A landscape assessment of CTSA evaluators and their work in the CTSA consortium, 2021 survey findings.

This article presents a landscape assessment of the findings from the 2021 Clinical and Translational Science Award (CTSA) Evaluators Survey. This survey was the most recent iteration of a well established, national, peer-led systematic snapshot of the CTSA evaluators, their skillsets, listed evaluation resources, preferred methods, and identified best practices. Three questions guided our study: who are the CTSA evaluators, what competencies do they share and how is their work used within hubs. We describe our survey process (logistics of development, deployment, and differences in historical context with prior instruments); and present its main findings. We provide specific recommendations for evaluation practice in two main categories (National vs Group-level) including, among others, the need for a national, strategic plan for evaluation as well as enhanced mentoring and training of the next generation of evaluators. Although based on the challenges and opportunities currently within the CTSA Consortium, takeaways from this study constitute important lessons with potential for application in other large evaluation consortia. To our knowledge, this is the first time 2021 survey findings are disseminated widely, to increase transparency of the CTSA evaluators' work and to motivate conversations within hub and beyond, as to how best to leverage existent evaluative capacity.

Shorter and longer-term risk for non-fatal suicide attempts among male U.S. military veterans after discharge from psychiatric hospitalization.

Although there are key differences in shorter-term (days 1-90) and longer-term (days 91-365) risk factors for suicide after discharge from inpatient psychiatry, there are no comparable data on non-fatal suicide attempts. Risk factors for non-fatal attempts in the first 90 days after discharge were compared with those over the remainder of the year to identify temporal changes in risk. Records were extracted from 208,554 male veterans discharged from Veterans Health Administration acute psychiatric inpatient units from 2008 through 2013. Proportional hazard regression models identified correlates of non-fatal attempts for 1-90 days and 91-365 days; adjusted piecewise proportional hazards regression compared risk between these time frames. 5010 (2.4%) veterans made a non-fatal attempt, 1261 (0.60%) on days 1-90 and 3749 (1.78%) on days 91-365. Risk across both time frames was highest among younger veterans ages 18-59, and those hospitalized with a suicide attempt or suicidal ideation. It was lowest among those with a dementia diagnosis. Risk estimates were generally stable over time but increased among those with substance use disorders and decreased among those with sleep disturbance and discharged against medical advice. Estimates of some risk factors for non-fatal attempts change over time in the year after discharge and differ from those that change for suicide. Different preventive approaches may be needed to reduce shorter and longer-term risk for non-fatal attempts and suicide in the year after discharge.

Shorter- and Longer-Term Risk for Suicide Among Male US Military Veterans in the Year After Discharge From Psychiatric Hospitalization.

OBJECTIVE: Risk for suicide is highest in the first 3 months (days 1-90) after discharge from acute psychiatric hospitalization yet remains elevated for the remainder of the year (days 91-365). The purpose of this study was to compare risk factors for suicide in the first 90 days to those over the remainder of the year to identify changes across time frames. METHODS: The study included 316,707 male veterans discharged from Veterans Health Administration acute psychiatric inpatient units from 2008 through 2013. Proportional hazard regression models were used to identify predictors of suicide death in the first 90 days and in days 91-365, defined via ICD-10 codes. Adjusted piecewise proportional hazard regression was used to compare risk across time frames. RESULTS: Among the 1,037 veterans (< 1%) who died by suicide, 471 (45%) died between days 1 and 90 and 566 (55%) died between days 91 and 365. There was little change regarding the strength of risk factors over time, with two exceptions: risk increased among those aged 18-29 years compared to those aged ≥ 65 years (days 1-90: hazard ratio [HR] = 0.83; 95% CI, 0.57-1.20 vs days 91-365: HR = 1.42; 95% CI, 1.03-1.97; P < .05), whereas, risk associated with suicidal ideation decreased (days 1-90: HR = 1.89; 95% CI, 1.57-2.28 vs days 91-365: HR = 1.40; 95% CI, 1.17-1.66, P < .05). CONCLUSIONS: The strength of association between common risk factors and suicide remains relatively stable during the year following psychiatric hospitalization. However, risk among veterans aged 19-29 years increased over time, whereas risk among those with suicidal ideation decreased.

Prescription Medications for the Treatment of Insomnia and Risk of Suicide Attempt: a Comparative Safety Study.

IMPORTANCE: Guidelines for the pharmacological treatment of chronic insomnia in adults recognize that trazodone and other off-label medications are commonly prescribed despite poor evidence. The Department of Veterans Health Affairs (VA) fills high volumes of inexpensive, over-the-counter sedating antihistamines and older antidepressants in addition to benzodiazepines and zolpidem. Yet little is known about the comparative safety of these agents with regard to suicidal behavior. OBJECTIVES: To assess the comparative effectiveness of the safety of medications routinely used to treat insomnia in VA. DESIGN: Comparative effectiveness using propensity score-matched samples. SETTING: VA. PARTICIPANTS: VA patients without any history of suicidal ideation or behavior 12 months prior to first exposure. EXPOSURES: VA formularies and data were used to identify prescriptions for insomnia. Agents accounting for at least 1% of total insomnia fill volume were < 200 mg trazodone, hydroxyzine, diphenhydramine, zolpidem, lorazepam, diazepam, and temazepam. Exposure was defined as an incident monotherapy exposure preceded by 12 months without any insomnia medications. Subjects with insomnia polypharmacy or cross-overs in the 12 months following first exposure were excluded. MAIN OUTCOMES AND MEASURES: Suicide attempts within 12 months of first exposure. RESULTS: Three hundred forty-eight thousand four hundred forty-nine subjects met criteria and three well-balanced cohorts by drug class matched to zolpidem were created. After adjusting for days' supply, mental health history, and pain and central nervous system medication history, hazard ratios (compared to zolpidem) were as follows: (< 200 mg) trazodone (HR = 1.61, 95% CI 1.07-2.43); sedating antihistamines (HR = 1.37, 95% CI 0.90-2.07); and benzodiazepines (HR = 1.31, 95% CI 0.85-2.08). CONCLUSIONS AND RELEVANCE: Compared to zolpidem, hazard of suicide attempt was 61% higher with trazodone (< 200 mg). No significant differences in suicide attempt risk were identified between benzodiazepines or sedating antihistamines and zolpidem, respectively. These findings provide the first comparative effectiveness evidence against the use of trazodone for insomnia.

Ambient and controlled exposures to particulate air pollution and acute changes in heart rate variability and repolarization.

Previous studies have reported increased risks of myocardial infarction in association with elevated ambient particulate matter (PM) in the previous hour(s). However, whether PM can trigger mechanisms that act on this time scale is still unclear. We hypothesized that increases in PM are associated with rapid changes in measures of heart rate variability and repolarization. We used data from panel studies in Augsburg, Germany, and Rochester, New York, USA, and two controlled human exposure studies in Rochester. Data included ECG recordings from all four studies, controlled exposures to (concentrated) ultrafine particles (UFP; particles with an aerodynamic diameter <100 nm) and ambient concentrations of UFP and fine PM (PM2.5, aerodynamic diameter <2.5 µm). Factor analysis identified three representative ECG parameters: standard deviation of NN-intervals (SDNN), root mean square of successive differences (RMSSD), and T-wave complexity. Associations between air pollutants and ECG parameters in the concurrent and previous six hours were estimated using additive mixed models adjusting for long- and short-term time trends, meteorology, and study visit number. We found decreases in SDNN in relation to increased exposures to UFP in the previous five hours in both of the panel studies (e.g. Augsburg study, lag 3 hours: -2.26%, 95% confidence interval [CI]: -3.98% to -0.53%; Rochester panel study, lag 1 hour: -2.69%; 95% CI: -5.13% to -0.26%) and one of the two controlled human exposure studies (1-hour lag: -13.22%; 95% CI: -24.11% to -2.33%). Similarly, we observed consistent decreases in SDNN and RMSSD in association with elevated PM2.5 concentrations in the preceding six hours in both panel studies. We did not find consistent associations between particle metrics and T-wave complexity. This study provided consistent evidence that recent exposures to UFP and PM2.5 can induce acute pathophysiological responses.

The Association of Pain Intensity and Suicide Attempts Among Patients Initiating Pain Specialty Services.

Using Veterans Health Administration data, we assessed the extent to which mean past-year (365 days) pain intensity scores were associated with suicide attempts in the year after the initiation of pain specialty services in fiscal years 2012 to 2014 (N = 221,817). Suicide attempts in the year after initiating Veterans Health Administration pain specialty services (ie, index visit) were identified using medical records and a suicide surveillance sources. Adjusted hazard models accounted for key covariates (eg, demographics, comorbidities). Subgroup analyses were also conducted on veterans without and with a suicide attempt in the year before the index visit to examine risk for first attempt and reattempts. Adjusted analyses revealed that pain intensity scores were significantly associated suicide attempts after the index visit. Specifically, veterans with severe and moderate pain had a hazards ratio of 1.41 (95% confidence interval = 1.21-1.63) and 1.29 (95% confidence interval = 1.13-1.47), respectively. These results were consistent for those without a past-year attempt and for those with a past-year attempt. The results suggest that moderate to severe pain intensity in the year before initiating pain specialty services may be a useful indicator of suicide risk, even when considered in the context of key factors. PERSPECTIVE: This study used national administrative and suicide surveillance data to assess the relationship between pain intensity and suicide attempts after an initial visit for pain specialty services among veterans. These findings highlight the potential usefulness of assessing pain intensity as an indicator for suicide risk.

Population metrics for suicide events: A causal inference approach.

Large-scale public health prevention initiatives and interventions are a very important component to current public health strategies. But evaluating effects of such large-scale prevention/intervention faces a lot of challenges due to confounding effects and heterogeneity of study population. In this paper, we will develop metrics to assess the risk for suicide events based on causal inference framework when the study population is heterogeneous. The proposed metrics deal with the confounding effect by first estimating the risk of suicide events within each of the risk levels, number of prior attempts, and then taking a weighted sum of the conditional probabilities. The metrics provide unbiased estimates of the risk of suicide events. Simulation studies and a real data example will be used to demonstrate the proposed metrics.

Chaplaincy Encounters Following a Suicide Attempt.

This descriptive study examines the provision of chaplaincy services to veterans who sought health care at a Department of Veterans Affairs (VA) Medical Center following a suicide attempt. A system-wide VA database of suicidal behavior was used to identify a cohort of n = 22,701 veterans who survived a suicide attempt. Next, an electronic review of VA clinical records found that n = 7,447 (32.8%) received chaplaincy services in the 30 days following their attempt. Of this group, the overwhelming majority of first chaplaincy encounters took place in in-patient settings: n = 6890 (92.5%). First chaplaincy encounters most often occurred 1-7 days following the attempt: n = 5,033 (67.6%). Most chaplaincy service users had only one chaplaincy encounter: n = 3,514 (47.2%). The findings suggest that, at VA Medical Centers, a relatively sizeable percentage of suicide attempt survivors have contact with chaplaincy services. Additional research is needed to ascertain if chaplaincy services yield any therapeutic benefit for this group.

Suicide mortality among male veterans discharged from Veterans Health Administration acute psychiatric units from 2005 to 2010.

PURPOSE: The purpose of this study was to calculate suicide rates and identify correlates of risk in the year following discharge from acute Veterans Health Administration psychiatric inpatient units among male veterans discharged from 2005 to 2010 (fiscal years). METHODS: Suicide rates and standardized mortality ratios were calculated. Descriptive analyses were used to describe suicides and non-suicides and provide base rates for interpretation, and unadjusted and adjusted proportional hazard models were used to identify correlates of suicide. RESULTS: From 2005 to 2010, 929 male veterans died by suicide in the year after discharge and the suicide rate was 297/100,000 person-years (py). The suicide rate significantly increased from 234/100,000 py (95% CI = 193-282) in 2005 to 340/100,000 py (95% CI = 292-393) in 2008, after which it plateaued. Living in a rural setting, HR (95% CI) = 1.20 (1.05, 1.36), and being diagnosed with a mood disorder such as major depression, HR (95% CI) = 1.60 (1.36, 1.87), or other anxiety disorder, HR (95% CI) = 1.52 (1.24, 1.87), were associated with increased risk for suicide. CONCLUSIONS: Among male veterans, the suicide rate in the year after discharge from acute psychiatric hospitalization increased from 2005 to 2008, after which it plateaued. Prevention efforts should target psychiatrically hospitalized veterans who live in rural settings and/or are diagnosed with mood or other anxiety disorders.

Triggering of ST-elevation myocardial infarction by ambient wood smoke and other particulate and gaseous pollutants.

We previously observed increased odds of ST-elevation myocardial infarctions (STEMIs) associated with increased ambient fine particulate matter (PM2.5) in the previous hour. However, data are lacking on the effects of specific PM sources. Using data from 362 patients, a case-crossover design, and conditional logistic regression, we estimated the relative odds of STEMI associated with increased Delta-C (wood smoke), black carbon (BC; traffic), PM2.5, and gaseous pollutants in the previous 1-72 h. We did not observe increased odds of STEMIs associated with increased Delta-C or BC. We did observe increased odds associated with each 7.1 µg/m3 increase in PM2.5 (OR (95% CI): 1.17 (0.99, 1.39)) and each 19.9 p.p.b. increase in ozone (O3; 1.27 (1.00, 1.63)) in the previous hour, and each 0.22 p.p.m. increase in 48-h carbon monoxide (CO) concentrations (1.32 (1.00, 1.73]). Larger relative odds were associated with PM2.5 in May-October, and O3 and CO in November-April. Increased PM2.5, O3, and CO, but not wood smoke or BC, were associated with increased odds of STEMI, and effects may differ by season. Studies using spatially adjusted pollution estimates are needed, as well as studies further examining O3 and CO effects on the risk of STEMI.

Suicide attempts among alcohol-dependent pain patients before and after an inpatient hospitalization.

BACKGROUND: This study examined (1) whether pain diagnoses were risk factors for non-fatal suicide attempts before and after inpatient hospitalizations in alcohol-dependent veterans, and (2) the characteristics of pain patients who attempted suicide. METHOD: Administrative data from the Veterans Health Administration were used to identify veterans with an alcohol use disorder who had an inpatient hospitalization during fiscal year 2011 (n=13,047). Logistic regression analyses were used to examine the associations of suicide attempts before and after hospitalizations with pain diagnoses, demographics, medical comorbidity, and psychiatric comorbidity. RESULTS: Bivariate analyses and analyses controlling for demographics and medical comorbidity, indicated that pain diagnoses were significantly associated with suicide attempts in the 365days before hospitalization (Odds Ratio Adjusted [OR]=1.22). This effect was not significant after controlling for psychiatric disorders. Pain diagnoses were not identified as risk factors of suicide attempts in the 365days following discharge. Subgroup analyses among only those with a pain diagnosis revealed that being younger (OR=2.64), being female (OR=2.28), and having an attempt in the year prior to hospitalization (OR=4.11) were risk factors of suicide attempts in the year following hospitalization. Additionally, younger age (OR=2.13) and depression (OR=3.53) were associated with attempts in the year prior to the hospitalization. CONCLUSIONS: This study suggests that psychiatric disorders account for the relationship between pain diagnoses and past suicide attempts among hospitalized alcohol-dependent veterans. Pain-specific suicide prevention efforts may be better targeted at less intensive levels of care.

Does total antioxidant capacity modify adverse cardiac responses associated with ambient ultrafine, accumulation mode, and fine particles in patients undergoing cardiac rehabilitation?

BACKGROUND: Previous studies suggest that pathways reducing oxidative stress may have a protective effect against adverse cardiac responses associated with ambient PM. However, few studies have directly assessed total antioxidant capacity (TAC) as a potential effect modifier of cardiac responses to increased ambient PM. OBJECTIVES: We examined if TAC modifies the association between ambient PM and markers of heart rate variability (HRV), repolarization, systemic inflammation, and systolic blood pressure (SBP) in post-infarction patients. METHODS: We recruited 76 patients with a recent coronary event (myocardial infarction or unstable angina) who participated in a cardiac rehabilitation program from June 2006 to November 2009 in Rochester, New York. Ambient fine particle (PM2.5,≤2.5µm in aerodynamic diameter), accumulation mode particle (AMP, 100-500nm) and ultrafine particle (UFP, 10-100nm) concentrations were measured continuously by fixed-site monitors. Markers of HRV and repolarization were measured by continuous Holter electrocardiogram (ECG) recordings before and during exercise sessions of the rehabilitation program. Blood pressure was measured and venous blood samples were collected before exercise to measure TAC and inflammation markers. We applied linear mixed models to assess changes in markers of HRV, repolarization, systemic inflammation, and SBP associated with increased PM concentrations in the low, medium and high TAC tertile groups, after adjusting for covariates including temperature, calendar time since the beginning of the study, visit number, month of year, and hour of day. RESULTS: Based on subject-visits with available TAC, we observed increases in SBP, C-reactive protein, and fibrinogen, and decreases in rMSSD (square root of the mean of the sum of the squared differences between adjacent normal to normal intervals) and SDNN (standard deviation of normal to normal beat intervals) associated with increased PM2.5, AMP and UFP in the previous 6-120h (e.g. change in SBP associated with each interquartile range (IQR) increase in PM2.5 lagged 0-5h was 1.27mmHg [95%CI: 0.09, 2.46mmHg]). However, we did not observe a consistent pattern of effect measure modification by TAC for any combination of pollutant and outcome (e.g. changes in SBP associated with each IQR increase in PM2.5 lagged 0-5h for the low, medium and high TAC tertile groups were 1.93mmHg [95%CI: 0.23, 3.63 mmHg], -0.31 mmHg [95%CI: -2.62, 2.01 mmHg], and 1.29mmHg [95%CI: -0.64, 3.21 mmHg], respectively. P for interaction=0.28). CONCLUSIONS: In a post-infarction population, total antioxidant capacity does not appear to modify the association between biomarkers of heart rate variability, repolarization, systemic inflammation, and systolic blood pressure and ambient PM concentrations in the previous 6-120h.

Increases in ambient particulate matter air pollution, acute changes in platelet function, and effect modification by aspirin and omega-3 fatty acids: A panel study.

Increased particulate matter (PM) air pollutant concentrations have been associated with platelet activation. It was postulated that elevated air pollutant concentrations would be associated with increases in measures of platelet function and that responses would be blunted when taking aspirin and/or fish oil. Data from a sequential therapy trial (30 subjects with type 2 diabetes mellitus), with 4 clinic visits (first: no supplements, second: aspirin, third: omega-3 fatty acid supplements, fourth: aspirin and omega-3 fatty acids) per subject, were utilized. Using linear mixed models, adjusted for relative humidity, temperature, visit number, and season, changes in three platelet function measures including (1) aggregation induced by adenosine diphosphate (ADP), (2) aggregation induced by collagen, and (3) thromboxane B2 production were associated with interquartile range (IQR) increases in mean concentrations of ambient PM2.5, black carbon, ultrafine particles (UFP; 10-100 nm), and accumulation mode particles (AMP; 100-500 nm) in the previous 1-96 h. IQR increases in mean UFP and AMP concentrations were associated with significant decreases in platelet response, with the largest being a -0.43 log(pg/ml) decrease in log(thromboxane B2) (95% CI = -0.8, -0.1) associated with each 582-particles/cm(3) increase in AMP, and a -1.7 ohm reduction in collagen-induced aggregation (95% CI = -3.1, -0.3) associated with each 2097-particles/cm(3) increase in UFP in the previous 72 h. This UFP effect on thromboxane B2 was significantly muted in diabetic subjects taking aspirin (-0.01 log[pg/ml]; 95% CI = -0.4, 0.3). The reason for this finding remains unknown, and needs to be investigated in future studies.

Use of ICD-9-CM Diagnosis Code V62.89 (Other Psychological or Physical Stress, Not Elsewhere Classified) Following a Suicide Attempt.

OBJECTIVE: This study examined the demographic, diagnostic, and service characteristics of veterans who received services for "other psychological or physical stress, not elsewhere classified" (ICD-9-CM V62.89) in the month following a suicide attempt. METHODS: An electronic search of a Veterans Health Administration (VHA) suicide event reporting system identified 22,701 veterans who were survivors of a suicide attempt. Their clinical service encounter records were extracted from a VHA administrative database to identify those who received services related to V62.89. RESULTS: Services related to V62.89 were provided to N=2,173 (9.6%) of the sample. Chaplains were the predominant service provider, identified in N=1,745 (80%) of the service encounters. Differences were noted between those who received services related to V62.89 from a chaplain or from another service provider. CONCLUSIONS: V62.89 appears to be a focus of clinical concern for some veteran suicide attempt survivors. Additional research is needed to better understand any implications for suicide "postvention."

Impact of the 2008 Beijing Olympics on the risk of pregnancy complications.

Taking advantage of the natural experiment of the 2008 Beijing Olympics (August 8 to September 24), when air pollution levels decreased by 13% to 60%, the authors assessed whether having ≥1 pregnancy month during the Olympics was associated with decreased risks of hypertensive disorders (HDs) and/or fetal-placental conditions (FPCs). Singleton births to mothers with ≥1 pregnancy month in 2008 or 2009 (N = 56,155) were included. Using generalized additive models, the authors estimated the risk of HDs and FPCs associated with (1) the 2008 Olympics compared with the same dates in 2009, and (2) increased mean ambient PM10 (particulate matter with an aerodynamic diameter <10 µm), NO2 (nitrogen dioxide), and SO2 (sulfur dioxide) concentrations during each trimester. However, no association between HDs or FPCs and having any trimester during the 2008 Olympic period was found. This may, in part, be due to a small number of pregnancy complications in this population.

Ambient and Controlled Particle Exposures as Triggers for Acute ECG Changes.

INTRODUCTION: Previous studies have examined changes in heart rate variability (HRV*) and repolarization associated with increased particulate matter (PM) concentrations on the same and previous few days. However, few studies have examined whether these health responses to PM occur within a few hours or even less. Moreover, it is not clear whether exposure of subjects to ambient or-controlled PM concentrations both lead to similar health effects or whether any of the subjects' individual characteristics modify any of their responses to PM. The aims of the cur- rent study were to investigate whether exposure to PM was associated with rapid changes (< 60 minutes or con- current hour up to a delay of 6 hours) in markers of car- diac rhythni or changes in total antioxidant capacity (a marker of protection against oxidative stress) and whether any PM effects on cardiac rhythm markers were modified by total antioxidant capacity, age, obesity, smoking, hypertension, exertion, prior myocardial infarction (MI), or medication. METHODS: We obtained data from a completed study in Augsburg, Germany (a panel study in N= 109 subjects, including a group with type 2 diabetes or impaired glucose tolerance [IGT; also known as prediabetes]) and a group of other- wise healthy subjects with a potential genetic susceptibil- ity to detoxifying and inflammatory pathways (Hampel et al. 2012b), as well as three completed studies in Rochester, New York (the REHAB panel study of N= 76 postinfarction patients in a cardiac rehabilitation pro- gram [Rich et al. 2012b]; the UPDIABETES study of con- trolled exposure to ultrafine particles [UFPs, particles with an aerodynamic diameter < 100 nm] of N = 19 patients with type 2 diabetes [Stewart et al. 2010; Vora et al. 2014j; and the UPCON controlled-exposure study of concentrated UFP exposure in N = 20 young, healthy, life- time nonsmokers). Data included 5-minute and 1-hour values for HRV and repolarization parameters from elec- trocardiogram (ECG) recordings and total antioxidant capacity measured in stored blood samples. Ambient con- centrations of UFPs, accumulation-mode particles (AMP, particles with an aerodynamic diameter of 100-500 nm), fine PM (PM2.5, particles with an aerodynamic diameter 2.5 pm), and black carbon (BC) were also available. We first conducted factor analyses in each study to find subgroups of correlated ECG outcomes and to reduce the number of outcomes examined in our statistical models. We then restricted the statistical analyses to the factors and representative.outcomes that were common to all four studies, including total HRV (measured as the standard deviation of normal-to-normal [NN] beat intervals [SDNNj), parasympathetic modulation (measured as the root mean square of the successive differences [RMSSD between adjacent NN beat intervals), and T-wave morphol- ogy (measured as T-wave complexity). Next, we used addi- tive mixed models to estimate the change in each outcome associated with increased pollutant concentrations in the . concurrent and previous 6 hours and with 5-minute inter- vals up to the previous 60 minutes, accounting for the correlation of repeated outcome measures for each subject and adjusting for time trend, hour of the day, temperature, relative humidity, day of the week, month, and visit number. Because multiple comparisons were an issue in our. analyses, we used a discovery-and-replication approach to draw conclusions across studies for each research question. RESULTS: In the Augsburg study, interquartile range (IQR) increases in UFP concentrations lagged 2 to 5 hours were associated with 1%-3% decreases in SDNN (e.g., lagged 3 hours in the group with a genetic susceptibility: -2.26%; 95% confidence interval [CI], -3.98% to -0.53%). In the REHAB study, similarly, IQR increases in UFP concentra- tions in the previous 5 hours were associated with < 3% decreases in SDNN (e.g., lagged 1 hour: -2.69%; 95% CI, -5.13% to -0.26%). We also found decreases in SDNN associated with IQR increases in total particle count-(a surrogate for UFP) in the UPDIABETES study (lagged 1 hour: -13.22%; 95% CI, -24.11% to -2.33%) but not in the UPCON study. In the Augsburg study, IQR increases in PM2.5 concen- trations in the concurrent hour and lagged 1-5 hours, AMP concentrations lagged 1 and 3 hours, and BC con- centrations lagged 1-5 hours were associated with -1%-5% decreases in SDNN (e.g., PM2.5 lagged 2 hours in the group with diabetes or IGT: -4.59%; 95% CI, -7.44% to -1.75%). In the REHAB study, IQR increases in PM2.5 concentrations lagged 5 and 6 hours and AMP concentra- tions in the concurrent hour and lagged up to 5 hours were associated with 1%-2% decreases in SDNN (e.g., PM2.5 lagged 4 hours: -2.13%; 95% CI, -3.91% to -0.35%). In the Augsburg study, IQR increases in PM2.5 concen- trations in the concurrent hour and BC lagged 1 and 6 hours were associated with 3%-7% decreases in RMSSD (e.g., PM2.5 concurrent hour in the group with diabetes or IGT: -7.20%; 95% CI, -12.11% to -2.02%). In the REHAB study, similarly, increases in PM2.5 concen- trations lagged 4 to 6 hours-though not AMP or BC con- centrations at any lag hour-were associated with -2.5%-3.5% decreases in RMSSD (e.g., PM2.5 lagged 5 hours: -3.49%; 95% CI, -6.13% to -0.84%). We did not find consistent evidence of any pollutant effects on T-wave complexity in 1-hour recordings. For 5-minute record- ings, there was no consistent evidence of UFP effects on SDNN, RMSSD, or T-wave complexity at any 5-minute interval within 60 minutes. We further concluded that these replicated hourly effects of UFP and PM2.5 on short-term measures of SDNN and RMSSD generally did not differ between the groups in the studies (i.e., type 2 diabetes, pre-diabetes/IGT, post- infarction, and healthy subjects). Last, we found no con- sistent evidence of effects of any pollutant on total anti- oxidant capacity and no consistent evidence of modification of our PM2.5-outcome associations by any of the potential effect modifiers. ONCLUSIONS: Increased UFP concentrations were associated with decreased SDNN in both of the panel studies and one of the two controlled-exposure studies. We also found that decreased SDNN was associated with both increased PM2.5 and AMP concentrations in the previous 6 hours in the panel studies and that decreased RMSSD was associ- ated with increased PM2.5 concentrations in the previous 6 hours in the panel studies. We therefore concluded that the research questions were replicated. Our findings suggest that both UFPs and PM2.5 are associated with autonomic dysfunction within hours of exposure, which may in part. explain the previously reported risk of acute cardiovascular events associated with increased PM in the previous few hours. Despite the heterogeneity of the study populations,and protocols, our findings provided consistent evidence for the induction of rapid pathophysiological responses by UFPs and PM2.5- The absence of consistent associations between UFPs, PM2.5, and these outcomes when examining shorter time intervals indicates that the 5- to 60-minute responses may be less pronounced than the responses occurring within hours. However, the findings from the 5-minute intervals may have been affected by the variety of proto- cols and conditions from study to study as well as by the potential effects of underlying diseases (e.g., healthy indi- viduals versus individuals with diabetes or a recent cor- onary artery. event), physical activity, circadian rhythms, stress, and/or medications.

Comorbid depression and alcohol use disorders and prospective risk for suicide attempt in the year following inpatient hospitalization.

OBJECTIVE: The purpose of this study is to identify predictors of nonfatal suicide attempts in veterans discharged from acute hospitalization with depression and/or alcohol use disorder (AUD) diagnoses. We hypothesized that primary depression confers similar risk for attempt whether or not it is accompanied by secondary AUD, and that a suicide attempt in the prior year would confer greatest risk of the variables studied. METHOD: Veteran Health Administration (VHA) patients discharged from acute inpatient hospitalization in 2011 with AUD and/or non-bipolar depression diagnoses (N=22,319) were analyzed using information from the computerized record system and national database on suicidal behavior. Proportional hazard regression models estimated unadjusted and adjusted hazard ratios (AHR) and confidence intervals (95% CI) for risk of a nonfatal attempt within one year following discharge. RESULTS: As hypothesized, primary depression with secondary AUD [AHR (95% CI)=1.41 (1.04, 1.92)] and without secondary AUD [AHR (95% CI)=1.30 (1.00, 1.71)] conferred similar prospective risk for attempt (AUD without depression, reference). Although prior suicide attempt was associated with increased risk, acute care in "general psychiatry" during hospitalization [AHR (95% CI)=6.35 (3.48, 13.00)] conferred the greatest risk among the variables studied. Transfer to another inpatient setting reduced risk [AHR (95% CI=0.53 (0.34, 0.79). LIMITATIONS: Analyses were based on administrative data and did not include information on mortality. CONCLUSION: When primary depression is severe enough to warrant inpatient hospitalization, a secondary diagnosis of AUD may not contribute additional prospective risk for nonfatal attempt. Within VHA, acute psychiatric care during hospitalization is a potential marker for increased risk for nonfatal attempt. Transfer to an additional inpatient setting may reduce risk for nonfatal attempt.

Triggering of myocardial infarction by increased ambient fine particle concentration: Effect modification by source direction.

BACKGROUND: Previously, we reported a 18% increased odds of ST-elevation myocardial infarction (STEMI) associated with each 7.1 µg/m(3) increase in PM2.5 concentration in the hour prior to MI onset. We found no association with non-ST elevation myocardial infarction (NSTEMI). We examined if this association was modified by PM2.5 source direction. METHODS: We used the NOAA HYbrid Single-Particle Lagrangian Trajectory (HYSPLIT) model to calculate each hourly air mass location for the 24 hours before each case or control time period in our previous PM2.5/STEMI case-crossover analysis. Using these data on patients with STEMI (n=338), hourly PM2.5 concentrations, and case-crossover methods, we evaluated whether our PM2.5/STEMI association was modified by whether the air mass passed through each of the 8 cardinal wind direction sectors in the previous 24h. RESULTS: When the air mass passed through the West-Southwest direction (WSW) any time in the past 24h, the odds of STEMI associated with each 7.1µg/m(3) increase in PM2.5 concentration in the previous hour (OR=1.27; 95% CI=1.08, 1.22) was statistically significantly (p=0.01) greater than the relative odds of STEMI associated with increased PM2.5 concentration when the wind arrived from any other direction (OR=0.99; 95% CI=0.80, 1.22). We found no other effect modification by any other source direction. Further, relative odds estimates were largest when the time spent in the WSW was 8-16 h, compared to ≤7 h or 17-24 h, suggesting that particles arising from sources in this direction were more potent in triggering STEMIs. CONCLUSIONS: Since relative odds estimates were higher when the air mass passed through the WSW octant in the past 24h, there may be specific components of the ambient aerosol that are more potent in triggering STEMIs. This direction is associated with substantial emissions from coal-fired power plants and other industrial sources of the Ohio River Valley, many of which are undergoing modifications to reduce their emissions.

Differences in Birth Weight Associated with the 2008 Beijing Olympics Air Pollution Reduction: Results from a Natural Experiment.

BACKGROUND: Previous studies have reported decreased birth weight associated with increased air pollutant concentrations during pregnancy. However, it is not clear when during pregnancy increases in air pollution are associated with the largest differences in birth weight. OBJECTIVES: Using the natural experiment of air pollution declines during the 2008 Beijing Olympics, we evaluated whether having specific months of pregnancy (i.e., 1st…8th) during the 2008 Olympics period was associated with larger birth weights, compared with pregnancies during the same dates in 2007 or 2009. METHODS: Using n = 83,672 term births to mothers residing in four urban districts of Beijing, we estimated the difference in birth weight associated with having individual months of pregnancy during the 2008 Olympics (8 August-24 September 2008) compared with the same dates in 2007 and 2009. We also estimated the difference in birth weight associated with interquartile range (IQR) increases in mean ambient particulate matter ≤ 2.5 µm in aerodynamic diameter (PM2.5), sulfur dioxide (SO2), nitrogen dioxide (NO2), and carbon monoxide (CO) concentrations during each pregnancy month. RESULTS: Babies whose 8th month of gestation occurred during the 2008 Olympics were, on average, 23 g larger (95% CI: 5 g, 40 g) than babies whose 8th month occurred during the same calendar dates in 2007 or 2009. IQR increases in PM2.5 (19.8 µg/m3), CO (0.3 ppm), SO2 (1.8 ppb), and NO2 (13.6 ppb) concentrations during the 8th month of pregnancy were associated with 18 g (95% CI: -32 g, -3 g), 17 g (95% CI: -28 g, -6 g), 23 g (95% CI: -36 g, -10 g), and 34 g (95% CI: -70 g, 3 g) decreases in birth weight, respectively. We did not see significant associations for months 1-7. CONCLUSIONS: Short-term decreases in air pollution late in pregnancy in Beijing during the 2008 Summer Olympics, a normally heavily polluted city, were associated with higher birth weight. CITATION: Rich DQ, Liu K, Zhang J, Thurston SW, Stevens TP, Pan Y, Kane C, Weinberger B, Ohman-Strickland P, Woodruff TJ, Duan X, Assibey-Mensah V, Zhang J. 2015. Differences in birth weight associated with the 2008 Beijing Olympics air pollution reduction: results from a natural experiment. Environ Health Perspect 123:880-887; http://dx.doi.org/10.1289/ehp.1408795.

Ambient fine particulate air pollution triggers ST-elevation myocardial infarction, but not non-ST elevation myocardial infarction: a case-crossover study.

BACKGROUND: We and others have shown that increases in particulate air pollutant (PM) concentrations in the previous hours and days have been associated with increased risks of myocardial infarction, but little is known about the relationships between air pollution and specific subsets of myocardial infarction, such as ST-elevation myocardial infarction (STEMI) and non ST-elevation myocardial infarction (NSTEMI). METHODS: Using data from acute coronary syndrome patients with STEMI (n = 338) and NSTEMI (n = 339) and case-crossover methods, we estimated the risk of STEMI and NSTEMI associated with increased ambient fine particle (<2.5 um) concentrations, ultrafine particle (10-100 nm) number concentrations, and accumulation mode particle (100-500 nm) number concentrations in the previous few hours and days. RESULTS: We found a significant 18% increase in the risk of STEMI associated with each 7.1 µg/m³ increase in PM2.5 concentration in the previous hour prior to acute coronary syndrome onset, with smaller, non-significantly increased risks associated with increased fine particle concentrations in the previous 3, 12, and 24 hours. We found no pattern with NSTEMI. Estimates of the risk of STEMI associated with interquartile range increases in ultrafine particle and accumulation mode particle number concentrations in the previous 1 to 96 hours were all greater than 1.0, but not statistically significant. Patients with pre-existing hypertension had a significantly greater risk of STEMI associated with increased fine particle concentration in the previous hour than patients without hypertension. CONCLUSIONS: Increased fine particle concentrations in the hour prior to acute coronary syndrome onset were associated with an increased risk of STEMI, but not NSTEMI. Patients with pre-existing hypertension and other cardiovascular disease appeared particularly susceptible. Further investigation into mechanisms by which PM can preferentially trigger STEMI over NSTEMI within this rapid time scale is needed.