Is age of onset and duration of stimulant therapy for ADHD associated with cocaine, methamphetamine, and prescription stimulant misuse?

BACKGROUND: To assess whether age of onset and duration of stimulant therapy for attention-deficit/hyperactivity disorder (ADHD) are associated with cocaine, methamphetamine, and prescription stimulant misuse during adolescence. METHODS: Nationally representative samples of US 10th and 12th grade students (N = 150,395) from the Monitoring the Future study were surveyed via self-administered questionnaires from 16 annual surveys (2005-2020). RESULTS: An estimated 8.2% of youth received stimulant therapy for ADHD during their lifetime (n = 10,937). More than one in 10 of all youth reported past-year prescription stimulant misuse (10.4%)-past-year cocaine (4.4%) and methamphetamine (2.0%) use were less prevalent. Youth who initiated early stimulant therapy for ADHD (≤9 years old) and for long duration (≥6 years) did not have significantly increased adjusted odds of cocaine or methamphetamine use relative to population controls (ie, non-ADHD and unmedicated ADHD youth). Youth who initiated late stimulant therapy for ADHD (≥10 years old) and for short duration (<1 year) had significantly higher odds of past-year cocaine or prescription stimulant misuse in adolescence than those initiating early stimulant therapy for ADHD (≤9 years old) and for long duration (≥6 years). Youth who initiated late stimulant therapy for ADHD (≥10 years) for short duration (<1 year) had significantly higher odds of past-year cocaine, methamphetamine, and prescription stimulant misuse versus population controls during adolescence. No differences in past-year cocaine, methamphetamine, and prescription stimulant misuse were found between individuals who only used non-stimulant therapy for ADHD relative to youth who initiated early stimulant therapy (≤9 years old) and for long duration (≥6 years). CONCLUSIONS: An inverse relationship was found between years of stimulant therapy and illicit and prescription stimulant misuse. Adolescents with later initiation and/or shorter duration of stimulant treatment for ADHD should be monitored for potential illicit and prescription stimulant misuse.

Gender Differences in Adolescents' Affective Symptoms and Behavioral Disorders After Mild Traumatic Brain Injury.

OBJECTIVE: Mild traumatic brain injuries (mTBI) are considered self-limiting and full recovery is expected. Recent studies identify deficits persisting years after mTBI. Large-scale prospective data permit testing the hypothesis that mTBI increases incidence of affective and behavioral symptoms after new, past , or new and past mTBI. SETTING: The study involved secondary analyses of survey responses from the Adolescent Brain Cognitive Development (ABCD) Study. PARTICIPANTS: Adolescents in the ABCD Study ( n = 11 869; Wave 1, aged 9-10 years; Wave 2, aged 11-12 years) whose parents reported a new ( n = 157), past ( n = 1318), or new and past ( n = 50) mTBI on the Ohio State University Traumatic Brain Injury Identification Method short form were compared with controls who had no history of mTBI ( n = 9,667). DESIGN: Multivariable binary logistic regression models examined associations between a new, past, or new and past mTBI and current affective (aggression, depression, anxiety) and behavioral (somatic, thought, social, attention, attention deficit hyperactivity disorder, conduct) disorders while controlling for demographic factors and baseline symptoms. MAIN MEASURES: The primary measure was parental reports of psychiatric and behavioral symptoms on the Child Behavior Checklist. RESULTS: Girls exhibited no significant effects after a new mTBI, although a past mTBI increased anxiety (adjusted odds ratios [aOR] = 1.83, 95% confidence interval [CI: 1.15-2.90]) and attention (1.89 [1.09-3.28]) problems. Girls with new and past mTBIs reported elevated anxiety (17.90 [4.67-68.7]), aggression (7.37 [1.49-36.3]), social (9.07 [2.47-33.30]), thought (7.58 [2.24-25.60]), and conduct (6.39 [1.25-32.50]) disorders. In boys, new mTBI increased aggression (aOR = 3.83, 95% CI [1.42-10.30]), whereas past mTBI heightened anxiety (1.91 [1.42-2.95]), but new and past mTBIs had no significant effects. CONCLUSION: Adolescents are at greater risk of affective and behavioral symptoms after an mTBI. These effects differ as a function of gender and time of injury. Extended screening for mTBI history and monitoring of affective and behavioral disorders after mTBI in adolescents are warranted.

Associations of sexual identity change and identity-attraction discordance with symptomatic alcohol and other drug use.

PURPOSE: National studies examining alcohol and other drug use by sexual orientation have been primarily cross-sectional. Understanding changes in sexual orientation over time may further elucidate the mechanisms behind sexual orientation differences in alcohol and other drug use. This national longitudinal study examines changes in sexual orientation across four waves (2013-2019), and the associations with symptomatic alcohol and other drug use. METHODS: Data from Waves 1 through 5 of the Population Assessment of Tobacco and Health (PATH) study were used to examine associations of sexual identity change/stability and sexual identity-attraction discordance/concordance from baseline to follow-up with symptomatic substance use at follow-up. We examined four outcomes: any symptomatic substance use, symptomatic alcohol use, symptomatic other drug use, and symptomatic alcohol + other drug use. Mixed effects logistic regression models were used and all analyses were weighted and stratified by sex. RESULTS: In models adjusting for potential confounders, greater likelihood of symptomatic alcohol and other drug use outcomes was found among males and females experiencing a change from a heterosexual to sexual minority identity and among females with new or consistent sexual identity-attraction discordance. CONCLUSION: These findings highlight important sex differences and suggest that the period of transitioning to a sexual minority identity is a particularly vulnerable period for symptomatic alcohol and other drug use. For females, incongruent sexual identity and attraction is also a risk factor. Interventions that assist individuals during this transitional period and during a time when identity and attraction are incongruent, may reduce symptomatic substance use during this period.

Substance Use and the Self-Management of Persistent Symptoms of COVID-19.

Background: Understanding the self-management practices of persistent symptoms of SARS-Cov-2 (COVID-19) is critical given the misinformation that has been presented about this disease in the U.S. The purpose of this descriptive study is to assess the self-management of persistent symptoms of COVID-19 with commonly used and misused substances (i.e., alcohol, marijuana and commonly prescribed medications) among adults in the U.S. Methods: The data for this study comes from a cross-sectional survey of U.S. adults that was designed to broadly assess symptom burden, persistent symptom patterns, self-efficacy for symptom management and self-management strategies among people who experienced persistent/Long COVID. Multiple logistic regression analyses were used to assess how symptom length of COVID-19 was associated with the use of several substances to manage these persistent symptoms. Results: The analysis found that adults who had COVID-19 symptoms that persisted for 13 weeks or longer had higher rates of using alcohol (27.3%), marijuana (30.9%) and prescription tranquilizers (21.4%) to manage these symptoms when compared to their adult peers who had COVID-19 symptoms persist for only 4 weeks or less. For instance, the odds of indicating the use of marijuana (AOR = 4.21 95% CI = 1.68,10.5) to manage COVID-19 related symptoms was roughly four times higher for respondents who had COVID-19 symptoms persist for 13 weeks or longer when compared to respondents whose COVID-19 symptoms persisted for only 4 weeks or less. Conclusion: The findings suggest that screening of substance use disorders should be considered among healthcare providers who are treating adults who have persistent symptoms of COVID-19.

The Initiation and Developmental Course of Prescription Drug Misuse Among High School Athletes During the Transition Through Young Adulthood.

The objective of this study was to examine the extent to which involvement in high-contact, semicontact, or noncontact sports during the 12th grade is associated with the initiation and developmental course of prescription drug misuse (PDM) between ages 17/18 years and 27/28 years. Data were collected from a national multicohort panel sample of US 12th-graders (cohorts 2006-2017; n = 4,772) from the Monitoring the Future Study who were followed for a decade, through age 27/28 years. Approximately 31% of high school seniors indicated PDM at baseline (age 17/18 years). While past-year PDM remained relatively stable between ages 17/18 years and 27/28 years, participation in both noncontact (adjusted odds ratio = 1.40, 95% confidence interval: 1.02, 1.91) and contact (adjusted odds ratio = 1.57, 95% confidence interval: 1.08, 2.28) sports in the 12th grade increased the odds of initiating prescription stimulant misuse during the 10 years following high school as compared with respondents who did not participate in these types of sports in the 12th grade. To our knowledge, this is the first national study to have assessed how sports participation during high school is associated with the initiation and developmental course of PDM from adolescence to young adulthood. These findings reinforce the need for PDM screening during adolescence, as nearly 1 in 3 high school seniors engage in PDM. Increased prescription stimulant misuse following high school warrants ongoing monitoring during young adulthood, especially among athletes.

Prediction of acute appendicitis among patients with undifferentiated abdominal pain at emergency department.

BACKGROUND: Early screening and accurately identifying Acute Appendicitis (AA) among patients with undifferentiated symptoms associated with appendicitis during their emergency visit will improve patient safety and health care quality. The aim of the study was to compare models that predict AA among patients with undifferentiated symptoms at emergency visits using both structured data and free-text data from a national survey. METHODS: We performed a secondary data analysis on the 2005-2017 United States National Hospital Ambulatory Medical Care Survey (NHAMCS) data to estimate the association between emergency department (ED) patients with the diagnosis of AA, and the demographic and clinical factors present at ED visits during a patient's ED stay. We used binary logistic regression (LR) and random forest (RF) models incorporating natural language processing (NLP) to predict AA diagnosis among patients with undifferentiated symptoms. RESULTS: Among the 40,441 ED patients with assigned International Classification of Diseases (ICD) codes of AA and appendicitis-related symptoms between 2005 and 2017, 655 adults (2.3%) and 256 children (2.2%) had AA. For the LR model identifying AA diagnosis among adult ED patients, the c-statistic was 0.72 (95% CI: 0.69-0.75) for structured variables only, 0.72 (95% CI: 0.69-0.75) for unstructured variables only, and 0.78 (95% CI: 0.76-0.80) when including both structured and unstructured variables. For the LR model identifying AA diagnosis among pediatric ED patients, the c-statistic was 0.84 (95% CI: 0.79-0.89) for including structured variables only, 0.78 (95% CI: 0.72-0.84) for unstructured variables, and 0.87 (95% CI: 0.83-0.91) when including both structured and unstructured variables. The RF method showed similar c-statistic to the corresponding LR model. CONCLUSIONS: We developed predictive models that can predict the AA diagnosis for adult and pediatric ED patients, and the predictive accuracy was improved with the inclusion of NLP elements and approaches.

Tobacco Use Among Gender-Varying and Gender-Stable Adolescents and Adults Living in the United States.

INTRODUCTION: This study examines the proportion of the United States adolescents and adults who are variable (ie, at least one change in gender identity) versus stable in their gender identities over time, and whether they differ significantly in their nicotine/tobacco use after adjusting for key covariates. METHODS: We fit multivariable logistic regression models to data from Waves 2-4 (2014/15-2016/18) of the Population Assessment of Tobacco and Health (PATH), a nationally representative study (n = 33 197 U.S. adolescents and adults aged ≥14 years). We examined associations of gender stability/variability over three waves with tobacco use at wave 4 (2016-2018). Differences in any past 30-day tobacco, cigarette, e-cigarette, other tobacco, and poly-tobacco use were assessed among cisgender-stable, transgender-stable, and gender-varying respondents. RESULTS: An estimated 1.0% of adolescents and adults were classified as gender-varying. Prevalence of any past 30-day tobacco use was higher among gender-varying individuals (42.7%) than among gender-stable individuals (transgender-stable, 37.8% and cisgender-stable, 26.7%). There were no significant differences in the odds of nicotine/tobacco use between the two gender-stable groups. However, gender-varying respondents had significant increased odds of any past 30-day tobacco use (adjusted odds ratio [AOR] = 2.0, 95% confidence interval [CI] = 1.3 to 3.0), cigarette use (AOR = 1.7, 95% CI = 1.1 to 2.5), e-cigarette use (AOR = 2.2, 95% CI = 1.4-3.5), other tobacco use (AOR = 2.2, 95% CI = 1.4 to 3.4), and poly-tobacco use (AOR = 2.0, 95% CI = 1.3 to 3.1) compared with cisgender-stable individuals. CONCLUSIONS: Gender-varying individuals are at higher risk for nicotine/tobacco use, placing them at greater risk for tobacco-related health consequences. IMPLICATIONS: Despite increased knowledge about transgender health in recent years, there remains a paucity of research about gender-varying individuals. This study is the first to examine the proportion of gender-varying individuals in the United States using a longitudinal, nationally representative sample and to explore differences in nicotine/tobacco use among gender-varying and gender-stable individuals. Our findings suggest that gender-varying people have an increased risk for nicotine/tobacco use, placing them at higher risk for tobacco-related health consequences. This study increases knowledge about nicotine/tobacco use among this under-represented population in research and underscores the importance of developing an awareness of gender diversity.

Physical activity in surgical lung cancer patients: a systematic review.

PURPOSE: Perioperative exercise could improve health outcomes of surgical lung cancer patients, but less is known about their natural physical activity (PA) behavior before exercise interventions. This review aimed to synthesize evidence on PA, regarding the following: (1) proportion of patients meeting PA guidelines, (2) amount of PA, (3) PA trajectory following surgery, and (4) correlates of PA before or after surgery. METHODS: We conducted a systematic review using PubMed, CINHAL, Scopus, and SPORTDiscus (July 2021). Observational or experimental studies that measure PA of lung cancer patients before/after surgery were included. We assessed methodological quality using the NIH Quality Assessment Tools and extracted data using a standardized form. RESULTS: Seventeen studies (25 articles, N = 1737 participants) published between 2009 and 2021 were included. Fourteen studies had sample sizes less than 100. Thirteen studies were of fair quality and four studies were of good quality. Only 23-28% of patients met PA guideline (150 min/week moderate-vigorous PA) at 6 months-6 years after surgery. Patients took an average of 3822-10,603 daily steps before surgery and 3934-8863 steps at 1-3 months after surgery. Physical activity was lower at 1 day-3 months after surgery, compared with preoperative levels. Perioperative PA was positively associated with exercise capacity, quality of life and reduced postoperative complications. CONCLUSION: This review suggests that PA is low among surgical lung cancer patients, and it may not recover within 3 months following surgery. Physical activity has the potential to improve postoperative outcomes. However, the existing evidence is weak, and future larger longitudinal studies are needed.

Trajectories of prescription opioid and heroin use in adulthood.

BACKGROUND AND OBJECTIVES: Due to a reduction in the availability of prescription opioids in the United States, the potential transition from prescription opioids to heroin is a public health concern. We assessed trajectories of both nonmedical prescription opioid (NMPO) and heroin use from adolescence (age 18) to adulthood (age 50) and how these trajectories were associated with substance use disorder (SUD) in adulthood (age 35-50). METHODS: A national sample of 26,569 individuals from eleven cohorts of US high school seniors (1976-1986) who were followed until age 50 (2008-2018). The analysis focuses on respondents who engaged in past-year NMPO and heroin use. Outcomes included the endorsement of two or more SUD symptoms. RESULTS: Among NMPO users, 7.5% had used heroin by the age of 50. The latent profile analyses assessing individuals who reported both NMPO and heroin use during the 32-year study period found four unique trajectory groups: (1) "age 18 concurrent use" (81.2%); (2) "mid-30s NMPO-to-heroin use transition" (10.7%); (3) age 19/20 NMPO-to-heroin use transition, followed by 40s heroin-to-NMPO use transition (4.3%); and (4) "mid-20s NMPO-to-heroin use transition" (3.7%). Respondents in the "mid-30s NMPO-to-heroin use transition" trajectory group had the highest odds of indicating two or more SUD symptoms between ages 35-50. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This is the first study to assess NMPO and heroin use trajectories among a national probability-based sample followed from age 18 to 50. The findings suggest that prescription opioid misuse is a risk factor in the development of SUDs and has a long-term impact.

The role of Savings and Internal Lending Communities (SILCs) in improving community-level household wealth, financial preparedness for birth, and utilization of reproductive health services in rural Zambia: a secondary analysis.

BACKGROUND: Savings and Internal Lending Communities (SILCs) are a type of informal microfinance mechanism widely adapted in Zambia. The benefits of SILCs paired with other interventions have been studied in many countries. However, limited studies have examined SILCs in the context of maternal health. This study examined the association between having access to SILCs and: 1) household wealth, 2) financial preparedness for birth, and 3) utilization of various reproductive health services (RHSs). METHODS: Secondary analysis was conducted on baseline and endline household survey data collected as part of a Maternity Waiting Home (MWH) intervention trial in 20 rural communities across seven districts of Zambia. Data from 4711 women who gave birth in the previous year (baseline: 2381 endline: 2330) were analyzed. The data were stratified into three community groups (CGs): CG1) communities with neither MWH nor SILC, CG2) communities with only MWH, and CG3) communities with both MWH and SILC. To capture the community level changes with the exposure to SILCs, different women were randomly selected from each of the communities for baseline and endline data, rather than same women being surveyed two times. Interaction effect of CG and timepoint on the outcome variables - household wealth, saving for birth, antenatal care visits, postnatal care visits, MWH utilization, health facility based delivery, and skilled provider assisted delivery - were examined. RESULTS: Interaction effect of CGs and timepoint were significantly associated only with MWH utilization, health facility delivery, and skilled provider delivery. Compared to women from CG3, women from CG1 had lower odds of utilizing MWHs and delivering at health facility at endline. Additionally, women from CG1 and women from CG2 had lower odds of delivering with a skilled provider compared to women from CG3. CONCLUSION: Access to SILCs was associated with increased MWH use and health facility delivery when MWHs were available. Furthermore, access to SILCs was associated with increased skilled provider delivery regardless of the availability of MWH. Future studies should explore the roles of SILCs in improving the continuity of reproductive health services. TRIAL REGISTRATION: NCT02620436.

Profiles of sedentary behaviors in the oldest old: findings from the National Health and Aging Trends Study.

BACKGROUND: Sedentary behavior is a significant health risk. Emerging research suggests that mentally active sedentary behaviors (e.g., computer use and reading) are associated with better health than mentally passive sedentary behaviors (e.g., watching TV). However, these relationships are not well established in the literature, and little is known about the oldest old (age ≥ 80). AIMS: The aims of this study were to (1) identify distinct subgroups of oldest old adults based on six domains of sedentary behavior (watching TV, using a computer/tablet, talking to friends or family members, doing hobby or other activities, transportation, and resting/napping); and (2) compare health-related outcomes across identified subgroups, using the National Health and Aging Trends Study (NHATS) dataset. METHODS: Latent profile analysis was used to identify distinct profiles of sedentary behavior. Design-based linear and logistic regressions were used to examine associations between different profiles and health outcomes, accounting for socio-demographic characteristics. RESULTS: A total of 852 participants were included. We identified four profiles and named them based on total sedentary time (ST) and passive/active pattern: "Medium-passive", "High-passive", "Low", "High-mentally active". Compared to the "High-passive" group, "Low" group and "High-mentally active" group were associated with fewer difficulties with activities of daily living, fewer problems limiting activities and higher cognitive function. CONCLUSION: This study, with a national representative sample of the oldest old population, suggests that both total ST and sedentary behavior pattern matter when evaluating health outcomes of being sedentary. Interventions should encourage oldest old adults to reduce ST and especially target mentally passive ST.

"Mourning the Experience of What Should Have Been": Experiences of Peripartum Women During the COVID-19 Pandemic.

OBJECTIVES: The ongoing COVID-19 pandemic may significantly affect the peripartum experience; however, little is known about the perceptions of women who gave birth during the COVID-19 pandemic. Thus, the purpose of our study was to describe the peripartum experiences of women who gave birth during the COVID-19 pandemic in the United States. METHODS: Using a cross-sectional design, we collected survey data from a convenience sample of postpartum women recruited through social media. Participants were 18 years of age or older, lived in the United States, gave birth after February 1, 2020, and could read English. This study was part of the COVID-19 Maternal Attachment, Mood, Ability, and Support study, which was a larger study that collected survey data describing maternal mental health and breastfeeding during the COVID-19 pandemic. This paper presents findings from the two free-text items describing peripartum experiences. Using the constant comparative method, responses were thematically analyzed to identify and collate major and minor themes. RESULTS: 371 participants responded to at least one free-text item. Five major themes emerged: (1) Heightened emotional distress; (2) Adverse breastfeeding experiences; (3) Unanticipated hospital policy changes shifted birthing plans; (4) Expectation vs. reality: "mourning what the experience should have been;" and (5) Surprising benefits of the COVID-19 pandemic to the delivery and postpartum experience. CONCLUSIONS FOR PRACTICE: Peripartum women are vulnerable to heightened stress induced by COVID-19 pandemic sequalae. During public health crises, peripartum women may need additional resources and support to improve their mental health, wellbeing, and breastfeeding experiences.

Is it all in the family? Sexual identity differences in DSM-5 alcohol and other drug use disorders and associations with alcohol and other drug misuse history among parents, offspring, and other relatives.

Background: The objectives of this study were to: (1) estimate the prevalence of family history of alcohol and other drug (AOD) misuse (positive family history [FH+]) in first- and second-degree relatives across sexual identity subgroups (i.e., lesbian, gay, bisexual, heterosexual); (2) compare AOD misuse among offspring of sexual minority and heterosexual parents; and (3) examine the relationships between FH+ and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) alcohol use disorder (AUD) and other drug use disorder (ODUD) across sexual identity subgroups. Methods: Data were from the National Epidemiologic Survey on Alcohol and Related Conditions-III (n = 36,309 non-institutionalized U.S. adults aged ≥ 18 years). Data collection occurred in households using structured diagnostic face-to-face interviews during 2012-2013. Results: The presence of FH+ in first- and second-degree relatives was most prevalent among bisexual women relative to all other sexual orientation subgroups. Multivariable regression analyses indicated that the odds of AUD and ODUD were higher among FH+ adults relative to negative family history (FH-) adults. Lesbian and bisexual women had higher odds of AUD compared to heterosexual women, controlling for any FH+; this sexual identity difference was not found for men. There were no significant differences in ODUD between heterosexual FH- men and gay FH- men. We found differences in AOD misuse among offspring of bisexual parents, but not gay or lesbian parents compared to heterosexual parents. Conclusions: Health professionals should consider the higher likelihood of a family history of AOD misuse among sexual minorities, especially bisexual women, when treating these individuals. The lack of differences in AOD misuse among offspring of gay or lesbian parents relative to heterosexual parents warrants attention for legal, policy, and clinical decisions.

Exploring change over time in community mobilization domains: results from a maternity waiting home intervention in rural Zambia.

BACKGROUND: Community mobilization (CM) is recommended as a best practice intervention for low resource settings to reduce maternal mortality. Measurement of process outcomes are lacking and little is known about how CM impacts individuals or how community members perceive its function. Given the complex and recursive nature of CM interventions, research that describes the CM process at multiple levels is needed. This study examines change in CM domains at baseline and endline in rural Zambia. METHODS: This secondary analysis uses data from a large maternity waiting homes intervention in rural Zambia that employed CM over 3 years as part of a package of interventions. A 19-item CM survey was collected from three groups (women with babies < 1, health workers, community members; n = 1202) with focus groups (n = 76) at two timepoints from ten intervention and ten comparison sites. Factor analysis refined factors used to assess temporal change through multivariable regression. Independent covariates included time (baseline vs endline), intervention vs comparison site, group (women with babies, healthworkers, community members), and demographic variables. Interaction effects were checked for time and group for each factor. RESULTS: Final analyses included 1202 individuals from two districts in Zambia. Factor analysis maintained domains of governance, collective efficacy, self-efficacy, and power in relationships. CM domains of self-efficacy, power in relationships, and governance showed significant change over time in multivariable models. All increases in the self-efficacy factor were isolated within intervention communities (b = 0.34, p < 0.001) at endline. Between groups comparison showed the women with babies groups consistently had lower factor scores than the healthworkers or community member groups. CONCLUSIONS: Community mobilization interventions increase participation in communities to address health as a human right as called for in the 1978 Alma Ata Declaration. Grounded in empowerment, CM addresses socially prescribed power imbalances and health equity through a capacity building approach. These data reflect CM interventions function and have impact in different ways for different groups within the same community. Engaging directly with marginalized groups, using the community action cycle, and simultaneous quality improvement at the facility level may increase benefit for all groups, yet requires further testing in rural Zambia.

Nicotine and Tobacco Product Use and Dependence Symptoms Among US Adolescents and Adults: Differences by Age, Sex, and Sexual Identity.

INTRODUCTION: Sexual minorities are at increased risk for tobacco use; however, there is heterogeneity in this risk by sociodemographic factors. AIMS AND METHODS: This study sought to understand if vulnerability to tobacco use among US sexual minorities varies by age group. For this study we used data from wave 4 of the Population Assessment of Tobacco and Health adolescent and adult surveys (n = 37 959), a nationally representative survey. We examined five nicotine/tobacco use outcomes by sex and sexual identity across four age groups. The five outcomes included past 30-day e-cigarette use, past 30-day cigarette use, past 30-day other tobacco use, the number of tobacco products used, and nicotine dependence symptoms. RESULTS: For males, sexual identity differences were greatest in middle adulthood, particularly for bisexual males; adjusted odds ratios and adjusted incident rate ratios ranged from 2.08 to 5.59 in middle adulthood compared to 0.83-1.62 in adolescence. For females, sexual identity differences were persistent from adolescence through middle adulthood. We found significant differences most consistently for nicotine dependence symptoms when comparing gay/lesbian and bisexual females across multiple age groups; adjusted incident rate ratios ranged from 1.90 in middle adulthood to 3.26 in adolescence. CONCLUSIONS: Risk among sexual minorities varied considerably across age groups and by nicotine/tobacco product and severity of symptoms. Our findings underscore the importance of looking beyond single tobacco products when examining nicotine/tobacco differences related to sexual identity and in examining differences by age group. Our results demonstrating age-varying risk among sexual minorities have important implications for tobacco prevention and cessation efforts. IMPLICATIONS: This study identifies important age variation in sexual minority differences in tobacco use, particularly among males. This study also shows that many sexual minorities not only have higher risk for tobacco and nicotine product use but also use significantly more tobacco products and have higher nicotine dependence symptom scores. These results have important implications for implementation of nicotine and tobacco prevention and cessation strategies for sexual minority adolescents and adults.

Financial Preparedness for Birth Among Rural Zambian Women: Do Antenatal Care Contacts Make a Difference?

INTRODUCTION: Financial constraints are one of the biggest barriers for women of low-income countries to receive necessary reproductive health services. Educating women about the importance of saving money has been incorporated as a component of antenatal care (ANC) contacts, but little is known whether ANC contacts influence women's saving. METHODS: A secondary analysis was conducted on data from a cross-sectional household survey study of 1109 women who recently gave birth in two rural districts of Zambia. RESULTS: Receiving ANC contacts early and often and discussing saving money during ANC were associated with saving money for the mother's birth, but not with saving enough money for the most recent birth. DISCUSSION: Continued effort is needed to encourage women to attend ANC contacts earlier and more frequently. Additionally, the importance of saving money for birth should be discussed during ANC contacts. Future studies need to explore why women's action in saving does not necessarily lead to saving enough for childbirth.

Severity of DSM-5 cannabis use disorders in a nationally representative sample of sexual minorities.

Background: Our study is the first using a national sample to examine the severity of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) cannabis use disorder (CUD) in sexual minorities. Drawing from current literature, we expected that bisexual individuals would have the highest prevalence of CUD and the most severe form of CUD. Methods: The National Epidemiological Survey on Alcohol and Related Conditions-III (NESARC-III; 2012-2013) provides a nationally representative adult sample (N = 36,309), including one of the largest samples of sexual minorities. The NESARC-III is large enough to compare subpopulations of sexual minorities on dimensions of substance use disorder severity. Results: Lesbians and gay men were more likely to report mild CUD, whereas bisexuals and respondents "not sure" of their sexual identity were more likely to report severe CUD when compared with heterosexuals. Sexual minorities and heterosexuals who reported lifetime use of medical cannabis had higher odds of having a severe CUD. Sexual minorities had significantly higher odds of lifetime medical cannabis use (adjusted odds ratio [AOR] = 2.39, 95% confidence interval [CI] = 1.42-3.66, P < .001) when compared with heterosexuals, with bisexuals having the highest odds (AOR = 2.81, 95% CI = 1.66-4.75, P < .001). Conclusions: Sexual minorities have the highest odds compared with heterosexuals of developing any CUD. Moreover, the higher rates of severe CUD among bisexuals and those "not sure" have implications for drug prevention with these particularly high-risk groups. It appears that lifetime medical marijuana use may play a role in the development of CUD, although more rigorous measures of medical marijuana use are needed to determine the nature of the relations.

EBP Implementation Leadership of Frontline Nurse Managers: Validation of the Implementation Leadership Scale in Acute Care.

BACKGROUND: Frontline nurse managers influence the implementation of evidence-based practices (EBP); however, there is a need for valid and reliable instruments to measure their leadership behaviors for EBP implementation in acute care settings. AIM: The aim of this study was to evaluate the validity and reliability of the Implementation Leadership Scale (ILS) in acute care settings using two unique nurse samples. METHODS: This study is a secondary analysis of ILS data obtained through two distinct multisite cross-sectional studies. Sample 1 included 200 registered nurses from one large Californian health system. Sample 2 was 284 registered nurses from seven Midwest and Northeast U.S. hospitals. Two separate studies by different research teams collected responses using written and electronic questionnaires. We analyzed each sample independently. Descriptive statistics described individual item, total, and subscale scores. We analyzed validity using confirmatory factor analysis and within-unit agreement (awg). We evaluated factorial invariance using multigroup confirmatory factor analyses and evaluating change in chi-square and comparative fit index values. We evaluated reliability using Cronbach's alpha. RESULTS: Confirmatory factor analyses in both samples provided strong support for first- and second-order factor structure of the ILS. The factor structure did not differ between the two samples. Across both samples, internal consistency reliability was strong (Cronbach's alpha: 0.91-0.98), as was within-unit agreement (awg: 0.70-0.80). LINKING EVIDENCE TO ACTION: Frontline manager implementation leadership is a critical contextual factor influencing EBP implementation. This study provides strong evidence supporting the validity and reliability of the ILS to measure implementation leadership behaviors of nursing frontline managers in acute care. The ILS can help clinicians, researchers, and leaders in nursing contexts assess frontline manager implementation leadership, deliver interventions to target areas needing improvement, and improve implementation of EBP.

Initiation Sequence of E-Cigarette and Cigarette Smoking among US Adolescents: A National Study.

BACKGROUND AND OBJECTIVES: The primary objectives were to: (1) examine the initiation sequence of e-cigarette use and cigarette smoking; (2) assess other substance use as a function of the initiation sequence of e-cigarettes and cigarettes; and (3) investigate the role of early e-cigarette initiation among US secondary school students. METHODS: Data were collected via self-administered questionnaires from independent 2015 and 2016 nationally representative cross-sectional samples of 8th grade, 10th grade, and 12th grade students (N = 36 410). RESULTS: The lifetime initiation sequence included: (1) e-cigarette use before cigarette smoking (1.7%); (2) e-cigarette use and cigarette smoking in same grade (4.2%); (3) cigarette smoking before e-cigarette use (6.1%); (4) e-cigarette use only (12.6%); (5) cigarette smoking only (3.6%); and (6) no e-cigarette use or cigarette smoking (71.8%). The risk of substance use was highest among dual users (regardless of initiation sequence), followed by cigarette smokers, e-cigarette users, and no e-cigarette use or cigarette smoking. The most prevalent initiation sequence of e-cigarette use involved initiating other substances before e-cigarettes, especially among older adolescents. Early initiation of e-cigarette use was associated with increased odds of substance use behaviors for all three age groups. DISCUSSION AND CONCLUSIONS: Adolescents who report a history of both e-cigarette use and cigarette smoking should be considered at high risk for substance-related problems. Early initiation of e-cigarette use is a signal for other substance use. SCIENTIFIC SIGNIFICANCE: Youth substance use prevention programs and prospective studies must take into account polysubstance use when addressing the relationships between e-cigarette use and cigarette smoking. (Am J Addict 2019;28:285-294).

Adolescent sexual violence: Prevalence, adolescent risks, and violence characteristics.

The purpose of this research is to investigate peer-to-peer sexual violence victimization and perpetration among male and female adolescents in a large, racially and economically diverse, community-based sample. Using cross-sectional data over a four-year period (2009-2013) from a regional sample of middle school and high school students in southeastern Michigan, we examined the prevalence and correlates of peer-to-peer sexual violence victimization and perpetration among adolescents. 33.9% of males and 53.5% of females reported sexual violence victimization, while 22.8% of males and 12.6% of females reported sexual violence perpetration. The majority of peer-to-peer sexual victimization and perpetration occurred by someone of the opposite sex, however, same-sex victimization and perpetration were not uncommon. Substance use, depression, Attention Deficit Hyperactivity Disorder (ADHD), and conduct disorder were associated with peer-to-peer sexual violence (victimization or perpetration) for both males and females, with few differences in the patterns of associations by sex. These findings are an important step in better understanding the types of peer-to-peer sexual violence that adolescents experience and risk factors for both male and female youth.