Patient, Family, and Clinician Perspectives on End-of-Life Care Quality Domains and Candidate Indicators for Adolescents and Young Adults With Cancer.

Importance: End-of-life care quality indicators specific to adolescents and young adults (AYAs) aged 12 to 39 years with cancer have not been developed. Objective: To identify priority domains for end-of-life care from the perspectives of AYAs, family caregivers, and clinicians, and to propose candidate quality indicators reflecting priorities. Design, Setting, and Participants: This qualitative study was conducted from December 6, 2018, to January 5, 2021, with no additional follow-up. In-depth interviews were conducted with patients, family caregivers, and clinicians and included a content analysis of resulting transcripts. A multidisciplinary advisory group translated priorities into proposed quality indicators. Interviews were conducted at the Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an AYA cancer support community (lacunaloft.org). Participants included 23 AYAs, 28 caregivers, and 29 clinicians. Exposure: Stage IV or recurrent cancer. Main Outcomes and Measures: Care priorities. Results: Interviews were conducted with 23 patients (mean [SD] age, 29.3 [7.3] years; 12 men [52%]; 18 White participants [78%]), 28 family caregivers (23 women [82%]; 14 White participants [50%]), and 29 clinicians (20 women [69%]; 13 White participants [45%]). Caregivers included 22 parents (79%), 5 spouses or partners (18%), and 1 other family member (4%); the 29 clinicians included 15 physicians (52%), 6 nurses or nurse practitioners (21%), and 8 social workers or psychologists (28%). Interviews identified 7 end-of-life priority domains: attention to physical symptoms, attention to quality of life, psychosocial and spiritual care, communication and decision-making, relationships with clinicians, care and treatment, and independence. Themes were consistent across the AYA age range and participant type. Although some domains were represented in quality indicators developed for adults, unique domains were identified, as well as AYA-specific manifestations of existing domains. For example, quality of life included global quality of life; attainment of life goals, legacy, and meaning; support of personal relationships; and normalcy. Within communication and decision-making, domains included communication early in the disease course, addressing prognosis and what to expect at the end of life, and opportunity for AYAs to hold desired roles in decision-making. Care and treatment domains relevant to cancer therapy, use of life-prolonging measures, and location of death emphasized the need for preference sensitivity rather than a standard path. This finding differs from existing adult indicators that propose that late-life chemotherapy, intensive measures, and hospital death should be rare. Conclusions and Relevance: The findings of this qualitative study suggest that AYAs with cancer have priorities for care at the end of life that are not fully encompassed in existing indicators for adults. Use of new indicators for this young population may better reflect patient- and family-centered experiences of quality care.

Effect of Maternal Distress on Perceptions of Infant Behavior May Differ in Chinese-American and European-American Mothers and Infants.

OBJECTIVE: This study examined the associations between maternal distress (symptoms of depression and anxiety) and observer and maternal ratings of infant temperament in Chinese-American (CA) and European-American (EA) 4-month-old infants (N = 114 dyads). METHODS: Maternal distress was obtained through self-reported symptoms of depression and anxiety. Mothers reported infant temperament (distress at limitations, soothability, and fear) through the short form of the Infant Behavior Questionnaire-Revised. To obtain observer-rated infant reactivity, infants were administered a battery of visual and auditory stimuli in the laboratory, in which infant behaviors (fret/cry, limb activity, and arching of the back) were coded. RESULTS: Maternal distress accounted more for the maternal perception of her infant among EA mothers than among CA mothers, but the relation was only observed for soothability. Higher maternal distress was associated with maternal report of lower soothability for EA mothers. Observer-rated infant reactivity, but not maternal distress, was positively associated with EA and CA maternal report of distress at limitations. Observer-rated infant negativity was associated with somewhat higher ratings of infant fear for EA mothers, although this association for EA mothers was not significantly different from CA mothers. CONCLUSIONS: Potential biases in maternal report of infant behavior due to effects from maternal distress may not be generalizable across cultures but may vary because of cultural norms for emotional experience and expectations for infant behavior. EA mothers' ratings of infant distress and soothability, but not fear, may be influenced by maternal distress.

Refugee Children's Participation in the Women, Infants, and Children Supplemental Nutrition (WIC) Program in Massachusetts, 1998-2010.

OBJECTIVES: To (1) describe prevalence of growth abnormalities and anemia in refugee children; (2) describe the proportion of age-eligible refugee children enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and (3) identify risk factors for lack of enrollment in WIC. DESIGN: Data were collected from 1731 health screenings for refugee children younger than 5 years in Massachusetts in 1998-2010 and matched to WIC program records. Risk factors for lack of WIC enrollment were analyzed in SAS using multivariate logistic regression. SETTING: Massachusetts. PARTICIPANTS: Refugee children under age 5 years. MAIN OUTCOME MEASURES: (1) prevalence of growth abnormalities and anemia in refugee children, (2) proportion of age-eligible refugee children enrolled in WIC, and (3) association of risk factors with lack of WIC enrollment. RESULTS: Overall, 33% of refugee children under age 5 in Massachusetts had at least 1 growth and nutrition problem, including anemia (31%), stunting (10%), wasting (8%), and low weight for age (10%). WIC enrollment among refugee children under 5 years of age was only 62%, lower than that of all eligible children under 5 in Massachusetts (86%). Risk factors for lack of WIC enrollment among refugee children included age, world region of origin, and arrival cohort. CONCLUSIONS: Although many refugee children under age 5 experience growth or nutrition problems, one-third of refugee children in Massachusetts were not enrolled in WIC for nutrition assistance, representing a failure of the system. Agencies providing services at the local level should be supported to facilitate enrollment and participation for shared clients.

A Qualitative Study of Spanish-Speakers' Experience with Dense Breast Notifications in a Massachusetts Safety-Net Hospital.

BACKGROUND: Legislation requiring mammography facilities to notify women if they have dense breast tissue found on mammography has been enacted in 34 US states. The impact of dense breast notifications (DBNs) on women with limited English proficiency (LEP) is unknown. OBJECTIVE: This study sought to understand Spanish-speaking women's experience receiving DBNs in a Massachusetts safety-net hospital. DESIGN: Eligible women completed one audio-recorded, semi-structured interview via telephone with a native Spanish-speaking research assistant trained in qualitative methods. Interviews were professionally transcribed verbatim and translated. The translation was verified by a third reviewer to ensure fidelity with audio recordings. PARTICIPANTS: Nineteen Spanish-speaking women ages 40-74 who received mammography with a normal result and recalled receiving a DBN. APPROACH: Using the verified English transcripts, we conducted a content analysis to identify women's perceptions and actions related to receiving the notification. A structured codebook was developed. Transcripts were independently coded and assessed for agreement with a modification of Cohen's kappa. Content codes were grouped to build themes related to women's perceptions and actions after receiving a DBN. KEY RESULTS: Nineteen Spanish-speaking women completed interviews. Nine reported not receiving the notification in their native language. Four key themes emerged: (1) The novelty of breast density contributed to notification-induced confusion; (2) women misinterpreted key messages in the notification; (3) varied actions were taken to seek further information; and (4) women held unrealized expectations and preferences for follow-up. CONCLUSIONS: Not having previous knowledge of breast density and receiving notifications in English contributed to confusion about its meaning and inaccurate interpretations of key messages by Spanish speakers. Tools that promote understanding should be leveraged in seeking equity in risk-based breast cancer screening for women with dense breasts.

Drug allergies documented in electronic health records of a large healthcare system.

BACKGROUND: The prevalence of drug allergies documented in electronic health records (EHRs) of large patient populations is understudied. OBJECTIVE: We aimed to describe the prevalence of common drug allergies and patient characteristics documented in EHRs of a large healthcare network over the last two decades. METHODS: Drug allergy data were obtained from EHRs of patients who visited two large tertiary care hospitals in Boston from 1990 to 2013. The prevalence of each drug and drug class was calculated and compared by sex and race/ethnicity. The number of allergies per patient was calculated and the frequency of patients having 1, 2, 3…, or 10+ drug allergies was reported. We also conducted a trend analysis by comparing the proportion of each allergy to the total number of drug allergies over time. RESULTS: Among 1 766 328 patients, 35.5% of patients had at least one reported drug allergy with an average of 1.95 drug allergies per patient. The most commonly reported drug allergies in this population were to penicillins (12.8%), sulfonamide antibiotics (7.4%), opiates (6.8%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (3.5%). The relative proportion of allergies to angiotensin-converting enzyme (ACE) inhibitors and HMG CoA reductase inhibitors (statins) have more than doubled since early 2000s. Drug allergies were most prevalent among females and white patients except for NSAIDs, ACE inhibitors, and thiazide diuretics, which were more prevalent in black patients. CONCLUSION: Females and white patients may be more likely to experience a reaction from common medications. An increase in reported allergies to ACE inhibitors and statins is noteworthy.

Racial and Ethnic Differences in Prenatal Life Stress and Postpartum Depression Symptoms.

This study determined the risk of core depression symptoms based on life stress domains during pregnancy and whether stressors varied by race/ethnicity. The sample consisted of 2,344 White, African American, Hispanic, and Asian/Pacific Islander (API) Massachusetts women who recently gave birth. African Americans and Hispanics who endorsed high relational and high financial stress were more likely to report high depressed mood and loss of interest; high physical stress was associated with high depressed mood among API. Screening based on life stress domains may be informative in determining risk for core depression symptoms during the postpartum period especially for minority groups.

Differences in Sexual Orientation Diversity and Sexual Fluidity in Attractions Among Gender Minority Adults in Massachusetts.

This study characterized sexual orientation identities and sexual fluidity in attractions in a community-based sample of self-identified transgender and gender-nonconforming adults in Massachusetts. Participants were recruited in 2013 using bimodel methods (online and in person) to complete a one-time, Web-based quantitative survey that included questions about sexual orientation identity and sexual fluidity. Multivariable logistic regression models estimated adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs) to examine the correlates of self-reported changes in attractions ever in lifetime among the whole sample (n = 452) and after transition among those who reported social gender transition (n = 205). The sample endorsed diverse sexual orientation identities: 42.7% queer, 19.0% other nonbinary, 15.7% bisexual, 12.2% straight, and 10.4% gay/lesbian. Overall, 58.2% reported having experienced changes in sexual attractions in their lifetime. In adjusted models, trans masculine individuals were more likely than trans feminine individuals to report sexual fluidity in their lifetime (aRR = 1.69; 95% CI = 1.34, 2.12). Among those who transitioned, 64.6% reported a change in attractions posttransition, and trans masculine individuals were less likely than trans feminine individuals to report sexual fluidity (aRR = 0.44; 95% CI = 0.28, 0.69). Heterogeneity of sexual orientation identities and sexual fluidity in attractions are the norm rather than the exception among gender minority people.

Racial and Ethnic Differences in the Likelihood of Vaginal Birth After Cesarean Delivery.

BACKGROUND: A major contributor to the increase in cesarean deliveries over recent decades is the decline in vaginal births after cesarean (VBAC). Racial and ethnic disparities in other perinatal outcomes are widely recognized, but few studies have been directed toward racial/ethnic differences in VBAC rates. METHODS: We used the population-based Massachusetts Pregnancy to Early Life (PELL) database to investigate racial/ethnic differences in rates of VBAC for Massachusetts residents with one prior cesarean from 1998 to 2008. RESULTS: The overall VBAC rate was 17.3 percent. After adjusting for demographic, behavioral, and medical risk factors, non-Hispanic Asian mothers had a greater likelihood of VBAC than non-Hispanic white mothers (adjusted risk ratio 1.31 [95% CI 1.23-1.39]). No other racial/ethnic group was significantly different from non-Hispanic whites in adjusted analyses. The likelihood of VBAC also decreased with increasing maternal age. DISCUSSION: Non-Hispanic Asian women are significantly more likely to have VBAC than non-Hispanic white women. Efforts to reduce cesarean delivery rates in the United States should address these disparities. Future research should investigate factors underlying these differences to ensure that all women have access to appropriate maternity care services.

Normal grief and complicated bereavement among traumatized Cambodian refugees: cultural context and the central role of dreams of the dead.

This article profiles bereavement among traumatized Cambodian refugees and explores the validity of a model of how grief and post-traumatic stress disorder (PTSD) interact in this group to form a unique bereavement ontology, a model in which dreams of the dead play a crucial role. Several studies were conducted at a psychiatric clinic treating Cambodian refugees who survived the Pol Pot genocide. Key findings included that Pol Pot deaths were made even more deeply disturbing owing to cultural ideas about "bad death" and the consequences of not performing mortuary rites; that pained recall of the dead in the last month was common (76 % of patients) and usually caused great emotional and somatic distress; that severity of pained recall of the dead was strongly associated with PTSD severity (r = .62); that pained recall was very often triggered by dreaming about the dead, usually of someone who died in the Pol Pot period; and that Cambodians have a complex system of interpretation of dreams of the deceased that frequently causes those dreams to give rise to great distress. Cases are provided that further illustrate the centrality of dreams of the dead in the Cambodian experiencing of grief and PTSD. The article shows that not assessing dreams and concerns about the spiritual status of the deceased in the evaluation of bereavement results in "category truncation," i.e., a lack of content validity, a form of category fallacy.

The relationship of PTSD to key somatic complaints and cultural syndromes among Cambodian refugees attending a psychiatric clinic: the Cambodian Somatic Symptom and Syndrome Inventory (CSSI).

This article describes a culturally sensitive questionnaire for the assessment of the effects of trauma in the Cambodian refugee population, the Cambodian Somatic Symptom and Syndrome Inventory (CSSI), and gives the results of a survey with the instrument. The survey examined the relationship of the CSSI, the two CSSI subscales, and the CSSI items to posttraumatic stress disorder (PTSD) severity and self-perceived functioning. A total of 226 traumatized Cambodian refugees were assessed at a psychiatric clinic in Lowell, MA, USA. There was a high correlation of the CSSI, the CSSI somatic and syndrome scales, and all the CSSI items to the PTSD Checklist (PCL), a measure of PTSD severity. All the CSSI items varied greatly across three levels of PTSD severity, and patients with higher levels of PTSD had very high scores on certain CSSI-assessed somatic items such as dizziness, orthostatic dizziness (upon standing), and headache, and on certain CSSI-assessed cultural syndromes such as khyâl attacks, "fear of fainting and dying upon standing up," and "thinking a lot." The CSSI was more highly correlated than the PCL to self-perceived disability assessed by the Short Form-12 Health Survey (SF-12). The study demonstrates that the somatic symptoms and cultural syndromes described by the CSSI form a central part of the Cambodian refugee trauma ontology. The survey indicates that locally salient somatic symptoms and cultural syndromes need be profiled to adequately assess the effects of trauma.

Vitamin D intake and serum vitamin D in ethnically diverse urban schoolchildren.

OBJECTIVE: Low serum vitamin D, which largely affects ethnic minorities, is associated with obesity and other chronic diseases. Little is known about racial/ethnic differences in intake, particularly in children, or if any differences are associated with differences in serum 25-hydroxyvitamin D (25(OH)D). The objective of the present study was to determine whether racial/ethnic differences in dietary vitamin D intake exist and whether they explain differences in 25(OH)D. DESIGN: Vitamin D intakes (Block Kids 2004 FFQ) and 25(OH)D were measured. Race/ethnicity was parent-reported (white (37·9 %), Hispanic (32·4 %), black (8·3 %), Asian (10·3 %), multi-racial/other (11·0 %)). Multivariable analyses were conducted to examine the associations among dietary vitamin D and race/ethnicity, as well as 25(OH)D, independent of BMI Z-score and other covariates. SETTING: Elementary/middle schools in Somerville, MA, USA, during January-April 2010. SUBJECTS: Schoolchildren (n 145) in 4th-8th grade. RESULTS: Only 2·1 % met the 2011 RDA (15 µg/d (600 IU/d)). Average dietary intake was 3.5 (sd 2.2) µg/d (140 (sd 89·0) IU/d). No racial/ethnic differences in intake were evident. Most (83·4 %) were 25(OH)D deficient (<20 ng/ml; 16·0 (sd 6·5) ng/ml). In ANOVA post hoc analyses, 25(OH)D levels were lower in Hispanics than whites (14·6 (sd 6·1) ng/ml v. 17·9 (sd 4·6) ng/ml; P < 0·01). Dietary vitamin D was associated with 25(OH)D overall (P < 0·05), but did not explain the racial/ethnic differences in 25(OH)D. CONCLUSIONS: Most children in this north-east US sample did not meet dietary recommendations for vitamin D and were vitamin D deficient. Dietary vitamin D did not explain the difference in 25(OH)D between Hispanic and white children. Further research is needed to determine if changes in dietary vitamin D by race/ethnicity can impact 25(OH)D levels.

Prenatal stress, anxiety, and depressive symptoms as predictors of intention to breastfeed among Hispanic women.

BACKGROUND: Studies on the relationship between prenatal psychosocial risk factors and breastfeeding are sparse, particularly in Hispanic women. METHODS: We evaluated this association among 424 participants in Proyecto Buena Salud, an ongoing prospective cohort of pregnant Hispanic women in Western Massachusetts. The Perceived Stress Scale (PSS), the State-Trait Anxiety Inventory (STAI), and the Edinburgh Postnatal Depression Scale (EPDS) were administered by bilingual interviewers in early pregnancy (mean 13.6 weeks gestation) and midpregnancy (mean 25.7 weeks gestation). Information on sociodemographic, behavioral, and acculturation factors was also collected. Breastfeeding intention was abstracted from medical records. Poisson regression was used to calculate prevalence risk ratios (PRR) and 95% confidence intervals (CI). RESULTS: A total of 274 (64.6%) women reported a positive intention to breastfeed. In multivariate analyses, women in the highest quartile of perceived stress (PRR 0.76, 95% CI 0.62-0.94) in early pregnancy and highest quartile of anxiety in early pregnancy (PRR 0.66, 95% CI 0.54-0.81) and midpregnancy (PRR 0.80, 95% CI 0.64-1.00) were less likely to intend to breastfeed compared to women in the lowest quartile. Women who had at least probable minor depression (EPDS score ≥13) (PRR 0.79, 95% CI 0.65-0.95) or probable major depression (EPDS score ≥15) (PRR 0.77, 95% CI 0.62-0.96) during midpregnancy were less likely to intend to breastfeed compared to women without depressive symptoms. Similarly, women with persistent depressive symptoms over pregnancy were 24%-33% less likely to intend to breastfeed compared to women without depressive symptoms. CONCLUSIONS: Psychosocial risk factors during pregnancy are important predictors of breastfeeding intention among Hispanic women.

Exiting shelter: an epidemiological analysis of barriers and facilitators for families.

This study examines the role of individual- and family-level factors in predicting the length of shelter stays for homeless families. Interviews were conducted with all families exiting one of six emergency family shelters in Worcester, Massachusetts, between November 2006, and November 2007. Analyses, using an ordinary least squares regression model, find that families with a positive alcohol or drug screen in the year prior stay 85 days longer than those without a positive screen; families leaving shelter with a housing subsidy stay 66 days longer than those leaving without a subsidy. Demographic factors, education, employment, health, and mental health are not found to predict shelter stay duration. Consistent with prior research, housing resources relate to families' time in shelter; with the exception of a positive substance abuse screen, individual-level problems are not related to their time in shelter. Efforts to expand these resources at the local, state, and national levels are a high priority.

When mothers have favourites: conditions under which mothers differentiate among their adult children.

Research has shown that mothers often differentiate among their adult children in terms of closeness and support; however, studies have not addressed why some mothers report preferences among children and others do not. To distinguish between mothers who do and do not report favouring some of their adult children, we used data from a within-family study in which 553 older mothers were interviewed about each of their children. Almost all of the mothers reported differentiating among their children regarding emotional closeness, confiding, or preference among caregivers. Multivariate analyses revealed that mothers' values and mother-child value similarity predicted which mothers differentiated among their children regarding closeness and confiding, whereas mothers' and children's demographic characteristics predicted which mothers differentiated regarding preferred caregivers. Black mothers were less likely than white mothers to differentiate when seeking a confidant; however, race played no role in mothers' likelihood of differentiating regarding emotional closeness or help during illness. Taken together, these findings indicate that differentiating among adult children is common; further, family-level predictors of mothers' differentiating mirror the patterns shown in dyad-level analyses of mothers' favouritism.

Variation in sweating patterns: implications for studies of hot flashes through skin conductance.

OBJECTIVE: The literature of sweat physiology and population variation in response to heat stress suggests that variation in sweating patterns may affect the measurement of hot flashes. This study examined variation in sweating patterns in Puebla, Mexico, and Amherst, MA, and compared the levels of concordance between subjective and objective measures of hot flashes. DESIGN: Thirteen women in Puebla, Mexico, and 15 women in Amherst, MA, aged 45 to 61, completed surveys, body diagrams of heat flow during a hot flash, anthropometric measures, and the measurement of hot flashes through skin conductance monitoring. Hot flashes were measured through sternal (Mexico and Massachusetts) and nuchal (Mexico only) skin conductance. RESULTS: Mexican women were significantly more likely to describe the heat of hot flashes on the back of their neck (100% vs 40%) and on their arms and/or hands (85% vs 40%) compared with women in Massachusetts. Hot flashes in the midback were associated with concordance between nuchal, but not sternal, measures of skin conductance and subjective report in Mexico. In comparing average scores for concordance between subjective and sternal measures of hot flashes, there was a higher mean score for true positives in Mexico (61% vs 29%, P=0.06) and a significantly higher mean score for false-negative measures in Massachusetts (57% vs 21%, P=0.04). CONCLUSIONS: Variation in rates of concordance between subjective and objective measures were not adequately explained by sweating patterns. Future studies should consider population variation in acclimatization and assess variation in the amount of sweat produced during a hot flash.

Comparing individual- and area-based socioeconomic measures for the surveillance of health disparities: A multilevel analysis of Massachusetts births, 1989-1991.

The absence of individual-level socioeconomic information in most US health surveillance data necessitates using area-based socioeconomic measures (ABSMs) to monitor health inequalities. Using the 1989-1991 birth weight data from Massachusetts, the authors compared estimates of health disparities detected with census tract- and block group-level ABSMs pertaining to poverty and education, as well as parental education, both independently and together. In separate models, adjusted for infant's sex, mother's age, and parents' race/ethnicity, worst-off categories of census tract ABSMs and parental education had a comparable birth weight deficit of approximately 70 g. Similar results were observed for low birth weight (<2,500 g), with worst-off categories of census tract ABSMs and parental education having an odds ratio of approximately 1.37 (p < 0.001). In mutually adjusted models for birth weight and low birth weight, census tract ABSMs still detected an effect estimate nearly 50% of that detected by parental education. Additionally, census tract ABSMs detected socioeconomic gradients in birth weight among births to mothers aged less than 25 years, an age group in which educational attainment is unlikely to be completed. These results suggest that aptly chosen ABSMs can be used to monitor socioeconomic inequalities in health. The risk, if any, in the absence of individual-level socioeconomic information is a conservative estimate of socioeconomic inequalities in health.

Risk factors for neonatal morbidity and mortality among "healthy," late preterm newborns.

Research about neonatal outcomes among late preterm infants (34 weeks through 36 6/7 weeks of gestation) is limited. Understanding which late preterm infants are at risk for neonatal morbidity or mortality is necessary to improve health outcomes and reduce hospital costs. We conducted a population-based cohort study of "healthy," singleton late preterm infants vaginally delivered in Massachusetts hospitals to Massachusetts residents between 1998 and 2002. We compared the incidence of neonatal morbidity (postdelivery inpatient readmissions, observational stays, or mortality) between "healthy," late preterm infants with and without infant, obstetric, and sociodemographic factors by calculating risk ratios adjusted for confounding. Of the 9552 late preterm, "healthy" infants, 4.8% had an inpatient readmission and 1.3% had an observational stay. Infants with neonatal morbidity were more likely to be firstborn, be breastfed at discharge, have labor and delivery complications, be a recipient of a public payer source at delivery, or have an Asian/Pacific Islander mother. Non-Hispanic blacks had a decreased risk for neonatal morbidity compared to other racial/ethnic groups. Knowledge of risk factors for neonatal morbidity among "healthy" late preterm infants can be used to identify infants needing closer monitoring and earlier follow-up after hospital discharge.

George Wilbur: Otto Rank and Hanns Sachs.

George Wilbur, a pioneering Cape Cod psychoanalytic psychiatrist, was a long-standing editor of the journal "American Imago," and an excellent source of information about the Viennese analysts Otto Rank and Hanns Sachs. Wilbur was also knowledgeable about the early reception of psychoanalysis in the Boston community.

Hispanic and non-Hispanic white elders from Massachusetts have different patterns of carotenoid intake and plasma concentrations.

Carotenoids have been linked with protective roles against diseases associated with aging, including cancer, cardiovascular disease, cataracts, and age-related macular degeneration. With data from a semiquantitative, validated FFQ, we examined carotenoid intake of 340 Puerto Ricans, 98 Dominicans, and 146 non-Hispanic whites (>60 y old) in Massachusetts. Compared with non-Hispanic white men, Hispanic men reported a higher intake of lycopene and lower intakes of alpha-carotene, lutein + zeaxanthin, beta-carotene (from diet only), and total beta-carotene (diet and supplements) (P < 0.001). Hispanic women reported higher intakes of beta-cryptoxanthin and lycopene but lower intakes of lutein + zeaxanthin (P < 0.001) than non-Hispanic white women. The frequency of consumption of fruit and vegetables was higher among Hispanic women, relative to non-Hispanic white women (P < 0.05). Plasma concentrations of alpha-carotene and lycopene were higher in Hispanic than in non-Hispanic white men and women. For both ethnic groups, higher intakes of carotenoids were associated with higher plasma concentrations of the respective carotenoids, except for lycopene (Hispanics) and lutein + zeaxanthin (non-Hispanic whites). Food sources contributing most to total intakes differed among the groups. The major sources of alpha- and beta-carotene were carrots for non-Hispanic whites and winter squash for Hispanics. The major source of lycopene was cooked tomato products for Hispanics, and pasta dishes for non-Hispanic whites. Traditional foods such as beans and plantains were also important contributors of carotenoids for Hispanics. Because of the potential importance of carotenoids as protective factors against chronic diseases, more attention to food-related practices associated with carotenoid intake in differing population groups is warranted.

Population-based surveillance for childhood invasive pneumococcal disease in the era of conjugate vaccine.

BACKGROUND: Heptavalent pneumococcal conjugate vaccine was licensed in the United States in February 2000 and, following national guidelines, universally distributed in Massachusetts starting in July 2000 to children younger than 2 years of age and selected children 2-5 years of age. We performed statewide surveillance for all cases of invasive pneumococcal disease (IPD) in children younger than 18 years of age to determine risk features and contribution of vaccine failure to ongoing pneumococcal invasive disease. METHODS: Massachusetts pediatric IPD cases were identified via enhanced passive surveillance of microbiology laboratory reports of pneumococcal isolates from sterile body sites of children younger than 18 years for 2 years starting in October 2001. Serotyping was performed on isolates of Streptococcus pneumoniae from normally sterile body fluid. Case demographic and clinical data (including dates of prior doses of PCV7) were collected via follow-up telephone interviews with case primary care providers and/or parents. RESULTS: Between October 1, 2001 and September 30, 2003, 191 cases of IPD were identified statewide (138 in children younger than 5 years). Annual incidence rate for IPD was 17.4 per 100,000 children younger than 5 years, representing a decline of 69% when compared with annual incidence rate of 56.9 per 100,000 from Massachusetts statewide active surveillance performed 1990-1991. In 2001-2003, 30% of cases occurred in the first year of life (36.5 per 100,000), representing a 7.8-fold increased risk compared with children older than 1 year of age. Race-specific annual incidence rates in blacks and Hispanics were 2.3-fold (95% confidence interval, 1.21-4.42) and 1.9-fold (95% confidence interval, 1.06-3.37), greater than in whites. Fifty-nine cases were reported to have underlying comorbid conditions. Serotyping was available for 136 of 191 (71%) cases younger than 18 years; of isolates available for serotyping, 40 (29%) were vaccine serotype (ST), 31 (23%) vaccine-related ST and 65 (48%) nonvaccine ST. Seven of 40 cases with IPD caused by vaccine ST received at least 3 doses of PCV7 vaccine before IPD. CONCLUSIONS: Universal administration of PCV7 to children younger than 2 years of age and selective administration to children 2-5 years of age has resulted in a significant decline in IPD in Massachusetts. Children younger than 1 year of age, African American and Hispanic children and those with recognized comorbid illnesses (malignancy, human immunodeficiency virus, immune deficiency, nephrotic syndrome, etc.) continue to remain at risk for IPD. These risk features should be considered when evaluating febrile infants and children.