Testing Interventions to Address Bias About Patients with Opioid Use Disorder in the Emergency Department.

INTRODUCTION: Reducing nurse bias about patients with opioid use disorder in the emergency department is critical for providing nonjudgmental care, enhancing patient outcomes, supporting effective communication, and promoting a holistic approach to care. Emergency nurses can make a positive impact on the lives of individuals diagnosed as having opioid use disorder by providing care that is free from stigma and discrimination. METHODS: The study used an observational, pretest-posttest design to compare educational sessions addressing bias and stigma toward patients with opioid use disorder. The study population consisted of emergency nurses who self-selected into a virtual learning experience consisting of e-modules or simulation-based experience consisting of simulation-based experience consisting of simulation, discussion, and a speaker. RESULTS: After the intervention, the simulation-based experience group showed an increase in total score postintervention from a mean of 118.6 to a mean of 127.1 (P < .001). The virtual learning experience group also showed an increase in total score postintervention from a mean of 116.3 to 120.7 (P < .001). Although both groups showed an increase in scores over time, the simulation-based experience group had a greater increase (P = .0037). Within the simulation-based experience, there was an increase in scores across all age groups (P < .05) but a significantly greater increase in scores among younger nurses (18-29 years) than the older age groups (P = .006). DISCUSSION: Opioid use disorder is a complex condition that requires a comprehensive and holistic approach to care. Study results indicate that providing an educational experience to address stigma about patients diagnosed as having opioid use disorder can significantly affect nurse perceptions about these patients and their self-efficacy when working with them. However, investing in a simulation-based educational experience provides a stronger experience and results in greater change, particularly for younger, less experienced emergency nurses.

Inhibin B and luteinizing hormone levels in girls aged 6-11 years from NHANES III, 1988-1994.

OBJECTIVE: To evaluate inhibin B and luteinizing hormone (LH) levels in a large, representative cross-sectional sample of US girls and characterize the relationships of these laboratory values with age, clinical signs of puberty and other correlates. DESIGN: Cross-sectional analysis of LH and inhibin B in banked serum from 720 girls aged 6-11 years who participated in the Third National Health and Nutrition Examination Survey (NHANES III). MEASUREMENTS: Levels of inhibin B and LH, race, ethnicity and anthropometric measurements were compared for all girls. Visual assessment of pubertal stage was performed on girls aged 8 years and older. A two-part model was used to establish normative data and Tobit regression models were used to evaluate associations with participant characteristics. Receiver operating characteristic (ROC) analysis was performed to identify optimum cut points predictive of puberty onset. RESULTS: Mean hormone levels progressively increased with age. LH levels progressively increased with pubertal stage. Inhibin B levels increased gradually from breast stage I to II, then more sharply to peak at stage III, followed by a plateau at stages IV and V. ROC curves indicated that both hormones were consistent with pubertal onset as indicated by breast stage II. CONCLUSIONS: This study characterizes inhibin B and LH values in a large, representative cross-sectional sample of US girls. Inhibin B can be a useful tool in combination with other clinical and biochemical parameters to evaluate gonadal function as a reflection of pubertal progression in girls.

Household chemical exposures and the risk of canine malignant lymphoma, a model for human non-Hodgkin's lymphoma.

BACKGROUND: Epidemiologic studies of companion animals offer an important opportunity to identify risk factors for cancers in animals and humans. Canine malignant lymphoma (CML) has been established as a model for non-Hodgkin's lymphoma (NHL). Previous studies have suggested that exposure to environmental chemicals may relate to development of CML. METHODS: We assessed the relation of exposure to flea and tick control products and lawn-care products and risk of CML in a case-control study of dogs presented to a tertiary-care veterinary hospital (2000-2006). Cases were 263 dogs with biopsy-confirmed CML. Controls included 240 dogs with benign tumors and 230 dogs undergoing surgeries unrelated to cancer. Dog owners completed a 10-page questionnaire measuring demographic, environmental, and medical factors. RESULTS: After adjustment for age, weight, and other factors, use of specific lawn care products was associated with greater risk of CML. Specifically, the use of professionally applied pesticides was associated with a significant 70% higher risk of CML (odds ratio(OR)=1.7; 95% confidence interval (CI)=1.1-2.7). Risk was also higher in those reporting use of self-applied insect growth regulators (OR=2.7; 95% CI=1.1-6.8). The use of flea and tick control products was unrelated to risk of CML. CONCLUSIONS: Results suggest that use of some lawn care chemicals may increase the risk of CML. Additional analyses are needed to evaluate whether specific chemicals in these products may be related to risk of CML, and perhaps to human NHL as well.

Clustering of fecundability within women.

Adverse pregnancy outcomes have long been observed to cluster within women resulting in the inclusion of past reproductive history in clinical assessments and perinatal scoring systems. However, limited study has focused on the clustering of fecundability as measured by time to pregnancy (TTP), despite growing evidence suggestive of a possible association with adverse pregnancy outcomes known to cluster within women. We sought to empirically evaluate the clustering of conception delay, and TTP more globally, in one of the few existing prospective pregnancy cohort studies that captured women's successive pregnancies. The study cohort comprised 544 women who contributed 1119 pregnancies in the U.S. Collaborative Perinatal Project. We used a discrete Cox frailty model to estimate the degree and significance of within-woman clustering of TTP. Women with an initial conception delay (TTP > 6 months) were older, less educated and had higher body mass indices than women not experiencing delays (TTP ≤ 6 months). Our analysis indicates that there is significant within-woman clustering of TTP (variance of the frailty = 0.80, [95% confidence interval 0.49, 1.11]) after adjusting for baseline maternal age, body mass index and education level. Similar to many other reproductive and perinatal outcomes, our findings suggest that TTP clusters within women. Identifying exposures or behaviours that affect TTP may offer strategies for reducing conception delay in future pregnancy attempts.

Physical activity and risk of small-for-gestational-age birth among predominantly Puerto Rican women.

To estimate the association between multiple domains of physical activity and risk of small-for-gestational-age (SGA) birth. We utilized data from 1,040 participants in the Latina Gestational Diabetes Mellitus Study, a prospective cohort of predominantly Puerto Rican prenatal care patients in Massachusetts. Physical activity was assessed by bilingual interviewers using a modified version of the Kaiser physical activity survey in early (mean = 15 weeks) and mid pregnancy (mean = 28 weeks). Physical activity (i.e., sports/exercise, household, occupational, and active living) in pre, early and mid pregnancy was categorized in quartiles. SGA was classified as <10th percentile of birth weight for gestational age. Pre- and early-pregnancy physical activity were not associated with SGA. In multivariable analyses, women with high total activity in mid-pregnancy had a decreased risk of SGA [risk ratio (RR) = 0.42; 95% confidence interval (CI) 0.21-0.82; p(trend) = 0.003] as compared to those with low total activity. Findings were similar for high household activity (RR = 0.69; 95% CI = 0.34-1.40; p(trend) = 0.26), active living (RR = 0.63; 95% CI = 0.35-1.13; p(trend) = 0.04), and occupational activity (RR = 0.79, 95% CI = 0.47-1.34; p(trend) = 0.26). High levels of sports/exercise were associated with an increased SGA risk without a significant dose-response association (RR = 2.14, 95% CI 1.04-4.39; p(trend) = 0.33). Results extend prior studies of physical activity and SGA to the Hispanic population.

Validity of retrospectively reported behaviors during the periconception window.

OBJECTIVE: To assess the validity of retrospectively reported maternal behaviors while attempting pregnancy. STUDY DESIGN: Participants in a prospective pregnancy cohort study with periconception enrollment were queried about use of cigarettes, alcohol, vitamins and caffeine and the consumption of sport fish while attempting pregnancy. Prospective longitudinal data reported in daily diaries (gold standard) were compared with data obtained a decade later using a self-administered questionnaire. Agreement was assessed by percent agreement and Kappa coefficients. RESULTS: Among the 82 participating women, percent agreement ranged from 54-74% for the 5 behaviors. Validity was highest for smoking (Kappa = 0.43, 95% confidence interval [CI]: 0.22, 0.65) followed by fish consumption (Kappa = 0.32, 95% CI: 0.09, 0.55), caffeine (Kappa = 0.21, 95% CI: 0.09, 0.51) and alcohol (Kappa = 0.20, 95% CI: 0.08, 0.33). There were no systematic differences in agreement by time to pregnancy or pregnancy outcome. Associations between smoking and alcohol consumption and pregnancy outcomes were highly sensitive to the levels of misclassification observed in this study. CONCLUSION: Validity was poor to moderate for the 5 behaviors, though higher for more regular behaviors such as smoking and caffeine consumption. The potential for misreporting of periconception behaviors can affect inferences, and thus efforts to capture information prospectively should be promoted.

Luteinizing hormone, testosterone and inhibin B levels in the peripubertal period and racial/ethnic differences among boys aged 6-11 years: analyses from NHANES III, 1988-1994.

OBJECTIVE: To determine whether the initial physical findings of puberty are accompanied by hormonal evidence of pubertal activation of the hypothalamic-pituitary-gonadal (HPG) axis and whether racial/ethnic differences exist, we have analysed hormone levels in relation to age, onset of puberty and race/ethnicity. DESIGN: Cross-sectional analysis of luteinizing hormone (LH), testosterone (T) and inhibin B from banked sera from a representative sample of US boys aged 6·0-11·99 years who participated in the National Health and Nutrition Examination Survey (NHANES) III. PATIENTS: Eight hundred and twenty-eight boys having sera including 228 non-Hispanic white (NHW), 266 non-Hispanic black (NHB), 288 Mexican-American (MA) and 46 'other'. MEASUREMENTS: Using analysis of variance and linear regression techniques, concentrations of LH, T and inhibin B were compared by race/ethnicity for all boys and pubertal status (Tanner's Staging 1, 2 and 3+) for boys aged 8 years and older. Receiver operating curves were utilized to identify cut-points predictive of pubertal HPG status. RESULTS: Mean hormones levels progressively increased with age. Receiver operating characteristic (ROC) curves indicate hormones are consistent with pubertal onset as indicated by Tanner stage 2, except for T and genital stage 2. Inhibin B and LH levels increased significantly by genital stage after adjusting for age and race/ethnicity, while LH and T concentrations increased significantly across pubic hair stages. Levels of inhibin B were significantly higher for NHB boys compared with other racial/ethnic groups. CONCLUSIONS: In these cross-sectional findings, hormone levels rise gradually as boys approach the peripubertal age, whereas an abrupt rise was not associated with the onset of physical changes of puberty.

In utero exposure to cigarette smoking, environmental tobacco smoke and reproductive hormones in US girls approaching puberty.

BACKGROUND/AIMS: Evidence is unclear whether prenatal smoking affects age at menarche and pubertal development, and its impact upon hormones has not been well studied. We aim to identify potential pathways through which prenatal smoking and environmental tobacco smoke (ETS) affect reproductive hormones in girls approaching puberty. METHODS: We examined the association between prenatal smoking, current ETS and luteinizing hormone (LH) and inhibin B (InB) in 6- to 11-year-old girls in the 3rd National Health and Nutrition Examination Survey, 1988-1994. Parents/guardians completed interviewer-assisted questionnaires on health and demographics at the time of physical examination. Residual blood samples were analyzed for reproductive hormones in 2008. RESULTS: Of 660 girls, 19 and 39% were exposed to prenatal smoke and current ETS, respectively. Accounting for multiple pathways in structural equation models, prenatally exposed girls had significantly lower LH (ß = -0.205 log-mIU/ml, p < 0.0001) and InB (ß = -0.162, log-pg/ml, p < 0.0001). Prenatal smoking also influenced LH positively and InB negatively indirectly through BMI-for-age. ETS was positively associated with LH, but not with InB. CONCLUSION: Exposure to maternal smoking may disrupt reproductive development manifesting in altered hormone levels near puberty.

Association between lead and cadmium and reproductive hormones in peripubertal U.S. girls.

BACKGROUND: Lead (Pb) and cadmium (Cd) are known reproductive toxicants thought to disrupt hormone production throughout sensitive developmental windows, although this has not been previously examined in nationally representative peripubertal children. OBJECTIVES: We examined the association between blood Pb and urinary Cd concentrations and the reproductive hormones inhibin B and luteinizing hormone (LH) in girls 6-11 years of age who participated in the cross-sectional Third National Health and Nutrition Examination Survey (NHANES III) (1988-1994). METHODS: Pb (micrograms per deciliter) was measured in whole blood, and Cd was measured in urine (nanograms per milliliter). Inhibin B (picograms per milliliter) and LH (milli-International units per milliliter) were measured in residual sera for 705 girls. Survey logistic regression was used to estimate associations with pubertal onset based on inhibin B concentration > 35 pg/mL or LH concentration > 0.4 mIU/mL, and multinomial logistic regression was used to estimate the association between Pb and increasing categories of hormone concentrations. RESULTS: High Pb (≥ 5 µg/dL) was inversely associated with inhibin B > 35 pg/mL [odds ratio (OR) = 0.26; 95% confidence interval (CI), 0.11-0.60; compared with Pb < 1 µg/dL]. At 10 and 11 years of age, girls with low Pb (< 1 µg/dL) had significantly higher inhibin B than did girls with moderate (1-4.99 µg/dL) or high Pb (≥ 5 µg/dL). In the subsample of 260 girls with levels of inhibin B above the level of detection and using survey regression modeling, inhibin B levels were lower among girls with both high Pb and high Cd (ß= -0.52; 95% CI, -0.09 to -1.04) than among girls with high Pb alone (ß= -0.35; 95% CI, -0.13 to -0.57), relative to girls with low Pb and low Cd. CONCLUSIONS: Higher Pb was inversely associated with inhibin B, a marker of follicular development, and estimated effects suggestive of pubertal delays appeared to be stronger in the context of higher Cd concentrations. These data underscore the importance of Pb and Cd as reproductive toxicants for young girls.

Sedentary behaviors and abnormal glucose tolerance among pregnant Latina women.

UNLABELLED: Studies conducted among nonpregnant populations have observed an association between sedentary behavior and glucose intolerance. Few studies have investigated this association during pregnancy, particularly among Latina women, a population with higher rates of sedentary behavior and abnormal glucose tolerance (AGT) as compared with non-Latina white women. OBJECTIVE: The purpose of this study was to estimate the association between sedentary behavior and AGT. RESEARCH DESIGN AND METHODS: We used data from the Latina gestational diabetes mellitus study, a prospective cohort of 1231 Latina prenatal care patients in western Massachusetts. Sedentary behavior was assessed by bilingual interviewers using a modified version of the Kaiser Physical Activity Survey in prepregnancy, early pregnancy, and midpregnancy and defined as hours spent TV watching, frequency of sitting at work, and participation in sports or exercise activity as well as a derived composite of total sedentary activity. AGT was measured at 24-28 wk of gestation and abstracted from medical records after delivery. Multivariate logistic regression was used to calculate odds ratios and 95% confidence intervals. RESULTS: A total of 12% (n = 119) of participants were classified as having AGT. After adjusting for AGT risk factors, sedentary behaviors in prepregnancy or in early pregnancy were not associated with AGT. However, in midpregnancy, low levels of participation in sports or exercise (odds ratio = 2.01, 95% CI = 1.01-4.02) and increasing total sedentary activity (Ptrend = 0.003) were associated with increased risk for AGT. CONCLUSIONS: Findings suggest an association between sedentary activity in midpregnancy and risk of AGT in this understudied population.

Maternal serum preconception polychlorinated biphenyl concentrations and infant birth weight.

BACKGROUND: Prenatal and postnatal polychlorinated biphenyl (PCBs) exposure has been associated with decrements in fetal and infant growth and development, although exposures during the preconception window have not been examined despite recent evidence suggesting that this window may correspond with the highest serum concentrations. OBJECTIVES: We assessed maternal serum PCB concentrations at two sensitive developmental windows in relation to birth weight. METHODS: Serum samples were collected from 99 women as they began trying to become pregnant (preconception) and after a positive pregnancy test (prenatal); 52 (53%) women gave birth and represent the study cohort. Using daily diaries, women recorded sexual intercourse, menstruation, and home pregnancy test results until pregnant or up to 12 menstrual cycles with intercourse during the estimated fertile window. With gas chromatography with electron capture, 76 PCB congeners were quantified (nanograms per gram serum) and subsequently categorized by purported biologic activity. Serum PCBs were log-transformed and entered both as continuous and categorized exposures along with birth weight (grams) and covariates [smoking (yes/no), height (inches), and infant sex (male/female)] into linear regression. RESULTS: A substantial reduction in birth weight (grams) was observed for women in the highest versus the lowest tertile of preconception antiestrogenic PCB concentration (beta; = 429.3 g, p = 0.038) even after adjusting for covariates (beta; = 470.8, p = 0.04). CONCLUSIONS: These data reflect the potential developmental toxicity of antiestrogenic PCBs, particularly during the sensitive preconception critical window among women with environmentally relevant chemical exposures, and underscore the importance of PCB congener-specific investigation.

Perceived stress and severity of perimenstrual symptoms: the BioCycle Study.

OBJECTIVE: To examine the longitudinal relation between perceived stress in the previous month and perimenstrual symptom severity across two cycles among regularly menstruating, healthy women (n = 259). METHODS: At baseline (11 days before the first cycle), participants completed the 4-item Perceived Stress Scale (PSS) for the previous month (first cycle exposure) and questionnaires on lifestyle factors. On cycle day 22 of a standardized 28-day cycle, participants again completed the PSS for the previous week (second cycle exposure) and each week rated the severity (none, mild, moderate, severe) of 17 psychological and physical symptoms (e.g., crying, cramping, pain). Mixed models estimated the association between perceived stress scores and number of moderate/severe symptoms and symptom severity scores, allowing both stress and perimenstrual symptoms to vary by cycle. RESULTS: Adjusting for age, education, passive and active smoking, and waist/height ratio (WHtR), high stress (fourth quartile PSS) was associated with an increased risk of reporting >or=8 or more (OR 7.2, 3.3-15.8) and >or=5 (OR 2.5, 1.6-4.1) symptoms as moderate/severe during the perimenstrual period compared with lower stress (quartiles one, two, and three). Stress scores were positively (p < 0.0001) associated with increased symptom severity scores for total, psychological, and physical symptoms. CONCLUSIONS: These analyses show that higher perceived stress precedes an increased severity of perimenstrual symptoms. Stress reduction programs may be an effective, nonpharmaceutical treatment for physical and psychological symptom relief.

Semen quality in fertile men in relation to psychosocial stress.

OBJECTIVE: To examine the association between stressful life events and semen parameters. DESIGN: Cross-sectional analysis in a pregnancy cohort study. SETTING: Prenatal clinics in five U.S. cities. PATIENT(S): Fertile men (n = 744) in the Study for Future Families, a cohort study of pregnant women and their partners. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Sperm concentration, percent motile, and percent normal morphology and classification above/below World Health Organization (WHO) cutoffs for semen quality. RESULT(S): After adjusting for confounders, men reporting 2+ recent stressful life events had an increased risk of being classified below WHO thresholds for "normal" defined by concentration, motility, and morphology criteria compared with men reporting <2 stressful life events (odds ratio [OR] = 2.06; 95% confidence interval [CI], 1.18, 3.61; OR = 1.54; 95% CI, 1.04, 2.29; OR = 1.93; 95% CI, 1.02, 3.66 for concentration, motility and morphology, respectively). Men experiencing 2+ stressful life events had lower sperm concentration (log scale, beta = -0.25; 95% CI, -0.38, -0.11) and lower percent motile sperm (beta = -1.95; 95% CI, -3.98, 0.07), but percent normal morphology was less affected. CONCLUSION(S): These results suggest that stressful life events may be associated with decreased semen quality in fertile men. The experience of psychosocial stress may be a modifiable factor in the development of idiopathic infertility.

Environmental tobacco smoke and canine urinary cotinine level.

Epidemiologic studies of companion animals such as dogs have been established as models for the relationship between exposure to environmental tobacco smoke (ETS) and cancer risk in humans. While results from these studies are provocative, pet owner report of a dog's ETS exposure has not yet been validated. We have evaluated the relationship between dog owner's report of household smoking by questionnaire and dog's urinary cotinine level. Between January and October 2005, dog owners presenting their pet for non-emergency veterinary care at the Foster Hospital for Small Animals at Cummings School of Veterinary Medicine, Tufts University, were asked to complete a 10-page questionnaire measuring exposure to household ETS in the previous 24 h and other factors. A free-catch urine sample was also collected from dogs. Urinary cotinine level was assayed for 63 dogs, including 30 whose owners reported household smoking and 33 unexposed dogs matched on age and month of enrollment. Urinary cotinine level was significantly higher in dogs exposed to household smoking in the 24 h before urine collection compared to unexposed dogs (14.6 ng/ml vs. 7.4 ng/ml; P=0.02). After adjustment for other factors, cotinine level increased linearly with number of cigarettes smoked by all household members (P=0.004). Other canine characteristics including age, body composition and nose length were also associated with cotinine level. Findings from our study suggest that household smoking levels as assessed by questionnaire are significantly associated with canine cotinine levels.