Change in 9/11-related post-traumatic stress symptoms following cancer diagnosis.

OBJECTIVE: Cancer can be a life-threatening stressor that may evoke pre-existing post-traumatic stress disorder (PTSD). We assessed change in 9/11-related PTSD symptoms following cancer diagnosis in a 9/11-exposed cohort, the World Trade Center Health Registry. METHODS: We examined enrollees who had a first-time post-9/11 invasive cancer diagnosis and at least one pre- and two post-diagnosis 9/11-related PTSD assessments from enrolment through 2015. PTSD symptoms were measured using 17-item PTSD Checklist (PCL, range 17-85). Cancer was identified from New York State Cancer Registry and categorized as localized or advanced stage. We used piecewise spline linear mixed-effects models to examine rate of change in PCL scores from pre- to post-diagnosis periods, and whether the change differed by gender or stage, with time as fixed and random effects, adjusting for baseline age, race, and education. RESULTS: 9/11-related PTSD symptoms were slightly increasing in the pre-diagnosis period, while this trend reversed in the post-diagnosis period (ß: -0.38; 95% CI: -0.60, -0.15). This trend was driven by male rescue/recovery workers (RRW), among whom significant decrease in rate of change in PCL scores was observed for those with advanced stage (slope change difference [95% CI]: -1.81 [-2.73, -0.90]). No significant difference in rate of change was observed among non-RRW. Among females, PCL scores tended to decrease slightly, with no significant difference in rate of change between pre- and post-diagnosis periods. CONCLUSIONS: We observed significant reduction in the rate of change in 9/11-related PTSD symptoms among male RRW. The underlying mechanism is unknown, necessitating future research.

Post-traumatic stress disorder and the association with overweight, obesity, and weight change among individuals exposed to the World Trade Center disaster, 2003-2016.

BACKGROUND: Among Veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with obesity and accelerated weight gain. Less is known among the general population. We sought to determine the impact of PTSD on body mass index (BMI) and weight change among individuals with exposure to the World Trade Center (WTC) disaster. METHODS: We examined individuals from the WTC Health Registry. PTSD symptoms were assessed on multiple surveys (Waves 1-4) using the PTSD Checklist-Specific. Three categories of post-9/11 PTSD were derived: no, intermittent, and persistent. We examined two outcomes: (1) Wave 3 BMI (normal, overweight, and obese) and (2) weight change between Waves 3 and 4. We used multivariable logistic regression to assess the association between PTSD and BMI (N = 34 958) and generalized estimating equations to assess the impact of PTSD on weight change (N = 26 532). Sex- and age-stratified analyses were adjusted for a priori confounders. RESULTS: At Wave 3, the observed prevalence of obesity was highest among the persistent (39.5%) and intermittent PTSD (36.6%) groups, compared to the no PTSD group (29.3%). In adjusted models, persistent and intermittent PTSD were consistently associated with a higher odds of obesity. Weight gain was similar across all groups, but those with persistent and intermittent PTSD had higher estimated group-specific mean weights across time. CONCLUSIONS: Our findings that those with a history of PTSD post-9/11 were more likely to have obesity is consistent with existing literature. These findings reaffirm the need for an interdisciplinary focus on physical and mental health to improve health outcomes.

The Association Between Birth Weight and Fat, Sugar, and Vegetable Consumption in a National Sample of U.S. Preschool Age Children.

INTRODUCTION: Adverse prenatal development is a contributor to obesity susceptibility in children. Dietary behavior is one mechanism through which adverse prenatal development may promote obesity, but evidence for the role of prenatal overnutrition in dietary intake in young children is scant. METHODS: We used data from the National Health and Nutrition Examination Survey 2009-2014. Our study sample included 1782 U.S. children 2-5 years old with available birth weight and two 24-h dietary recalls. We used linear and Poisson regression to examine the association of birth weight (LBW < 2500 g, HBW > 4100 g) and 2-day average intake of dietary variables. We tested interactions between birthweight and breastfeeding (breastfed > 5 months vs. not breastfed or breastfed 0-5 months), and report breastfeeding-specific results. RESULTS: In multivariable regression analysis, in boys, LBW was associated with 2.4 (95% CI - 4.3, - 0.5) lower percent of kcal from solid fat; lower sugar intake, marginally lower saturated and total fat intake, and 0.6 cup (95% CI 0.1, 1.0) greater vegetable consumption; HBW was marginally associated with lower fat. Birth weight was unrelated to diet in girls. Breastfeeding modified associations between birth weight and dietary intake, but the direction of modification was mixed. DISCUSSION: Our findings do not support the hypothesis that LBW or HBW are associated with adverse diet consumption in preschool age U.S. children. Improved understanding of the role of early life development of dietary behavior requires further research on the development of appetitive traits and the role of the family and preschool food environments.

Insurance status differences in weight loss and regain over 5 years following bariatric surgery.

BACKGROUND: The effectiveness of bariatric surgery among Medicaid beneficiaries, a population with a disproportionately high burden of obesity, remains unclear. We sought to determine if weight loss and regain following bariatric surgery differed in Medicaid patients compared to commercial insurance. SUBJECTS/METHODS: Data from the Longitudinal Assessment of Bariatric Surgery, a ten-site observational cohort of adults undergoing bariatric surgery (2006-2009) were examined for patients who underwent Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Band (LAGB), or Sleeve Gastrectomy (SG). Using piecewise spline linear mixed-effect models, weight change over 5 years was modeled as a function of insurance type (Medicaid, N = 190; commercially insured, N = 1448), time, procedure type, and sociodemographic characteristics; additionally, interactions between all time, insurance, and procedure type indicators allowed time- and procedure-specific associations with insurance type. For each time-spline, mean (kg) difference in weight change in commercially insured versus Medicaid patients was calculated. RESULTS: Medicaid patients had higher mean weight at baseline (138.3 kg vs. 131.2 kg). From 0 to 1 year post-operatively, Medicaid patients lost similar amounts of weight to commercial patients following all procedure types (mean weight Δ difference [95% CI]: RYGB: -0.9 [-3.2, 1.4]; LAGB: -1.5 [-6.7, 3.8]; SG: 5.1 [-4.0, 14.2]). From 1 to 3 years post-operatively Medicaid and commercial patients continued to experience minimal weight loss or began to slowly regain weight (mean weight Δ difference [95% CI]: RYGB: 0.9 [0.0, 2.0]; LAGB: -2.1 [-4.2, 0.1]; SG: 0.7 [-3.0, 4.3]). From 3 to 5 years post-operatively, the rate of regain tended to be faster among commercial patients compared to Medicaid patients (mean weight Δ difference [95% CI]: RYGB: 1.1 [0.1, 2.0]; LAGB: 1.5 [-0.5, 3.5]; SG: 1.0 [-2.5, 4.5]). CONCLUSIONS: Although Medicaid patients had a higher baseline weight, they achieved similar amounts of weight loss and tended to regain weight at a slower rate than commercial patients.

Inequities in naloxone administration among fatal overdose decedents by race and ethnicity in Pennsylvania, 2019-21.

AIMS: The aim of this study was to characterize the circumstances of drug overdose deaths and determine whether naloxone administration differed by overdose decedent race and ethnicity. DESIGN AND SETTING: Analysis of data on unintentional and undetermined intent drug overdose deaths in Pennsylvania (2019-21) was collected from death certificates and the State Unintentional Drug Overdose Reporting System. Multivariable logistic regression models were adjusted for overdose death circumstances and the odds of naloxone administration were estimated by race/ethnicity and year. CASES: The analytical sample included 3386 fatal overdose decedents in 2019, 3864 in 2020 and 3816 in 2021. MEASUREMENTS: Evidence of naloxone administration (yes/no) was defined using scene evidence and toxicology reports from coroner and medical examiner records, while race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White) was based on the death certificate. FINDINGS: In the analytic sample, overdose death rates were the highest among Black people and increased over time (rate per 10 000 population, 2019: 4.3; 2020: 6.1; 2021: 6.5); rates were lowest among White people and remained constant over time (rate per 10 000 population, 2019: 2.6; 2020: 2.7; 2021: 2.6). Throughout all years, Black decedents had approximately 40-50% lower odds of naloxone administration compared with White decedents as referent [2019: odds ratio (OR) = 0.7, 95% confidence interval (CI) = 0.5-0.9; 2020: OR = 0.5, 95% CI = 0.4-0.7; 2021: OR = 0.6, 95% CI = 0.5-0.8], while Hispanic decedents had similar odds of naloxone administration to that of White decedents. CONCLUSION: After controlling for overdose circumstances in drug overdose deaths in Pennsylvania, USA, from 2019 to 2021, Black people had lower odds of naloxone administration compared with White people, while there were no differences between Hispanic and White people.

Post-traumatic stress disorder and risk of first-time and repeated opioid-related hospitalizations among World Trade Center Health Registry enrollees.

In 2021, and average of 220 deaths from opioid-related overdoses occurred daily in the US. Recent evidence suggests there is an association between post-traumatic stress disorder (PTSD) and increased opioid misuse, while little is known about opioid-related hospitalizations. This study used data from the World Trade Center Health Registry (WTCHR), a longitudinal cohort consisting of individuals directly exposed to the September 11th terrorist attacks with a high prevalence of resulting PTSD (3.8-29.6%). We linked WTCHR data to New York State hospitalization data to examine the question: do opioid-related hospitalizations (first time and repeated) differ by PTSD status. In a study sample of 37,968 adults, 145 experienced at least one episode of opioid-related hospitalization and 64 had repeated episodes during the study period. We found that in the 13-years post-9/11, individuals with PTSD had a significantly higher risk of a first-time opioid-related hospitalization (Hazard Ratio: 3.6, 95% CI: 2.7, 5.0) and repeated opioid-related hospitalizations (Hazard Ratio: 3.9, 95% CI: 2.7, 5.8) than those who did not have PTSD. Improved treatment of and increased screenings for PTSD may reduce the likelihood of opioid misuse in this population and consequently overdoses, hospitalizations, and healthcare costs.

Mortality after the 9/11 terrorist attacks among world trade center health registry enrollees with cancer.

BACKGROUND: While several studies have reported the association between 9/11 exposure and cancer risk, cancer survival has not been well studied in the World Trade Center (WTC) exposed population. We examined associations of 9/11-related exposures with mortality in WTC Health Registry enrollees diagnosed with cancer before and after 9/11/2001. PATIENTS AND METHODS: This is a longitudinal cohort study of 5061 enrollees with a first-ever primary invasive cancer diagnosis between 1995 and 2015 and followed through 2016. Based on the timing of first cancer diagnosis, pre-9/11 (n = 634) and post-9/11 (n = 4427) cancer groups were examined separately. 9/11-related exposures included witnessing traumatic events, injury on 9/11, and 9/11-related post-traumatic stress disorder (PTSD). Associations of exposures with all-cause mortality were examined using Cox proportional hazards regression. In the post-9/11 group, cancer-specific mortality was evaluated by enrollee group (WTC rescue/recovery workers vs. non-workers) using Fine and Gray's proportional sub-distribution hazard models, adjusting for baseline covariates, tumor characteristics, and treatment. RESULTS: In the pre-9/11 group, 9/11-related exposures were not associated with all-cause mortality. In the post-9/11 group, increased risk of all-cause mortality was associated with PTSD (adjusted HR = 1.35; 95% CI = 1.11-1.65), but not with injury or witnessing traumatic events. Cancer-specific mortality was not statistically significantly associated with 9/11-related exposures. In rescue/recovery workers, increased non-cancer mortality risk was associated with PTSD (aHR = 2.13, 95% CI = 1.13-4.00) and witnessing ≥3 traumatic events (aHR = 2.00, 95% CI = 1.13-3.55). CONCLUSIONS: We did not observe associations between 9/11-related exposures and cancer-specific mortality. Similar to findings in the non-cancer WTC exposed population, PTSD was associated with increased risk of all-cause mortality in cancer patients.

Self-Efficacy and Mental Health Help-Seeking Behavior of World Trade Center Health Registry Enrollees, 2015-2016.

The September 11th World Trade Center (WTC) disaster resulted in an elevated prevalence of Post-Traumatic Stress Disorder (PTSD) among those directly exposed, yet lower than expected rates of mental health treatment seeking and high levels of reported perceived unmet mental healthcare need were observed in this population in the years following. Self-efficacy, an individual's self-perception of their ability to succeed in specific situations or accomplish a task or goal, may in part explain this discrepancy; however, little is known about its interplay with the help-seeking behaviors of disaster-exposed populations. We used WTC Health Registry data (n = 11,851) to describe the relationship between self-efficacy and three outcomes related to help-seeking behavior: (1) seeking mental health treatment, (2) perceived unmet mental health care needs, and (3) satisfaction with mental health treatment. Multinomial logistic regression models were used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CI). We found a dose-response relationship between self-efficacy score and mental health help-seeking: for every one unit increase in self-efficacy score, we observed a 6% increase in the odds of having treatment 4 to 12 months ago (OR = 1.06, CI: 1.03-1.09), a 7% increase in the odds of having had treatment 1 to 2 years ago (OR = 1.07, CI: 1.04, 1.09), and a 10% increase in the odds of having sought treatment 2 or more years ago (OR = 1.10, CI: 1.08, 1.12) compared to those who had sought treatment more recently. An understanding of individual self-efficacy may help improve post-disaster mental health treatment in order to provide more tailored and helpful care.

Cancer Incidence in World Trade Center Rescue and Recovery Workers: 14 Years of Follow-Up.

BACKGROUND: Statistically significantly increased cancer incidence has been reported from 3 cohorts of World Trade Center (WTC) disaster rescue and recovery workers. We pooled data across these cohorts to address ongoing public concerns regarding cancer risk 14 years after WTC exposure. METHODS: From a combined deduplicated cohort of 69 102 WTC rescue and recovery workers, a sample of 57 402 workers enrolled before 2009 and followed through 2015 was studied. Invasive cancers diagnosed in 2002-2015 were identified from 13 state cancer registries. Standardized incidence ratios (SIRs) were used to assess cancer incidence. Adjusted hazard ratios (aHRs) were estimated from Cox regression to examine associations between WTC exposures and cancer risk. RESULTS: Of the 3611 incident cancers identified, 3236 were reported as first-time primary (FP) cancers, with an accumulated 649 724 and 624 620 person-years of follow-up, respectively. Incidence for combined FP cancers was below expectation (SIR = 0.96, 95% confidence interval [CI] = 0.93 to 0.99). Statistically significantly elevated SIRs were observed for melanoma-skin (SIR = 1.43, 95% CI = 1.24 to 1.64), prostate (SIR = 1.19, 95% CI = 1.11 to 1.26), thyroid (SIR = 1.81, 95% CI = 1.57 to 2.09), and tonsil (SIR = 1.40, 95% CI = 1.00 to 1.91) cancer. Those arriving on September 11 had statistically significantly higher aHRs than those arriving after September 17, 2001, for prostate (aHR = 1.61, 95% CI = 1.33 to 1.95) and thyroid (aHR = 1.77, 95% CI = 1.11 to 2.81) cancers, with a statistically significant exposure-response trend for both. CONCLUSIONS: In the largest cohort of 9/11 rescue and recovery workers ever studied, overall cancer incidence was lower than expected, and intensity of WTC exposure was associated with increased risk for specific cancer sites, demonstrating the value of long-term follow-up studies after environmental disasters.

Association between post-traumatic stress disorder and alcohol-related hospitalizations among World Trade Center Health Registry enrollees.

BACKGROUND: We examined both the impact of 9/11-related exposures and repeated assessments of post-traumatic stress disorder (PTSD) on the risk of alcohol-related hospitalizations (ARH) among individuals exposed to the World Trade Center (WTC) disaster. METHODS: 9/11-related exposures (witnessing traumatic events, physical injuries, or both) were measured at baseline and PTSD symptoms were assessed at four time points (2003-2016) using the PTSD Checklist-17 among 53,174 enrollees in the WTC Health Registry. ICD-9-CM and ICD-10-CM codes were used to identify ARHs (2003-2016) through linked administrative data. For the effect of 9/11-related exposures on ARH, Cox proportional-hazards regression estimated hazard ratios (HR) and 95 % confidence intervals (CI); for time-varying PTSD, extended Cox proportional-hazards regression was used. Models were adjusted fora priori confounders and stratified by enrollee group (uniformed rescue and recovery worker (RRW), non-uniformed RRW, and community members). Person-time was calculated from baseline or 9/12/2001 to the earliest of ARH, withdrawal, death, or end of follow-up (12/31/2016). RESULTS: Across all 9/11-related exposures, community members and non-uniformed RRWs were at increased risk of ARHs; uniformed RRWs were not. In adjusted models, PTSD was associated with an increased risk of hospitalization across all groups [HR, (95 % CI): uniformed RRWs: 2.6, (1.9, 3.6); non-uniformed RRWs: 2.1, (1.7, 2.7); and community members: 2.6, (2.1, 3.2)]. CONCLUSIONS: Among certain enrollee groups, 9/11-related exposures are associated with an increased risk of ARH and that PTSD is strongly associated with ARHs among all enrollee groups. Findings may assist the clinical audience in improving screening and treatment.

Exploratory Case Study of Suicide among a Sample of 9/11 Survivors.

BACKGROUND: Previous research has found higher than expected suicide mortality among rescue/recovery workers (RRWs) enrolled in the World Trade Center Health Registry (WTCHR). Whether any enrollee suicides are related to the decedents' experiences on 9/11 is unknown. We abstracted medical examiner file data to learn more about 9/11-related circumstances of suicides among WTCHR enrollees. METHODS: We identified 35 enrollee suicide cases that occurred in New York City using linked vital records data. We reviewed medical examiner files on each case, abstracting demographic and circumstantial data. We also reviewed survey data collected from each case at WTCHR enrollment (2003-2004) and available subsequent surveys to calculate descriptive statistics. RESULTS: Cases were mostly non-Hispanic White (66%), male (83%), and middle-aged (median 58 years). Nineteen decedents (54%) were RRWs, and 32% of them worked at the WTC site for >90 days compared to 18% of the RRW group overall. In the medical examiner files of two cases, accounts from family mentioned 9/11-related circumstances, unprompted. All deaths occurred during 2004-2018, ranging from one to four cases per year. Leading mechanisms were hanging/suffocation (26%), firearm (23%), and jump from height (23%). Sixty percent of the cases had depression mentioned in the files, but none mentioned posttraumatic stress disorder. CONCLUSIONS: RRWs may be at particular risk for suicide, as those who worked at the WTC site for long periods appeared to be more likely to die by suicide than other RRWs. Mental health screening and treatment must continue to be prioritized for the 9/11-exposed population. More in-depth investigations of suicides can elucidate the ongoing impacts of 9/11.

Confirming mortality in a longitudinal exposure cohort: optimizing National Death Index search result processing.

PURPOSE: The National Death Index (NDI) is an important resource for mortality ascertainment. Methods selected to process NDI search results are rarely described in studies using linked data and can have an impact on resources and mortality ascertainment. We evaluate methods to process NDI search results among a 9/11-exposed cohort-the World Trade Center Health Registry (Registry). METHODS: We describe three approaches to process search results (NDI-recommended cutoff points [NDIc]; National Program of Cancer Registries [NPCR] algorithm, and modified National Institute of Occupational Safety and Health algorithm [mNIOSH]). We calculate percent agreement, positive predictive value, sensitivity, specificity, and quantify the burden of manual review to compare the approaches. RESULTS: Of 51,158 Registry enrollees submitted for linkage, 9449 enrollee-level and 17,909 record-level matches were identified. NPCR and mNIOSH were highly concordant (97.1%); more record pairs required manual review for mNIOSH (mNIOSH: 2.7% and NPCR: 1.8%). NDIc sensitivity was 82.9%, with differences observed by race and ethnicity (Asian: 74.4% and White: 86.1%). CONCLUSIONS: NPCR algorithm minimized false matches and reduced the manual review burden. NDIc had nonrandom distribution of missed matches and low sensitivity. NDI search processing methods have important implications for resulting linked data; measures of linkage quality should be available to data users.

Post-traumatic stress disorder and risk of prescription opioid use, over-use, and misuse among World Trade Center Health Registry enrollees, 2015-2016.

BACKGROUND: Among veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with the use and misuse of prescription opioids. Less is known about PTSD among the general population and PTSD resulting from non-combat related trauma. We sought to determine if PTSD following exposure to the World Trade Center (WTC) disaster is associated with the recent use, over use, or misuse of prescription opioids. METHODS: This study, conducted in 2018, examined 26,840 individuals from the WTC Health Registry. PTSD symptoms were assessed on multiple surveys (2003-2016) using the PCL Checklist-17. Three categories of post-9/11 PTSD were derived: never, past, and current. Self-reported opioid use outcomes (past year, 2015-2016) were defined as (yes/no): recent use (use of a prescription opioid), over-use (use of a prescribed opioid in a manner other than prescribed) and misuse (use of a prescription opioid prescribed to someone else). RESULTS: Opioid use, over-use, and misuse prevalence was highest among those with current PTSD (prevalence: 12.2 %-46.1 %) compared to past PTSD (prevalence: 6.7 %-35.8 %) and never PTSD (prevalence: 3.6 %-22.9 %). In adjusted models, individuals with past and current PTSD had a greater risk of all opioid outcomes compared to never PTSD. CONCLUSIONS: Past and current 9/11-related PTSD is a risk factor for opioid use and misuse among the general population, findings which may assist in improving screening and surveillance measures.

Physical and Mental Health-Related Quality of Life Changes Among Insurer Subgroups Following Bariatric Surgery.

OBJECTIVE: This study sought to determine improvements in mental and physical health-related quality of life (HRQOL) following bariatric surgery in Medicaid and commercially insured patients. METHODS: Using data from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery (2006-2009), changes in Short Form 36 mental component summary (MCS) and physical component summary (PCS) scores were examined in 1,529 patients who underwent Roux-en-Y gastric bypass, laparoscopic adjustable band, or sleeve gastrectomy and were followed for 5 years. Piecewise linear mixed-effects models estimated MCS and PCS scores as a function of insurance group (Medicaid, N = 177; commercial, N = 1,352) from 0 to 1 year and from 1 to 5 years after surgery, with interactions between insurance group and surgery type. RESULTS: Patients with Medicaid had lower PCS and MCS scores at baseline. At 1 year after surgery, patients with Medicaid and commercial insurance experienced similar improvement in PCS scores (commercial-Medicaid difference in PCS change [95% CI]: Roux-en-Y gastric bypass, 1.5 [-0.2, 3.3]; laparoscopic adjustable band, 1.9 [-2.2, 6.0]; sleeve gastrectomy, 6.4 [0.0, 12.8]). One-year MCS score improvement was minimal and similar between insurance groups. In years 1 to 5, PCS and MCS scores were stable in all groups. CONCLUSIONS: Both insurance groups experienced improvements in physical HRQOL and minimal changes in mental HRQOL.

Association Between Socioeconomic Status and Asthma-Related Emergency Department Visits Among World Trade Center Rescue and Recovery Workers and Survivors.

Importance: Although the association between poor economic or social standing and health is well established, few studies have attempted to examine the mediational pathways that produce adverse outcomes in disadvantaged populations. Objective: To determine whether barriers to care mediate the association between socioeconomic status (SES) and asthma-related emergency department (ED) visits. Design, Setting, and Participants: This cohort study used data from the World Trade Center Health Registry, which comprises rescue and recovery workers and community members who worked, lived, studied or were otherwise present in downtown Manhattan, New York, during or immediately after the September 11, 2001, disaster. Data were matched to an administrative database of ED visits. Those who experienced an asthma-related ED visit and those who did not were compared in bivariate analysis. A mediation analysis was conducted to determine the role of barriers to care in the association between number of ED visits and SES. Exposures: Education, income, and race/ethnicity, which were collected at first survey in 2003 to 2004. Main Outcomes and Measures: Asthma-related ED visits that occurred after survey responses regarding barriers to care were collected (2006-2007) but before 2016, the latest date that data were available. Results: The analytic sample included 30 452 enrollees (18 585 [61%] male; median [interquartile range] age, 42.0 [35.0-50.0] years; 20 180 [66%] white, 3834 [13%] African American, and 3961 [13%] Hispanic or Latino [any race]). Approximately half (49%) had less than a bachelor's degree, and 15% had an annual income less than $35 000. Those of lower SES were more likely to experience an asthma-related ED visit. Although number of barriers to care mediated this association, they explained only a small percentage of the overall health disparity (ranging from 3.0% [95% CI, 2.3%-3.9%]) of the differences between African American and white individuals to 9.8% [95% CI, 7.7%-11.9%]) comparing those with less than a high school diploma to those with at least a bachelor's degree. However, the association varied by specific barrier to care. Lack of money, insurance, and transportation mediated up to 11.8% (95% CI, 8.1%-15.9%), 12.5% (95% CI, 8.5%-17.4%), and 4.3% (95% CI, 1.7%-8.4%), respectively, of the association between SES and number of ED visits. Lack of childcare, not knowing where to go for care, and inability to find a health care professional mediated a smaller or no percentage of the association. Conclusions and Relevance: The identification of vulnerable subpopulations is an important goal to reduce the burden of asthma-related hospital care. More research is needed to fully understand all of the pathways that lead disaster survivors of lower SES to disproportionately experience ED visits due to asthma.

Association Between Posttraumatic Stress Disorder and Mortality Among Responders and Civilians Following the September 11, 2001, Disaster.

Importance: Posttraumatic stress disorder (PTSD) has been associated with increased mortality, primarily in studies of veterans. The World Trade Center Health Registry (Registry) provides a unique opportunity to study the association between PTSD and mortality among a population exposed to the World Trade Center attacks in New York, New York, on September 11, 2001 (9/11). Objectives: To assess whether 9/11-related probable PTSD (PTSD) is associated with increased mortality risk, as well as whether this association differs when including repeated measures of PTSD over time vs a single baseline assessment. Design, Setting, and Participants: A longitudinal cohort study of 63 666 Registry enrollees (29 270 responders and 34 396 civilians) was conducted from September 5, 2003, to December 31, 2016, with PTSD assessments at baseline (wave 1: 2003-2004) and 3 follow-up time points (wave 2: 2006-2007, wave 3: 2011-2012, wave 4: 2015-2016). Data analyses were conducted from December 4, 2018, to May 20, 2019. Exposures: Posttraumatic stress disorder was defined using the 17-item PTSD Checklist-Specific (PCL-S) self-report measure (score ≥50) at each wave (waves 1-4). Baseline PTSD was defined using wave 1 PCL-S, and time-varying PTSD was defined using the PCL-S assessments from all 4 waves. Main Outcomes and Measures: Mortality outcomes were ascertained through National Death Index linkage from 2003 to 2016 and defined as all-cause, cardiovascular, and external-cause mortality. Results: Of 63 666 enrollees (38 883 men [61.1%]; mean [SD] age at 9/11, 40.4 [10.4] years), 6689 (10.8%) had PTSD at baseline (responders: 2702 [9.5%]; civilians: 3987 [12.0%]). Participants who were middle aged (2022 [12.5%]), female (3299 [13.8%]), non-Latino black (1295 [17.0%]), or Latino (1835 [22.2%]) were more likely to have PTSD. During follow-up, 2349 enrollees died (including 230 external-cause deaths and 487 cardiovascular deaths). Among all enrollees in time-varying analyses, PTSD was associated with all-cause, cardiovascular, and external-cause mortality, with adjusted hazard ratios (AHRs) of greater magnitude compared with analyses examining baseline PTSD. Among responders, time-varying PTSD was significantly associated with increased risk of all-cause (AHR, 1.91; 95% CI, 1.58-2.32), cardiovascular (AHR, 1.95; 95% CI, 1.25-3.04), and external-cause (AHR, 2.40; 95% CI, 1.47-3.91) mortality. Among civilians, time-varying PTSD was significantly associated with increased risk of all-cause (AHR, 1.54; 95% CI, 1.28-1.85), cardiovascular (AHR, 1.72; 95% CI, 1.15-2.58), and external-cause (AHR, 2.11; 95% CI, 1.06-4.19) mortality. Conclusions and Relevance: The risk of mortality differed in examination of baseline PTSD vs repeated measures of PTSD over time, suggesting that longitudinal data should be used where possible. Comparable findings between responders and civilians suggest that 9/11-related PTSD is associated with an increased mortality risk.

Preoperative prealbumin and transferring: Relation to 30-day risk of complication in elective spine surgical patients.

OF BACKGROUND DATA: There is growing interest in identifying nutritional biomarkers associated with poor outcomes of elective spine surgery. Prealbumin and transferrin are both biomarkers of nutritional status that can be obtained from clinical laboratories. However, associations of preoperative measures of these nutritional biomarkers across their range with risk of complications from spine surgery have not been fully investigated. OBJECTIVE: Determine associations of preoperative prealbumin and transferrin levels with 30-day risk of complication among elective spine surgery patients. STUDY DESIGN: Cohort study with preoperative prealbumin and transferrin collected as standard of care. OUTCOME MEASURES: 30-day risk of medical complication. METHODS: Data were obtained from medical records of 274 consecutive adult patients ages ≥50 years who underwent elective spine surgery from June 2013 to June 2014. Prealbumin (mg/dL), serum transferrin (mg/dL), and preoperative factors were abstracted from medical records. Prealbumin and transferrin levels were categorized into quartiles and as below versus median or higher. The primary outcome measure was 30-day risk of medical complication, such as renal failure or infections. Associations of the biomarkers with outcome risk were assessed with chi-square tests and with risk ratios (RR) and 95% confidence intervals (CI) estimated with multivariable log-binomial regression. RESULTS: The 274 adults studied had a median prealbumin level of 27.4 mg/dL and a median transferrin level of 265.0 mg/dL. The 30-day risk of complication was 12.8% (95% CI: 8.8%-16.7%). Risk of complication did not vary by quartile for either prealbumin (P = .26) or transferrin (P = .49) and was not associated either with prealbumin (below median, RR = 1.1, 95% CI: 0.8, 1.5) or transferrin (below median, RR = 1.1, 95% CI: 0.8, 1.6). CONCLUSIONS: Among adults undergoing elective spine surgery, the 30-day risk of complication was not associated with prealbumin or transferrin. Nutrition status, as measured by prealbumin and transferrin, does not appear to be associated with complication risk. LEVEL OF EVIDENCE: Level III.

Bariatric Surgery Among Medicare Subgroups: Short- and Long-Term Outcomes.

OBJECTIVE: This study sought to examine weight change, postoperative adverse events, and related outcomes of interest among age-qualified (AQ) and disability-qualified (DQ) Medicare recipients compared with non-Medicare (NM) patients undergoing an initial bariatric procedure. METHODS: The Longitudinal Assessment of Bariatric Surgery (LABS-2) is an observational cohort study of 2,458 adults who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) bariatric surgery. Weight, percentage body fat, functional status, and comorbidities, as well as postoperative adverse events, were assessed at baseline and annually for 5 years. The 1,943 participants who reported insurance type were categorized into the following groups: AQ, DQ, or NM. RESULTS: The median preoperative BMI ranged from 45 to 48 kg/m2 across groups. For RYGB, 5-year BMI loss was approximately 30% for all groups, and for LAGB, BMI loss was 12% to 15%. Diabetes remission after 5 years was also similar across groups within procedure types (RYGB: 33%-40%; LAGB: 13%-19%). The frequency of adverse events after RYGB ranged from 4.1% for NM participants to 6.7% for DQ participants. After LAGB, there were no adverse events for the AQ group, whereas 3% of DQ participants and 1.8% of NM participants had at least one adverse event. CONCLUSIONS: Medicare participants experienced substantial BMI loss and diabetes remission, with a frequency of adverse events similar to that of NM participants.

Reduction in Comorbid Conditions Over 5 Years Following Bariatric Surgery in Medicaid and Commercially Insured Patients.

OBJECTIVE: This study sought to determine changes in the prevalence of comorbid disease following bariatric surgery in Medicaid patients compared with commercially insured patients. METHODS: Data were obtained from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery at one of six geographically diverse centers in the United States. A total of 1,201 patients who underwent Roux-en-Y gastric bypass with 5 years of follow-up were identified. Poisson mixed models were used to estimate relative risks (RRs) and compare changes in common comorbidities between insurance groups within 0-1 and 1-5 years post surgery. Propensity scores were used to achieve balance in the baseline comorbidity burden between Medicaid and commercial patients. RESULTS: In the first year, risk of all six comorbidities decreased substantially over time in both groups, ranging from a 32% to a 69% decrease from baseline. After 1 year post surgery, the risk of disease was stable in both groups (RRs ranged from 1.0 to 1.1). After propensity score weighting, the RRs in the first year were more similar in magnitude, while the RRs in the 1- to 5-year period were unchanged. CONCLUSIONS: These results suggest that Medicaid patients experience a medium-term reduction in comorbid disease after bariatric surgery.

Weighing in on Bariatric Surgery: Effectiveness Among Medicaid Beneficiaries-Limited Evidence and Future Research Needs.

INTRODUCTION: In the general population, bariatric surgery is well documented as the most effective obesity treatment for sustained weight loss and remission of comorbidities. Characterization of the patient populations most likely to benefit from surgical intervention is needed, but the heterogeneity of treatment effects across payer groups has not been reviewed. METHODS: A systematic review of published studies focusing on bariatric surgery outcomes among Medicaid beneficiaries was conducted. By using PubMed and Scopus, this study searched for studies that quantitatively compared clinical or social bariatric surgery outcomes for United States adult Medicaid recipients and commercially insured patients. RESULTS: Of the 568 titles reviewed, 21 met inclusion criteria. Weight loss and the remission of comorbidities at 1 or 2 years postoperatively were similar between groups despite differences in baseline health status. Short-term health care utilization and mortality outcomes were worse in Medicaid recipients; for instance, Medicaid patients had an average length of stay that was 2 days longer and experienced three more deaths in the first postoperative year. CONCLUSIONS: The critical research gaps in the evidence base needed to improve treatment guidelines for Medicaid patients undergoing bariatric surgery include an understanding of the causes of the baseline health differences and how these differences contribute to postoperative outcomes.