Inhaled Corticosteroids Increase Risk of Nontuberculous Mycobacterial Lung Disease: A Nested Case-Control Study and Meta-analysis.

Studies on use of inhaled corticosteroids (ICS) and the risk of nontuberculous mycobacterial lung disease (NTM-LD) are limited and have some conflicting results. We recruited 1235 NTM-LD patients and found that ICS use within 1 year was associated with increased NTM-LD, and the risk increased with elevated ICS dose and cumulative duration. Discontinuation of ICS use for more than 120 days could reduce the risk of NTM-LD to an insignificant level. For NTM species, the development of NTM-LD by ICS was highest for Mycobacterium kansasii lung disease. The pooled results of the meta-analysis showed that ICS use might increase the risk of NTM-LD with dose response in medium and high dose of daily ICS. In addition, budesonide had a smaller impact on the risk of NTM-LD than other ICS medications. The present study and meta-analysis provide evidence for ICS adjustment, including dose, discontinuation effect, and medications to possibly reduce the risk of NTM-LD.

Bandgap Shrinkage and Charge Transfer in 2D Layered SnS2 Doped with V for Photocatalytic Efficiency Improvement.

Effects of electronic and atomic structures of V-doped 2D layered SnS2 are studied using X-ray spectroscopy for the development of photocatalytic/photovoltaic applications. Extended X-ray absorption fine structure measurements at V K-edge reveal the presence of VO and VS bonds which form the intercalation of tetrahedral OVS sites in the van der Waals (vdW) gap of SnS2 layers. X-ray absorption near-edge structure (XANES) reveals not only valence state of V dopant in SnS2 is ≈4+ but also the charge transfer (CT) from V to ligands, supported by V Lα,ß resonant inelastic X-ray scattering. These results suggest V doping produces extra interlayer covalent interactions and additional conducting channels, which increase the electronic conductivity and CT. This gives rapid transport of photo-excited electrons and effective carrier separation in layered SnS2 . Additionally, valence-band photoemission spectra and S K-edge XANES indicate that the density of states near/at valence-band maximum is shifted to lower binding energy in V-doped SnS2 compare to pristine SnS2 and exhibits band gap shrinkage. These findings support first-principles density functional theory calculations of the interstitially tetrahedral OVS site intercalated in the vdW gap, highlighting the CT from V to ligands in V-doped SnS2 .

Clinical efficacy and safety of remdesivir in patients with COVID-19: a systematic review and network meta-analysis of randomized controlled trials.

OBJECTIVES: We performed a systematic review and network meta-analysis of randomized controlled trials (RCTs) to provide updated information regarding the clinical efficacy of remdesivir in treating coronavirus disease 2019 (COVID-19). METHODS: PubMed, Embase, Cochrane Library, clinical trial registries of ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform were searched for relevant articles published up to 18 November 2020. RESULTS: Five RCTs, including 13 544 patients, were included in this meta-analysis. Among them, 3839 and 391 patients were assigned to the 10 day and 5 day remdesivir regimens, respectively. Patients receiving 5 day remdesivir therapy presented greater clinical improvement than those in the control group [OR = 1.68 (95% CI 1.18-2.40)], with no significant difference observed between the 10 day and placebo groups [OR = 1.23 (95% CI 0.90-1.68)]. Patients receiving remdesivir revealed a greater likelihood of discharge [10 day remdesivir versus control: OR = 1.32 (95% CI 1.09-1.60); 5 day remdesivir versus control: OR = 1.73 (95% CI 1.28-2.35)] and recovery [10 day remdesivir versus control: OR = 1.29 (95% CI 1.03-1.60); 5 day remdesivir versus control: OR = 1.80 (95% CI 1.31-2.48)] than those in the control group. In contrast, no mortality benefit was observed following remdesivir therapy. Furthermore, no significant association was observed between remdesivir treatment and an increased risk of adverse events. CONCLUSIONS: Remdesivir can help improve the clinical outcome of hospitalized patients with COVID-19 and a 5 day regimen, instead of a 10 day regimen, may be sufficient for treatment. Moreover, remdesivir appears as tolerable as other comparators or placebo.

Correlates of self-report chronic insomnia disorders with 1-6 month and 6-month durations in home-dwelling urban older adults - the Shih-Pai Sleep Study in Taiwan: a cross-sectional community study.

BACKGROUND: To examine the correlates of insomnia disorder with different durations in home-dwelling older adults. METHODS: A cross-sectional survey in the Shih-Pai area of Taipei City, Taiwan (The Shih-Pai Sleep Study). A total 4047 subjects over the age of 65 years completed the study (2259 men and 1788 women). The Pittsburgh Sleep Quality Index and the duration of insomnia symptoms were used to identify DSM-IV 1-6 month and 6-month insomnia disorders. RESULTS: The prevalence of DSM-IV defined insomnia disorder was 5.8 %; two-thirds of these case lasted for ≥6 months. The shared correlates for both 1-6 and 6-month insomnia disorders were gender (women), depression and moderate pain. Pulmonary diseases were exclusively associated with 1-6 month insomnia disorder (OR: 2.57, 95 % CI: 1.46-4.52). In contrast, heart disease (OR: 1.73, 95 % CI: 1.21-2.49) and severe pain (OR: 2.34, 95 % CI: 1.14-4.40) were associated with 6-month insomnia disorder. CONCLUSION: The prevalence of persistent insomnia disorder is higher than short-term insomnia disorder. Correlates for less persistent and more persistent insomnia disorder appears to be partially different. Duration quantifiers may be important in the identification of the etiology of insomnia and further studies with follow-ups are needed to examine the order of developing insomnia disorder and associated conditions.

The influence of prior use of inhaled corticosteroids on COVID-19 outcomes: A systematic review and meta-analysis.

The influence of inhaled corticosteroids (ICS) on COVID-19 outcomes remains uncertain. To address this, we conducted a systematic review and meta-analysis, analyzing 30 studies, to investigate the impact of ICS on patients with COVID-19. Our study focused on various outcomes, including mortality risk, hospitalization, admission to the intensive care unit (ICU), mechanical ventilation (MV) utilization, and length of hospital stay. Additionally, we conducted a subgroup analysis to assess the effect of ICS on patients with chronic obstructive pulmonary disease (COPD) and asthma. Our findings suggest that the prior use of ICS did not lead to significant differences in mortality risk, ICU admission, hospitalization, or MV utilization between individuals who had used ICS previously and those who had not. However, in the subgroup analysis of patients with COPD, prior ICS use was associated with a lower risk of mortality compared to non-users (OR, 0.95; 95% CI, 0.90-1.00). Overall, while the use of ICS did not significantly affect COVID-19 outcomes in general, it may have beneficial effects specifically for patients with COPD. Nevertheless, more research is needed to establish a definitive conclusion on the role of ICS in COVID-19 treatment. PROSPERO registration number: CRD42021279429.

The association between inhaled corticosteroid and the risks of SARS-COV-2 infection: A systematic review and meta-analysis.

BACKGROUND: The effect of inhaled corticosteroid (ICS) on the risk of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection is unclear. METHODS: We performed a systematic review and meta-analysis of clinical studies that assessed the association between the use of ICS and the risk of SARS-COV-2 infection. PubMed, Web of Science, Scopus, Cochrane Library and Google Scholar were searched to January 1st, 2023. ROBINS-I was used to assess risk of bias of included studies. The outcome of interest was the risk of SARS-COV-2 infection in patients and odds ratio (OR) with 95% confidence interval (95% CI) were calculated using Comprehensive Meta-analysis software version 3. RESULTS: Twelve studies involving seven observational cohort studies, three case-control studies, and two cross-sectional studies were included in this meta-analysis. Overall, compared to non-ICS use, the pooled odds ratio (OR) of the risk of SARS-COV-2 infection was 0.997 (95% confidence interval [CI] 0.664-1.499; p = 0.987) for patients with ICS use. Subgroup analyses demonstrated no statistical significance in the increased risk of SARS-COV-2 infection in patients with ICS monotherapy or in combination with bronchodilators (pooled OR=1.408; 95% CI=0.693-2.858; p = 0.344 in ICS monotherapy, and pooled OR=1.225; 95% CI=0.533-2.815; p = 0.633 in ICS combination, respectively). In addition, no significant association was observed between ICS use and the risk of SARS-COV-2 infection for patients with COPD (pooled OR=0.715; 95% CI=0.415-1.230; p = 0.225) and asthma (pooled OR=1.081; 95% CI=0.970-1.206; p = 0.160). CONCLUSIONS: The use of ICS, either monotherapy or in combination with bronchodilators, does not have impact on the risk of SARS-COV-2 infection.

Dipeptidyl peptidase IV inhibitors and the risk of mycobacterial pulmonary infections in type 2 diabetes mellitus.

BACKGROUND: Type 2 diabetes mellitus (DM) is a risk factor for mycobacterial pulmonary infections (MPI), including tuberculosis (TB) and nontuberculous mycobacterial lung disease (NTM-LD). Dipeptidyl peptidase IV inhibitor (DPP4i), a common DM medication, has an immune-modulation effect that raises concerns about developing MPI. However, there is scarce research on the topic. METHODS: This retrospective study was conducted in a tertiary-referral center in Taiwan from 2009 to 2016. Patients with type 2 DM who were receiving any DM medication were enrolled. TB and NTM-LD were defined by microbiological criteria. We analyzed the risk of MPI in DPP4i users using Cox proportional hazard regression with adjusted inverse probability of treatment weighting. RESULTS: A total of 9963 patients were included. Among them, 3931 were classified as DPP4i users, and 6032 patients were DPP4i nonusers. DPP4i users had no increase in incidences of MPI (604 vs. 768 per 100,000 person-years, p = 0.776), NTM-LD (174 vs. 255 per 100,000 person-years, p = 0.228), and TB (542 vs. 449 per 100,000 person-years, p = 0.663) relative to those of DPP4i nonusers. After adjustment, the adjusted hazard ratios for MPI (aHR: 1.07, 95% CI: 0.79-1.45), TB (aHR: 1.15, 95% CI: 0.81-1.64) and NTM-LD (aHR: 0.85, 95% CI: 0.49-1.47) were not significantly increased relative to those of nonusers. The subgroup analysis also showed that DPP4i use did not increase the risk of MPI in different DM severities and comorbidities. CONCLUSIONS: According to our large cohort study, DPP4i use is safe for patients with type 2 DM and might not increase the risk of MPI.

The Clinical Efficacy and Safety of Anti-Viral Agents for Non-Hospitalized Patients with COVID-19: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

This network meta-analysis compared the clinical efficacy and safety of anti-viral agents for the prevention of disease progression among non-hospitalized patients with COVID-19. PubMed, Embase, Web of Science, Cochrane Library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform were searched from their inception to 28 May 2022. Only randomized controlled trials (RCTs) that investigated the clinical efficacy of anti-viral agents for non-hospitalized patients with COVID-19 were included. Three RCTs involving 4241 patients were included. Overall, anti-viral agents were associated with a significantly lower risk of COVID-19 related hospitalization or death compared with the placebo (OR, 0.23; 95% CI: 0.06-0.96; p = 0.04). Compared with the placebo, patients receiving nirmatrelvir plus ritonavir had the lowest risk of hospitalization or death (OR, 0.12; 95% CI: 0.06-0.24), followed by remdesivir (OR, 0.13; 95% CI: 0.03-0.57) and then molnupiravir (OR, 0.67; 95% CI: 0.46-0.99). The rank probability for each treatment calculated using the P-score revealed that nirmatrelvir plus ritonavir was the best anti-viral treatment, followed by remdesivir and then molnupiravir. Finally, anti-viral agents were not associated with an increased risk of adverse events compared with the placebo. For non-hospitalized patients with COVID-19 who are at risk of disease progression, the currently recommended three anti-viral agents, nirmatrelvir plus ritonavir, molnupiravir and remdesivir, should continue to be recommended for the prevention of disease progression. Among them, oral nirmatrelvir plus ritonavir and intravenous remdesivir seem to be the better choice, followed by molnupiravir, as determined by this network meta-analysis. Additionally, these three anti-viral agents were shown to be as tolerable as the placebo in this clinical setting.

The Impact of 52-Week Single Inhaler Device Triple Therapy versus Dual Therapy on the Mortality of COPD Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

There are more single inhaler device triple therapy available for COPD patients now. However, the effect of long-term triple therapy fixed dose combination (FDC) on mortality remains unclear. This study aimed to evaluate the impact of one-year single inhaler device triple therapy, including long-acting ß2-agonists (LABAs), long-acting muscarinic receptor antagonists (LAMAs), and inhaled corticosteroids (ICSs), with dual therapies, comprised of either LABA/LAMA or ICS/LABA, on the mortality of patients with COPD. We searched the PubMed, Cochrane library, Web of Science, Embase databases, and clinical trial registry of clinicaltrials.gov and WHO ICTRP. Randomized controlled trials (RCTs) compared single inhaler device triple and dual therapies for 52 weeks were selected for the meta-analysis. The primary endpoint was all-cause mortality. A total of 6 RCTs were selected for the meta-analysis, including 10,274 patients who received single inhaler device triple therapy (ICS/LABA/LAMA FDC) and 12,395 patients who received ICS/LABA or LABA/LAMA dual therapy. Risk of death was significantly lower in the ICS/LABA/LAMA FDC group compared to the LABA/LAMA group (RR = 0.69, 95% CI = 0.53-0.90, p = 0.007). There was no significant difference in mortality between the ICS/LABA/LAMA FDC and ICS/LABA therapy groups (RR = 0.94, 95% CI = 0.72-1.24, p = 0.66). In addition, patients receiving ICS/LABA/LAMA FDC therapy had less moderate or severe exacerbations compared with the dual therapy groups (RR = 0.76, 95% CI = 0.73-0.80, p < 0.001 for LABA/LAMA; RR = 0.84, 95% CI = 0.78-0.90, p < 0.001 for ICS/LABA). By contrast, the risk of pneumonia in the ICS/LABA/LAMA FDC group was higher than in the LABA/LAMA group (RR = 1.43, 95% CI = 1.21-1.68, p < 0.001). In conclusion, ICS/LABA/LAMA FDC therapy could help improve the clinical outcomes of patients with COPD. However, triple therapy could increase the risk of pneumonia in comparison with LABA/LAMA dual therapy.

The effect of inhaled corticosteroids on the outcomes of patients with COVID-19: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The effect of inhaled corticosteroids (ICS) on the clinical outcomes of patients with coronavirus disease 2019 (COVID-19) was not known. RESEARCH DESIGN AND METHODS: Only phase 2 and 3 randomized clinical trials (RCTs) from electronic databases that investigated ICS in the treatment of COVID-19 patients were included. The outcomes of interest were the resolution of symptoms, risk of hospitalization or urgent medical visit, mortality, and the incidence of adverse events (AEs). RESULTS: Five RCTs involving 1243 patients who received ICS and 1526 patients with placebo or usual care were included. The ICS group had a higher rate of symptom resolution than the control group at day 14 (risk ratio [RR], 1.21; 95% confidence interval [CI], 1.12-1.30, p < 0.00001) and day 28 (RR, 1.12; 95% CI, 1.06-1.18, p < 0.0001). Additionally, the ICS group had a significantly lower risk of needing urgent medical care or hospitalization than the control group (RR, 0.15; 95% CI, 0.05-0.50; I2 = 0, p = 0.002). However, no significant difference in the 28-day mortality rate. CONCLUSIONS: In patients with mild-to-moderate COVID-19, ICS therapy improved symptom resolution, and decreased the risk of needing urgent medical care or hospitalization.

Differential relationships of family drinking with alcohol expectancy among urban school children.

BACKGROUND: Positive alcohol outcome expectancy has consistently been linked with problematic drinking, but there is little population-based evidence on its role on early stages of drinking in childhood. The present study seeks to understand the extent to which drinking of family members is differentially associated with the endorsement of alcohol expectancy in late childhood. METHODS: A representative sample of 4th and 6th graders (N = 2455) drawn from 28 public schools in an urban region of Taiwan completed a self-administered paper-and-pencil questionnaire. Each student provided information on alcohol expectancy, drinking experiences, and individual and family attributes. Complex survey analyses were performed to evaluate the relationship, with stratification by children's alcohol drinking history. RESULTS: An estimated 29% of the 4th graders and 43% of the 6th graders had initiated alcohol consumption (over 40% of them had drank on three or more occasions). Alcohol drinking-related differences appear in both the endorsement and the correlates of alcohol expectancy. Positive alcohol expectancy was strongly associated with family drinking, particularly the dimension of "enhanced social behaviors"; negative alcohol expectancy was inversely associated with drinking frequency. Among alcohol naïve children, significant connections appear between paternal drinking and three dimensions of positive alcohol expectancy (i.e., enhanced social behaviors:ßwt = 0.15, promoting relaxation or tension reduction:ßwt = 0.18, and global positive transformation:ßwt = 0.22). CONCLUSIONS: Individual tailored strategies that address family influences on alcohol expectancy may be needed in prevention programs targeting drinking behaviors in children.

The Association between the Risk of Aortic Aneurysm/Aortic Dissection and the Use of Fluroquinolones: A Systematic Review and Meta-Analysis.

This study aimed to investigate the association between the risk of aortic aneurysm (AA)/aortic dissection (AD) and the use of fluoroquinolones (FQs). PubMed, Embase, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Web of Science and Scopus were searched for relevant articles to 21st February 2021. Studies that compared the risk of AA/AD in patients who did and did not receive FQs or other comparators were included. The pooled results of nine studies with 11 study cohorts showed that the use of FQs increased the risk of AA/AD by 69% (pooled risk ratio (RR) = 1.69 (95% CI = 1.08, 2.64)). This significant association remained unchanged using leave-one-out sensitivity test analysis. Similar results were found for AA (pooled RR = 1.58 (1.21, 2.07)) but no significant association was observed for AD (pooled RR = 1.23 (0.93, 1.62)). Stratified by the comparators, the use of FQs was associated with a significantly higher risk of AA/AD compared to azithromycin (pooled RR = 2.31 (1.54, 3.47)) and amoxicillin (pooled RR = 1.57 (1.39, 1.78)). In contrast, FQ was not associated with a higher risk of AA/AD, when compared with amoxicillin/clavulanic acid or ampicillin/sulbactam (pooled RR = 1.18 (0.81, 1.73)), sulfamethoxazole-trimethoprim (pooled RR = 0.89 (0.65, 1.22)) and other antibiotics (pooled RR = 1.14 (0.90, 1.46)). In conclusion, FQs were associated with an increased risk of AA or AD, although the level of evidence was not robust. However, FQs did not exhibit a higher risk of AA or AD compared with other broad-spectrum antibiotics. Further studies are warranted to clarify the role of FQs in the development of AA or AD.

Increased risks of congenital, neurologic, and endocrine disorders associated with autism in preschool children: cognitive ability differences.

OBJECTIVE: To investigate the increased risk of congenital, neurologic, and endocrine disorders in autistic preschool children and to probe possible cognitive impairment-associated variation in such risks. STUDY DESIGN: Using a population-based longitudinal study, a total of 3440 autistic children born in 1997-1999 and 33,391 age- and residential urbanicity-matched control subjects were identified from the National Health Insurance Research Database in Taiwan. Conditional logistic analyses were performed to estimate the strength of association stratified by the presence of cognitive impairment. RESULTS: Autistic children were found to have greatly elevated risks of congenital anomalies (eg, tuberous sclerosis: adjusted odds ratio [aOR] = 34 approximately 61) and neurologic disorders (eg, epilepsy: aOR = 5 approximately 13) compared with their matched nonautistic peers. The increased risk of medical diseases for mentally retarded autism were approximately 1.6 to 9 times greater than those for isolated autism. CONCLUSIONS: The observed cognitive impairment-related variation in the increased risk of congenital, neurological, and endocrine disorders with autism may provide some clinical and etiologic implications that warrant investigation in the future.

School District Variation in Parental Influence on Underage Drinking Behaviors.

PURPOSE: We examined the relationship between alcohol-specific and nonalcohol-specific parental characteristics with occasional alcohol drinking in early adolescence and probed potential school district variation. METHODS: A total of 1,581 fourth and sixth graders (age range: 10-12 years) were ascertained from 17 elementary schools in a cohort study conducted in northern Taiwan in 2006, with three waves of follow-up between 2007 and 2009. Information on alcohol-specific and nonalcohol-specific parental attributes was obtained from the first two waves of self-administered paper-and-pencil questionnaires; occasional drinking, defined by having drunk on three or more occasions in the past year, was assessed at fourth wave. School district characteristics were retrieved from official statistics and self-report. Multilevel analyses were used to evaluate strength of association, with stratification by disadvantaged status of school districts. RESULTS: Thirteen percent (95% confidence interval [CI] = 10.1%-15.8%) of young adolescents reported to drink occasionally; higher grade level, childhood drinking experience, lower parental education, maternal drinking, and positive parental attitude toward drinking were significant predictors. Nonalcohol parental predictors, including not living with both parents (adjusted odds ratio [aOR] = 2.34, 95% CI = 1.21-4.53) and parental involvement/reinforcement (aOR = .44; 95% CI = .22-.87), were only significant for the children of socioeconomically disadvantaged school districts. As to alcohol-specific parental characteristics, the effects of maternal drinking appear more salient in socioeconomically advantaged school districts (aOR = 2.63; 95% CI = 1.66-4.18). CONCLUSIONS: Alcohol-specific and nonalcohol-specific parental influence may operate differentially across school districts sub-grouped by socioeconomic attributes. Preventive strategies raising the awareness of underage drinking and strengthening parenting skills should be devised and implemented in the perspective of social context.

Effects of genetic variants of ADH1B and ALDH2 and social network on continued alcohol drinking among young adolescents in Taiwan.

BACKGROUND: This study aimed (i) to evaluate the effects of genetic variants of ADH1B and ALDH2 and social network position on continued alcohol use in early adolescence, and (ii) to explore possible moderating role of pubertal development on genetic effects. METHODS: The sample comprised 496 children who ever drank alcohol before the ages of 10-12. Information pertaining to sociodemographic background, pubertal development, parental drinking, alcohol and tobacco use, alcohol-metabolizing genes, and nominated best friends was collected in four waves of assessment. Polymorphisms of ADH1B (rs1229984) and ALDH2 (rs671) were genotyped. The latent class analysis was first used to characterize longitudinal alcohol use pattern, followed by the multinomial logistic regression analyses to assess its association with genes, pubertal development, and social network. RESULTS: Three distinct classes of alcohol users (i.e. ex-drinkers, sporadic drinkers, and continued drinkers) were derived from alcohol-experienced children. Both alcohol-metabolizing genes appear to have protective effects, yet such relationships were only significant for youngsters in pre-to-early pubertal stage: the adjusted odds ratio (aOR) of ADH1B fast-genotype for sporadic drinkers was 0.46 and that of ALDH2 slow-genotype for both sporadic and continued drinkers was 0.47 and 0.42, respectively. Children having the bridge position in their peer network were more likely to be sporadic drinkers (aOR=4.15) and continued drinkers (aOR=3.16). CONCLUSIONS: Our results illustrate a potential moderating effect of pubertal development on the protective influence of alcohol-metabolizing genes on subsequent alcohol use among alcohol-experienced children as well as the independent contribution of early life's social network to their alcohol involvement.

Gender differences in widowhood effects among community-dwelling elders by causes of death in Taiwan.

PURPOSE: We sought to determine whether widowhood-associated excess mortality differs by gender in terms of causes of death. METHODS: Data were collected from a five-wave interview of approximately 2500 community-dwelling elders in the Survey of Health and Living Status of the Nearly Elderly and Elderly. Baseline characteristics were used to derive the risk score (RS) to reflect individual's baseline pre-widowhood vulnerability. Time-dependent Cox regression analyses were used to estimate spousal loss-related mortality by causes. RESULTS: For males, the adjusted hazard ratios (aHRs) of widowhood for all-cause and some major causes of death (e.g., neoplasm) increased inversely with RS: the aHRs for all-cause death were 4.81 and 1.76 in the lowest and highest RS groups, respectively. In contrast, the corresponding aHRs were relatively homogeneous for women (1.52 and 1.70). CONCLUSIONS: Identifying gender heterogeneity in widowhood effects can guide further efforts to devise gender-tailored programs to enhance healthy aging.

Multilevel influences of school and family on alcohol-purchasing behaviors in school-aged children.

BACKGROUND: Little has been known about children's illegal alcohol purchasing behaviors and associated contextual factors influencing commercial accessibility to alcohol. The aims are to determine multilevel effects of school- and family-characteristics on children's alcohol purchase and to probe possible drinking experience-related heterogeneity in such links. METHODS: A representative sample of 2630 4th- and 6th-graders in an urban region of Taiwan in 2007 was drawn via multistage probability sampling. Information about family background and individual drinking experiences was collected via paper-and-pencil self-administered questionnaires; school neighborhood characteristics were assessed via commercial datasets of geographic information system. RESULTS: Roughly one in nine 10-12-year-old children ever purchased alcoholic beverages by 6th grade. Children who did not participate in after-school programs or had observed parental drinking had 2-3-fold increased risk to buy alcoholic beverages alone. Living with one or none of parents was associated with alcohol purchase in children who never drank alcohol (Odds Ratio [OR]=3.51; 95% Confidence Interval [CI]=2.14, 5.76). School contextual characteristics have salient effects on minors' alcohol accessibility from commercial sources (e.g., the density of nearby educational institutions, OR=0.33-0.53), and certain school neighborhood effects were notably different by children's drinking experience (e.g., the density of public transportation). CONCLUSIONS: The present study suggests the significant effects of family socioeconomics, family drinking, and school neighboring environment on children's independent alcohol purchase, which may operate differentially by one's drinking experience. Our findings may provide implications that family and school neighborhood contexts should be considered in the devising and delivery of underage drinking prevention programs.

Differential effects of predictors on methylphenidate initiation and discontinuation among young people with newly diagnosed attention-deficit/hyperactivity disorder.

OBJECTIVE: Previous population-based studies have identified factors accounting for differential utilization of psychotropic medications among young patients with attention-deficit/hyperactivity disorders (ADHDs); yet, few analyses have addressed changes in such factors that can occur in the help-seeking process. The aim of this study was to examine patient- and service provider-level predictors for methylphenidate (MPH) initiation and discontinuation. METHOD: This cohort study included 10,153 newly diagnosed ADHD patients under 18 years of age in 2000, identified from the National Health Insurance Research Database. The risk association was estimated by time-dependent survival analyses, as indexed by hazard ratio. RESULTS: Approximately 30% of young people received MPH treatment within the year of their ADHD diagnosis, and virtually none remained in treatment beyond 12 months. Regardless of co-morbidity status, the following were significantly associated with earlier initiation of MPH treatment: older age (e.g., adjusted hazard ratio [aHR] for age 12-17 = 4.5-7.6), lower socioeconomic status (aHR = 1.2-1.4), southern residence (aHR = 1.4-1.6), receiving the diagnosis while school was in session (aHR = 1.3-1.4), receiving the diagnosis from a physician specializing in pediatrics or psychiatry (aHR = 7.3-16.8), and receiving the diagnosis in a district hospital/clinic (aHR = 1.3-1.7). However, once treatment started, older ages appeared to increase the risk of early discontinuation by 15%, and the corresponding estimates for receiving initial MPH in a regional hospital or district hospital/clinic were 27% and 32%, respectively. Change in treatment location upon subsequent visit was associated with a 58% reduction in early discontinuation. CONCLUSIONS: This information about time-varying predictors for MPH utilization throughout treatment may provide insight into the delivery of pediatric mental health services and has important implications for the design of clinical treatment programs.