Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall.

STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Increases in drug-related infant mortality in the United States.

OBJECTIVES: We explored temporal trends in drug-related infant deaths in the United States (U.S.) from 2018 to 2022. METHODS: We used data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER). A total of 295 drug-involved infant deaths were identified from 2018 to 2022 (provisional mortality data for year 2022) based on the underlying cause of death. RESULTS: In the U.S. from 2018 to 2022, there was a significant 2.2-fold increase in drug-involved infant mortality. The observed increases were higher in non-Hispanic White and Black infants. The findings show that drug-involved infant deaths were more likely to occur in the postneonatal period, defined as ages 28-364 days (81.4 %) compared to the neonatal period. The most prevalent underlying causes of death included assault (homicide) by drugs, medicaments and biological substances (35.6 %) followed by poisoning due to exposure to narcotics and psychodysleptics (hallucinogens) (15.6 %). The most common multiple causes of drug-involved infant deaths were psychostimulants with abuse potential of synthetic narcotics. CONCLUSIONS: Drug-related infant mortality has increased significantly from 2018 to 2022. These increases are particularly evident among White and Black infants and occurred predominantly in the postneonatal period. These findings require more research but also indicate the need to address drug-involved infant deaths as preventable clinical and public health issues. Effective strategies to reduce drug-involved infant deaths will require preventing and treating maternal substance use disorders, enhancing prenatal care access, and addressing broader social and behavioral risk factors among vulnerable maternal and infant populations.

Temporal trends and geographic variations in mortality rates from tobacco and firearms in the United States.

We explored temporal trends and geographic variations in United States of America (US) mortality rates from smoking and firearms from 1999 to 2019. To do so, we used the publicly available Centers for Disease Control and Prevention (CDC) Wide Ranging Online Data for Epidemiologic Research (WONDER) with Multiple Cause of Death files from 1999 to 2019. Using age-specific rates and ArcGIS Pro Advanced software for Optimized Hot Spot Analyses from Esri, we generated maps of statistically significant spatial clusters with 90-99% confidence intervals with the Getis-Ord Gi* statistic for mortality from smoking-related causes and firearms. These data show temporal trends and geographic variations in mortality from smoking and firearms in the US. Smoking and firearm-related mortality from assault and suicide increased throughout the US and clustered in the Southeast. Firearm-related suicide also clustered in the continental West and Alaska. These descriptive data generate many hypotheses which are testable in analytic epidemiologic studies designed a priori to do so. The trends suggest smoking and firearm-related causes pose particular challenges to the Southeast and firearms also to the West and Alaska. These data may aid clinicians and public health authorities to implement evidence-based smoking avoidance and cessation programs as well as address firearm mortality, with particular attention to the areas of highest risks. As has been the case with cigarettes, individual behavior changes as well as societal changes are likely to be needed to achieve decreases in premature mortality.

Cross-sectional examination of ultra-processed food consumption and adverse mental health symptoms.

OBJECTIVE: To explore whether individuals who consume higher amounts of ultra-processed food (UPF) have more adverse mental health symptoms. DESIGN: Using a cross-sectional design, we measured the consumption of UPF as a percentage of total energy intake in kilo-calories using the NOVA food classification system. We explored whether individuals who consume higher amounts of UPF were more likely to report mild depression, more mentally unhealthy days and more anxious days per month using multivariable analyses adjusting for potential confounding variables. SETTING: Representative sample from the United States National Health and Nutrition Examination Survey between 2007 and 2012. PARTICIPANTS: 10 359 adults aged 18+ without a history of cocaine, methamphetamine or heroin use. RESULTS: After adjusting for covariates, individuals with the highest level of UPF consumption were significantly more likely to report at least mild depression (OR: 1·81; 95 % CI1·09, 3·02), more mentally unhealthy (risk ratio (RR): 1·22; 95 % CI 1·18, 1·25) and more anxious days per month (RR: 1·19; 95 % CI 1·16, 1·23). They were also significantly less likely to report zero mentally unhealthy (OR: 0·60; 95 % CI 0·41, 0·88) or anxious days (OR: 0·65; 95 % CI 0·47, 0·90). CONCLUSIONS: Individuals reporting higher intakes of UPF were significantly more likely to report mild depression, more mentally unhealthy and more anxious days and less likely to report zero mentally unhealthy or anxious days. These data add important information to a growing body of evidence concerning the potential adverse effects of UPF consumption on mental health.

Perceptions, Coping Strategies, and Mental Health of Residents during COVID-19.

OBJECTIVES: Since the inception of the coronavirus disease 2019 (COVID-19) pandemic, the United States has been the leader in cases and deaths. Healthcare workers treating these severely ill patients are at risk of many deleterious consequences. Residents, in particular, may be affected by physical as well as psychological consequences. Because data are sparse on perceptions, coping strategies, and the mental health of residents during COVID-19, we explored these issues in survey data from a community-based academic program in the southeastern United States. METHODS: In May 2020, when US deaths from COVID-19 reached 100,000, we administered multiple-choice online anonymous surveys to assess resident perceptions, coping strategies, and self-reported levels of depression, anxiety, and stress. We used the COPE inventory to assess coping strategies and the Depression, Anxiety, and Stress Scale-21 questionnaire. RESULTS: A total of 59 (41.3%) of 143 eligible residents completed the survey, 52 (88.1%) of whom believed that they were likely or very likely to become infected with COVID-19. If infected, 17 (28.8%) believed that their illness would be serious or very serious. The top three strategies to cope with COVID-19 included acceptance, self-distraction, and use of emotional support. With respect to depression, anxiety, and stress, all of the mean scores were in the normal range. CONCLUSIONS: During COVID-19, residents in a southern community-based program with an academic affiliation reported effective coping strategies, predominantly acceptance, self-distraction, and use of emotional support. They reported concerns about becoming infected and, if they did, that their illness would likely be serious. Finally, they have not experienced depression, anxiety, or reported stress. The findings may be restricted in generalizability to a southern community-based program with an academic affiliation.

Temporal Trends and Geographic Variations in Mortality Rates from Prescription Opioids: Lessons from Florida and West Virginia.

OBJECTIVES: To explore temporal trends and geographic variations in mortality from prescription opioids from 1999 to 2016. METHODS: Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Multiple Cause of Death files were used to calculate age-adjusted rates and 95% confidence intervals (CIs) and create spatial cluster maps. RESULTS: From 1999 to 2016, counties in West Virginia experienced the highest overall mortality rates in the United States from prescription opioids. Specifically, from 1999 to 2004, the highest rate in West Virginia of 24.87/100,000 (95% CI 17.84-33.73) was the fourth highest in the United States. From 2005 to 2009, West Virginia experienced the highest rate in the United States, 60.72/100,000 (95% CI 47.33-76.71). From 2010 to 2016, West Virginia also experienced the highest rate in the United States, which was 90.24/100,000 (95% CI 73.11-107.36). As such, overall, West Virginia experienced the highest rates in the United States and the largest increases overall of ~3.6-fold between 1999 and 2004 and 2010 and 2016. From 1999 to 2004, Florida had no "hot spots," but from 2006 to 2010 they did appear, and from 2011 to 2016, they disappeared. CONCLUSIONS: These data show markedly divergent temporal trends and geographic variations in mortality rates from prescription opioids, especially in the southern United States. Specifically, although initial rates were high and continued to increase alarmingly in West Virginia, they increased but then decreased in Florida. These descriptive data generate hypotheses requiring testing in analytic epidemiological studies. Understanding the divergent patterns of prescription opioid-related deaths, especially in West Virginia and Florida, may have important clinical and policy implications.

Accidental Infant Suffocation and Strangulation in Bed: Disparities and Opportunities.

Objectives (a) Update previous descriptions of trends in ASSB; (b) determine if factors previously associated with ASSB are replicated by updated data; and (c) generate new hypotheses about the occurrence of ASSB and racial inequalities in ASSB mortality. Methods National Center for Health Statistics files (International Classification of Diseases, Tenth Edition) Code W75 to describe race-ethnicity-specific ASSB occurrence. Results (a) ASSB mortality continues to increase significantly; for 1999-2016, 4.4-fold for NHB girls (45.8 per 100,000 in 2016), 3.5-fold for NHB boys (53.8), 2.7-fold for NHW girls (15.8) and 4.0-fold for NHW boys (25.9); (b) F actors previously associated with ASSB (unmarried mothers and mothers with low educational attainment, low infant birth weight, low gestational age, lack of prenatal care, male infant, multiple birth, high birth order) continue to be associated with both overall ASSB and inequalities adversely affecting NHB; (c) (1) geographic differences and similarities in ASSB occurrence support hypotheses related to positive deviance; (2) lower ASSB mortality for births attended by midwives as contrasted to physicians generate hypotheses related to both medical infrastructure and maternal engagement; (3) high rates of ASSB among infants born to teenage mothers generate hypotheses related to the possibility that poor maternal health may be a barrier to ASSB prevention based on education, culture and tradition. Conclusions for Practice These descriptive data may generate new hypotheses and targets for interventions for reducing both ASSB mortality and racial inequalities. Analytic epidemiologic studies designed a priori to do so are required to address these hypotheses.

Interrelationships of Cadmium, Smoking, and Angina in the National Health and Nutrition Examination Survey, a Cross-Sectional Study.

The interrelationships between cadmium biomarker levels, smoking, and myocardial infarction and stroke have been established. In this cross-sectional analysis, we explored the interrelationships of blood cadmium levels, smoking, and angina. We analyzed the National Health and Nutrition Examination Survey (NHANES, 2003-2014) accounting for the multi-staged complex sampling design. Participants 40-79 years of age with blood cadmium levels but without a history of myocardial infarction and/or stroke were included (n = 14,832). We examined blood cadmium levels (3 tertile groups) in relation to 3 (diagnosed, undiagnosed, and composite diagnosed and/or undiagnosed) angina outcomes. Multivariable logistic regression models adjusted for age, diabetes, smoking status, and household income were used to estimate odds ratios (ORs) and their corresponding 95% confidence intervals (CIs). Of 14,832 participants, 741 (4.2%) had positive composite angina. The crude and adjusted ORs comparing those in the lowest tertile (referent group) of blood cadmium to those in the highest tertile for the composite outcome were 1.82 (95% CI 1.42-2.34) and 1.45 (95% CI 1.12-1.88), respectively. These cross-sectional data from a nationally representative sample contribute to the hypothesis that there are interrelationships between smoking, cadmium, and angina.

Homicide in the South: Higher Rates Among Whites and Fewer Racial Disparities.

OBJECTIVE: Describe southern US homicide rates in whites and blacks between 1999 and 2015. METHODS: The Centers for Disease Control and Prevention Multiple Cause of Death Files provided mortality rates and 95% confidence intervals (CIs) for non-Hispanic whites (NHW) as well as non-Hispanic blacks and African Americans (NHB). RESULTS: Overall, age-adjusted (1 to ≥85 years) homicide was significantly higher in the South (7.6/100,000, 95% CI 7.6-7.7) than the rest of the United States (4.9/100,000, 95% CI 4.8-4.9) even though the southern rate among NHB (18.7/100,000, 95% CI 18.5-18.8) was lower than the rest of the United States (23.3/100,000, 95% CI 23.1-23.5). The overall southern NHB:NHW mortality rate ratio was 5.1 and 10.6 in the rest of the nation. Homicide rates among NHW men were higher in the South than in each of the other US Census areas, whereas corresponding rates among NHB men were lower. For both men and women the NHB:NHW mortality rate ratio was lower in the South than in any other region. In addition, homicide rates among NHB women in the South were equal to or lower than corresponding rates in the West and Midwest. Finally, higher rates for NHW in metropolitan areas led to overall higher NHW mortality rates and relatively low NHB:NHW rates. Southern NHW had a higher percentage of firearms-related homicides (58.4%) than the corresponding percentage in the rest of the United States (49.8%; P < 0.001). Southern NHB used firearms for 78.8% of homicides compared with 83.9% in the rest of the United States (P < 0.001). CONCLUSIONS: The overall high homicide rates in the southern United States were attributable to relatively higher NHW rates than those found in the rest of the country. Further research targeting the role of firearms as well as cultural and other issues could further the understanding of the interrelations of homicide with complex regional and cultural factors.

Data monitoring committees: Promoting best practices to address emerging challenges.

BACKGROUND AND PURPOSE: Data monitoring committees are responsible for safeguarding the interests of study participants and assuring the integrity and credibility of clinical trials. The independence of data monitoring committees from sponsors and investigators is essential in achieving this mission. Creative approaches are needed to address ongoing and emerging challenges that potentially threaten data monitoring committees' independence and effectiveness. METHODS: An expert panel of representatives from academia, industry and government sponsors, and regulatory agencies discussed these challenges and proposed best practices and operating principles for effective functioning of contemporary data monitoring committees. RESULTS AND CONCLUSIONS: Prospective data monitoring committee members need better training. Options could include didactic instruction as well as apprenticeships to provide real-world experience. Data monitoring committee members should be protected against legal liability arising from their service. While avoiding breaches in confidentiality of interim data remains a high priority, data monitoring committees should have access to unblinded efficacy and safety data throughout the trial to enable informed judgments about risks and benefits. Because overly rigid procedures can compromise their independence, data monitoring committees should have the flexibility necessary to best fulfill their responsibilities. Data monitoring committee charters should articulate principles that guide the data monitoring committee process rather than list a rigid set of requirements. Data monitoring committees should develop their recommendations by consensus rather than through voting processes. The format for the meetings of the data monitoring committee should maintain the committee's independence and clearly establish the leadership of the data monitoring committee chair. The independent statistical group at the Statistical Data Analysis Center should have sufficient depth of knowledge about the study at hand and experience with trials in general to ensure that the data monitoring committee has access to timely, reliable, and readily interpretable insights about emerging evidence in the clinical trial. Contracts engaging data monitoring committee members for industry-sponsored trials should have language customized to the unique responsibilities of data monitoring committee members rather than use language appropriate to consultants for product development. Regulatory scientists would benefit from experiencing data monitoring committee service that does not conflict with their regulatory responsibilities.

Infant Deaths and Mortality from Gun Violence: Causal or Casual?

OBJECTIVE: Describe trends in non-Hispanic black infant mortality (IM) in the New York City (NYC) counties of Bronx, Kings, Queens, and Manhattan and correlations with gun-related assault mortality. METHODS: Linked Birth/Infant Death data (1999-2013) and Compressed Mortality data at ages 1 to ≥85 years (1999-2013). NYC and United States (US) Census data for income inequality and poverty. Pearson coefficients were used to describe correlations of IM with gun-related assault mortality and other causes of death. RESULTS: In NYC, the risk of non-Hispanic black IM in 2013 was 49% lower than in 1995 (rate ratio: 0.51; 95% CI: 0.43, 0.61). Yearly declines between 1999 and 2013 were significantly correlated with declines in gun-related assault mortality (correlation coefficient (r) = 0.70, p = 0.004), drug-related mortality (r = 0.59, p = 0.020), major heart disease and stroke (r = 0.85, p < 0.001), malignant neoplasms (r = 0.57, p = 0.026), diabetes mellitus (r = 0.63, p = 0.011), and pneumonia and influenza (r = 0.78, p < 0.001). There were no significant correlations of IM with chronic lower respiratory or liver disease, non-drug-related accidental deaths, and non-gun-related assault. Yearly IM (1995-2012) was inversely correlated with income share of the top 1% of the population (r = -0.66, p = 0.007). CONCLUSIONS: In NYC, non-Hispanic black IM declined significantly despite increasing income inequality and was strongly correlated with gun-related assault mortality and other major causes of death. These data are compatible with the hypothesis that activities related to overall population health, including those pertaining to gun-related homicide, may provide clues to reducing IM. Analytic epidemiological studies are needed to test these and other hypotheses formulated from these descriptive data.

A cross-sectional survey of cadmium biomarkers and cigarette smoking.

Cadmium contamination of tobacco may contribute to the health hazards of cigarette smoking. The 2005-2012 United States National Health and Nutrition Examination Survey data provided a unique opportunity to conduct a cross-sectional survey of cadmium biomarkers and cigarette smoking. Among a sample of 6761 participants, we evaluated mean differences and correlations between cadmium biomarkers in the blood and urine and characteristics of never, former and current smokers. We found statistically significant differences in mean cadmium biomarker levels between never and former smokers as well as between never and current smokers. In current smokers, duration in years had a higher correlation coefficient with urinary than blood cadmium levels. In contrast, number of cigarettes smoked per day had a higher correlation coefficient with blood than urinary cadmium levels. These data suggest that blood and urine cadmium biomarker levels differ by duration and dose. These findings should be considered in evaluating any association between cadmium and smoking related diseases, especially cardiovascular disease.

Variations in mortality from legal intervention in the United States-1999 to 2013.

BACKGROUND: In the United States (US) between 279 and 507 people were killed yearly by legal intervention/ law enforcement other than by legal execution (1999-2013). METHODS: We explored variations in US deaths by legal intervention using the Compressed Mortality File and CDC WONDER. RESULTS: Among 5551 deaths by legal intervention, rates increased from 0.11/100,000 (95% Confidence Interval (CI) 0.10, 0.12) in 1999 to 0.16/100,000 (0.14, 0.17) in 2012-2103. Further, for 1999-2013, 71% (3912) occurred at ages 20-44 with the highest rates at ages 20-24 (0.30 (0.28, 0.32)) and 25-34 (0.0.27 (0.26, 0.28)) per 100,000. In addition, 96% (5335) occurred among males, 78% at ages 15-44 years. Among men ages 15-44, rates were highest among American Indian or Alaska Natives (1.04 (95% CI 0.83, 1.29)), who comprise 2.06% of deaths and non-Hispanic Black or African American men (0.97 (0.92, 1.03)), who comprise 29.60%. Rates among men ages 15 to 44 were also higher among Hispanic whites (0.58(0.54, 0.61)), than among non-Hispanic Whites (0.3(0.28, 0.31)), or non-Hispanic or Latino Asian and Pacific Islanders (0.18 (0.15, 0.23)). Among places with reliable rates, the highest State rate for non-Hispanic Black males occurred in Nevada (1.27/100,000 (95% CI 0.77, 1.96) while the highest county was Riverside, CA (2.40(1.52, 3.61)). Corresponding values for Hispanic whites were New Mexico (1.07 (0.83,1.37) and Denver, CO (1.76(1.11, 2.67)) and for non-Hispanic whites, New Mexico (0.54 (0.36, 078) and San Bernardino, CA (0.73 (0.52, 1.00). CONCLUSIONS AND RELEVANCE: Community-based programs, with collaboration from policy makers and community members, may reduce these potentially avoidable premature deaths from legal intervention by targeting high risk sub-populations.

American association of clinical endocrinologists and american college of endocrinology consensus conference on obesity: building an evidence base for comprehensive action.

OBJECTIVE/METHODS: The American Association of Clinical Endocrinologists/American College of Endocrinology "Consensus conference on obesity: building an evidence base for comprehensive action" convened March 23-25, 2014, in Washington, D.C. The premise of the conference was that by bringing together stakeholders in U.S. obesity care, representing the biomedical and public health models, new information would emerge to formulate actionable recommendations. RESULTS: Key conference findings include 5 affirmed and 8 emergent concepts. These concepts include the need for a medically meaningful and actionable diagnosis of obesity, research that evaluates and refines a complications-centric clinical approach to obesity, the need for a better understanding of reimbursement mechanisms and the value associated with obesity prevention and management, increased nutrition and obesity education, and enhanced public awareness and health literacy. CONCLUSION: Next steps include deriving a more robust medical definition of obesity, translation of the affirmed and emergent concepts into actionable recommendations in the interests of patients with obesity, and developing logistics for effective implementation.

Enhancing trial integrity by protecting the independence of data monitoring committees in clinical trials.

Data monitoring committees (DMCs) have important roles in safeguarding patient interests and enhancing trial integrity and credibility. To effectively fulfill their responsibilities, DMCs should be independent of study sponsors, study investigators, and caregivers managing study participants. Unfortunately, in real-world settings where DMCs are in place, there are some practices that threaten to diminish the level of independence of these committees. To address this, some important approaches should be considered: A DMC charter should outline the roles and responsibilities of the DMC without appearing to be a legal contract; the meetings of the DMC should be led by its chair, ideally with a meeting format that ensures independence from the investigators and sponsor; the DMC and those having leadership roles in the monitoring process should have adequate training and experience; procedures should be in place to enable the DMC to have access to interim safety and efficacy data that are accurate, current, and comprehensive; these data should be presented to the DMC unblinded by treatment group, while being kept confidential from all others; DMC recommendations should be developed through consensus development rather than by casting votes; creative approaches are needed for the engagement of DMC members to increase the transparency such that they are neither employees of nor consultants to the sponsor of the trial; meaningful conflicts of interest should be identified and addressed; and finally, members of DMCs should have adequate indemnification that provides effective protection.

Newest Updates to Health Providers on the Hazards of Ultra-Processed Foods and Proposed Solutions.

At present, the United States has the lowest life expectancy of all 12 large, rich countries in the world. While overweight and obesity, as well as lack of regular physical activity, are well recognized, another less well-known plausible hypothesis to explain this observation is the unprecedented consumption of ultra-processed food in the United States. Whether ultra-processed food contributes to our currently rising rates of morbidity and mortality from noncommunicable diseases requires direct testing in analytic studies designed a priori to do so. At present, ultra-processed foods are likely to play major roles in a myriad of diseases such as diabetes, coronary heart disease, stroke, a variety of cancers, and even mental health disorders. As was the case with cigarettes, we find ourselves needing to fight a battle where the entertainment industry, the food industry, and public policy do not align with our patients' needs. This does not mean that we should not begin to engage our patients in this vital conversation. Indeed, it makes it all the more important, and timely, that we do so.

Electronic Vapor Products: Alarming Trends in United States Adolescents.

Background: The use of electronic vapor products (EVPs) increases the risks of nicotine addiction, drug-seeking behavior, mood disorders, and avoidable premature morbidities and mortality. We explored temporal trends in EVP use among US adolescents. Methods: We used data from the Youth Risk Behavior Survey for school grades 9 through 12 from 2015 (earliest available data) to 2021 (the most recently available data) from the US Centers for Disease Control and Prevention (n=57,006). Results: Daily use of EVPs increased from 2.0% in 2015 to 7.2% in 2019, a greater than 3.5-fold increase. Although the percentage decreased to 5.0% in 2021, it was still a >2.5-fold increase since 2015. In 2015, the percentage of EVP use was significantly higher in boys (2.8%) than girls (1.1%). By 2021, the percentage of EVP use was higher in girls (5.6%) than boys (4.5%), a 1.24-fold increase. In addition, the percentage of EVP use in 2021 was higher in White youth (6.5%) vs Black (3.1%), Asian (1.2%), and Hispanic/Latino (3.4%) youth compared to 2015, but White and Black adolescents had the highest increases of approximately 3.0-fold between 2015 and 2021. Adolescents in grade 12 had the highest percentages of EVP use at all periods. Conclusion: These data show alarming statistically significant and clinically important increases in EVP use in US adolescents in school grades 9 through 12. The magnitude of the increases may have been blunted by coronavirus disease 2019, a hypothesis that requires direct testing in analytic studies. These trends create clinical and public health challenges that require targeted interventions such as mass media campaigns and peer interventions to combat the influences of social norms that promote the adoption of risky health behaviors during adolescence.