Technology-Based Smoking Cessation for Youth Exiting Foster Care: A Pilot Randomized Trial.

Despite high rates of cigarette use, little attention has been paid to screening and cessation services for youth in foster care. Study aims were to test the feasibility, acceptability, and preliminary efficacy of a technology-based smoking cessation intervention. Study enrollment, satisfaction, and engagement were high in the intervention arm, where readiness to change also significantly increased over time. Intervention and control participants significantly reduced cigarette use at 6-month follow up, though groups did not differ. Technology-based interventions appear to be attractive and offer a potentially scalable link to health care that this vulnerable population may not otherwise seek.

Cannabis use during alcohol treatment is associated with alcohol-related problems one-year post-treatment.

BACKGROUND: Prior research shows that cannabis use during treatment for Alcohol Use Disorders (AUD) is related to fewer abstinent days from alcohol, although only among those who use cannabis 1-2x/month. Here we extend prior research by assessing the relationship between the frequency of cannabis use during AUD treatment and post-treatment alcohol-related consequences. METHODS: Data come from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study, a large US randomized control trial of treatments for AUD. The current analyses include 206 cannabis users and 999 cannabis abstainers and compare longitudinal drinking data between those who used cannabis versus those who abstained during COMBINE treatment. The primary exposure was quartiles of cannabis use (Q1: less than 1x/month during treatment, Q2: 1-2x/month, Q3: 4-8x/month, Q4: 12x/month or more), with cannabis abstainers as the reference group. Outcomes were alcohol-related problems at the end of treatment and one-year post-treatment as measured by the Drinker Inventory Consequences. RESULTS: Compared to cannabis abstinence, the most frequent use during treatment was related to 1.44 times as many physical consequences one-year post-treatment. Cannabis use was not related to physical consequences immediately after treatment, or to intrapersonal, interpersonal, social responsibility or impulse control problems at either post-treatment time point. CONCLUSIONS: In a sample of individuals in treatment for AUD, using cannabis 12x/month or more during treatment is associated with increased rates of physical consequences attributed to alcohol use. Individuals in treatment for AUD who also use cannabis might benefit from reducing or stopping cannabis use to avoid alcohol-related physical problems.

2014 CRL Build Study of Life Insurance Applicants.

Objective .- Determine the impact of build on insurance applicant mortality accounting for smoking, laboratory test values and blood pressure. Method .- The study consisted of 2,051,370 applicants tested at Clinical Reference Laboratory between 1993 and 2007 with build and cotinine measurements available whose body mass index (BMI) was between 15 and 47. Vital status was determined as of September, 2011 by the Social Security Death Master File. Excluded from the primary study were applicants with HbA1c values ≥6.5%, systolic BP ≥141 mmHg, albumin values ≤3.3 g/dL or total cholesterol values ≤130 mg/dL. Relative mortality was determined by Cox regression analysis for bands of BMI split by age, sex and smoking status (urine cotinine positive). Results .- A majority of applicants had BMI >24 (overweight or obese by WHO criteria). After the exclusions noted above, relative mortality does not increase by >34% unless BMI is <20 (<18 for female non-smokers age 18 to 59) or BMI is >34. BMI values in the range of 22 to 24 and 25 to 29, overall, had similar and the lowest relative risks. For most nonsmokers, risk was lowest in the lower of these two BMI bands but for smokers (and non-smoking males age 60 to 89) risk was lowest in the higher BMI band. Additional analysis showed limited reduction in relative risk by accounting for all laboratory test values as well as continuing the exclusions. Eliminating the exclusions resulted in only a modest increase in relative risk because the mortality rate of the reference band increased as well. Conclusion .- After excluding elevated HbA1c and blood pressure (associated with high BMI) and low albumin and cholesterol (associated with low BMI) which are usually evaluated separately, mortality varies by a limited degree for BMI 20 to 34. Accounting for the mortality impact of other test values, in addition to the exclusions noted, reduced mortality associated with high BMI to a limited extent, but had little impact on mortality associated with low BMI.

2014 CRL Blood Pressure Study of Life Insurance Applicants.

Objective .- Define the relative mortality risk by systolic (SBP) and diastolic blood pressure (DBP) in a relatively healthy cohort split by age and sex with adjustment for smoking status, other findings and admitted heart disease history. Method .- Blood pressure (BP in mm Hg), build, laboratory studies and limited medical history are collected when people apply for individual life insurance. Information on 2,472,706 applicants tested by Clinical Reference Laboratory from 1993 to 2007 was utilized with follow-up for vital status using the September 2011 Social Security Death Master File identifying 31,033 deaths. Data was analyzed by SBP and DBP split by age and sex accounting for smoking and for BMI, urine protein/creatinine ratio and history of heart disease in a Cox multivariate survival analysis. Separate analysis by admitted hypertension history was also conducted. Results are presented by SBP and DBP for 4 age-sex groups with and without added covariates beyond age and smoking status. Results .- Relative mortality progressively increased by SBP level from the 90 to 119 band (down to 80 in younger women) upward with little additional impact by DBP. Addition of covariates beyond age and smoking resulted in a 5% to 10% reduction in relative risk. Although high DBP had limited impact, a pulse pressure/SBP ratio >½ identified 1% of applicants at high mortality risk, with little difference in risk for ratios ≤½. Hypertension history with current BP control was associated with a 10% to 25% increase in relative mortality risk as compared to those with similar BP but no such history. Conclusion .- Increasing SBP is closely associated with increasing relative mortality, starting from the lowest SBP. Increasing DBP has little additional impact, but a pulse pressure/SBP ratio >½ is a potent marker of increased risk as well. Accounting for build and other laboratory findings reduces risk modestly. A history of hypertension with current control increases risk.

NT-proBNP as a predictor of all-cause mortality in a population of insurance applicants.

OBJECTIVE: Quantify the independent value of NT-proBNP in predicting all-cause mortality for individual life insurance applicants and establish risk-based reference ranges. METHOD: By use of the Social Security Death Master File and multivariate analysis, relative mortality was determined for 144,027 life insurance applicants tested (almost all routinely rather than for cause) for NT-proBNP along with other laboratory testing and measurement of BP and BMI. RESULTS: Risk increased substantially for NT-proBNP values > 300 pg/mL in women and > 200 pg/mL in men after age, smoking status and other cardiovascular risk factors were accounted for. The relative risk reached > 10 fold at NT-proBNP levels > 1000 pg/mL. For those age 50 to 89 and denying a history of heart disease, this level occurred in only 0.5% of applicants but was present in 7% of all deaths. CONCLUSION: NT-proBNP is a strong independent predictor of all-cause mortality but values associated with increased risk vary by sex.

Trends in mortality of insurance applicants with HIV infection.

OBJECTIVE: Provide a brief review of HIV history and determine the relative mortality of life insurance applicants who are HIV positive and how that has changed over time with advances in treatment. METHOD: By use of the Social Security Death Master File and multivariate analysis, mortality of those HIV positive relative to those HIV negative was determined for life insurance applicants from 1991 to 2009. RESULTS: Relative mortality varied by type of testing (blood, urine or oral fluid) and by age, ranging from 320% at the oldest ages to over 1300% at the youngest ages for applicants with blood testing. Surprisingly, there was little change in relative risk among HIV-positive applicants over this period. CONCLUSION: Relative risk for life insurance applicants who are HIV positive remains high despite advances in therapy.

Scoring life insurance applicants' laboratory results, blood pressure and build to predict all-cause mortality risk.

OBJECTIVE: Evaluate the degree of medium to longer term mortality prediction possible from a scoring system covering all laboratory testing used for life insurance applicants, as well as blood pressure and build measurements. METHOD: Using the results of testing for life insurance applicants who reported a Social Security number in conjunction with the Social Security Death Master File, the mortality associated with each test result was defined by age and sex. The individual mortality scores for each test were combined for each individual and a composite mortality risk score was developed. This score was then tested against the insurance applicant dataset to evaluate its ability to discriminate risk across age and sex. RESULTS: The composite risk score was highly predictive of all-cause mortality risk in a linear manner from the best to worst quintile of scores in a nearly identical fashion for each sex and decade of age. CONCLUSION: Laboratory studies, blood pressure and build from life insurance applicants can be used to create scoring that predicts all-cause mortality across age and sex. Such an approach may hold promise for preventative health screening as well.

Mortality associated with bilirubin levels in insurance applicants.

OBJECTIVE: Determine the relationship between bilirubin levels with and without other liver function test (LFT) elevations and relative mortality in life insurance applicants. METHOD: By use of the Social Security Death Master File mortality was determined in 1,905,664 insurance applicants for whom blood samples were submitted to the Clinical Reference Laboratory. There were 50,174 deaths observed in this study population. Results were stratified by 3 age/sex groups: females, age <60; males, age <60; and all, age 60+. The median follow-up was 12 years. RESULTS: Relative mortality increased as bilirubin decreased below bilirubin levels seen for the middle 50% of the population. The known association of smoking with lower bilirubin values explained only part of the additional elevated risk at low bilirubin levels. In the absence of other LFT elevations, relative mortality remained unchanged as bilirubin increased beyond levels seen for the middle 50% of the population. When a bilirubin elevation was combined with other LFT elevations, mortality further increased only at the highest elevations of other LFTs, seen only in <2.5% of applicants. CONCLUSION: Isolated elevations of bilirubin in this healthy screening population were not associated with excess mortality but values below the midpoint were. Other investigations have suggested a cardiovascular cause may underlie the excess mortality associated with low bilirubin. In association with other LFT elevations, bilirubin elevation further increases the mortality risk only at the highest elevations of other LFTs.

Increased mortality associated with elevated carcinoembryonic antigen in insurance applicants.

OBJECTIVE: Determine the relationship between the carcinoembryonic antigen (CEA) value and all-cause mortality in life insurance applicants aged 50 years and over. METHOD: By use of the Social Security Master Death Index, mortality was examined in 115,590 insurance applicants aged 50 and up for whom blood samples for CEA were submitted to the Clinical Reference Laboratory. Results were stratified by CEA value (<5 ng/mL, 5 to 9.9 ng/mL, 10+ ng/mL), smoking status, and age groups (50-59 years, 60-69 years, and 70 years and up). RESULTS: Relative mortality is increased at CEA values between 5 and 9.9 ng/mL and further increased at 10+ ng/mL for all age groups, with the most dramatic increase at the youngest ages. Excess mortality appears to last at least 3 to 4 years after the elevated result. Five-year all-cause mortality in applicants with CEA values of 10+ ng/mL is 25.2% with a mortality ratio relative to those with a CEA <5 ng/mL of 1156%. CONCLUSION: This study shows that CEA can detect the risk of early excess mortality in life insurance applicants; CEA levels of 5 ng/mL and over may be of concern. CEA testing beginning at age 50 years for life insurance applicants could capture 4.6% of early mortality if the threshold for further evaluation was set at 10 ng/mL. Only 0.4% of all applicants aged 50 and over have CEA values at or above this threshold.

Relationship of hemoglobin A1c to mortality in nonsmoking insurance applicants.

OBJECTIVE: Determine the relationship between hemoglobin A1c value and 5-year, all-cause mortality in nonsmoking life insurance applicants. METHOD: By use of the Social Security Master Death Index, mortality was examined in 286,443 non-smoking insurance applicants aged 40 and up for whom blood samples for hemoglobin A1c were submitted to the Clinical Reference Laboratory. Results were stratified by hemoglobin A1c value, gender and age bands 40 to 59, 60 to 69 and 70 and up. RESULTS: Increased mortality is apparent at hemoglobin A1c values of 6% and above, is linear, and on a percentage basis decreases with age. Hemoglobin A1c values less than 5% also are associated with increased mortality. Absolute mortality rates for females with elevated hemoglobin A1c are generally lower than rates for males, although mortality relative to the gender-specific reference group with hemoglobin A1c of 5% to 5.9% is generally the same for both. CONCLUSION: The importance of even small elevations of hemoglobin A1c above 5.9% is apparent. For screening, it is the degree of blood sugar elevation as measured by hemoglobin A1c rather than any diagnostic label that is critical in risk assessment.

Predictors of remission from body dysmorphic disorder: a prospective study.

In the first naturalistic, prospective study of the course of body dysmorphic disorder (BDD), we examined predictors of remission in 161 subjects over 1 year of follow-up. Data were obtained on clinical characteristics at the intake interview and weekly BDD symptom severity over 1 year using the Longitudinal Interval Follow-Up Evaluation. More severe BDD at intake, longer BDD duration, and the presence of a comorbid personality disorder predicted a lower likelihood of partial or full remission from BDD. BDD remission was not predicted by gender; race/ethnicity; socioeconomic status; being an adult versus an adolescent; age of BDD onset; delusionality of BDD symptoms; or the presence at intake of major depression, a substance use disorder, social phobia, obsessive compulsive disorder, or an eating disorder. Receipt of mental health treatment or nonmental health treatment (e.g., surgery, dermatologic treatment) during the follow-up year also did not predict remission from BDD.

Psychobehavioral risk factors, substance treatment engagement and clinical outcomes as predictors of emergency department use and medical hospitalization.

OBJECTIVE: Prior research on health care utilization after treatment for substance misuse disorders has not accounted for posttreatment clinical outcomes as well as putative confounds associated with both substance use and health care. This study examined the association of posttreatment health care utilization with treatment factors (program type and time in treatment) and baseline psychological/behavioral risk factors (smoking status and level of depressive, alcohol and drug dependence symptoms). The study also examined whether posttreatment clinical outcomes-participation in aftercare, Alcoholic Anonymous (AA) attendance, substance use, depressive symptoms and smoking- were associated with subsequent health care utilization. METHOD: We analyzed predictors of posttreatment medical hospitalizations and emergency department (ED) use among 15,041 participants in a multistate treatment evaluation project conducted from 1987 to 1995. RESULTS: Greater time in treatment reduced the likelihood of future hospitalizations and ED use, whereas clients in outpatient treatment were less likely to be hospitalized. Baseline measures of depressive, alcohol and drug dependence symptoms were each independently associated with subsequent health care use. Posttreatment aftercare participation reduced the likelihood of future hospitalization and ED use, whereas AA attendance also reduced the likelihood of hospitalization. In addition, posttreatment counts of depressive symptoms increased the likelihood of future hospitalization and ED use. Substance relapse increased the likelihood of subsequent ED use. CONCLUSIONS: The study supports the public health importance of substance misuse disorders treatment, with greater treatment involvement associated with lower high-cost medical utilization. Treatment clinical outcomes-posttreatment relapse and depressive symptoms-partially mediate the effect of treatment on health care utilization.