Helping individuals with firearm injuries: A cluster randomized trial.

BACKGROUND: Patients with firearm injuries are at high risk of subsequent arrest and injury following hospital discharge. We sought to evaluate the effect of a 6-month joint hospital- and community-based low-intensity intervention on risk of arrest and injury among patients with firearm injuries. METHODS: We conducted a cluster randomized controlled trial, enrolling patients with firearm injuries who received treatment at Harborview Medical Center, the level 1 trauma center in Seattle, Washington, were 18 years or older at the time of injury, spoke English, were able to provide consent and a method of contact, and lived in one of the five study counties. The intervention consisted of hospital-based motivational interviewing, followed by a 6-month community-based intervention, and multiagency support. The primary outcome was the risk of subsequent arrest. The main secondary outcome was the risk of death or subsequent injury requiring treatment in the emergency department or hospitalization. RESULTS: Neither assignment to or engagement with the intervention, defined as having at least 1 contact point with the support specialist, was associated with risk of arrest at 2 years post-hospital discharge (relative risk for intervention assignment, 1.15; 95% confidence interval, 0.90-1.48; relative risk for intervention engagement, 1.07; 95% confidence interval, 0.74-2.19). There was similarly no association observed for subsequent injury. CONCLUSIONS: This study represents one of the first randomized controlled trials of a joint hospital- and community-based intervention delivered exclusively among patients with firearm injuries. The intervention was not associated with changes in risk of arrest or injury, a finding most likely due to the low intensity of the program. LEVEL OF EVIDENCE: Care management, level II.

Implications of Cannabis Legalization on Juvenile Justice Outcomes and Racial Disparities.

INTRODUCTION: The objective of this study is to assess the changes in rates of juvenile cannabis criminal allegations and racial disparities in Oregon after legalization of cannabis (July 2015) for adults. METHODS: This study included all allegations for cannabis-related offenses that occurred from January 2012 to September 2018 in Oregon. Negative binomial regression models were used to examine monthly cannabis allegation rates over time, and tested differences between youth of color and white youth, adjusting for age, gender, and month the allegation occurred. Analysis was conducted in January-March 2019. RESULTS: Cannabis allegation rates increased 28% among all youth and 32% among cannabis-using youth after legalization. Rates of allegations were highest for American Indian/Alaska Native and black youth. Rates for black youth were double that of whites before legalization, and this disparity decreased after legalization. For American Indian/Alaska Native youth, rates were higher than whites before legalization, and this disparity remained unchanged. CONCLUSIONS: Adult cannabis legalization in Oregon was associated with increased juvenile cannabis allegations; increases are not explained by changes in underage cannabis use. Relative disparities decreased for black youth but remained unchanged for American Indian/Alaska Native youth. Changing regulations following adult cannabis legalization could have unintended negative impacts on youth.

Retrospective cohort study of the association between maternal employment precarity and infant low birth weight in women in the USA.

OBJECTIVES: To investigate the association between maternal employment precarity and infant low birth weight (LBW), and to assess if this association differs by race/ethnicity. METHODS: Data were collected from 2871 women enrolled in the National Longitudinal Survey of Youth 1979 and the National Longitudinal Survey of Youth 1979 Children and Young Adult Cohort. Employment precarity was evaluated using a summary variable that combined several employment attributes: availability of employer-sponsored insurance, income, long shifts, non-daytime shifts, availability of employer sponsored training or educational benefits and membership in a union or collective bargaining unit. Employment precarity scores (a sum of the number of negative employment attributes) were categorised into low (0-2), medium (3) and high (4-6). LBW was defined as weight less than 2500 g at birth. Modified Poisson models were fit to calculate risk ratios and 95% CIs and adjusted for maternal age, race/ethnicity, educational attainment, nativity, prepregnancy body mass index, alcohol consumption, smoking during pregnancy and infant year of birth. We assessed effect modification by maternal race/ethnicity using a composite exposure-race variable. RESULTS: Women with high employment precarity had higher risk of a LBW delivery compared with women with low employment precarity (RR: 1.48, 95% CI: 1.11 to 1.98). Compared to non-Hispanic/non-black women with low employment precarity, non-Hispanic black women (RR: 2.68; 95% CI: 1.72 to 4.15), Hispanic women (RR: 2.53; 95% CI: 1.54 to 4.16) and non-Hispanic/non-black women (RR: 1.46; 95% CI: 0.98 to 2.16) with high employment precarity had higher risk of LBW. CONCLUSIONS: We observed higher risk of LBW in pregnancies of women with high employment precarity; this association was stronger among black and Hispanic mothers compared to non-Hispanic/non-black women. Findings of this study can be used to inform antenatal care and identify workplace policies to better support women who work during pregnancy.

Misclassification of Sex Assigned at Birth in the Behavioral Risk Factor Surveillance System and Transgender Reproductive Health: A Quantitative Bias Analysis.

BACKGROUND: National surveys based on probability sampling methods, such as the Behavioral Risk Factor and Surveillance System (BRFSS), are crucial tools for unbiased estimates of health disparities. In 2014, the BRFSS began offering a module to capture transgender and gender nonconforming identity. Although the BRFSS provides much needed data on the this population, these respondents are vulnerable to misclassification of sex assigned at birth. METHODS: We applied quantitative bias analysis to explore the magnitude and direction of the systematic bias present as a result of this misclassification. We use multivariate Poisson regression with robust standard errors to estimate the association between gender and four sex-specific outcomes: prostate-specific antigen testing, Pap testing, hysterectomy, and pregnancy. We applied single and multiple imputation methods, and probabilistic adjustments to explore bias present in these estimates. RESULTS: Combined BRFSS data from 2014, 2015, and 2016 included 1078 transgender women, 701 transgender men, and 450 gender nonconforming individuals. Sex assigned at birth was misclassified among 29.6% of transgender women and 30.2% of transgender men. Transgender and gender nonconforming individuals excluded due to sex-based skip patterns are demographically distinct from those who were asked reproductive health questions, suggesting that there is noteworthy selection bias present in the data. Estimates for gender nonconforming respondents are vulnerable to small degrees of bias, while estimates for cancer screenings among transgender women and men are more robust to moderate degrees of bias. CONCLUSION: Our results demonstrate that the BRFSS methodology introduces substantial uncertainty into reproductive health measures, which could bias population-based estimates. These findings emphasize the importance of implementing validated sex and gender questions in health surveillance surveys. See video abstract at, http://links.lww.com/EDE/B562.

Time to fecal immunochemical test completion for colorectal cancer screening.

OBJECTIVES: Fecal immunochemical tests (FITs) can efficiently screen for colorectal cancer (CRC), but little is known on the timing to their completion. We investigate the time to return of a FIT following an order and describe patient characteristics associated with FIT return. STUDY DESIGN: Retrospective cohort study. METHODS: We identified 63,478 members of Kaiser Permanente Washington, aged 50 to 74 years, who received a FIT order from 2011 through 2012. Patient characteristics were ascertained through administrative and electronic health record data sources. We compared time from FIT order to return by patient characteristics using Kaplan-Meier and Cox regression methods. RESULTS: About half (53.7%) of members completed a FIT. Median time from order to return was 13 days (mean, 44.5 days; interquartile range, 6-42 days). There was higher completion of FITs among Asian patients (hazard ratio [HR], 1.43; 95% CI, 1.38-1.48), black patients (HR, 1.13; 95% CI, 1.08-1.19), and Hispanic patients (HR, 1.10; 95% CI, 1.04-1.16) compared with white patients; among patients with recent CRC testing (vs no testing in past 2 years; HR, 1.90; 95% CI, 1.86-1.95); and among patients with Medicare insurance (vs commercial; HR, 1.30; 95% CI, 1.24-1.37). Factors associated with decreased FIT completion included younger age (50-54 years vs 70-74 years; HR, 0.87; 95% CI, 0.82-0.92), obesity (vs normal body mass index; HR, 0.88; 95% CI, 0.86-0.91), and higher Charlson Comorbidity Index score (≥3 vs 0; HR, 0.82; 95% CI, 0.79-0.87). CONCLUSIONS: Time to return of FIT varies by patient characteristics. We observed greater FIT completion among people of color, suggesting that racial disparities in CRC may not be due to patient completion of the test after an order is received.

Integrating hypertension screening at the time of voluntary HIV testing among adults in South Africa.

BACKGROUND: Guidelines recommend integrating hypertension screening for HIV-infected adults, but blood pressure measurements may be dynamic around the time of HIV testing. METHODS: We measured a seated resting blood pressure in adults (≥18 years) prior to HIV testing, and again after receiving HIV test results, in an ambulatory HIV clinic in KwaZulu-Natal, South Africa. We assessed sociodemographics, smoking, body mass index, diabetes, substance abuse, and anxiety/depression. We used blood pressure categories defined by the Seventh Joint National Committee (JNC 7) classifications, which includes normal, pre-hypertension, stage 1 hypertension, and stage 2 hypertension. RESULTS: Among 5,428 adults, mean age was 31 years, 51% were male, and 35% tested HIV-positive. Before HIV testing, 47% (2,634) had a normal blood pressure, 40% (2,225) had prehypertension, and 10% (569) had stage 1 or 2 hypertension. HIV-infected adults had significantly lower blood pressure measurements and less hypertension, as compared to HIV-negative adults before HIV testing; while also having significantly elevated blood pressures after HIV testing. In a multivariable model, HIV-infected adults had a 30% lower odds of hypertension, compared to HIV-uninfected adults (aOR = 0.70, 95% CI: 0.57-0.85). In a separate multivariable model, HIV-infected adults with CD4 ≤200 cells/mm3 had a 44% lower odds of hypertension (aOR = 0.56, 95% CI: 0.38-0.83), as compared to adults with CD4 >200 cells/mm3. The mean arterial blood pressure was 6.5 mmHg higher among HIV-infected adults after HIV testing (p <0.001). CONCLUSIONS: HIV-infected adults experienced a transient blood pressure increase after receiving HIV results. Blood pressure measurements may be more accurate before HIV testing and repeated blood pressure measurements are recommended after ART initiation before formally diagnosing hypertension in HIV-infected adults.

Long-term exposure to air pollution and markers of inflammation, coagulation, and endothelial activation: a repeat-measures analysis in the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Air pollution is associated with cardiovascular disease, and systemic inflammation may mediate this effect. We assessed associations between long- and short-term concentrations of air pollution and markers of inflammation, coagulation, and endothelial activation. METHODS: We studied participants from the Multi-Ethnic Study of Atherosclerosis from 2000 to 2012 with repeat measures of serum C-reactive protein (CRP), interleukin-6 (IL-6), fibrinogen, D-dimer, soluble E-selectin, and soluble Intercellular Adhesion Molecule-1. Annual average concentrations of ambient fine particulate matter (PM2.5), individual-level ambient PM2.5 (integrating indoor concentrations and time-location data), oxides of nitrogen (NOx), nitrogen dioxide (NO2), and black carbon were evaluated. Short-term concentrations of PM2.5 reflected the day of blood draw, day prior, and averages of prior 2-, 3-, 4-, and 5-day periods. Random-effects models were used for long-term exposures and fixed effects for short-term exposures. The sample size was between 9,000 and 10,000 observations for CRP, IL-6, fibrinogen, and D-dimer; approximately 2,100 for E-selectin; and 3,300 for soluble Intercellular Adhesion Molecule-1. RESULTS: After controlling for confounders, 5 µg/m increase in long-term ambient PM2.5 was associated with 6% higher IL-6 (95% confidence interval = 2%, 9%), and 40 parts per billion increase in long-term NOx was associated with 7% (95% confidence interval = 2%, 13%) higher level of D-dimer. PM2.5 measured at day of blood draw was associated with CRP, fibrinogen, and E-selectin. There were no other positive associations between blood markers and short- or long-term air pollution. CONCLUSIONS: These data are consistent with the hypothesis that long-term exposure to air pollution is related to some markers of inflammation and fibrinolysis.

Relationship between alcohol consumption and myocardial infarction among ageing men using a marginal structural model.

BACKGROUND: Studies on the association between alcohol consumption and myocardial infarction (MI) have typically used baseline data on alcohol consumption and potential confounders. This study aimed at investigating the association between alcohol consumption and MI considering time-varying alcohol consumption and time-varying confounders. METHODS: Data were available for 1030 males participating in the Kuopio Ischaemic Heart Disease Risk Factor Study (Finland). Baseline data for the present study were collected in 1991-93. MIs were ascertained from national registries until December 2005. Alcohol consumption was categorized into four groups. Data were analysed using conventional discrete-time hazard and marginal structural models (MSMs). Time-invariant covariates were age, working status, diabetes and cigarette-years. Time-varying covariates in the MSM were prior alcohol consumption, smoking, history of cardiovascular diseases, body mass index, high-density lipoprotein cholesterol, systolic blood pressure, insulin and fibrinogen. RESULTS: An insignificant increase of MI risk among the heaviest alcohol consumers (≥168 g week(-1)) compared with the reference group (12-83 g week(-1)) was observed when using a conventional model including baseline alcohol consumption and confounders measured prior to baseline [relative risk (RR) = 1.20, 95% confidence interval (95% CI) = 0.68-2.12]. When using a conventional model with time-varying alcohol consumption and adjusting for prior confounders, an increased risk of MI among the heaviest alcohol consumers was revealed (RR = 1.71, 95% CI = 1.03-2.85). There was also a trend towards increased risk among the heaviest consumers using the MSM (RR = 1.59, 95% CI = 0.93-2.72). CONCLUSION: Our findings suggest that standard methods using only baseline data on alcohol consumption and confounders may lead to biased estimates on the association between alcohol consumption and MI.

Colon cancer screening practices in New York City, 2003: results of a large random-digit dialed telephone survey.

BACKGROUND: New York City (NYC) has one of the highest concentrations of gastroenterologists in the country, yet only 33% of colorectal cancers in NYC are diagnosed early, and approximately 1500 New Yorkers die from colorectal cancer each year. METHODS: Using data from a large, local, random-digit dialed telephone survey (n = 9802), the authors of the current study described types of colorectal cancer screening modalities and characteristics of adults undergoing screening within a recommended timeframe. Multivariate analyses were used to examine demographic, behavioral, socioeconomic, and neighborhood-level predictors of screening participation, with particular attention to factors associated with colonoscopy, the recommended screening modality in NYC. RESULTS: Fifty-five percent of NYC adults aged > or = 50 years reported a recent colorectal cancer screening test, and 42% reported a colonoscopy within the past 10 years. After multiple statistical adjustments, groups with the lowest likelihood of screening were the poor (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.53-0.83) and uninsured (OR, 0.31; 95% CI, 0.20-0.48), as well as Asians (OR, 0.46; 95% CI, 0.29-0. 72), and current smokers (OR, 0.62; 95% CI, 0.50-0.78). Colonoscopy was less frequently reported by non-Hispanic Black New Yorkers and by women; both groups reported higher use of fecal occult blood tests. Less than 10% of adult New Yorkers reported a sigmoidoscopy in the past 5 years. CONCLUSIONS: Low screening uptake in NYC leaves nearly 1 million New Yorkers, particularly poor and uninsured adults, at risk for undetected colorectal cancer. Colonoscopy screening programs in NYC should address health care and socioeconomic barriers and target racial and ethnic minorities and women.

Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003.

OBJECTIVES: We sought to determine the impact of comprehensive tobacco control measures in New York City. METHODS: In 2002, New York City implemented a tobacco control strategy of (1) increased cigarette excise taxes; (2) legal action that made virtually all work-places, including bars and restaurants, smoke free; (3) increased cessation services, including a large-scale free nicotine-patch program; (4) education; and (5) evaluation. The health department also began annual surveys on a broad array of health measures, including smoking. RESULTS: From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, approximately 140000 fewer smokers). Smoking declined among all age groups, race/ethnicities, and education levels; in both genders; among both US-born and foreign-born persons; and in all 5 boroughs. Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third. CONCLUSIONS: Concerted local action can sharply reduce smoking prevalence. However, further progress will require national action, particularly to increase cigarette taxes, reduce cigarette tax evasion, expand education and cessation services, and limit tobacco marketing.

Smoking practices in New York City: the use of a population-based survey to guide policy-making and programming.

To inform New York City's (NYC's) tobacco control program, we identified the neighborhoods with the highest smoking rates, estimated the burden of second-hand smoke exposure, assessed the early response to state taxation, and examined cessation practices. We used a stratified random design to conduct a digit-dialed telephone survey in 2002 among 9,674 New York City adults. Our main outcome measures included prevalence of cigarette smoking, exposure to second-hand smoke, the response of smokers to state tax increases, and cessation practices. Even after controlling for sociodemographic factors (age, race/ethnicity, income, education, marital status, employment status, and foreign-born status) smoking rates were highest in Central Harlem and in the South Bronx. Sixteen percent of nonsmokers reported frequent exposure to second-hand smoke at home or in a workplace. Among smokers with a child with asthma, only 33% reported having a no-smoking policy in their homes. More than one fifth of smokers reported reducing the number of cigarettes they smoked in response to the state tax increase. Of current smokers who tried to quit, 65% used no cessation aid. These data were used to inform New York City's smoke-free legislation, taxation, public education, and a free nicotine patch give-away program. In conclusion, large, local surveys can provide essential data to effectively advocate for, plan, implement, and evaluate a comprehensive tobacco control program.