In-Hospital Delirium and Disability and Cognitive Impairment After COVID-19 Hospitalization.

Importance: Older adults who are hospitalized for COVID-19 are at risk of delirium. Little is known about the association of in-hospital delirium with functional and cognitive outcomes among older adults who have survived a COVID-19 hospitalization. Objective: To evaluate the association of delirium with functional disability and cognitive impairment over the 6 months after discharge among older adults hospitalized with COVID-19. Design, Setting, and Participants: This prospective cohort study involved patients aged 60 years or older who were hospitalized with COVID-19 between June 18, 2020, and June 30, 2021, at 5 hospitals in a major tertiary care system in the US. Follow-up occurred through January 11, 2022. Data analysis was performed from December 2022 to February 2024. Exposure: Delirium during the COVID-19 hospitalization was assessed using the Chart-based Delirium Identification Instrument (CHART-DEL) and CHART-DEL-ICU. Main Outcomes and Measures: Primary outcomes were disability in 15 functional activities and the presence of cognitive impairment (defined as Montreal Cognitive Assessment score <22) at 1, 3, and 6 months after hospital discharge. The associations of in-hospital delirium with functional disability and cognitive impairment were evaluated using zero-inflated negative binominal and logistic regression models, respectively, with adjustment for age, month of follow-up, and baseline (before COVID-19) measures of the respective outcome. Results: The cohort included 311 older adults (mean [SD] age, 71.3 [8.5] years; 163 female [52.4%]) who survived COVID-19 hospitalization. In the functional disability sample of 311 participants, 49 participants (15.8%) experienced in-hospital delirium. In the cognition sample of 271 participants, 31 (11.4%) experienced in-hospital delirium. In-hospital delirium was associated with both increased functional disability (rate ratio, 1.32; 95% CI, 1.05-1.66) and increased cognitive impairment (odds ratio, 2.48; 95% CI, 1.38-4.82) over the 6 months after discharge from the COVID-19 hospitalization. Conclusions and Relevance: In this cohort study of 311 hospitalized older adults with COVID-19, in-hospital delirium was associated with increased functional disability and cognitive impairment over the 6 months following discharge. Older survivors of a COVID-19 hospitalization who experience in-hospital delirium should be assessed for disability and cognitive impairment during postdischarge follow-up.

Assessment of disparities in timely diagnosis and comprehensive workup of cognitive impairment between English and Spanish speakers.

BACKGROUND: Previous studies have examined disparities in dementia care that affect the U.S. Hispanic/Latino population, including clinician bias, lack of cultural responsiveness, and less access to health care. However, there is limited research that specifically investigates the impact of language barriers to health disparities in dementia diagnosis. METHODS: In this retrospective cross-sectional study, 12,080 English- or Spanish- speaking patients who received an initial diagnosis of mild cognitive impairment (MCI) or dementia between July 2017 and June 2019 were identified in the Yale New Haven Health (YNHH) electronic medical record. To evaluate the timeliness of diagnosis, an initial diagnosis of MCI was classified as "timely", while an initial diagnosis of dementia was considered "delayed." Comprehensiveness of diagnosis was assessed by measuring the presence of laboratory studies, neuroimaging, specialist evaluation, and advanced diagnostics six months before or after diagnosis. Binomial logistic regressions were calculated with and without adjustment for age, legal sex, ethnicity, neighborhood disadvantage, and medical comorbidities. RESULTS: Spanish speakers were less likely to receive a timely diagnosis when compared with English speakers both before (unadjusted OR, 0.65; 95% CI, 0.53-0.80, p <0.0001) and after adjusting for covariates (adjusted OR, 0.55; 95% CI, 0.40-0.75, p = 0.0001). Diagnostic services were provided equally between groups, except for referrals to geriatrics, which were more frequent among Spanish-speaking patients. A subgroup analysis revealed that Spanish-speaking Hispanic/Latino patients were less likely to receive a timely diagnosis compared to English-speaking Hispanic/Latino patients (adjusted OR, 0.53; 95% CI, 0.38-0.73, p = 0.0001). CONCLUSIONS: Non-English language preference is likely to be a contributing factor to timely diagnosis of cognitive impairment. In this study, Spanish language preference rather than Hispanic/Latino ethnicity was a significant predictor of a less timely diagnosis of cognitive impairment. Policy changes are needed to reduce barriers in cognitive disorders care for Spanish-speaking patients.

Late endocrine diseases in survivors of adolescent and young adult cancer in California: a population-based study.

BACKGROUND: Cancer survivors have increased risk of endocrine complications, but there is a lack of information on the occurrence of specific endocrinopathies at the population-level. METHODS: We used data from the California Cancer Registry (2006-2018) linked to statewide hospitalisation, emergency department, and ambulatory surgery databases. We estimated the cumulative incidence of and factors associated with endocrinopathies among adolescents and young adults (AYA, 15-39 years) who survived ≥2 years after diagnosis. RESULTS: Among 59,343 AYAs, 10-year cumulative incidence was highest for diabetes (4.7%), hypothyroidism (4.6%), other thyroid (2.2%) and parathyroid disorders (1.6%). Hypothyroidism was most common in Hodgkin lymphoma, leukaemia, breast, and cervical cancer survivors, while diabetes was highest among survivors of leukaemias, non-Hodgkin lymphoma, colorectal, cervical, and breast cancer. In multivariable models, factors associated with increased hazard of endocrinopathies were treatment, advanced stage, public insurance, residence in low/middle socioeconomic neighbourhoods, older age, and non-Hispanic Black or Hispanic race/ethnicity. Haematopoietic cell transplant was associated with most endocrinopathies, while chemotherapy was associated with a higher hazard of ovarian dysfunction and hypothyroidism. CONCLUSIONS: We observed a high burden of endocrinopathies among AYA cancer survivors, which varied by treatment and social factors. Evidence-based survivorship guidelines are needed for surveillance of these diseases.

Estimates of 30-day postoperative pulmonary complications after gastrointestinal endoscopic procedures: A retrospective cohort analysis of a health system population.

The incidence of 30-day postoperative pulmonary complications (PPC) of gastrointestinal endoscopic procedures (GIEP) are not well characterized in the literature. The primary aim of this study was to identify the incidence of 30-day PPC after GIEP within a large healthcare system. We conducted a retrospective cohort study of 5377 patients presenting for GIEP between January 2013 and January 2022. Our primary outcome was the Agency for Healthcare Research and Quality PPC composite (AHRQ-PPC). Secondary outcomes were sub-composites derived from the AHRQ-PPC; including pneumonia (AHRQ-PNA), respiratory failure (AHRQ-RF), aspiration pneumonia/ pneumonitis (AHRQ-ASP) and pulmonary emboli (AHRQ-PE). We performed propensity score matching (PSM) followed by multivariable logistic regression to analyze primary and secondary outcomes. Inpatients had higher 30-day AHRQ-PPC (6.0 vs. 1.2%, p<0.001), as well as sub-composite AHRQ-PNA (3.2 vs. 0.7%, p<0.001), AHRQ-RF (2.4 vs. 0.5%, p<0.001), and AHRQ-ASP (1.9 vs. 0.4%, p<0.001). After PSM adjustment, pre-procedural comorbidities of electrolyte disorder [57.9 vs. 31.1%, ORadj: 2.26, 95%CI (1.48, 3.45), p<0.001], alcohol abuse disorder [16.7 vs. 6.8%, ORadj: 2.66 95%CI (1.29, 5.49), p = 0.01], congestive heart failure (CHF) [22.3 vs. 8.7%, ORadj: 2.2 95%CI (1.17, 4.15), p = 0.02] and pulmonary circulatory disorders [21 vs. 16.9%, ORadj: 2.95, 95%CI (1.36, 6.39), p = 0.01] were associated with 30-day AHRQ-PPC. After covariate adjustment, AHRQ-PPC was associated with upper endoscopy more than lower endoscopy [5.9 vs. 1.0%, ORadj: 3.76, 95%CI (1.85, 7.66), p<0.001]. When compared to gastroenterologist-guided conscious sedation, anesthesia care team presence was protective against AHRQ-PPC [3.7 vs. 8.4%, ORadj: 0.032, 95%CI (0.01, 0.22), p<0.001] and AHRQ-ASP [1.0 vs. 3.37%, ORadj: 0.002, 95%CI (0.00, 0.55), p<0.001]. In conclusion, we report estimates of 30-day PPC after GIEP across inpatient and outpatient settings. Upper endoscopic procedures confer a higher risk, while the presence of an anesthesia care team may be protective against 30-day PPC.

Uncovering Primary Extranodal Diffuse Large B Cell Lymphoma in the Adrenal and Thyroid Glands.

BACKGROUND Primary extranodal diffuse large B-cell lymphoma (DLBCL) is a rare, yet highly aggressive and invasive malignancy that can masquerade as a solid organ tumor. Timely diagnosis is critical for improving prognosis; however, it is challenging to achieve. CASE REPORT We report 2 cases treated at Yale New Haven Hospital (New Haven, CT, USA) and the West Haven Veteran's Affairs Medical Center (West Haven, CT, USA) in 2023. Case 1 describes a 69-year-old woman who presented with a large left adrenal mass that was suspicious for adrenocortical carcinoma and was found to have primary adrenal DLBCL following surgical resection. Case 2 describes a 59-year-old woman with Hashimoto's thyroiditis and goiter who was found to have primary thyroid DLBCL following partial thyroidectomy. CONCLUSIONS Primary extranodal DLBCL should be included in the differential diagnosis of solid adrenal and thyroid tumors. The risks of biopsy, given currently available techniques, should be weighed against the benefits of achieving a definite diagnosis, allowing for timely initiation of systemic immunochemotherapy. When biopsy can be safely performed, techniques designed to evaluate for DLBCL should be incorporated.

Implementation of a universal screening and follow-up care system for pediatric developmental and behavioral health in federally qualified health center sites.

BACKGROUND: Despite guidelines from the American Academy of Pediatrics (AAP), many pediatric practices still do not have standardized screening processes in place to identify children with developmental delays. From April 2014 to April 2017, six federally qualified health center (FQHC) sites in Northern California implemented an intervention to increase (a) standardized developmental screening at recommended intervals and (b) follow-up care and support for early intervention services. METHOD: The intervention aimed to optimize each site's screening processes, supported by an automated electronic tablet-based system. To improve follow-up support, social workers were hired to conduct follow-up clinical assessments, provide psychosocial education and treatment, provide referrals and case management support, and collaborate with service partners. We analyze operational and implementation data to characterize site adoption, patient reach, implementation processes, and intervention effectiveness. RESULTS: During the intervention's final year, when tablet-based screening was adopted, the sites screened an estimated 6,550 children ages 0-18 at 23 intervals in three domains (developmental, autism, and psychosocial/behavioral), compared to a baseline where they screened ages 0-3 at four intervals in one domain. Screening rates increased from 65.3% to 75.5% after automation was extended from the first to the second site, then to 91.8% after automation was expanded to the remaining sites. Follow-up visit rates ranged between 74% and 88%. CONCLUSIONS: Implementation of a multicomponent developmental and behavioral health screening and follow-up care intervention enabled FQHC sites to meet AAP recommendations and provide follow-up support. Disseminating the intervention may support population-level improvement in early detection and intervention for developmental delays and behavioral health concerns. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Adaptively leveraging external data with robust meta-analytical-predictive prior using empirical Bayes.

The robust meta-analytical-predictive (rMAP) prior is a popular method to robustly leverage external data. However, a mixture coefficient would need to be pre-specified based on the anticipated level of prior-data conflict. This can be very challenging at the study design stage. We propose a novel empirical Bayes robust MAP (EB-rMAP) prior to address this practical need and adaptively leverage external/historical data. Built on Box's prior predictive p-value, the EB-rMAP prior framework balances between model parsimony and flexibility through a tuning parameter. The proposed framework can be applied to binomial, normal, and time-to-event endpoints. Implementation of the EB-rMAP prior is also computationally efficient. Simulation results demonstrate that the EB-rMAP prior is robust in the presence of prior-data conflict while preserving statistical power. The proposed EB-rMAP prior is then applied to a clinical dataset that comprises 10 oncology clinical trials, including the prospective study.

Do mitochondria use efflux pumps to protect their ribosomes from antibiotics?

Fungal environments are rich in natural and engineered antimicrobials, and this, combined with the fact that fungal genomes are rich in coding sequences for transporters, suggests that fungi are an intriguing group in which to search for evidence of antimicrobial efflux pumps in mitochondria. Herein, the range of protective mechanisms used by fungi against antimicrobials is introduced, and it is hypothesized, based on the susceptibility of mitochondrial and bacterial ribosomes to the same antibiotics, that mitochondria might also contain pumps that efflux antibiotics from these organelles. Preliminary evidence of ethidium bromide efflux is presented and several candidate efflux pumps are identified in fungal mitochondrial proteomes.

Maternal immune activation and adolescent alcohol exposure increase alcohol drinking and disrupt cortical-striatal-hippocampal oscillations in adult offspring.

Maternal immune activation (MIA) is strongly associated with an increased risk of developing mental illness in adulthood, which often co-occurs with alcohol misuse. The current study aimed to begin to determine whether MIA, combined with adolescent alcohol exposure (AE), could be used as a model with which we could study the neurobiological mechanisms behind such co-occurring disorders. Pregnant Sprague-Dawley rats were treated with polyI:C or saline on gestational day 15. Half of the offspring were given continuous access to alcohol during adolescence, leading to four experimental groups: controls, MIA, AE, and Dual (MIA + AE). We then evaluated whether MIA and/or AE alter: (1) alcohol consumption; (2) locomotor behavior; and (3) cortical-striatal-hippocampal local field potentials (LFPs) in adult offspring. Dual rats, particularly females, drank significantly more alcohol in adulthood compared to all other groups. MIA led to reduced locomotor behavior in males only. Using machine learning to build predictive models from LFPs, we were able to differentiate Dual rats from control rats and AE rats in both sexes, and Dual rats from MIA rats in females. These data suggest that Dual "hits" (MIA + AE) increases substance use behavior and disrupts activity in reward-related circuits, and that this may be a valuable heuristic model we can use to study the neurobiological underpinnings of co-occurring disorders. Our future work aims to extend these findings to other addictive substances to enhance the translational relevance of this model, as well as determine whether amelioration of these circuit disruptions can reduce substance use behavior.

Lower cerebral oxygen utilization is associated with Alzheimer's disease-related neurodegeneration and poorer cognitive performance among apolipoprotein E ε4 carriers.

Oxygen extraction fraction (OEF) and cerebral metabolic rate of oxygen (CMRO2) are markers of cerebral oxygen homeostasis and metabolism that may offer insights into abnormal changes in brain aging. The present study cross-sectionally related OEF and CMRO2 to cognitive performance and structural neuroimaging variables among older adults (n = 246, 74 ± 7 years, 37% female) and tested whether apolipoprotein E (APOE)-ε4 status modified these associations. Main effects of OEF and CMRO2 were null (p-values >0.06), and OEF interactions with APOE-ε4 status on cognitive and structural imaging outcomes were null (p-values >0.06). However, CMRO2 interacted with APOE-ε4 status on language (p = 0.002), executive function (p = 0.03), visuospatial (p = 0.005), and episodic memory performances (p = 0.03), and on hippocampal (p = 0.006) and inferior lateral ventricle volumes (p = 0.02). In stratified analyses, lower oxygen metabolism related to worse language (p = 0.02) and episodic memory performance (p = 0.03) among APOE-ε4 carriers only. Associations between CMRO2 and cognitive performance were primarily driven by APOE-ε4 carriers with existing cognitive impairment. Congruence across language and episodic memory results as well as hippocampal and inferior lateral ventricle volume findings suggest that APOE-ε4 may interact with cerebral oxygen metabolism in the pathogenesis of Alzheimer's disease and related neurodegeneration.

Association of Aortic Stiffness With Biomarkers of Neuroinflammation, Synaptic Dysfunction, and Neurodegeneration.

OBJECTIVES: To test the hypothesis that increased aortic stiffening is associated with greater CSF evidence of core Alzheimer disease pathology (ß-amyloid [Aß], phosphorylated tau [p-tau]), neurodegeneration (total tau [t-tau]), synaptic dysfunction (neurogranin), neuroaxonal injury (neurofilament light [NFL]), and neuroinflammation (YKL-40, soluble triggering receptor expressed on myeloid cells 2 [sTREM2]), we analyzed pulse wave velocity (PWV) data and CSF data among older adults. METHODS: Participants free of stroke and dementia from the Vanderbilt Memory and Aging Project, an observational community-based study, underwent cardiac magnetic resonance to assess aortic PWV (meters per second) and lumbar puncture to obtain CSF. Linear regressions related aortic PWV to CSF Aß, p-tau, t-tau, neurogranin, NFL, YKL-40, and sTREM2 concentrations after adjustment for age, race/ethnicity, education, apolipoprotein (APOE) ε4 status, Framingham Stroke Risk Profile, and cognitive diagnosis. Models were repeated testing PWV interactions with age, diagnosis, APOE ε4, and hypertension on each biomarker. RESULTS: One hundred forty-six participants were examined (age 72 ± 6 years). Aortic PWV interacted with age on p-tau (ß = 0.31, p = 0.04), t-tau, (ß = 2.67, p = 0.05), neurogranin (ß = 0.94, p = 0.04), and sTREM2 (ß = 20.4, p = 0.05). Among participants >73 years of age, higher aortic PWV related to higher p-tau (ß = 2.4, p = 0.03), t-tau (ß = 19.3, p = 0.05), neurogranin (ß = 8.4, p = 0.01), and YKL-40 concentrations (ß = 7,880, p = 0.005). Aortic PWV had modest interactions with diagnosis on neurogranin (ß = -10.76, p = 0.03) and hypertension status on YKL-40 (ß = 18,020, p < 0.001). CONCLUSIONS: Among our oldest participants, ≥74 years of age, greater aortic stiffening is associated with in vivo biomarker evidence of neuroinflammation, tau phosphorylation, synaptic dysfunction, and neurodegeneration, but not amyloidosis. Central arterial stiffening may lead to cumulative cerebral microcirculatory damage and reduced blood flow delivery to tissue, resulting in neuroinflammation and neurodegeneration in more advanced age.

The Use of Victim Video Statements in Family Violence Cases Increases the Rate of Early Guilty Pleas.

A natural experiment is used to determine the effect of victim video statements (VVS) on the rate of early guilty pleas in cases of domestic violence. Participants were part of a trial conducted in 2017-2018 by New Zealand Police, in Counties Manukau District, South Auckland. Cases that met the eligibility criteria but did not result in a VVS formed the control group with written statements taken. Analyses were restricted to cases that proceeded to a court hearing (VVS group: n = 168, control group: n = 108). The key question was whether taking a VVS would increase the rate of early guilty pleas. A logistic regression model controlled two additional factors: (a) being bailed or remanded and (b) the seriousness of charges. VVS cases resulted in 44% early guilty pleas compared with 30% for those with written statements. VVS have a statistically significant increase in the odds of making a guilty plea, adjusted odds ratio (AOR) =1.77, 95% confidence interval (CI) = [1.02, 3.06], when controlling for the other factors. The results indicate that VVS can be used to reduce demand pressure on the criminal justice system. The findings are considered in terms of the complex relationship between offenders and victims that commonly results in the retraction of written statements.

Clinical Training Innovation for Prelicensure Graduate Nursing Students to Expand Roles in Primary Care.

BACKGROUND: With the aging population, the prevalence of chronic disease is increasing, requiring a team-based approach to care with registered nurses (RNs) playing a vital role. PROBLEM: Nursing education generally prioritizes acute care rather than ambulatory care; however, nursing students should also be prepared to adequately respond to the population needs for longitudinal chronic care management. APPROACH: To address the need for RNs to assume a role in chronic care management, a School of Nursing and Health Professions piloted a clinical option in which second-degree master of science in nursing students are prepared to function as health coaches on primary care teams at a local community health center. CONCLUSIONS: Reshifting the focus of nursing education to integrate primary care nursing, it is important to embed nursing students into primary care practices where they can learn about the longitudinal care of patients with chronic conditions.

Interdisciplinary Safety Evaluation and Quantitative Safety Monitoring: Introduction to a Series of Papers.

The American Statistical Association and DIA have created an interdisciplinary working group of drug safety experts from academia, industry and regulatory backgrounds to explore the future direction for safety monitoring. This introduction to the series explains the background and rationale for this special section.

Impact on Smoking Behavior of the New Zealand Annual Increase in Tobacco Tax: Data for the Fifth and Sixth Year of Increases.

INTRODUCTION: New Zealand has implemented a series of seven annual increases in tobacco tax since 2010. All tax increases, except for the first in the series, were preannounced. It is unusual for governments to introduce small, persistent, and predictable increases in tobacco tax, and little is known about the impact of such a strategy. This paper evaluates the impact of the fifth and sixth annual increases. METHODS: Smokers' behaviors were self-reported during the 3-month period before, and the 3-month period after, the two annual increases. Responses to the two increases were analyzed separately, and generalized estimating equations models were used to control for sociodemographic variables, recent quit attempts, and the research design. RESULTS: Findings were consistent across years. The proportion of participants who made a smoking-related (54%-56% before and after each tax increase) or product-related change (fifth tax increase: 17%-19%; sixth tax increase: 21%-22%) did not significantly alter from before to after each tax increase. However, it should be noted that the proportion of participants making smoking-related changes was generally high, even prior to each increase. For example, before the 2015 tax increase, 1% reported quitting completely, 21% trying to quit, and 53% cutting down. CONCLUSIONS: In New Zealand, with its series of annual tobacco tax increases since 2010, there were no significant changes in smoking- or product-related behavior associated with the fifth and sixth increases. Nevertheless, overall cessation-related activity was high, with a majority of participants reporting either quitting and/or cutting down recently. IMPLICATIONS: Little is known about the impact of small, persistent, predictable tobacco tax increases on smoking behavior. This study evaluated the impact of the fifth (in 2014) and sixth (2015) tax increases in an annual series implemented in New Zealand. Although there were no detectable changes in smoking behaviors from before to after each tax increase, self-reported cessation-related activity was high overall (i.e., even prior to each increase). Given that there are multiple possible interpretations for these findings, more in-depth time-series analyses are needed to understand how such a tax strategy influences smoking behavior.

Smoking in cars: knowledge, behaviours and support for smokefree cars legislation among New Zealand smokers and recent quitters.

AIM: Exposure to second-hand smoke (SHS) poses serious health consequences to non-smokers, and normalises smoking. Currently, there is no legislation restricting smoking in private cars in New Zealand. This paper supplements previous New Zealand studies on exposure to SHS in cars by examining smokers and recent quitters' knowledge and behaviours towards smoking in cars, and their support for two possible smokefree cars policy options. METHOD: The New Zealand Smoking Monitor is a fortnightly survey that uses a self-refreshing panel approach. The questionnaire contains smoking- and cessation-related questions, including eight non-core questions addressing smoking in homes or cars. These questions were answered by 364 respondents in 2014. Responses were compared by socio-demographic variables and recent quit attempt status. RESULTS: Smoking in cars was common among the respondents in our sample: 63% had recently smoked in a car when they were the only person in it, and 27% had done so when there were other people present. Some groups of respondents exhibited information gaps around the harms (eg, compared with males, females had reduced odds of agreeing with the false statement: "it's OK to smoke inside cars if there are windows open", OR=0.41, 0.21-0.78); however, support for banning smoking in cars if there are children in them was consistently high across different sub-groups (92% overall). CONCLUSION: Our data show the importance of providing specific information around the danger of smoking in cars, and strategies to enforce a complete smokefree rule in cars. Legislation may be required to further protect children from SHS exposure.

Addressing prior-data conflict with empirical meta-analytic-predictive priors in clinical studies with historical information.

A common question in clinical studies is how to use historical data from earlier studies, leveraging relevant information into the design and analysis of a new study. Bayesian approaches are particularly well-suited to this task, with their natural ability to borrow strength across data sources. In this paper, we propose an eMAP approach for incorporating historical data into the analysis of clinical studies, and we discuss an application of this method to the analysis of observational safety studies for a class of products for patients with hemophilia A. The eMAP prior approach is flexible and robust to prior-data conflict. We conducted simulations to compare the frequentist operating characteristics of three approaches under different prior-data conflict assumptions and sample size scenarios.

Stages of physical dependence in New Zealand smokers: Prevalence and correlates.

BACKGROUND: Physically dependent smokers experience symptoms of wanting, craving or needing to smoke when too much time has passed since the last cigarette. There is interest in whether wanting, craving and needing represent variations in the intensity of a single physiological parameter or whether multiple physiological processes may be involved in the developmental progression of physical dependence. AIM: Our aim was to determine how a population of cigarette smokers is distributed across the wanting, craving and needing stages of physical dependence. METHODS: A nationwide survey of 2594 New Zealanders aged 15years and over was conducted in 2014. The stage of physical dependence was assessed using the Levels of Physical Dependence measure. Ordinal logistic regression analysis was used to assess relations between physical dependence and other variables. RESULTS: Among 590 current smokers (weighted 16.2% of the sample), 22.3% had no physical dependence, 23.5% were in the Wanting stage, 14.4% in the Craving stage, and 39.8% in the Needing stage. The stage of physical dependence was predicted by daily cigarette consumption, and the time to first cigarette, but not by age, gender, ethnicity or socioeconomic status. CONCLUSION: Fewer individuals were in the craving stage than either the wanting or needing stages. The resulting inverted U-shaped curve with concentrations at either extreme is difficult to explain as a variation of a single biological parameter. The data support an interpretation that progression through the stages of wanting, craving and needing may involve more than one physiological process. WHAT THIS RESEARCH ADDS: Physical dependence to tobacco develops through a characteristic sequence of wanting, craving and needing which correspond to changes in addiction pathways in the brain. It is important to neuroscience research to determine if the development of physical dependence involves changes in a single brain process, or multiple processes. Our data suggests that more than one physiologic process is involved in the progression of physical dependence.

Use of full strength fluoride toothpaste among preschoolers in New Zealand, and factors determining toothpaste choice.

AIM: International researchers have highlighted an inconsistent knowledge-base for parents and caregivers regarding the use of toothpaste among preschoolers. The New Zealand Government has published recommendations on the use of toothpaste in this age group. This study aimed to explore parents and caregivers' knowledge about toothpaste, with the aim of improving health literacy and overall oral health of New Zealand preschoolers. METHOD: The study was conducted via an online sample of parents and caregivers of preschoolers (n=1,056). RESULTS: Only 19% of the preschoolers in the sample used full-strength fluoride toothpaste. Preschoolers were significantly more likely to use full-strength toothpaste if they were not the first child in the family (OR=1.77, 1.28-2.47) or have previously visited a dental professional (OR=1.84, 1.18-2.85). In addition, parents and caregivers made decisions around purchasing of toothpaste based on the level of trust they had in the brand (59%) and also matching age-specific toothpaste to their child (49%). CONCLUSION: The findings of this research highlight the need for timely advice for parents and caregivers on toothpaste choices for preschool children. The New Zealand Government has published recommendations on the use of full-strength fluoride toothpaste for all ages, including pre-schoolers.