally injured in states with laws permitting recreational use of cannabis were significantly more likely to test positive for cannabis use than those in states without such laws. State medical cannabis laws had little impact on the odds of cannabis positivity among fatally injured drivers.

Behavioural disorders after prenatal exposure to anaesthesia for maternal surgery.

BACKGROUND: The association between prenatal exposure to general anaesthesia for maternal surgery during pregnancy and subsequent risk of disruptive or internalising behavioural disorder diagnosis in the child has not been well-defined. METHODS: A nationwide sample of pregnant women linked to their liveborn infants was evaluated using the Medicaid Analytic eXtract (MAX, 1999-2013). Multivariate matching was used to match each child prenatally exposed to general anaesthesia owing to maternal appendectomy or cholecystectomy during pregnancy with five unexposed children. The primary outcome was diagnosis of a disruptive or internalising behavioural disorder in children. Secondary outcomes included diagnoses for a range of other neuropsychiatric disorders. RESULTS: We matched 34,271 prenatally exposed children with 171,355 unexposed children in the database. Prenatally exposed children were more likely than unexposed children to receive a diagnosis of a disruptive or internalising behavioural disorder (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.23-1.40). For secondary outcomes, increased hazards of disruptive (HR, 1.32; 95% CI, 1.24-1.41) and internalising (HR, 1.36; 95% CI, 1.20-1.53) behavioural disorders were identified, and also increased hazards of attention-deficit/hyperactivity disorder (HR, 1.32; 95% CI, 1.22-1.43), behavioural disorders (HR, 1.28; 95% CI, 1.14-1.42), developmental speech or language disorders (HR, 1.16; 95% CI, 1.05-1.28), and autism (HR, 1.31; 95% CI, 1.05-1.64). CONCLUSIONS: Prenatal exposure to general anaesthesia is associated with a 31% increased risk for a subsequent diagnosis of a disruptive or internalising behavioural disorder in children. Caution is advised when making any clinical decisions regarding care of pregnant women, as avoidance of necessary surgery during pregnancy can have detrimental effects on mothers and their children.

Motor Vehicle Crash Risk in Older Adult Drivers With Attention-Deficit/Hyperactivity Disorder.

Importance: Symptoms of attention-deficit/hyperactivity disorder (ADHD), such as inattentiveness and impulsivity, could affect daily functioning and driving performance throughout the life span. Previous research on ADHD and driving safety is largely limited to adolescents and young adults. Objective: To examine the prevalence of ADHD and the association between ADHD and crash risk among older adult drivers. Design, Setting, and Participants: This prospective cohort study collected data from primary care clinics and residential communities in 5 US sites (Ann Arbor, Michigan; Baltimore, Maryland; Cooperstown, New York; Denver, Colorado; and San Diego, California) between July 6, 2015, and March 31, 2019. Participants were active drivers aged 65 to 79 years at baseline enrolled in the Longitudinal Research on Aging Drivers project who were studied for up to 44 months through in-vehicle data recording devices and annual assessments. The data analysis was performed between July 15, 2022, and August 14, 2023. Exposure: Lifetime ADHD based on an affirmative response to the question of whether the participant had ever had ADHD or had ever been told by a physician or other health professional that he or she had ADHD. Main Outcomes and Measures: The main outcomes were hard-braking events defined as maneuvers with deceleration rates of 0.4g or greater, self-reported traffic ticket events, and self-reported vehicular crashes. Multivariable negative binomial modeling was used to estimate adjusted incidence rate ratios (aIRRs) and 95% CIs of outcomes according to exposure status. Results: Of the 2832 drivers studied, 1500 (53.0%) were women and 1332 (47.0%) were men with a mean (SD) age of 71 (4) years. The lifetime prevalence of ADHD in the study sample was 2.6%. Older adult drivers with ADHD had significantly higher incidence rates of hard-braking events per 1000 miles than those without ADHD (1.35 [95% CI, 1.30-1.41] vs 1.15 [95% CI, 1.14-1.16]), as well as self-reported traffic ticket events per 1 million miles (22.47 [95% CI, 16.06-31.45] vs 9.74 [95% CI, 8.99-10.55]) and self-reported vehicular crashes per 1 million miles (27.10 [95% CI, 19.95-36.80] vs 13.50 [95% CI, 12.61-14.46]). With adjustment for baseline characteristics, ADHD was associated with a significant 7% increased risk of hard-braking events (aIRR, 1.07; 95% CI, 1.02-1.12), a 102% increased risk of self-reported traffic ticket events (aIRR, 2.02; 95% CI, 1.42-2.88), and a 74% increased risk of self-reported vehicular crashes (aIRR, 1.74; 95% CI, 1.26-2.40). Conclusions and Relevance: As observed in this prospective cohort study, older adult drivers with ADHD may be at a significantly elevated crash risk compared with their counterparts without ADHD. These findings suggest that effective interventions to improve the diagnosis and clinical management of ADHD among older adults are warranted to promote safe mobility and healthy aging.

Epidemiologic Patterns of Autism Spectrum Disorder in Pediatric Inpatients in the United States, 1997-2019.

The reported prevalence of autism spectrum disorder (ASD) has more than tripled in the past two decades in the United States, due in part to improved screening and diagnostic techniques. Epidemiologic data on ASD, however, are largely limited to population-based surveillance systems. We examined epidemiologic patterns in ASD diagnoses among inpatients aged 1-20 years, using data from the Kids' Inpatient Database (KID) from 1997 to 2019. ASD cases were identified using ICD-9-CM and ICD-10-CM codes. Of 9,267,881 hospital discharges studied, 110,090 (1.19%) had a diagnosis of ASD. The prevalence of ASD was higher among males compared to females (1.53% vs. 0.54%) and was highest among non-Hispanic Whites (1.28% vs. 0.95% in non-Hispanic Blacks, 0.94% in Hispanics, and 1.18% in Other races). ASD prevalence increased from 0.18% to 1997 to 3.36% in 2019 (Z= -273.40, p < 0.001). The absolute increase was higher among males compared to females (0.26-4.90% vs. 0.08-1.77%) and among non-Hispanic Whites (0.18-2.88%) compared to non-Hispanic Blacks (0.23-2.72%), Hispanics (0.14-2.60%), and Other races (0.19-2.97%). The epidemiologic patterns of ASD based on inpatient data are generally consistent with reports from the community-based autism surveillance system. Our findings indicate that KID and other health services data might play a complementary role in ASD surveillance.

Interaction between benzodiazepines and prescription opioids on incidence of hard braking events in older drivers.

BACKGROUND: Polypharmacy use among older adults is of increasing concern for driving safety. This study assesses the individual and joint effects of benzodiazepines and prescription opioids on the incidence of hard braking events in older drivers. METHODS: Data for this study came from the Longitudinal Research on Aging Drivers project-a multisite, prospective cohort study of 2990 drivers aged 65-79 years at enrollment (2015-2017). Adjusted incidence rate ratios (aIRRs) and 95% confidence intervals (CIs) of hard braking events (defined as maneuvers with deceleration rates ≥0.4 g and commonly known as near-crashes) were estimated through multivariable negative binominal modeling. RESULTS: Of the 2929 drivers studied, 167 (5.7%) were taking benzodiazepines,  163 (5.6%) prescription opioids, and 23 (0.8%) both drugs at baseline. The incidence rates of hard braking events per 1000 miles driven were 1.14 (95% CI 1.10-1.18) for drivers using neither benzodiazepines nor prescription opioids, 1.25 (95% CI 1.07-1.43) for those using benzodiazepines only, 1.55 (95% CI 1.35-1.76) for those using prescription opioids only, and 1.63 (95% CI 1.11-2.16) for those using both medications. Multivariable modeling revealed that the use of prescription opioids was associated with a 19% increased risk of hard braking events (aIRR 1.19, 95% CI 1.03-1.36). There existed a positive interaction between the two drugs on the additive scale but not on the multiplicative scale. CONCLUSION: Concurrent use of benzodiazepines and prescription opioids by older drivers appears to affect driving safety through increased incidence of hard braking events.

Place of Death From Cancer in US States With vs Without Palliative Care Laws.

Importance: In the US, improving end-of-life care has become increasingly urgent. Some states have enacted legislation intended to facilitate palliative care delivery for seriously ill patients, but it is unknown whether these laws have any measurable consequences for patient outcomes. Objective: To determine whether US state palliative care legislation is associated with place of death from cancer. Design, Setting, and Participants: This cohort study with a difference-in-differences analysis used information about state legislation combined with death certificate data for 50 US states (from January 1, 2005, to December 31, 2017) for all decedents who had any type of cancer listed as the underlying cause of death. Data analysis for this study occurred between September 1, 2021, and August 31, 2022. Exposures: Presence of a nonprescriptive (relating to palliative and end-of-life care without prescribing particular clinician actions) or prescriptive (requiring clinicians to offer patients information about care options) palliative care law in the state-year where death occurred. Main Outcomes and Measures: Multilevel relative risk regression with state modeled as a random effect was used to estimate the likelihood of dying at home or hospice for decedents dying in state-years with a palliative care law compared with decedents dying in state-years without such laws. Results: This study included 7 547 907 individuals with cancer as the underlying cause of death. Their mean (SD) age was 71 (14) years, and 3 609 146 were women (47.8%). In terms of race and ethnicity, the majority of decedents were White (85.6%) and non-Hispanic (94.1%). During the study period, 553 state-years (85.1%) had no palliative care law, 60 state-years (9.2%) had a nonprescriptive palliative care law, and 37 state-years (5.7%) had a prescriptive palliative care law. A total of 3 780 918 individuals (50.1%) died at home or in hospice. Most decedents (70.8%) died in state-years without a palliative care law, while 15.7% died in state-years with a nonprescriptive law and 13.5% died in state-years with a prescriptive law. Compared with state-years without a palliative care law, the likelihood of dying at home or in hospice was 12% higher for decedents in state-years with a nonprescriptive palliative care law (relative risk, 1.12 [95% CI 1.08-1.16]) and 18% higher for decedents in state-years with a prescriptive palliative care law (relative risk, 1.18 [95% CI, 1.11-1.26]). Conclusions and Relevance: In this cohort study of decedents from cancer, state palliative care laws were associated with an increased likelihood of dying at home or in hospice. Passage of state palliative care legislation may be an effective policy intervention to increase the number of seriously ill patients who experience their death in such locations.

Beyond exercise. Can application of manual therapy before exercise benefit a low functioning person with limb loss? A case study.

BACKGROUND: Most people with lower-limb loss (PLL) have musculoskeletal conditions and range-of-motion and muscle performance impairments. Such impairments limit potential for functional movement but can be reduced with manual therapy. Manual therapy, however, is rarely used for PLL. This case demonstrated how integrating manual therapy, exercise, and functional training led to lasting benefits for one low functioning PLL. CASE DESCRIPTION: A 54-year-old woman more than 1 year after transtibial amputation due to peripheral artery disease presented with multiple comorbidities and yellow flags. Her function remained limited to the Medicare K-1 household walking level with slow gait speed <0.25 m/s. Treatment included four weekly sessions each beginning with manual therapy, followed by exercise and functional training. OUTCOMES: After 1 month, performance-based strength, balance, walking speed, and physical activity increased. She advanced to the K-2 limited community walking level and maintained her functional level without further treatment after 3 months. DISCUSSION: Improvements maintained without treatment expanded upon research that lacked follow-up and excluded K-1 level walkers. Marked improvement after only four sessions was noteworthy since exercise protocols require ≥4 sessions. CONCLUSION: Manual therapy followed by exercise and functional training may optimize movement potential and contribute to improving strength, balance, gait, and physical activity among PLL.

Poisoning-related emergency department visits in children with autism spectrum disorder.

BACKGROUND: Autism spectrum disorder (ASD) is a complex neurodevelopmental condition, and its prevalence has increased markedly in the past two decades. Research indicates that people with ASD are at increased risk for premature mortality from injuries. Often, children with ASD are prescribed multiple medications, increasing their risk for intentional and unintentional poisonings. We examined the epidemiologic patterns of emergency department (ED)-treated poisonings in children with ASD and the association of ED-treated poisonings with ASD according to common co-occurring conditions. METHODS: We analyzed data from the Nationwide Emergency Department Sample for 2016-2018 to estimate the frequencies of ED-treated poisonings among autistic children aged 1-20 years and adjusted odds ratios of ED-treated poisoning associated with ASD in the presence or absence of co-occurring attention-deficit hyperactivity disorder (ADHD) or intellectual disability (ID). The ICD-10-CM external cause-of-injury matrix was utilized to identify poisoning cases. RESULTS: During 2016-2018, there were an estimated 523,232 ED visits in children with ASD aged 1-20 years, including 12,152 (2.3%) visits for poisoning. Of ED-treated poisonings in children with ASD, 73.6% were related to pharmaceutical drugs, such as psychotropic medications and prescription opioids, 16.6% were intentional, 36.5% were unintentional, and 47.0% were undetermined. Among children with ASD, those aged 5-9 had the highest odds of poisoning-related ED visits compared to all other age-groups (adjusted OR = 3.41; 95% CI 3.15, 3.68). The odds of poisoning for children with ASD were 59.0% greater than for their peers (adjusted OR = 1.59; 95% CI 1.53, 1.66) and varied significantly with age and co-occurring ADHD or ID. CONCLUSIONS: Children with ASD are at a significantly increased risk of poisoning, particularly among those aged 5-9 years. Co-occurring ADHD or ID with ASD further increases the risk of poisoning. Interventions to reduce poisoning in children with ASD should prioritize the safety of prescription medications.

Walking asymmetry and its relation to patient-reported and performance-based outcome measures in individuals with unilateral lower limb loss.

Gait asymmetry persists for most people after lower limb amputation and is associated with slower walking speeds. However, the relationship between gait asymmetry and patient-reported function remains unclear because they are not commonly assessed together. The purpose of this study was to determine relationships between gait asymmetries in people with lower limb loss and (1) patient-reported outcomes and (2) performance-based prosthetic functional measures. This cross-sectional analysis included nine people with unilateral limb loss aged 48.2 ± 13.1 years of mixed amputation etiology. Patient-reported outcomes included the Prosthetic Evaluation Questionnaire mobility subscale and Activities-specific Balance Confidence scale. Performance outcomes included the Berg Balance Scale and the 30-second sit-to-stand test. Walking performance measures included the 2-Minute Walk Test, during which APDM Opal sensors recorded spatiotemporal gait parameters, and daily step-counts from StepWatch4 activity monitors. The study found that the most asymmetric gait symmetry ratios (prosthetic-limb divided by intact-limb) could be attributed to prosthetic foot dorsiflexion-plantarflexion and rotation motion limitations: prosthetic-limb trailing double support (0.789 ± 0.052), toe-off (0.760 ± 0.068) and toe-out angle (0.653 ± 0.256). Single limb stance, and stance and swing phase durations were most strongly associated with balance and walking performance measures. Notably, no symmetry ratio was significantly associated with patient-reported prosthetic function (unadjusted Pearson correlation coefficients r < 0.50, P > 0.05). More gait symmetry was associated with better balance and walking performance but had no significant relationship with patient-reported function. Although achieving gait symmetry after lower limb loss is a common walking goal, symmetry was unrelated to the perception of functional mobility for people with lower limb loss.

Preliminary analysis of reliability and validity of the Life Space Questionnaire as a real-world mobility measure for people with lower limb loss: A technical note.

People with lower-limb loss (PLL) often have reduced mobility that translates into limited community access. The Life Space Questionnaire (LSQ) measures a person's real-world mobility within their home environment and community but has not been used among PLL. This study assessed preliminary LSQ test-retest reliability and discriminant validity from subjective and objective balance and walking measures in PLL. In addition, LSQ was hypothesized to have an inverse association with overall health status. Nine subjects were analyzed with mean age 48.2 ± 13.1 years and 4.8 ± 3.9 years' time since amputation. Six had transtibial and three had transfemoral amputations due to diabetes (4), vascular disease (3), and trauma (2). The primary outcome was the LSQ, a 9-level scale quantifying the extent to which people accessed their life space including home, yard, and community. Test-retest reliability for the LSQ was moderate (intraclass coefficient = 0.61 with 90% confidence interval: 0.19-0.87). Discriminant validity from balance and walking function was demonstrated by lack of correlation between LSQ score and the Activities-specific Balance Confidence and Berg Balance Scale and the Prosthetic Evaluation Questionnaire mobility subscale and walking speed (r < 0.50, P > .05). LSQ correlated with health status assessed with the Charlson Comorbidity Index (r = -0.84, P = .005). In this sample of PLL, the LSQ demonstrated moderate test-retest reliability as a measure of real-world mobility distinct as a construct from subjective and objective balance or walking measures. People may access their communities using various levels of assistance and methods of transportation. For this sample of PLL, health status was most strongly associated with LSQ score.

Allogeneic Red Blood Cell Transfusion and Infectious Complications Following Pediatric Spinal Fusion: NSQIP-P Analysis.

Substantial bleeding occurs during spinal fusion surgery in the pediatric population, and many patients receive allogeneic red blood cell transfusion (ARBT) for the treatment of resulting perioperative anemia. ARBT is thought to increase vulnerability to postoperative infections following major surgical procedures, but studies of this relationship in children undergoing spinal fusion have yielded conflicting results. Methods: Patients who underwent spinal fusion before the age of 18 years were identified from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2016 to 2019 databases, along with patient and procedure-specific characteristics, transfusion events and volumes, and postoperative infectious complications such as wound-related infection, pneumonia, urinary tract infection (UTI), and sepsis. Multivariable logistic regression analyses provided adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between ARBT and each infection outcome and the overall risk of infection. Results: Among 19,159 patients studied, 714 (3.7%) developed a total of 931 episodes of postoperative infection. In multivariable logistic regression analyses, perioperative ARBT was independently associated with postoperative pneumonia (aOR = 1.93, 95% CI = 1.40 to 2.68), UTI (aOR = 1.80, 95% CI = 1.19 to 2.73), sepsis (aOR = 1.58, 95% CI = 1.10 to 2.28), and the overall risk of infection (aOR = 1.40, 95% CI = 1.20 to 1.64). The risk of any postoperative infection increased in a dose-response fashion with transfusion volume. Conclusions: ARBT in pediatric spinal fusion is associated with significantly increased risks of postoperative pneumonia, UTI, and sepsis. The overall risk of postoperative infection increases with the volume transfused. Enhanced efforts to minimize perioperative anemia and ARBT should be considered as a means of improving patient outcomes. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity.

Importance: Addressing severe maternal morbidity (SMM) is a public health priority in the US. Use of labor neuraxial analgesia for vaginal delivery is suggested to reduce the risk of postpartum hemorrhage (PPH), the leading cause of preventable severe maternal morbidity. Objective: To assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM. Design, Setting, and Participants: In this population-based cross-sectional study, women aged 15 to 49 years undergoing their first vaginal delivery were included. Data were taken from hospital discharge records from New York between January 2010 and December 2017. Data were analyzed from November 2020 to November 2021. Exposures: Neuraxial analgesia (ie, epidural or combined spinal-epidural) vs no neuraxial analgesia. Main Outcomes and Measures: The primary outcome was SMM, as defined by the US Centers for Disease Control and Prevention, and the secondary outcome was PPH. Adjusted odds ratios (aORs) and 95% CIs of SMM associated with neuraxial analgesia were estimated using the inverse propensity score-weighting method and stratified according to race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity) and to the comorbidity index for obstetric patients (low-risk vs high-risk women). The proportion of the association of neuraxial analgesia with the risk of SMM mediated through PPH was estimated using mediation analysis. Results: Of 575 524 included women, the mean (SD) age was 28 (6) years, and 46 065 (8.0%) were non-Hispanic Asian or Pacific Islander, 88 577 (15.4%) were non-Hispanic Black, 104 866 (18.2%) were Hispanic, 258 276 (44.9%) were non-Hispanic White, and 74 534 (13.0%) were other race and ethnicity. A total of 400 346 women (69.6%) were in the low-risk group and 175 178 (30.4%) in the high-risk group, and 272 921 women (47.4%) received neuraxial analgesia. SMM occurred in 7712 women (1.3%), of which 2748 (35.6%) had PPH. Before weighting, the incidence of SMM was 1.3% (3486 of 272 291) with neuraxial analgesia compared with 1.4% (4226 of 302 603) without neuraxial analgesia (risk difference, -0.12 per 100; 95% CI, -0.17 to -0.07). After weighting, the aOR of SMM associated with neuraxial analgesia was 0.86 (95% CI, 0.82-0.90). Decreased risk of SMM associated with neuraxial analgesia was similar between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women. More than one-fifth (21%; 95% CI, 14-28) of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH. Conclusions and Relevance: Findings from this study suggest that use of neuraxial analgesia for vaginal delivery is associated with a 14% decrease in the risk of SMM. Increasing access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

Association of Medicaid Expansion Under the Affordable Care Act With Perinatal Care Access and Utilization Among Low-Income Women: A Systematic Review and Meta-analysis.

OBJECTIVE: To synthesize the empirical research evidence about the association between Medicaid expansion under the Affordable Care Act (ACA) and increasing perinatal care access and utilization among low-income women. DATA SOURCES: We searched MEDLINE through PubMed (1966-present), EMBASE (Ovid), the Cumulative Index to Nursing and Allied Health (1982-present), PAIS Index (ProQuest), Web of Science (1900-present), and the Cochrane Central Register of Controlled Trials. Our review focuses on the association between Medicaid expansion under the ACA and perinatal care access and utilization, which cannot be subjected to randomized controlled trials, therefore ClinicalTrials.gov was not included in our search. METHODS OF STUDY SELECTION: A comprehensive search of the research literature was performed using Covidence. Studies were eligible if they were based on population data and research designs ensuring that the exposure (ie, Medicaid expansion under the ACA) preceded the perinatal care access or utilization outcome, had an appropriate comparison group, presented quantitative data, and examined pregnant or postpartum women. The search in six bibliographic databases returned 1,243 records, with 855 abstracts reviewed, 34 full-text articles screened for eligibility, and nine eligible studies included in the systematic review. TABULATION, INTEGRATION, AND RESULTS: Stata 16 software was used to generate summary estimates, forest plots, funnel plots, and heterogeneity statistics. Random effects modeling based on pooled data revealed that Medicaid expansion was associated with a 6.1% increase in Medicaid enrollment for pregnant women (95% CI 1.3-10.9%) and a 3.3% increase in perinatal care utilization (95% CI 0.2-6.3%). CONCLUSION: Medicaid expansion under the ACA is associated with a modest and statistically significant increase in perinatal care access and utilization among low-income women.

Hopelessness in New York State Physicians During the First Wave of the COVID-19 Outbreak.

BACKGROUND: In the United States, New York State's health care system experienced unprecedented stress as an early epicenter of the coronavirus disease 2019 (COVID-19) pandemic. This study aims to assess the level of hopelessness in New York State physicians working on the frontlines during the first wave of the COVID-19 outbreak. METHODS: A confidential online survey sent to New York State health care workers by the state health commissioner's office was used to gather demographic and hopelessness data as captured by a brief Hopelessness Scale. Adjusted linear regression models were used to assess the associations of physician age, sex, and number of triage decisions made, with level of hopelessness. RESULTS: In total, 1330 physicians were included, of whom 684 were male (51.4%). Their average age was 52.4 years (SD=12.7), with the majority of respondents aged 50 years and older (55.2%). Almost half of the physician respondents (46.3%) worked directly with COVID-19 patients, and 163 (12.3%) were involved in COVID-19-related triage decisions. On adjusted analysis, physicians aged 40 to 49 years had significantly higher levels of hopelessness compared with those aged 50 years or more (µ=0.441, SD=0.152, P=0.004). Those involved in 1 to 5 COVID-19-related triage decisions had a significantly lower mean hopelessness score (µ=-0.572, SD=0.208, P=0.006) compared with physicians involved in none of these decisions. CONCLUSION: Self-reported hopelessness was significantly higher among physicians aged 40 to 49 years and those who had not yet been involved in a life or death triage decision. Further work is needed to identify strategies to support physicians at high risk for adverse mental health outcomes during public health emergencies such as the COVID-19 pandemic.

Homicide Incidents Involving Children with Autism Spectrum Disorder as Victims Reported in the US News Media, 2000-2019.

Recent research indicates that children with autism are at increased risk of maltreatment. We examined news media reports on homicide incidents involving children with autism as victims in the United States between 2000 and 2019. Of the 52 victims studied, 47 (90.4%) were male. Age of victims ranged from 2 to 20 years (mean = 10.4 ± 5.3 years). Parents and other caregivers accounted for 63.5% and 13.5% of the perpetrators, respectively. The leading injury mechanism was gunshot wounds (23.1%), followed by drowning (19.2%), and suffocation, strangulation, or asphyxiation (19.2%). The most commonly cited contributing factor (47.1%) was overwhelming stress from caring for the autistic child. These results underscore the importance of supporting services for caregivers of children with autism.

Development of a preoperative risk score predicting allogeneic red blood cell transfusion in children undergoing spinal fusion.

BACKGROUND: Children undergoing spinal fusion often receive blood products. The goal of this study was to develop a preoperative score to help physicians identify those who are at risk of allogeneic red blood cell (RBC) transfusion. STUDY DESIGN AND METHODS: This retrospective study of children undergoing spinal fusion in the ACS-NSQIP Pediatric database (2016-2019) aimed at identifying risk factors associated with allogeneic RBC transfusion. Univariable logistic regression and multivariable logistic regression were performed using preoperative patient characteristics and aided in the creation of a simplified scoring system. RESULTS: Out of 13,929 total patients, 2990 (21.5%) were transfused. We created a risk score based on 10 independent predictors of transfusion: age, sex, race, weight < 3rd percentile, American Society of Anesthesiologists physical status classification, cardiac risk factors, hematologic disease, preoperative anemia, deformity type, and number of spinal levels to be fused. Patients in both the training and testing cohorts were assigned a score ranging from 0 (lowest risk) to 21 (highest risk). The developed transfusion risk score showed 77% accuracy in distinguishing patients who did not receive a transfusion during or soon after surgery (AUROC 0.7736 [95% CI, 0.7619-0.7852]) in the training cohort and 77% accuracy (AUROC 0.7732 [95% CI, 0.7554-0.7910]) in the testing cohort. DISCUSSION: Our score, based on routinely available preoperative data, accurately estimates the risk of allogeneic RBC transfusion in pediatric patients undergoing spinal fusion. Future studies will inform whether patient blood management interventions targeted to high-risk patients can help reduce the need for transfusion and improve outcomes.

Risk of Self-harm in Children and Adults With Autism Spectrum Disorder: A Systematic Review and Meta-analysis.

Importance: Multiple studies have reported that people with autism spectrum disorder (ASD) are at a higher risk for self-injurious behavior and suicide. However, the magnitude of this association varies between studies. Objective: To appraise the available epidemiologic studies on the risk of self-injurious behavior and suicidality among children and adults with ASD. Data Sources: PubMed, Embase, CINAHL, PsycINFO, and Web of Science were systematically searched for epidemiologic studies on the association between ASD and self-injurious behavior and suicidality. Databases were searched from year of inception to April through June 2020. No language, age, or date restrictions were applied. Study Selection: This systematic review and meta-analysis included studies with an observational design and compared self-injurious behavior (defined as nonaccidental behavior resulting in self-inflicted physical injury but without intent of suicide or sexual arousal) and/or suicidality (defined as suicidal ideation, suicide attempt, or suicide) in children (aged <20 years) or adults (aged ≥20 years) with ASD. Data Extraction and Synthesis: Information on study design, study population, ASD and self-harm definitions, and outcomes were extracted by independent investigators. Study quality was assessed using the Newcastle-Ottawa Scale. Overall summary odds ratios (ORs) and 95% CIs were estimated using DerSimonian-Laird random-effects models. Main Outcomes and Measures: The ORs for the associations of ASD with self-injurious behavior and suicidality were calculated. Analyses were stratified by study setting and age groups as planned a priori. Results: The search identified 31 eligible studies, which were of moderate to high quality. Of these studies, 16 (52%) were conducted in children, 13 (42%) in adults, and 2 (6%) in both children and adults. Seventeen studies assessed the association between ASD and self-injurious behavior and reported ORs that ranged from 1.21 to 18.76, resulting in a pooled OR of 3.18 (95% CI, 2.45-4.12). Sixteen studies assessed the association between ASD and suicidality and reported ORs that ranged from 0.86 to 11.10, resulting in a pooled OR of 3.32 (95% CI, 2.60-4.24). In stratified analyses, results were consistent between clinical and nonclinical settings and between children and adults. Conclusions and Relevance: This study found that ASD was associated with a substantial increase in odds of self-injurious behavior and suicidality in children and adults. Further research is needed to examine the role of primary care screenings, increased access to preventive mental health services, and lethal means counseling in reducing self-harm in this population.

Factors Related to Self-Reported Distress Experienced by Physicians During Their First COVID-19 Triage Decisions.

OBJECTIVE: The aim of this study was to identify factors associated with distress experienced by physicians during their first coronavirus disease 2019 (COVID-19) triage decisions. METHODS: An online survey was administered to physicians licensed in New York State. RESULTS: Of the 164 physicians studied, 20.7% experienced severe distress during their first COVID-19 triage decisions. The mean distress score was not significantly different between physicians who received just-in-time training and those who did not (6.0 ± 2.7 vs 6.2 ± 2.8; P = 0.550) and between physicians who received clinical guidelines and those who did not (6.0 ± 2.9 vs 6.2 ± 2.7; P = 0.820). Substantially increased odds of severe distress were found in physicians who reported that their first COVID-19 triage decisions were inconsistent with their core values (adjusted odds ratio, 6.33; 95% confidence interval, 2.03-19.76) and who reported having insufficient skills and expertise (adjusted odds ratio 2.99, 95% confidence interval 0.91-9.87). CONCLUSION: Approximately 1 in 5 physicians in New York experienced severe distress during their first COVID-19 triage decisions. Physicians with insufficient skills and expertise, and core values misaligned to triage decisions are at heightened risk of experiencing severe distress. Just-in-time training and clinical guidelines do not appear to alleviate distress experienced by physicians during their first COVID-19 triage decisions.