Trends in Elective Deliveries in California and New Jersey.

Introduction: Cesarean section deliveries in the U.S. increased from 5% of births in 1970 to 32% in 2020. Little is known about trends in cesarean sections and inductions in low-risk pregnancies (i.e., those for which interventions would not be medically necessary). This study addresses the following questions: (1) what is the prevalence of elective deliveries at the population level?, (2) how has that changed over time?, and (3) to what extent do the rates of elective deliveries vary across the population? Methods: We first documented long-term trends in cesarean sections in the U.S., California, and New Jersey. We then used linked birth and hospital discharge records and an algorithm based on Joint Commission guidelines to identify low-risk pregnancies and document trends in cesarean sections and inductions in low-risk pregnancies in California and New Jersey over a recent 2-decade period, overall and by maternal characteristics and gestational age. Results: In low-risk pregnancies in California and New Jersey, rates of cesarean sections and inductions increased sharply from the early 1990s through the mid-2000s, peaked at 33% in California and 41% in New Jersey in 2007, and then declined somewhat, and the proportions of inductions that were followed by cesarean sections increased from fewer than 1 in 5 to about 1 in 4. More education, non-Hispanic White race/ethnicity, U.S.-born status, and non-Medicaid were associated with higher rates of interventions. Trends were similar across all socioeconomic groups, but differences have been narrowing in California. Among early-term (gestational age of 37-38 weeks) births in low-risk pregnancies, the rates of elective deliveries increased substantially in both states until the mid/late-2000s, peaked at about 35% in California and over 40% in New Jersey, and then decreased in both states to about 20%. Conclusions: Given established health risks of nonmedically necessary cesarean sections, that a nontrivial share of induced deliveries in low-risk pregnancies result in cesarean sections, and that interventions in low-risk pregnancies have not substantially declined since their peak in the mid-2000s, the trends documented in this paper suggest that sustained, even increased, public health attention is needed to address the still-too-high rates of cesarean sections and inductions in the U.S.

Subjective experiences as nodes within mental disorder networks.

What are the functional roles of subjective experiences? Answering this question amounts to charting a course for the cognitive science of consciousness, where mental processes can be described in terms of their functions. If we strategically focus on mental disorders, preliminary answers may be in sight within 25 years.

Think about your friends and family: The disparate impacts of relationship-centered messages on privacy concerns, protective health behavior, and vaccination against Covid-19.

OBJECTIVE: To understand which factors affect how willing people are to share their personal information to combat the Covid-19 pandemic, and compare them to factors that affect other public health behaviors. METHOD: We analyze data from three pre-registered online experiments conducted over eight months during the Covid-19 pandemic in the United States (April 3 2020 -November 25, 2020). Our primary analysis tests whether support for data sharing and intention to practice protective behavior increase in response to relationship-centered messages about prosociality, disease spread, and financial hardship. We then conduct a secondary correlational analysis to compare the demographic and attitudinal factors associated with willingness to share data, protective behavior, and intent to get vaccinated. Our sample (N = 650) is representative to socio-demographic characteristics of the U.S. population. RESULTS: We find the altruistic condition increased respondents' willingness to share data. In our correlational analysis, we find interactive effects of political ID and socio-demographic traits on likelihood to share data. In contrast, we found health behavior was most strongly associated with political ID, and intent to vaccinate was more associated with socio-demographic traits. CONCLUSIONS: Our findings suggest that some public health messaging, even when it is not about data sharing or privacy, may increase public willingness to share data. We also find the role of socio-demographic factors in moderating the effect of political party ID varies by public health behavior.

Elective Deliveries and the Risk of Autism.

INTRODUCTION: Cesarean section and induced deliveries have increased substantially in the U.S., coinciding with increases in autism spectrum disorder. Studies have documented associations between cesarean section deliveries and autism spectrum disorder but have not comprehensively accounted for medical risks. This study evaluates the extent to which cesarean section and induced deliveries are associated with autism spectrum disorder in low-risk births. METHODS: In this retrospective cohort study, California's birth records (1992-2012) were linked to hospital discharge records to identify low-risk births using a stringent algorithm based on Joint Commission guidelines. Autism spectrum disorder status was based on California Department of Developmental Service data. Logistic regression models were used to estimate associations between autism spectrum disorder and induced vaginal deliveries, cesarean section deliveries not following induction, and cesarean section deliveries following induction, with noninduced vaginal deliveries as the reference category. RESULTS: A total of 1,488,425 low-risk births took place in California from 1992 to 2012. The adjusted odds of autism spectrum disorder were 7% higher for induced vaginal deliveries (AOR=1.07, 95% CI=1.01, 1.14), 26% higher for cesarean section deliveries not following induction (AOR=1.26, 95% CI=1.19, 1.33), and 31% higher for cesarean section deliveries following induction (AOR=1.31, 95% CI=1.18, 1.45) than for noninduced vaginal deliveries. Lower gestational age and neonatal morbidities did not appear to be important underlying pathways. The associations were insensitive to alternative model specifications and across subpopulations. These results suggest that, in low-risk pregnancies, up to 10% of autism spectrum disorder cases are potentially preventable by avoiding cesarean section deliveries. CONCLUSIONS: After accounting for medical risks, elective deliveries-particularly cesarean section deliveries-were associated with a substantially increased risk of autism spectrum disorder.

Sociodemographic, geographic and clinical factors associated with functional outcome and discharge location in US inpatient rehabilitation settings.

OBJECTIVE: To assess the impact of sociodemographic factors, clinical factors and regional differences on both patients' functional outcome and discharge location in U.S. inpatient rehabilitation settings. METHODS: Using eRehabData, 536,453 admissions was used for functional outcome analyses (based on FIM gain) while 259,308 admissions was used for the discharge location analyses. Regression models were used to look at both outcomes. RESULTS: Having private insurance and being young and male was associated with the higher FIM gains while being African American, widowed, and living in the Midwest was associated with the lower FIM gains. Furthermore, having private insurance, being young, male, married and African American or Hispanic was associated with the lower odds of being discharged to a skilled nursing facility while living in the Midwest was associated with the greatest odds of being discharged to a skilled nursing facility. Clinical factors such as days from onset and length of stay also had a significant effect on both outcomes. CONCLUSION: Our findings suggest that, in the U.S., one of the challenges to successful recovery in the inpatient rehabilitation setting includes insurance status (Medicare/Medicaid), race (African American) but also regional differences (Midwest) and length of stay.

Spatial Clustering of Vaccine Exemptions on the Risk of a Measles Outbreak.

OBJECTIVES: Areas of increased school-entry vaccination exemptions play a key role in epidemics of vaccine-preventable diseases in the United States. California eliminated nonmedical exemptions in 2016, which increased overall vaccine coverage but also rates of medical exemptions. We examine how spatial clustering of exemptions contributed to measles outbreak potential pre- and postpolicy change. METHODS: We modeled measles transmission in an empirically calibrated hypothetical population of youth aged 0 to 17 years in California and compared outbreak sizes under the observed spatial clustering of exemptions in schools pre- and postpolicy change with counterfactual scenarios of no postpolicy change increase in medical exemptions, no clustering of exemptions, and lower population immunization levels. RESULTS: The elimination of nonmedical exemptions significantly reduced both average and maximal outbreak sizes, although increases in medical exemptions resulted in more than twice as many infections, on average, than if medical exemptions were maintained at prepolicy change levels. Spatial clustering of nonmedical exemptions provided some initial protection against random introduction of measles infections; however, it ultimately allowed outbreaks with thousands more infections than when exemptions were randomly distributed. The large-scale outbreaks produced by exemption clusters could not be reproduced when exemptions were distributed randomly until population vaccination was lowered by >6 percentage points. CONCLUSIONS: Despite the high overall vaccinate rate, the spatial clustering of exemptions in schools was sufficient to threaten local herd immunity and reduce protection from measles outbreaks. Policies strengthening vaccine requirements may be less effective if alternative forms of exemptions (eg, medical) are concentrated in existing low-immunization areas.

The Emergence of Spatial Clustering in Medical Vaccine Exemptions Following California Senate Bill 277, 2015-2018.

Objectives. To understand how the elimination of nonmedical vaccine exemptions through California Senate Bill 277 (SB277) may have resulted in increased spatial clustering of medical exemptions.Methods. We used spatial scan statistics and negative binomial regression models to examine spatial clustering in medical vaccine exemptions in California kindergartens from 2015 to 2018.Results. Spatial clustering of medical exemptions across schools emerged following SB277. Clusters were located in similar geographic areas to previous clusters of nonmedical vaccine exemptions, suggesting a spatial association between high nonmedical exemption prevalence and increasing rates of medical exemptions. Regression results confirmed this positive association at the local level. The sociodemographic characteristics of the neighborhoods in which schools were located explained some, but not all, of the positive spatial associations between exemptions before and after SB277.Conclusions. Elimination of nonmedical vaccine exemptions via SB277 may have prompted some parents to instead seek medical exemptions to required school vaccines. The spatial association of these 2 types of exemptions has implications for maintaining pockets of low vaccine compliance and increased disease transmission.

An Informal Internet Survey on the Current State of Consciousness Science.

The scientific study of consciousness emerged as an organized field of research only a few decades ago. As empirical results have begun to enhance our understanding of consciousness, it is important to find out whether other factors, such as funding for consciousness research and status of consciousness scientists, provide a suitable environment for the field to grow and develop sustainably. We conducted an online survey on people's views regarding various aspects of the scientific study of consciousness as a field of research. 249 participants completed the survey, among which 80% were in academia, and around 40% were experts in consciousness research. Topics covered include the progress made by the field, funding for consciousness research, job opportunities for consciousness researchers, and the scientific rigor of the work done by researchers in the field. The majority of respondents (78%) indicated that scientific research on consciousness has been making progress. However, most participants perceived obtaining funding and getting a job in the field of consciousness research as more difficult than in other subfields of neuroscience. Overall, work done in consciousness research was perceived to be less rigorous than other neuroscience subfields, but this perceived lack of rigor was not related to the perceived difficulty in finding jobs and obtaining funding. Lastly, we found that, overall, the global workspace theory was perceived to be the most promising (around 28%), while most non-expert researchers (around 22% of non-experts) found the integrated information theory (IIT) most promising. We believe the survey results provide an interesting picture of current opinions from scientists and researchers about the progresses made and the challenges faced by consciousness research as an independent field. They will inspire collective reflection on the future directions regarding funding and job opportunities for the field.

Unconscious Psychological Treatments for Physiological Survival Circuits.

The idea of targeting unconscious or implicit processes in psychological treatments is not new, but until recently it has not been easy to manipulate these processes without also engaging consciousness. Here we review how this is possible, using various modern cognitive neuroscience methods including a technique known as Decoded Neural-Reinforcement. We discuss the general advantages of this approach, such as how it can facilitate double-blind placebo-controlled studies, and minimize premature patient dropouts in the treatment of fear. We also speculate how this may generalize to other similar physiological survival processes.

The roles of neighborhood composition and autism prevalence on vaccination exemption pockets: A population-wide study.

The number of children entering schools without mandated vaccinations has increased in high-income countries due to the rise of nonmedical exemptions from school vaccination requirements. Herd immunity is threatened when unvaccinated children are concentrated in spatial pockets. Despite the role of vaccine-autism controversy in the current wave of the anti-vaccine movement, we do not know if exemption clusters are associated with local autism rates; it is often assumed that these clusters are merely the result of sociodemographic composition. This study uses data on the number of students with a Personal Belief Exemption reported by schools from 1992 to 2014 and unique data on the locations of children with an autism diagnosis in California to study the correlates of large exemption pockets. Our spatial analysis shows that the prevalence of autism is not associated with the locations of large pockets of vaccination exemptions. Likewise, the spatial distributions of socioeconomic factors and proximity to health care resources have limited roles in explaining these large exemption pockets. Racial/ethnic composition, however, has strong associations with the locations of the large pockets. Our results suggest that community-level interventions are needed to maintain herd immunity as exemption pockets are not merely the result of population composition.

Six-fold over-representation of graduates from prestigious universities does not necessitate unmeritocratic selection in the faculty hiring process.

To achieve faculty status, graduating doctoral students have to substantially outperform their peers, given the competitive nature of the academic job market. In an ideal, meritocratic world, factors such as prestige of degree-granting university ought not to overly influence hiring decisions. However, it has recently been reported that top-ranked universities produced about 2-6 times more faculty than did universities that were ranked lower [1], which the authors claim suggests the use of un-meritocratic factors in the hiring process: how could students from top-ranked universities be six times more productive than their peers from lower-ranked universities? Here we present a signal detection model, supported by computer simulation and simple proof-of-concept example data from psychology departments in the U.S., to demonstrate that substantially higher rates of faculty production need not require substantially (and unrealistically) higher levels of student productivity. Instead, a high hiring threshold due to keen competition is sufficient to cause small differences in average student productivity between universities to result in manifold differences in placement rates. Under this framework, the previously reported results are compatible with a purely meritocratic system. Whereas these results do not necessarily mean that the actual faculty hiring market is purely meritocratic, they highlight the difficulty in empirically demonstrating that it is not so.

To Compare is to Despair? A Population-Wide Study of Neighborhood Composition and Suicide in Stockholm.

Neighborhood context can change the effect of a socio-demographic attribute on the risk of suicide. Eight hypotheses about the interactions between neighborhood composition, ethnicity, income, and socially disadvantaged propositions are proposed based on social support, social comparison, and social regulation mechanisms. They are tested with a population-based dataset of all adults (1.4 million) who lived in the greater Stockholm area in the 1990s. On one hand, multilevel analysis shows that suicide risk increases with the level of affluence in one's neighborhood, particularly among individuals with low income. This supports the notion that income comparison can have negative consequences. On the other hand, social welfare recipients are less likely to commit suicide when there are other social welfare recipients in the neighborhood. Suicide risk among immigrants deceases with the proportion of co-ethnics in the neighborhood, confirming previous findings on social support and suicide. However, further analyses show that the protection effect of having co-ethnic neighbors is limited to immigrants from countries with low suicide rates. This study shows that administrative data can be used to examine neighborhood effects on rare outcomes. The findings are relevant to the contemporary trends towards rising income inequality and ethnic diversity.

Can Sibling Sex Ratios Be Used as a Valid Test for the Prenatal Androgen Hypothesis of Autism Spectrum Disorders?

BACKGROUND: Sibling sex ratios have been applied as an indirect test of a hypothesized association between prenatal testosterone levels and risk for autism, a developmental disorder disproportionately affecting males. Differences in sibling sex ratios between those with and without autism would provide evidence of a shared risk factor for autism and offspring sex. Conclusions related to prenatal testosterone, however, require additional assumptions. Here, we used directed acyclic graphs (DAGs) to clarify the elements required for a valid test of the hypothesis that sibling sex ratios differ between children with and without autism. We then conducted such a test using a large, population-based sample of children. METHODS: Over 1.1 million subjects, born in California from 1992-2007, and identified through birth records, were included. The association between autism diagnosis, determined using the administrative database of the California Department of Developmental Services, and the sex of the subsequent sibling was examined using generalized estimating equations. Sources of potential bias identified using DAGs were addressed. RESULTS: Among male children with autism, 52.2% of next-born siblings were brothers, versus 51.0% for unaffected males. For females with autism, 50.2% of following siblings were brothers versus 51.2% among control females. The relative risk of a subsequent male sibling associated with autism diagnosis was 1.02 (95% confidence interval: 0.99, 1.04). CONCLUSIONS: In a large, population-based sample we failed to find evidence suggesting an excess of brothers among children with autism while controlling for several threats to validity. This test cannot rule out a role of any given exposure, including prenatal testosterone, in either risk of autism or offspring sex ratio, but suggests against a common cause of both.

Focal Points, Endogenous Processes, and Exogenous Shocks in the Autism Epidemic.

Autism prevalence has increased rapidly in the United States during the past two decades. We have previously shown that the diffusion of information about autism through spatially proximate social relations has contributed significantly to the epidemic. This study expands on this finding by identifying the focal points for interaction that drive the proximity effect on subsequent diagnoses. We then consider how diffusion dynamics through interaction at critical focal points, in tandem with exogenous shocks, could have shaped the spatial dynamics of autism in California. We achieve these goals through an empirically calibrated simulation model of the whole population of 3- to 9-year-olds in California. We show that in the absence of interaction at these foci-principally malls and schools-we would not observe an autism epidemic. We also explore the idea that epigenetic changes affecting one generation in the distal past could shape the precise spatial patterns we observe among the next generation.

Spatial clusters of autism births and diagnoses point to contextual drivers of increased prevalence.

Autism prevalence has risen dramatically over the past two decades in California. Although often suggested to have been crucial to the rise of autism, environmental and social contextual drivers of diagnosis have not been extensively examined. Identifying the spatial patterning of autism cases at birth and at diagnosis can help clarify which contextual drivers are affecting autism's rising prevalence. Children with autism not co-morbid with mental retardation served by the California Department of Developmental Services during the period 1992-2005 were matched to California's Birth Master Files. We search for spatial clusters of autism at time of birth and at time of diagnosis using a spatial scan approach that controls for key individual-level risk factors. We then test whether indicators of neighborhood-level diagnostic resources are associated with the diagnostic clusters and assess the extent of clustering by autism symptom severity through a multivariate scan. Finally, we test whether children who move into neighborhoods with higher levels of resources are more likely to receive an autism diagnosis relative to those who do not move with regard to resources. Significant birth and diagnostic clusters of autism are observed independent of key individual-level risk factors. While the clusters overlap, there is a strong positive association between the diagnostic clusters and neighborhood-level diagnostic resources. In addition, children with autism who are higher functioning are more likely to be diagnosed within a cluster than children with autism who are lower functioning. Most importantly, children who move into a neighborhood with more diagnostic resources than their previous residence are more likely to subsequently receive an autism diagnosis than children whose neighborhood resources do not change. We identify birth and diagnostic clusters of autism in California that are independent of individual-level autism risk factors. Our findings implicate a causal relationship between neighborhood-level diagnostic resources and spatial patterns of autism incidence but do not rule out the possibility that environmental toxicants have also contributed to autism risk.

The disappearing seasonality of autism conceptions in California.

BACKGROUND: Autism incidence and prevalence have increased dramatically in the last two decades. The autism caseload in California increased 600% between 1992 and 2006, yet there is little consensus as to the cause. Studying the seasonality of conceptions of children later diagnosed with autism may yield clues to potential etiological drivers. OBJECTIVE: To assess if the conceptions of children later diagnosed with autism cluster temporally in a systematic manner and whether any pattern of temporal clustering persists over time. METHOD: We searched for seasonality in conceptions of children later diagnosed with autism by applying a one-dimensional scan statistic with adaptive temporal windows on case and control population data from California for 1992 through 2000. We tested for potential confounding effects from known risk factors using logistic regression models. RESULTS: There is a consistent but decreasing seasonal pattern in the risk of conceiving a child later diagnosed with autism in November for the first half of the study period. Temporal clustering of autism conceptions is not an artifact of composition with respect to known risk factors for autism such as socio-economic status. CONCLUSION: There is some evidence of seasonality in the risk of conceiving a child later diagnosed with autism. Searches for environmental factors related to autism should allow for the possibility of risk factors or etiological drivers that are seasonally patterned and that appear and remain salient for a discrete number of years.

Cohort effects explain the increase in autism diagnosis among children born from 1992 to 2003 in California.

BACKGROUND: The incidence and prevalence of autism have dramatically increased over the last 20 years. Decomposition of autism incidence rates into age, period and cohort effects disentangle underlying domains of causal factors linked to time trends. We estimate an age-period-cohort effect model for autism diagnostic incidence overall and by level of functioning. METHODS: Data are drawn from sequential cohorts of all 6 501 262 individuals born in California from 1992 to 2003. Autism diagnoses from 1994 to 2005 were ascertained from the California Department of Development Services Client Development and Evaluation Report. RESULTS: Compared with those born in 1992, each successively younger cohort has significantly higher odds of an autism diagnosis than the previous cohort, controlling for age and period effects. For example, individuals born in 2003 have 16.6 times the odds of an autism diagnosis compared with those born in 1992 [95% confidence interval (CI) 7.8-35.3]. The cohort effect observed in these data is stronger for high than for low-functioning children with an autism diagnosis. DISCUSSION: Autism incidence in California exhibits a robust and linear positive cohort effect that is stronger among high-functioning children with an autism diagnosis. This finding indicates that the primary drivers of the increases in autism diagnoses must be factors that: (i) have increased linearly year-to-year; (ii) aggregate in birth cohorts; and (iii) are stronger among children with higher levels of functioning.

A study of deliberate self-harm and its repetition among patients presenting to an emergency department.

BACKGROUND: Marked differences have been found in the characteristics of people dying by suicide in Western and Asian countries. However, there is less information available on possible differences for deliberate self-harm (DSH). AIMS: To compare the characteristics of people presenting to hospital in Hong Kong and Oxford (UK) with DSH, and to assess the outcome of those persons in Hong Kong. METHODS: A sample of DSH patients admitted to the accident and emergency (A&E) department of a regional hospital in Hong Kong was assessed and followed up 6 months later to assess the risk of repetition of DSH, and was then compared with such patients in Oxford. RESULTS: The majority of patients in Hong Kong were female (male:female ratio of 1:2.4), young (59% were under 35), and had used self-poisoning (78%). Over one-third were single (37%) and one-fourth unemployed (26%). About half (49%) scored in the high or very high categories of the Beck's Suicide Intent Scale, considerably more so than in Oxford; 44.6% of patients defaulted psychiatric outpatient service during the 6-month follow-up period. The repetition rate within the following 6 months was 16.7%. The number of self-reported adverse life problems, history of childhood sexual and physical abuse, and repetitive self-mutilation were shown to be the factors most strongly correlated with the risk of re-attempt. Alcohol problems were much lower than in Oxford. CONCLUSIONS: The findings show that DSH patients in Hong Kong show some marked differences compared to those in Oxford. Implications for the prevention of repeated DSH in Hong Kong are discussed.