Suicide acts in 8 states: incidence and case fatality rates by demographics and method

OBJECTIVES

This study examined incidence rates of medically identified suicide acts (self-inflicted injuries, either fatal or nonfatal) and case fatality rates by age, sex, race, and method used.

METHODS

The authors analyzed data on 10,892 suicides and 57,439 attempted suicides among hospital-admitted individuals in 8 states, along with 6219 attempted suicides among individuals released from emergency departments in 2 states.

RESULTS

The 8 states experienced a mean of 11 suicides and 119 attempted suicides per 100,000 residents each year. Groups with high suicide rates were men, the elderly, and Whites; groups with high attempted suicide rates were teenagers, young adults, women, and Blacks and Whites aged 25 to 44 years. Blacks aged 15 to 44 years evidenced high attempted suicide rates undocumented in previous studies. Poisoning and firearm were the most common methods used among those attempting suicide and those completing suicide acts, respectively. The most lethal method was firearm.

CONCLUSIONS

The characteristics of suicides and attempted suicides differ dramatically. Method used is important in the lethality of the act.

The Early Food Insecurity Impacts of COVID-19

COVID-19 has disrupted food access and impacted food insecurity, which is associated with numerous adverse individual and public health outcomes. To assess these challenges and understand their impact on food security, we conducted a statewide population-level survey using a convenience sample in Vermont from March 29 to April 12, 2020, during the beginning of a statewide stay-at-home order. We utilized the United States Department of Agriculture six-item validated food security module to measure food insecurity before COVID-19 and since COVID-19. We assessed food insecurity prevalence and reported food access challenges, coping strategies, and perceived helpful interventions among food secure, consistently food insecure (pre-and post-COVID-19), and newly food insecure (post COVID-19) respondents. Among 3219 respondents, there was nearly a one-third increase (32.3%) in household food insecurity since COVID-19 (p < 0.001), with 35.5% of food insecure households classified as newly food insecure. Respondents experiencing a job loss were at higher odds of experiencing food insecurity (OR 3.06; 95% CI, 2.114-0.46). We report multiple physical and economic barriers, as well as concerns related to food access during COVID-19. Respondents experiencing household food insecurity had higher odds of facing access challenges and utilizing coping strategies, including two-thirds of households eating less since COVID-19 (p < 0.001). Significant differences in coping strategies were documented between respondents in newly food insecure vs. consistently insecure households. These findings have important potential impacts on individual health, including mental health and malnutrition, as well as on future healthcare costs. We suggest proactive strategies to address food insecurity during this crisis.

Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network

OBJECTIVE

To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model.

DESIGN

Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997.

SETTING

Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group.

PATIENTS

Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738).

INTERVENTIONS

NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits.

MAIN OUTCOME MEASURES

The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g.

RESULTS

Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997.

CONCLUSION

We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.

Methicillin-resistant Staphylococcus aureus in a high school wrestling team and the surrounding community

OBJECTIVES

To describe a community outbreak of methicillin-resistant Staphylococcus aureus (MRSA) and to investigate risk factors for MRSA transmission and infection in a wrestling team.

DESIGN

Case series and retrospective cohort study.

SETTING

A high school wrestling team and the surrounding community in southern Vermont, 1993 to 1994.

PATIENTS OR OTHER PARTICIPANTS

The case series included persons whose MRSA-positive infections were identified at a hospital laboratory from January 1, 1993, through February 28, 1994, and a health maintenance organization laboratory from July 1, 1993, through February 28, 1994. A wrestling team case-patient was a 1993-1994 team member with an MRSA-positive culture during the period from January 1, 1993, through February 28, 1994.

INTERVENTIONS

Visual inspection of wrestlers before matches was instituted. Affected wrestlers were excluded from wrestling and advised to seek appropriate medical care. Heightened attention was given to personal and environmental hygiene.

MAIN OUTCOME MEASURES

Colonization or infection with MRSA.

RESULTS

Seven of 32 team members were MRSA positive (6 infected, 1 colonized). All lesion-positive wrestlers were tested by pulsed field gel electrophoresis and found to be infected with the same MRSA strain, as were 6 nonwrestlers. No risk factors for MRSA infection were identified.

CONCLUSIONS

The MRSA was transmitted among members of a wrestling team. Infection with MRSA should be suspected in outbreaks of boils that are nonresponsive to standard antibiotic therapy among healthy participants of contact sports and their close contacts.

Reexploration for hemorrhage following coronary artery bypass grafting: incidence and risk factors. Northern New England Cardiovascular Disease Study Group

OBJECTIVE

To assess mortality and risk factors associated with reexploration for hemorrhage in patients undergoing coronary artery bypass grafting (CABG).

DESIGN

Regional cohort study. Patient characteristics, treatment variables, and outcome measures were collected prospectively.

SETTING

All 5 centers performing cardiac surgery in Maine, New Hampshire, and Vermont.

PATIENTS

A consecutive cohort of 8586 patients undergoing isolated CABG between 1992 and 1995.

MAIN OUTCOME MEASURES

Postoperative hemorrhage leading to reexploration, in-hospital mortality, and length of stay.

RESULTS

A total of 305 patients (3.6%) underwent reexploration for bleeding. In these patients, in-hospital mortality was nearly 3 times higher (9.5% vs 3.3% for patients not requiring reoperation, P<.001) and average length of stay from surgery to discharge was significantly longer (14.5 days vs 8.6 days, P<.001). High rates of reexploration for hemorrhage were observed in patients with prolonged (> 150 minutes) cardiopulmonary bypass (39 [11.1%] of 351) and in those requiring an intra-aortic balloon pump intraoperatively (12 [8%] of 139). In multivariate analysis, older age, smaller body surface area, prolonged cardiopulmonary bypass, and number of distal anastomoses were associated with increased bleeding risks. The use of thrombolytic therapy within 48 hours of surgery was weakly but not significantly associated with the need for reexploration. Factors not significantly associated with reexploration included patient sex, preoperative ejection fraction, surgical priority, history of liver disease, myocardial infarction, prior CABG, renal failure, and diabetes mellitus.

CONCLUSIONS

Hemorrhage requiring reexploration after CABG is associated with markedly increased mortality and length of stay. Patients predicted to have increased risks of bleeding may benefit from prophylactic use of aprotinin, aminocaproic acid, or other agents shown to reduce hemorrhage.

Effect of seeing tobacco use in films on trying smoking among adolescents: cross sectional study

OBJECTIVE

To test the hypothesis that greater exposure to smoking in films is associated with trying smoking among adolescents.

DESIGN

Cross sectional survey of 4919 schoolchildren aged 9-15 years, and assessment of occurrence of smoking in 601 films.

SETTING

Randomly selected middle schools in Vermont and New Hampshire, USA.

MAIN OUTCOME MEASURE

Number of schoolchildren who had ever tried smoking a cigarette.

RESULTS

The films contained a median of 5 (interquartile range 1-12) occurrences of smoking. The typical adolescent had seen 17 of 50 films listed. Exposure to smoking in films varied widely: median 91 (49-152) occurrences. The prevalence of ever trying smoking increased with higher categories of exposure: 4.9% among students who saw 0-50 occurrences of smoking, 13.7% for 51-100 occurrences, 22.1% for 101-150, and 31.3% for >150. The association remained significant after adjustment for age; sex; school performance; school; parents' education; smoking by friend, sibling, or parent; and receptivity to tobacco promotions. The adjusted odds ratios of ever trying smoking for students in the higher categories of exposure, compared with students exposed to 0-50 occurrences of smoking in films, were 1.7 (95% confidence interval 1.2 to 2.4), 2.4 (1.7 to 3.4), and 2.7 (2.0 to 3.8). These odds ratios were not substantially affected by adjustment for parenting style or for personality traits of the adolescent.

CONCLUSION

In this sample of adolescents there was a strong, direct, and independent association between seeing tobacco use in films and trying cigarettes, a finding that supports the hypothesis that smoking in films has a role in the initiation of smoking in adolescents.

The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries

Prehospital or admission hypotension doubles the mortality for patients with severe head injury (SHI = Glasgow Coma Scale score less than or equal to 8). To our knowledge no study to date has determined the effects of intraoperative hypotension [IH: systolic blood pressure (SBP) less than 90 mm Hg] on outcome in patients with SHI. This study examined 53 patients who had SHI and required early surgical intervention (surgery within 72 hours of injury). All patients were initially normotensive on arrival. There were 17 patients (32%) who developed IH and 36 (68%) who remained normotensive throughout surgery. The mortality rate was 82% in the IH group and 25% in the normotensive group (p less than 0.001). The duration of IH was inversely correlated with Glasgow Outcome Scale using linear regression (R = -0.30; p = 0.02). Despite vigorous fluid resuscitation in the IH group, additional pharmacologic support was used in only 32%. These data suggest that IH is not uncommon after SHI (32%) and that it does have a significant effect on patient outcome.

A method to help reduce the risk of serious knee sprains incurred in alpine skiing

The incidence of severe anterior cruciate ligament sprains was once only a third the current rate. This fact led the authors to believe a means to help reduce the risk of anterior cruciate ligament injury among skiers might be found. Using videotapes of the occurrences of anterior cruciate ligament sprains in alpine skiers and the data associated with more than 1400 anterior cruciate ligament injuries observed in a 22-year study, the authors identified two common mechanisms of anterior cruciate ligament injury. From this information, a study was designed to determine if training could help reduce the risk of anterior cruciate ligament sprains. During the 1993 to 1994 season, the on-slope staff from 20 ski areas participated in a training program involving viewing videotaped scenes where knee injuries occurred. Data from 22 ski areas, where staff were not exposed to the training, were assembled to form a control group. Data concerning anterior cruciate ligament injuries were collected from both groups for the three seasons 1991 to 1994. A total of 179 serious knee sprains were evaluated. Serious knee sprains declined by 62% among trained patrollers and instructors compared with the two previous seasons, but no decline occurred in the control group.

Nicotine and caffeine use in cocaine-dependent individuals

Nicotine and caffeine use in 87 cocaine-dependent persons seeking treatment at an outpatient clinic were compared to use of those substances in a matched general population sample (n = 78). The prevalence of cigarette smoking was significantly greater in the cocaine-dependent sample (75% vs. 22%). Within the cocaine-dependent sample, smokers were younger, less educated, employed in lesser skilled jobs, and reported an earlier onset and more frequent use of cocaine. The prevalence of caffeine use was significantly less in the cocaine-dependent group (68% vs. 83%), although, among caffeine users, the cocaine group drank significantly more caffeinated beverages per day than matched controls (4.9 vs. 3.3). Interestingly, regular caffeine use was associated with less frequent cocaine use within the cocaine-dependent sample. To our knowledge, this study is the first to report on prevalence of smoking and caffeine use among cocaine-dependent individuals, and suggests that use of these other substances may influence the onset and pattern of cocaine use.

Early prediction of chronic disability after occupational low back injury

STUDY DESIGN

An inception cohort design was used to study a consecutive sample of back-injured workers.

OBJECTIVE

To refine and to test the Vermont Disability Prediction Questionnaire's ability to indicate an individual's relative risk for chronic disability after occupational low back injury.

SUMMARY OF BACKGROUND DATA

Although most back-injured workers return to work quickly, the minority who do not account for the majority of associated costs and health care. Early identification of workers at high risk for disability would facilitate intervention strategies.

METHODS

During the study recruitment period, people aged 18-60 years reporting occupational low back injury to the Vermont Department of Labor and Industry within 11 days of onset were eligible. A Vermont Disability Prediction Questionnaire was mailed to the 442 subjects who could be contacted and who gave informed consent. One hundred sixty-three of the 166 subjects who completed and returned the questionnaire within 15 days of initial injury were telephoned 3 months later to determine work status. Those who returned the questionnaire were compared with those who would not consent or did not return the questionnaire in time according to age, sex, residence, wages, work hours per week, and length of employment. Employment status (inability to work because of low back pain) was evaluated by telephone interview 3 months after initial injury.

RESULTS

The follow-up interviewer was blinded to the Vermont Disability Prediction Questionnaire scores. of the 163 subjects, 16 (10%) were not working because of low back pain. Using a simple dichotomous scoring system for 11 questionnaire items, a cut-off score of 0.48 identified 3-month postinjury work status, with 0.94 sensitivity and 0.84 specificity.

CONCLUSIONS

The Vermont Disability Prediction Questionnaire is a brief, easily administered and scored tool for identifying back-injured workers at relative risk for chronic disability. Such early identification should increase the efficiency of disability prevention strategies by directing them toward people who need them most. The accuracy of the questionnaire needs to be tested in a variety of different clinical and socioeconomic settings.

Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants. Vermont Oxford Network

BACKGROUND

The outcomes for very low birth weight infants vary among neonatal intensive care units (NICUs), but the reasons for this variation are not well understood. We used the database of a large neonatology research network to determine whether either admission characteristics of the infants or specific characteristics of the units such as annual patient volume and the presence of a pediatric residency program could account for observed differences in neonatal mortality rates among units.

METHODS

We studied 7672 infants with birth weights from 501 to 1500 g treated during 1991 and 1992 at 62 NICUs participating in the Vermont Oxford Network Database.

RESULTS

Overall, 14.7% of the study infants died within 28 days of birth (interquartile range 9.9% to 18.1%). The ratio of the number of observed deaths at an NICU to the number of deaths predicted based on the characteristics of infants treated at the NICU (standardized neonatal mortality ratio, [SNMR]) varied significantly among units (range 0 to 1.69, z = 4.24). There was no association between annual patient volume and either mortality rate (r = .17) or SNMR (r = .22). Observed mortality rates (17% vs 13%) and SNMR (1.04 vs .87) were both higher at the 24 hospitals with pediatric residency training programs than at the 38 hospitals without such programs. Hospitals with residency programs had higher average annual patient volumes (104 vs 66). In an analysis simultaneously adjusting for patient characteristics, volume, and presence of a residency program, neither volume (odds ratio [OR] per 10 additional cases treated 1.01, 95% confidence interval [CI], .98 to 1.04) nor presence of a pediatric residency program (OR 1.18, 95% CI, .94 to 1.47) was significantly associated with neonatal mortality risk.

CONCLUSION

There are differences in neonatal mortality rates among NICUs that cannot be explained by differences in the measured admission characteristics of the infants, suggesting that the effectiveness of medical care varies among units. Neither the annual volume of very low birth weight infants treated in a unit nor the presence of a pediatric residency training program was independently associated with neonatal mortality rates for very low birth weight infants.

Cardiac rehabilitation participation predicts lower rehospitalization costs

The effect of participation in cardiac rehabilitation on medical costs was determined by measuring hospitalization charges for cardiac admissions over a 3-year period in 580 post-coronary event patients (58% after coronary bypass surgery, 42% after myocardial infarction), of whom 230 entered a cardiac rehabilitation program and 350 did not. Baseline left ventricular ejection fraction was similar in entrants and nonentrants (59.9% vs 59.5%). Over the 1 to 46-month follow-up period (mean 21 months), per capita hospitalization charges for participants in cardiac rehabilitation were $739 lower than charges for nonparticipants ($1197 +/- 3911 vs $1936 +/- 5459, p = 0.022). This was due to both a lower incidence of hospitalizations and lower charges per hospitalization. Inasmuch as groups differed with regard to age, sex, diagnostic category, and smoking status, data were adjusted for these baseline differences by means of analysis of covariance. Rehospitalization charges remained significantly higher in nonparticipants (p = 0.015). Because physician charges were not measured, the cost differential between groups is underestimated. Results of this study show an association between participation in comprehensive cardiac rehabilitation and lowered cardiac rehospitalization costs in the years after an acute coronary event.

Lung cancer in a U.S. population with low to moderate arsenic exposure

BACKGROUND

Little is known about the carcinogenic potential of arsenic in areas with low to moderate concentrations of arsenic (< 100 microg/L) in drinking water.

OBJECTIVES

We examined associations between arsenic and lung cancer.

METHODS

A population-based case-control study of primary incident lung cancer was conducted in 10 counties in two U.S. states, New Hampshire and Vermont. The study included 223 lung cancer cases and 238 controls, each of whom provided toenail clippings for arsenic exposure measurement by inductively coupled-plasma mass spectrometry. We estimated odds ratios (ORs) of the association between arsenic exposure and lung cancer using unconditional logistic regression with adjustment for potential confounders (age, sex, race/ethnicity, smoking pack-years, education, body mass index, fish servings per week, and toenail selenium level).

RESULTS

Arsenic exposure was associated with small-cell and squamous-cell carcinoma of the lung [OR = 2.75; 95% confidence interval (CI), 1.00-7.57] for toenail arsenic concentration > or = 0.114 microg/g, versus < 0.05 microg/g. A history of lung disease (bronchitis, chronic obstructive pulmonary disease, or fibrosis) was positively associated with lung cancer (OR = 2.86; 95% CI, 1.39-5.91). We also observed an elevated risk of lung cancer among participants with a history of lung disease and toenail arsenic > or = 0.05 microg/g (OR = 4.78; 95% CI, 1.87-12.2) than among individuals with low toenail arsenic and no history of lung disease.

CONCLUSION

Although this study supports the possibility of an increased risk of specific lung cancer histologic types at lower levels of arsenic exposure, we recommend large-scale population-based studies.

Severity of Bronchopulmonary Dysplasia Among Very Preterm Infants in the United States

BACKGROUND AND OBJECTIVES

The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network recently proposed new, severity-based diagnostic criteria for bronchopulmonary dysplasia (BPD). This study provides the first benchmark epidemiological data applying this definition.

METHODS

Retrospective cohort study of infants born from 22 to 29 weeks' gestation in 2018 at 715 US hospitals in the Vermont Oxford Network. Rates of BPD, major neonatal morbidities, and common respiratory therapies, stratified by BPD severity, were determined.

RESULTS

Among 24 896 infants, 2574 (10.3%) died before 36 weeks' postmenstrual age (PMA), 12 198 (49.0%) did not develop BPD, 9192 (36.9%) developed grade 1 or 2 BPD, and 932 (3.7%) developed grade 3 BPD. Rates of mortality before 36 weeks' PMA and grade 3 BPD decreased from 52.7% and 9.9%, respectively, among infants born at 22 weeks' gestation to 17.3% and 0.8% among infants born at 29 weeks' gestation. Grade 1 or 2 BPD peaked in incidence (51.8%) among infants born at 25 weeks' gestation. The frequency of severe intraventricular hemorrhage or cystic periventricular leukomalacia increased from 4.8% among survivors without BPD to 23.4% among survivors with grade 3 BPD. Similar ranges were observed for late onset sepsis (4.8%-31.4%), surgically treated necrotizing enterocolitis (1.4%-17.1%), severe retinopathy of prematurity (1.2%-23.0%), and home oxygen therapy (2.0%-67.5%).

CONCLUSIONS

More than one-half of very preterm infants born in the United States died before 36 weeks' PMA or developed BPD. Greater BPD severity was associated with more frequent development of major neonatal morbidities, in-hospital mortality, and use of supplemental respiratory support at discharge.

Viewing tobacco use in movies: does it shape attitudes that mediate adolescent smoking?

BACKGROUND

Social cognitive theory posits that children develop intentions and positive expectations (utilities) about smoking prior to initiation. These attitudes and values result, in part, from observing others modeling the behavior. This study examines, for the first time, the association between viewing tobacco use in movies and attitudes toward smoking among children who have never smoked a cigarette.

DESIGN/SETTING

Cross-sectional school-based survey was used among randomly selected Vermont and New Hampshire middle schools. The sample consisted of 3766 middle school students (grades 5-8). The sample was primarily white and equally distributed by gender. The primary exposure was number of movie tobacco-use occurrences viewed. We first counted occurrences of tobacco use in each of 601 recent popular motion pictures. Each student was asked to select movies they had seen from a random subset of 50 movies. Based on movies the adolescent had seen, movie tobacco-use occurrences were summed to determine exposure . The outcome was susceptibility to smoking, positive expectations, and perceptions of smoking as normative behavior for adolescents or adults.

RESULTS

The movies in this sample contained a median of five occurrences of tobacco use (interquartile range=1, 12). The typical adolescent never-smoker had viewed 15 of the 50 movies on his/her list. From movies adolescents reported seeing, exposure to movie tobacco-use occurrences varied widely: median=80, and interquartile range 44 to 136. The prevalence of susceptibility to smoking increased with higher categories of exposure: 16% among students who viewed 0 to 50 movie tobacco occurrences; 21% (51 to 100); 28% (101 to 150); and 36% (>150). The association remained statistically significant after controlling for gender, grade in school, school performance, school, friend, sibling and parent smoking, sensation-seeking, rebelliousness, and self-esteem. Compared with adolescents exposed to < or =50 occurrences of tobacco use, the adjusted odds ratio of susceptibility to smoking for each higher category was 1.2 (95% confidence interval 0.9, 1.5), 1.4 (1.1, 1.9), and 1.6 (1.3, 2.1), respectively. Similarly, higher exposure to tobacco use in movies significantly increased the number of positive expectations endorsed by the adolescent and the perception that most adults smoke, but not the perception that most peers smoke.

CONCLUSIONS

This study provides empirical evidence that viewing movie depictions of tobacco use is associated with higher receptivity to smoking prior to trying the behavior.

Associations between health risk behaviors and opposite-, same-, and both-sex sexual partners in representative samples of vermont and massachusetts high school students

OBJECTIVE

To examine associations between health risk behaviors and sexual experience with opposite-, same-, or both-sex partners in representative samples of high school students.

DESIGN

We used 1995 and 1997 data from the Vermont and Massachusetts Youth Risk Behavior Surveys. Logistic regression and multiple regression analyses were used to compare health risk behaviors among students who reported sex with opposite-sex partners only (opposite-sex students), with same-sex partners only (same-sex students), and with both male and female sexual partners (both-sex students).

SETTING

Public high schools in Vermont and Massachusetts.

PARTICIPANTS

Representative, population-based samples of high school students. The combined samples had 14 623 Vermont students and 8141 Massachusetts students.

MAIN OUTCOME MEASURE

Violence, harassment, suicidal behavior, alcohol and other drug use, and unhealthy weight control practices.

RESULTS

In both states, both-sex students were significantly more likely to report health risk behaviors than were opposite-sex students. For example, both-sex students had odds 3 to 6 times greater than opposite-sex students of being threatened or injured with a weapon at school, making a suicide attempt requiring medical attention, using cocaine, or vomiting or using laxatives to control their weight. In both states, same-sex students were as likely as opposite-sex students to report most health risk behaviors.

CONCLUSION

Relative to opposite- and same-sex students, both-sex students may be at elevated risk of injury, disease, and death by experiencing serious harassment and engaging in violence, suicidal behavior, alcohol and other drug use, and unhealthy weight control practices.

Elevated Bladder Cancer in Northern New England: The Role of Drinking Water and Arsenic

BACKGROUND

Bladder cancer mortality rates have been elevated in northern New England for at least five decades. Incidence rates in Maine, New Hampshire, and Vermont are about 20% higher than the United States overall. We explored reasons for this excess, focusing on arsenic in drinking water from private wells, which are particularly prevalent in the region.

METHODS

In a population-based case-control study in these three states, 1213 bladder cancer case patients and 1418 control subjects provided information on suspected risk factors. Log transformed arsenic concentrations were estimated by linear regression based on measurements in water samples from current and past homes. All statistical tests were two-sided.

RESULTS

Bladder cancer risk increased with increasing water intake (Ptrend = .003). This trend was statistically significant among participants with a history of private well use (Ptrend = .01). Among private well users, this trend was apparent if well water was derived exclusively from shallow dug wells (which are vulnerable to contamination from manmade sources, Ptrend = .002) but not if well water was supplied only by deeper drilled wells (Ptrend = .48). If dug wells were used pre-1960, when arsenical pesticides were widely used in the region, heavier water consumers (>2.2 L/day) had double the risk of light users (<1.1 L/day, Ptrend = .01). Among all participants, cumulative arsenic exposure from all water sources, lagged 40 years, yielded a positive risk gradient (Ptrend = .004); among the highest-exposed participants (97.5th percentile), risk was twice that of the lowest-exposure quartile (odds ratio = 2.24, 95% confidence interval = 1.29 to 3.89).

CONCLUSIONS

Our findings support an association between low-to-moderate levels of arsenic in drinking water and bladder cancer risk in New England. In addition, historical consumption of water from private wells, particularly dug wells in an era when arsenical pesticides were widely used, was associated with increased bladder cancer risk and may have contributed to the New England excess.

Fat intake and adiposity in children of lean and obese parents

We examined the relations between obesity in parents and fat intake in their children, and the effect of fat intake on fat mass in these children. Our heterogenous sample (-x+/-SD: 20.2+/-3.4 kg; 3.2+/-1.3kg fat mass) consisted of 56 white and 15 Mohawk children 4-7 y of age (35 girls and 36 boys). Dietary intake was assessed with the Willett food-frequency questionnaire revised for children. Body composition was measured by bioelectrical resistance and subscapular and triceps skinfold thicknesses. Physical-activity energy expenditure was estimated by the difference between total energy expenditure (measured over 14 d by the doubly labeled water method) and postprandial resting energy expenditure (measured by indirect calorimetry). Before statistical analysis, fat mass was adjusted for fat-free mass, and fat intake was adjusted for nonfat intake. There was no effect of sex or ethnicity on fat intake and no effect of ethnicity on the relation between fat intake and fat mass. Adjusted mean (+/-SE) fat intakes for the groups of children, based on parental obesity status, were as follows: 1.65+/-0.09 MJ/d (nonobese mother and father), 2.58+/-0.10 MJ/d (obese father, nonobese mother), and 2.79+/-0.10 MJ/d (obese mother and father). We found an influence of maternal obesity on dietary fat intake in children (P=0.052) and a significant correlation between fat mass and fat intake in boys (r=0.48, P<0.01) but not in girls after adjustment for physical-activity energy expenditure. Our data suggest that 1)mothers may contribute to the development of obesity in children by influencing their dietary fat intake, and 2) dietary fat intake contributes to obesity in boys, independent of physical-activity energy expenditure.

Intraoperative red blood cell transfusion during coronary artery bypass graft surgery increases the risk of postoperative low-output heart failure

BACKGROUND

Hemodilutional anemia during cardiopulmonary bypass (CPB) is associated with increased mortality during coronary artery bypass graft (CABG) surgery. The impact of intraoperative red blood cell (RBC) transfusion to treat anemia during surgery is less understood. We examined the relationship between anemia during CPB, RBC transfusion, and risk of low-output heart failure (LOF).

METHODS AND RESULTS

Data were collected on 8004 isolated CABG patients in northern New England between 1996 and 2004. Patients were excluded if they experienced postoperative bleeding or received > or = 3 units of transfused RBCs. LOF was defined as need for intraoperative or postoperative intra-aortic balloon pump, return to CPB, or > or = 2 inotropes at 48 hours. Having a lower nadir HCT was also associated with an increased risk of developing LOF (adjusted odds ratio, 0.90; 95% CI, 0.82 to 0.92; P=0.016), and that risk was further increased when patients received RBC transfusion. When adjusted for nadir hematocrit, exposure to RBC transfusion was a significant, independent predictor of LOF (adjusted odds ratio, 1.27; 95% CI, 1.00 to 1.61; P=0.047).

CONCLUSIONS

In this study, we observed that exposure to both hemodilutional anemia and RBC transfusion during surgery are associated with increased risk of LOF, defined as placement of an intraoperative or postoperative intra-aortic balloon pump, return to CPB after initial separation, or treatment with > or = 2 inotropes at 48 hours postoperatively, after CABG. The risk of LOF is greater among patients exposed to intraoperative RBCs versus anemia alone.

Indirect vs direct hospital quality indicators for very low-birth-weight infants

CONTEXT

Evidence-based selective referral strategies are being used by an increasing number of insurers to ensure that medical care is provided by high-quality providers. In the absence of direct-quality measures based on patient outcomes, the standards currently in place for many conditions rely on indirect-quality measures such as patient volume.

OBJECTIVES

To assess the potential usefulness of volume as a quality indicator for very low-birth-weight (VLBW) infants and compare volume with other potential indicators based on readily available hospital characteristics and patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study of 94 110 VLBW infants weighing 501 to 1500 g born in 332 Vermont Oxford Network hospitals with neonatal intensive care units between January 1, 1995, and December 31, 2000.

MAIN OUTCOME MEASURES

Mortality among VLBW infants prior to discharge home; detailed case-mix adjustment was performed by using patient characteristics available immediately after birth.

RESULTS

In hospitals with less than 50 annual admissions of VLBW infants, an additional 10 admissions were associated with an 11% reduction in mortality (95% confidence interval [CI], 5%-16%; P<.001). The annual volume of admissions only explained 9% of the variation across hospitals in mortality rates, and other readily available hospital characteristics explained an additional 7%. Historical volume was not significantly related to mortality rates in 1999-2000, implying that volume cannot prospectively identify high-quality providers. In contrast, hospitals in the lowest mortality quintile between 1995 and 1998 were found to have significantly lower mortality rates in 1999-2000 (odds ratio [OR], 0.64; 95% CI, 0.55-0.76; P<.001) and hospitals in the highest mortality quintile between 1995 and 1998 had significantly higher mortality rates in 1999-2000 (OR, 1.37; 95% CI, 1.16-1.64; P<.001). The percentage of hospital-level variation in mortality in 1999-2000 that was forecasted by the highest and lowest quintiles based on patient mortality was 34% compared with only 1% for the highest and lowest quintiles of volume.

CONCLUSIONS

Referral of VLBW infants based on indirect-quality indicators such as patient volume may be minimally effective. Direct measures based on patient outcomes are more useful quality indicators for the purposes of selective referral, as they are better predictors of future mortality rates among providers and could save more lives.

Validation of self-reported maternal and infant health indicators in the Pregnancy Risk Assessment Monitoring System

To assess the validity of self-reported maternal and infant health indicators reported by mothers an average of 4 months after delivery. Three validity measures-sensitivity, specificity and positive predictive value (PPV)-were calculated for pregnancy history, pregnancy complications, health care utilization, and infant health indicators self-reported on the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire by a representative sample of mothers delivering live births in New York City (NYC) (n = 603) and Vermont (n = 664) in 2009. Data abstracted from hospital records served as gold standards. All data were weighted to be representative of women delivering live births in NYC or Vermont during the study period. Most PRAMS indicators had >90 % specificity. Indicators with >90 % sensitivity and PPV for both sites included prior live birth, any diabetes, and Medicaid insurance at delivery, and for Vermont only, infant admission to the NICU and breastfeeding in the hospital. Indicators with poor sensitivity and PPV (<70 %) for both sites (i.e., NYC and Vermont) included placenta previa and/or placental abruption, urinary tract infection or kidney infection, and for NYC only, preterm labor, prior low-birth-weight birth, and prior preterm birth. For Vermont only, receipt of an HIV test during pregnancy had poor sensitivity and PPV. Mothers accurately reported information on prior live births and Medicaid insurance at delivery; however, mothers' recall of certain pregnancy complications and pregnancy history was poor. These findings could be used to prioritize data collection of indicators with high validity.

Self-report of drinking using touch-tone telephone: extending the limits of reliable daily contact

OBJECTIVE

Retrospective self-reports of alcohol consumption are ubiquitous in the alcohol research field. Time frames of these reports range from a week to a year or longer and are subject to several influences of bias that may have important clinical, epidemiological and methodological consequences. In order to specify drinking patterns more precisely, a study was conducted to monitor alcohol consumption on a daily basis.

METHOD

Subjects (N = 51) responded for 112 days on an Interactive Voice Response system by entering their data daily using the touch-tone pad of their telephone. Each day, subjects answered 11 questions relating to drinking (including quantity) and to variables believed to affect consumption (e.g., stress level).

RESULTS

The overall response rate was 93.0%. Subjects reported consuming at least one drink on 51.2% of all 5,151 reporting days (mean number of drinks reported = 4.6). Following completion of the study, subjects were also asked to recall consumption retrospectively using a standard quantity-frequency questionnaire.

CONCLUSIONS

The present study demonstrated that: (1) data can be collected on a daily basis efficiently, and (2) traditional methods of data collection (e.g., quantity-frequency) result in a significant underreporting bias for heavier drinkers.

Hyperplastic polyposis and the risk of colorectal cancer

PURPOSE

Hyperplastic polyps are usually considered to be an innocent finding with little or no potential to progress to colorectal cancer. However, recent literature suggests that some of these polyps may be morphologically and genetically distinct and lead to microsatellite unstable colorectal cancers. The purpose of this study was to define the cancer risk associated with hyperplastic polyposis.

METHODS

All patients with hyperplastic polyposis diagnosed by a single colorectal surgeon at a university hospital were followed prospectively. The diagnosis of hyperplastic polyposis was made by the presence of more than 20 hyperplastic polyps distributed throughout the colon and/or a hyperplastic polyp at least 1 cm in size in diameter in the right colon. Patient demographics, family history, size, location, and distribution of polyps and the development of colorectal cancer were noted.

RESULTS

Thirteen patients who met the criteria for hyperplastic polyposis were identified and followed prospectively. All of these patients had at least 30 polyps distributed throughout the colon, often > 100. Nine of 13 also had a hyperplastic polyp at least 1 cm in size, usually in the right colon. Of particular note, 7 of 13 patients (54 percent) were diagnosed with colorectal cancer during the study period. Four had cancer on initial diagnosis and three patients developed cancer despite frequent colonoscopic surveillance. Five of seven colorectal cancers were located in the right colon.

CONCLUSIONS

Patients with hyperplastic polyposis are at high risk for colorectal cancer. Failure to identify this subset of patients could have dire consequences.

Children with a TV in their bedroom at higher risk for being overweight

OBJECTIVE

We examined having a TV in the bedroom as a risk factor for child overweight.

DESIGN

Cross-sectional study.

SETTING

School- and telephone-based surveys in New Hampshire and Vermont between 2002 and 2004.

PARTICIPANTS

Two thousand three hundred and forty-three children enrolled in public schools, aged 9-12 years, and one of their parents.

MAIN EXPOSURES

The child having a TV in the bedroom.

MAIN OUTCOME MEASURES

Age- and gender-standardized child body mass index (zBMI). Overweight was defined as equal to or above the 95th percentile for zBMI.

RESULTS

Overall, 22.3% (N=523) of the children were overweight, and almost half of all children (48.2%, N=1130) had a TV in their bedroom. Children with a TV in their bedroom had a higher zBMI and were significantly more likely to be overweight compared to those without a TV in their bedroom (27.3 versus 17.7%, respectively; P<0.05). After controlling for sociodemographics, physical activity, frequency of TV or movie watching and internet use, children with a TV in their bedroom who watched at least one session of TV or movies per day were more likely to be overweight compared to those without a TV in their bedroom (odds ratio=1.32, 95% confidence interval: 1.03, 1.70).

CONCLUSIONS

Having a TV in the bedroom is a risk factor for child overweight, independent of reported physical activity, participation in team sports, TV or movie watching time and internet use at home. Further study is needed to fully understand the mechanism by which having a TV in the bedroom increases children's risk for overweight.

The effect of secondary insults on mortality and long-term disability after severe head injury in a rural region without a trauma system

Outcome after head injury appears to be adversely affected by secondary insults such as hypoxia or hypotension. Previous work examining the influence of these secondary insults on outcome has originated from urban environments with organized systems of trauma care. We hypothesized that secondary insults would be more frequent and that outcome of severe head injury would be worse in a rural region without a trauma system. To validate these hypotheses we retrospectively reviewed the course and outcome of all patients admitted to the Medical Center Hospital of Vermont with severe head injuries between 1980 and 1985. A cohort of 170 patients was assigned to one of two groups: group I had neither hypotension nor hypoxia at the time of admission; group II had either hypotension or hypoxia at the time of admission. The groups were similar in terms of demographics, incidence of mass lesions, frequency of craniotomy, and incidence of intracranial hypertension. Only 23% of group II patients made a good recovery compared with 56% of group I patients (p < 0.01). The mortality rate of group II patients was twice that of group I patients (66% vs. 33%; p < 0.01). When compared with data provided by the National Trauma Coma Data Bank from urban areas with trauma systems, there was no difference in outcome of patients similarly grouped according to the presence or absence of secondary insults between Vermont's rural cohort and the urban cohort. We conclude that hypotension and hypoxia adversely effect the outcome of severe head injury.(ABSTRACT TRUNCATED AT 250 WORDS)