The association between adverse childhood experiences and depression trajectories in the Add Health study.

BACKGROUND: Adverse childhood experiences (ACEs) are potentially traumatic experiences that occur before age 18. ACEs are linked to depression in adulthood, but little is known about the association between ACEs and depression trajectories across the lifespan. OBJECTIVE: To examine the association between specific types of ACEs, cumulative ACE scores, and depression trajectories from adolescence to adulthood. PARTICIPANTS AND SETTING: Waves 1-4 of the National Longitudinal Study of Adolescent to Adult Health (N = 12,888), spanning ages 12 years to 43 years. METHODS: We constructed trajectories of depression scores using a modified 9-item Center for Epidemiologic Studies Depression Scale (CES-D-9). We used weighted logistic regression to calculate odds ratios and confidence intervals for each ACE and ACE score and depression trajectories after adjusting for confounders. RESULTS: We found 75.3 % experienced at least one ACE and 14.7 % experienced 4+ ACEs. We identified three CES-D-9 trajectories: consistently low (Group 1), decreasing (Group 2), and increasing (Group 3) depression scores. All types of abuse, neglect, and community violence were significantly associated with trajectory Groups 2 and 3 vs 1 (p < .05). Foster home placement, poverty, and parental incarceration were associated with Group 2 vs 1. ACE scores showed a dose-response association with Group 3 vs 1 [aORs for 1ACE = 1.43 (0.93-2.20); 2-3ACEs = 1.97 (1.30-3.00); 4+ACEs = 3.08 (1.86-5.09)], and Group 2 vs 1 [aORs for 1ACE = 1.26 (0.87-1.83); 2-3ACEs = 1.93 (1.36-2.74); 4+ACES = 2.70 (1.90-3.84)]. CONCLUSIONS: ACEs can have a lasting impact on depression through adulthood, highlighting the need to mitigate their impact to prevent depression-associated morbidity and mortality.

LDL Reduction and Risk of Diabetes in Veteran Statin Users.

BACKGROUND: While statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) reduce cardiovascular morbidity and mortality, there is controversy regarding a potentially causal link with incident diabetes mellitus (DM). This association may partially be due to confounding by indication; since prescription guidelines encourage statin use among those diagnosed with DM, this may encourage their prescription among those with elevated blood glucose in the absence of DM diagnosis. OBJECTIVE: The study examined the association between low-density lipoprotein (LDL) reduction following initiation of statin use and new-onset DM among veterans. METHODS: We conducted a retrospective cohort study using data from the James A. Haley Veteran's Hospital in Tampa, Florida. Patients with a visit between January 2007 and December 2011 were selected from the Veterans Information Systems and Technology Architecture system. Individuals were classified into categories of statin usage based on LDL reduction percentages and frequency-matched with controls. The primary outcome of interest was incident DM. RESULTS: There was a significant association between LDL reduction and DM which was higher in lower LDL reduction groups (low response hazard ratio [HR]: 2.12, 95% CI: 1.62, 2.79; moderate response HR: 1.85, 95% CI: 1.40, 2.45; high response HR: 1.24, 95% CI: 0.74, 2.07). CONCLUSION AND RELEVANCE: This association may partially be explained by potential lifestyle modifications individuals may make when prescribed a statin which may reduce their risk of DM independent of the statin usage. This research has demonstrated a protective association between greater LDL reduction and DM at the individual level while reenforcing the evidence of an association between statin usage and DM.

Nightmare disorder and low back pain in veterans: cross-sectional association and effect over time.

Low back pain (LBP) disproportionately impacts US military veterans compared with nonveterans. Although the effect of psychological conditions on LBP is regularly studied, there is little published to date investigating nightmare disorder (NMD) and LBP. The purpose of this study was to (1) investigate whether an association exists between NMD and LBP and (2) estimate the effect of NMD diagnosis on time to LBP. We used a retrospective cohort design with oversampling of those with NMD from the Veterans Health Administration (n = 15 983). We used logistic regression to assess for a cross-sectional association between NMD and LBP and survival analysis to estimate the effect of NMD on time to LBP, up to 60-month follow-up, conditioning on age, sex, race, index year, Charlson Comorbidity Index, depression, anxiety, insomnia, combat exposure, and prisoner of war history to address confounding. Odds ratios (with 95% confidence intervals [CIs]) indicated a cross-sectional association of 1.35 (1.13 to 1.60) and 1.21 (1.02 to 1.42) for NMD and LBP within 6 months and 12 months pre- or post-NMD diagnosis, respectively. Hazard ratios (HRs) indicated the effect of NMD on time to LBP that was time-dependent-HR (with 95% CIs) 1.27 (1.02 to 1.59), 1.23 (1.03 to 1.48), 1.19 (1.01 to 1.40), and 1.10 (0.94 to 1.29) in the first 3, 6, 9, and 12 months post-diagnosis, respectively-approximating the null (1.00) at >12 months. The estimated effect of NMD on LBP suggests that improved screening for NMD among veterans may help clinicians and researchers predict (or intervene to reduce) risk of future back pain.

Sleep duration patterns from adolescence to young adulthood and the risk of asthma.

PURPOSE: This study examined the association between sleep duration trajectories from adolescence to young adulthood and the risk of asthma into young adulthood. METHODS: Using data from 10,362 participants in the National Longitudinal Study of Adolescent to Adult Health (Add Health) free of asthma at baseline, we constructed trajectories of sleep duration from adolescence (age 13-18 years) to young adulthood (age 24-32 years) and used them to examine the association between sleep duration patterns and the risk of new-onset asthma using a log-binomial regression model after adjusting for potential confounders. RESULTS: The results revealed that 14.4% of nonasthmatic participants had persistent short sleep duration, whereas 80.0% had adequate sleep duration from adolescence through young adulthood. Consistently short-sleepers had 1.52 times the risk of new-onset asthma by age 32 years (95% CI 1.11, 2.10) compared with consistently adequate sleepers. The association was stronger in those with a family history of asthma (aRR = 2.43, 95% CI 1.15, 5.13) than in those without such history (aRR = 1.43, 95% CI 1.05, 1.95). CONCLUSIONS: We conclude that persistent short sleep duration is associated with an increased risk of new-onset asthma in young adults. This association may be more pronounced among those at high risk of asthma because of family history.

Prevalence and incidence of narcolepsy in a US health care claims database, 2008-2010.

STUDY OBJECTIVES: To determine the prevalence and incidence of narcolepsy using a large US health care claims database. METHODS: The Truven Health MarketScan Commercial Dissertation Database (THMCDD) was used to estimate prevalence and incidence of narcolepsy, with and without cataplexy, by age groups, gender, and region among patients under age 66 years with continuous enrollment for years 2008-2010. THMCDD contains health claims information for more than 18 million people. Prevalence was expressed as cases/100 000 persons. Average annual incidence (using varying criteria for latency between the diagnostic tests, polysomnograph coupled with multiple sleep latency test [MSLT], and the diagnosis) was expressed as new cases/100 000 persons/year. RESULTS: There were 8 444 517 continuously enrolled patients and 6703 diagnosed with narcolepsy (prevalence overall: 79.4/100 000; without cataplexy: 65.4/100 000; with cataplexy: 14.0/100 000). On the basis of the three definitions of incidence, overall average annual incidence was 7.67, 7.13, and 4.87/100 000 persons/year. Incidence for narcolepsy without cataplexy was generally several times higher than narcolepsy with cataplexy. Prevalence and incidence were approximately 50% greater for females compared to males across most age groups. Prevalence was highest among the 21-30 years age group, with incidence highest among enrollees in their early 20s and late teens. Regionally, the North Central United States had the highest prevalence and incidence, whereas the West was the lowest. CONCLUSION: We found greater prevalence and incidence of narcolepsy (including without cataplexy) than most previous studies. The increased proportions in females, enrollees in their early 20s, and US regional differences require further study. Increased awareness and early identification is critical in the management of this burdensome condition.

Exertional heat illness and acute injury related to ambient wet bulb globe temperature.

BACKGROUND: The Deepwater Horizon disaster cleanup effort provided an opportunity to examine the effects of ambient thermal conditions on exertional heat illness (EHI) and acute injury (AI). METHODS: The outcomes were daily person-based frequencies of EHI and AI. Exposures were maximum estimated WBGT (WBGTmax) and severity. Previous day's cumulative effect was assessed by introducing previous day's WBGTmax into the model. RESULTS: EHI and AI were higher in workers exposed above a WBGTmax of 20°C (RR 1.40 and RR 1.06/°C, respectively). Exposures above 28°C-WBGTmax on the day of the EHI and/or the day before were associated with higher risk of EHI due to an interaction between previous day's environmental conditions and the current day (RRs from 1.0-10.4). CONCLUSIONS: The risk for EHI and AI were higher with increasing WBGTmax. There was evidence of a cumulative effect from the prior day's WBGTmax for EHI. Am. J. Ind. Med. 59:1169-1176, 2016. © 2016 Wiley Periodicals, Inc.

Racial disparity in adherence to positive airway pressure among US veterans.

PURPOSE: Despite advances in continuous positive airway pressure (CPAP) technology, compliance with CPAP therapy remains suboptimal. Studies conducted since the advent of objective CPAP recording have noted that African Americans (AA) may use CPAP less than Whites. We sought to confirm this finding among a large sample of veterans and examine effect modifiers of the differential usage. METHODS: A retrospective cohort of 233 AA and 1939 White Veterans Administration (VA) patients who had a sleep study between January 2003 and October 2006 and received CPAP therapy by the end of 2007. CPAP compliance was summarized at 2 weeks and 6 months post CPAP receipt. RESULTS: AAs were significantly less adherent than Whites even when controlling for age, gender, marital status, median household income for zip code, BMI, comorbidities, and obstructive sleep apnea (OSA) severity. AAs with severe OSA were 3 times more likely to use CPAP than AAs with mild/moderate OSA (p ≤ 0.001); a much smaller but still statistically significant difference was seen for Whites. CONCLUSIONS: CPAP compliance is considerably lower in AAs than in Whites, though severity of OSA modifies this association. These findings are not readily explained by differences in demographics or comorbidity.

Correlates of a prescription for Bilevel positive airway pressure for treatment of obstructive sleep apnea among veterans.

INTRODUCTION: The acceptance of portable home-based polysomnography together with auto-titrating CPAP has bypassed the need for a laboratory polysomnography. Since bilevel airway pressure (BPAP) is titrated in the sleep lab, patients diagnosed using portable home-based polysomnography may not have the opportunity to receive BPAP. It is unknown whether the patients who would have ordinarily received a BPAP would benefit from it. We determine correlates of receiving BPAP and of being switched from BPAP to CPAP. We examine whether patients with these correlates have better adherence to BPAP versus CPAP. METHODS: Retrospective Cohort Study (Correlates at baseline) of 2,513 VA patients with a sleep study between January 2003 and October 2006 and receiving continuous or bilevel positive airway pressure (CPAP [N = 2,251]) or BPAP [N = 262]) by the end of 2007. PAP adherence up to 30 months was assessed. RESULTS: Significant correlates of BPAP were older age (p < 0.001), higher BMI and CHF (p < 0.01), COPD (p < 0.001), higher blood CO2 (p < 0.05), higher AHI and OSA severity (p < 0.001), lower nadir SpO2 (p < 0.001), and greater sleepiness (ESS) (p < 0.01). Patients on BPAP were more adherent to PAP therapy (p < 0.01), but the association largely disappeared following adjustment for BPAP correlates. There was preliminary evidence that these correlates predict long-term adherence to PAP therapy regardless of mode. CONCLUSIONS: We identified baseline factors that can help clinicians decide whether to prescribe an auto-BPAP as first-line therapy and that predict good long-term PAP adherence.

Improving prostate cancer detection in veterans through the development of a clinical decision rule for prostate biopsy.

BACKGROUND: We sought to improve prostate cancer (PC) detection through developing a prostate biopsy clinical decision rule (PBCDR), based on an elevated PSA and laboratory biomarkers. This decision rule could be used after initial PC screening, providing the patient and clinician information to consider prior to biopsy. METHODS: This case-control study evaluated men from the Tampa, Florida, James A. Haley (JH) Veteran's Administration (VA) (N = 1,378), from January 1, 1998, through April 15, 2005. To assess the PBCDR we did all of the following: 1) Identified biomarkers that are related to PC and have the capability of improving the efficiency of PC screening; 2) Developed statistical models to determine which can best predict the probability of PC; 3) Compared each potential model to PSA alone using Receiver Operator Characteristic (ROC) curves, to evaluate for improved overall effectiveness in PC detection and reduction in (negative) biopsies; and 4) Evaluated dose-response relationships between specified lab biomarkers (surrogates for extra-prostatic disease development) and PC progression. RESULTS: The following biomarkers were related to PC: hemoglobin (HGB) (OR = 1.42 95% CI 1.27, 1.59); red blood cell (RBC) count (OR = 2.52 95% CI 1.67, 3.78); PSA (OR = 1.04 95% CI 1.03, 1.05); and, creatinine (OR = 1.55 95% CI 1.12, 2.15). Comparing all PC stages versus non-cancerous conditions, the ROC curve area under the curve (AUC) enlarged (increasing the probability of correctly classifying PC): PSA (alone) 0.59 (95% CI 0.55, 0.61); PBCDR model 0.68 (95% CI 0.65, 0.71), and the positive predictive value (PPV) increased: PSA 44.7%; PBCDR model 61.8%. Comparing PC (stages II, III, IV) vs. other, the ROC AUC increased: PSA (alone) 0.63 (95% CI 0.58, 0.66); PBCDR model 0.72 (95% CI 0.68, 0.75), and the PPV increased: 20.6% (PSA); PBCDR model 55.3%. CONCLUSIONS: These results suggest evaluating certain common biomarkers in conjunction with PSA may improve PC prediction prior to biopsy. Moreover, these biomarkers may be more helpful in detecting clinically relevant PC. Follow-up studies should begin with replicating the study on different U.S. VA patients involving multiple practices.

WBGT clothing adjustment factors for four clothing ensembles and the effects of metabolic demands.

This study measured the clothing adjustment factors (CAFs) for four clothing ensembles (Cotton Coveralls, Tyvek 1427 Coveralls, NexGen Coveralls, and Tychem QC Coveralls; all coveralls were worn without hoods) against a baseline of cotton work clothes to determine whether the CAFs would be affected by the metabolic rate. Fifteen participants wore one of the five ensembles while walking on a treadmill at low, moderate, and high rates of work in an environment maintained at 50% relative humidity. A climatic chamber was used to slowly increase the level of heat stress by increasing air temperature. When the participant's core temperature reached a steady-state, the dry bulb temperature was increased. The point at which the core temperature began to increase was defined as the inflection point, and the WBGT recorded 5 min before the inflection point was the critical WBGT for each ensemble. A three-way mixed effects linear model with ensemble by metabolic rate category interactions demonstrated that the CAF did not change with metabolic rate, so CAFs can be used over a wide range of metabolic rates. The data at the moderate metabolic rate were combined with data on 14 participants from a previous study under the same conditions. The CAFs in degrees C WBGT were 0 for cotton coveralls, 1.0 for Tyvek 1422A, and 2.5 for NexGen. Although the value of 7.5 for Tychem QC was found, the recommendation remained at 10 to account for the effects of humidity. The standard error for the determination of WBGT crit at 50% relative humidity was 1.60 degrees C WBGT.

WBGT clothing adjustments for four clothing ensembles under three relative humidity levels.

Threshold limit values for heat stress and strain are based on an upper limit wet bulb globe temperature (WBGT) for ordinary work clothes, with clothing adjustment factors (CAF) for other clothing ensembles. The purpose of this study was to determine the CAF for four clothing ensembles (Cotton Coveralls, Tyvek 1424 Coveralls, NexGen Coveralls, and Tychem QC Coveralls) against a baseline of cotton work clothes and to determine what effect relative humidity may have. A climatic chamber was used to slowly increase the level of heat stress by increasing air temperature at three levels of relative humidity (20%, 50%, and 70%). Study participants wore one of the five ensembles while walking on a treadmill at a moderate metabolic rate of 155 W m-2 (about 300 W). Physiological data and environmental data were collected. When the participant's core temperature reached a steady state, the dry bulb temperature was increased at constant relative humidity. The point at which the core temperature began to increase was defined as the inflection point. The environmental temperature recorded 5 min before the inflection point was used to calculate the critical WBGT for each ensemble. A three-way analysis of variance with ensemble by humidity protocol interactions and a multiple comparison test were used to make comparisons among the mean values. Only the vapor-barrier ensemble (Tychem QC) demonstrated an interaction with humidity level. The following CAFs are proposed: Cotton Coveralls (0 degrees C-WBGT), Tyvek 1424 Coveralls (+1), NexGen Coveralls (+2), and Tychem QC Coveralls (+10).

Demographic differences in injuries among the elderly: an analysis of emergency department visits.

BACKGROUND: An understanding of demographic differences in injury types among the elderly will help in targeting interventions. METHODS: Rates were calculated from the 1997 to 1999 National Hospital Ambulatory Medical Care Surveys by dividing the estimated number of visits by census population estimates. Age-adjusted standardized morbidity ratios were calculated to facilitate comparison between genders and between races. RESULTS: Although men had fewer fractures than expected on the basis of the rate for women (standardized morbidity ratio = 0.57), they had more open wounds (standardized morbidity ratio = 1.785, p < 0.001). Blacks had fewer fractures than expected, based on the rates for whites (standardized morbidity ratio = 0.601, p = 0.004) but had higher visit rates than expected for less severe injuries such as contusions, strains, and sprains. CONCLUSION: The trends noted in the present analysis suggest interventions for improved machinery safety targeted at elderly men and a continuing focus on access to primary care for minority elderly.

A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients.

OBJECTIVE: The timing of tracheotomy in patients requiring mechanical ventilation is unknown. The effects of early percutaneous dilational tracheotomy compared with delayed tracheotomy in critically ill medical patients needing prolonged mechanical ventilation were assessed. DESIGN: Prospective, randomized study. SETTING: Medical intensive care units. PATIENTS: One hundred and twenty patients projected to need ventilation >14 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were prospectively randomized to either early percutaneous tracheotomy within 48 hrs or delayed tracheotomy at days 14-16. Time in the intensive care unit and on mechanical ventilation and the cumulative frequency of pneumonia, mortality, and accidental extubation were documented. The airway was assessed for oral, labial, laryngeal, and tracheal damage. Early group showed significantly less mortality (31.7% vs. 61.7%), pneumonia (5% vs. 25%), and accidental extubations compared with the prolonged translaryngeal group (0 vs. 6). The early tracheotomy group spent less time in the intensive care unit (4.8 +/- 1.4 vs. 16.2 +/- 3.8 days) and on mechanical ventilation (7.6 +/- 2.0 vs. 17.4 +/- 5.3 days). There was also significantly more damage to mouth and larynx in the prolonged translaryngeal intubation group. CONCLUSIONS: This study demonstrates that the benefits of early tracheotomy outweigh the risks of prolonged translaryngeal intubation. It gives credence to the practice of subjecting this group of critically ill medical patients to early tracheotomy rather than delayed tracheotomy.

Synergism between smoking and vital exhaustion in the risk of ischemic stroke: evidence from the ARIC study.

PURPOSE: To examine the synergism between vital exhaustion and cigarette smoking in producing ischemic stroke. Vital exhaustion (VE), a state characterized by unusual fatigue, irritability, and feelings of demoralization, is measured by the Maastricht questionnaire (MQ), a 21-item inventory of symptoms. METHODS: The Atherosclerosis Risk in Communities (ARIC) Study is an ongoing cohort study, initiated in 1987. The MQ was administered at the second follow-up visit (1990-1992), and participants were subsequently followed for an average of 6.27 years. Four US communities (Minneapolis, Minnesota; Washington County, Maryland; Forsyth County, North Carolina; and Jackson, Mississippi). 13,066 participants aged 48 to 67 years at baseline (Visit 2) with no history of stroke. Validated hospitalized ischemic stroke. RESULTS: During the follow-up period, there were 202 incident ischemic strokes. After multivariate adjustment, current smoking, and high VE were independent risk factors for incident stroke: (smoking vs. non-smoking HR=1.76, p < 0.01; high VE vs. low VE HR=1.94, p < 0.01). For persons with both VE and smoking vs. persons with neither, HR=2.71 (p < 0.001). The proportion of stroke disease burden due to VE and smoking that could be attributed to their interaction was 81 to 93 percent. CONCLUSIONS: The combination of cigarette smoking and VE is synergistic in the production of stroke.

Does warfarin therapy influence the risk of bladder cancer?

There has been growing interest in studying the biological effects of certain drugs and their potential to reduce the risk of various cancers. One study reported a decrease in the incidence of urogenital cancers in a trial with patients who received warfarin for treatment of venous thromboembolism, but a limitation to this study of urogenital cancers was the very small number of bladder cancer cases that developed following warfarin therapy. The objective of the present study is to measure the association between warfarin use and bladder cancer. A total of 330 cases with bladder cancer were identified at the James A. Haley Veterans' Administration (VA) Hospital in Tampa, Florida, using a combination of computerized pathology records and inpatient and outpatient diagnoses. Controls were randomly selected from the VA computerized administrative database and 1293 controls were included for analysis. Unconditional logistic regression analysis was performed to assess the risk of bladder cancer after adjusting for age, gender, and cigarette smoking. Among warfarin users, although there was a 27% elevation in risk, it did not differ significantly from nonusers (OR = 1.27, 95% CI = 0.85, 1.89). No duration-response relationship was observed between anticoagulant use and risk of bladder cancer. The results suggest that warfarin does not protect against bladder cancer, at least in male smokers, the highest risk population for bladder cancer.

Analgesic therapy and the prevention of bladder cancer.

The aim of this study was to measure the association between analgesic use and risk of bladder cancer among patients seen at the James A. Haley Veterans' Administration (VA) Hospital in Tampa, FL. A total of 330 cases were obtained using a combination of computerized pathology records, and inpatient and outpatient diagnoses. Controls were randomly selected from the VA computerized administrative database, and 1293 controls were included for analysis. Unconditional logistic regression analysis was performed to assess the risk of bladder cancer after adjusting for age, gender, and cigarette smoking. Among analgesic users, we were able to identify a nearly 20% reduction in risk potentially consistent with a protective role (OR = 0.81, 95% CI = 0.63, 1.05). Nonsmokers had a 43% decrease in risk (OR = 0.57, 95% CI = 0.33, 0.98). While smoking is a strong and recognized cause of bladder cancer, 50% of bladder cancer cases are not attributable to tobacco consumption. Given that nonsmokers prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) were observed to have a 43% reduction in risk, it is important to study whether nonsmokers may benefit from therapy with NSAIDs.