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Public Water Arsenic and Birth Outcomes in the Environmental Influences on Child Health Outcomes Cohort
No full textIMPORTANCE: Inorganic arsenic is associated with adverse birth outcomes, but evidence is limited for public water concentrations (modifiable by federal regulatory action) in US populations.
OBJECTIVE: To evaluate the association between prenatal public water arsenic exposure below the federal regulatory standard of 10 μg/L and birth outcomes in the US.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study analyzed observational pregnancy cohort data from the Environmental Influences on Child Health Outcomes (ECHO) Cohort for birthing parent-infant dyads from 35 pregnancy cohort sites. Infants were born between 2005 and 2020. The data were analyzed between 2024 and 2025.
EXPOSURE: Individual, time-weighted, mean prenatal public water arsenic exposures were estimated by joining Zip Code Tabulation Area-level public water arsenic concentrations with monthly residential history data during pregnancy.
MAIN OUTCOME AND MEASURE: Adjusted risk ratios (RRs) of preterm birth, low birth weight, and small for gestational age were evaluated. Adjusted RRs, mean differences in birth weight-for-gestational age z score and birth weight, and the geometric mean ratio of gestational age at birth were calculated via cubic splines, per 1 μg/L higher prenatal water arsenic, and across policy-relevant categories of exposure.
RESULTS: The cohort comprised 13 998 birthing parents (mean [SD] age, 30.8 [5.6] years) of whom 4.5% were of American Indian, Alaska Native, Native Hawaiian, or Pacific Islander; 7.2% Asian; 12.4% Black; 56.1% White; 4.2% multiple races; and 8.5% another race and 28.1% were of Hispanic/Latino and 70.4% non-Hispanic/Latino ethnicity. Prenatal public water arsenic ranged from less than 0.35 to 37.28 μg/L. In spline models, prenatal public water arsenic was associated with a higher risk of low birth weight, lower birth weight, and lower birth weight-for-gestational age z score, although effect estimates lacked precision. The RR of low birth weight per 1 μg/L higher prenatal water arsenic was higher among Black (1.02; 95% CI, 1.01-1.03), Hispanic/Latino (1.07; 95% CI 1.02-l.12), and White (1.04; 95% CI, 102-1.06) birthing parents, and the RR for preterm birth was higher among Hispanic/Latino birthing parents (1.05; 95% CI, 1.01-1.09). The mean difference of birth weight and birth weight-for-gestational age z score per 1 μg/L higher prenatal water arsenic was more pronounced among White birthing parents (-10 g [95% CI, -17 to -3 g]; -0.02 SDs [95% CI -0.03 to -0.01 SDs]). No evidence that prenatal public water arsenic mediated the association between birthing parent race and ethnicity and adverse birth outcomes was observed.
CONCLUSIONS AND RELEVANCE: In this cohort study of birthing parent-infant dyads across the US, arsenic measured in public water systems was associated with birth outcomes at levels below the current US Environmental Protection Agency\u27s maximum contaminant level. The findings suggest that further reducing the maximum contaminant level for arsenic may decrease the number of infants with low birth weight in the US
Using cancer survivor narratives to increase parents\u27 human papillomavirus vaccination intentions
No full textOBJECTIVE: To compare the preliminary efficacy and acceptability of three narrative communication messages about human papillomavirus (HPV) vaccination to a fact-based informational control message among parents with an unvaccinated child.
METHOD: A national sample of 948 U.S. parents/guardians with an unvaccinated child aged 9-17 years participated in an online experiment in June or July of 2023. Forty-nine percent of children were female, 23% were a racial or ethnic minority, and 55% received free school lunch. Parents were randomly assigned to watch one of four brief videos: a nonnarrative informational control, a role model only narrative, a precancer survivor narrative, or a cancer survivor narrative. The primary outcome variable was HPV vaccination intentions. The secondary outcomes were message acceptance and rejection. Covariates and a potential mediator were also assessed. Intervention effects were assessed using analysis of variance, hierarchical linear regression, and mediation analyses.
RESULTS: Parents were satisfied with all four messages, as indicated by high levels of message acceptance and low levels of message rejection. Higher intentions to vaccinate were observed for parents exposed to the HPV cancer survivor narrative message (vs. the control message) and the effect remained statistically significant after controlling for covariates including child age, free lunch status (a proxy for family income), parent gender, provider recommendation, and previous refusal of HPV vaccine. Exploratory mediation analyses indicated that the cancer survivor narrative effect was mediated by increases in emotional engagement with the message.
CONCLUSION: Cancer survivor narratives are a highly acceptable and potentially promising intervention strategy for increasing HPV vaccine uptake
Impact of Nasal and Inhaled Corticosteroids on SARS-CoV-2 Infection Susceptibility
No full textBACKGROUND: It is unknown whether nasal (NCS) or inhaled corticosteroid (ICS) use impacts the susceptibility to SARS-CoV-2 infection.
OBJECTIVES: To examine the associations of NCS and ICS use with the risk of SARS-CoV-2 infection among individuals with allergic rhinitis or asthma.
METHODS: This is a prospective, multicenter, SARS-CoV-2 surveillance study of households with children. Nasal swabs were obtained from participants every two weeks with additional collections based on COVID-19-related symptoms. In our primary adjusted models, we examined the association of NCS or ICS use at study entry (in participants with allergic rhinitis or asthma, respectively) with the time to the first SARS-CoV-2 positive quantitative PCR testing using Cox proportional hazard regression.
RESULTS: There were 2,211 participants in 1,113 households included. The associations of NCS and ICS use with the risk of SARS-CoV-2 infection were modified by age (p for both interactions\u3c 0.05). NCS and ICS use were individually associated with higher risks of SARS-CoV-2 infection among adults (adjusted hazard ratio [aHR]=1.88, 95% CI=1.14-3.12, p=0.01, and aHR=2.15, 95% CI=1.003-4.63, p=0.049, respectively). The association of NCS use with the risk of SARS-CoV-2 infection in adults was consistent in a series of sensitivity analyses. There was no association of NCS or ICS use with the risk of SARS-CoV-2 infection in children.
CONCLUSIONS: Our findings suggest that the risk of SARS-CoV-2 infection is increased in adults who use NCS but not in children. Similar, albeit less consistent, age-dependent findings were observed for ICS use. While the results of this observational study should be interpreted with caution, they emphasize the need to conduct studies to understand potential mechanisms that could explain these findings
Impact of disease location and laterality on hemodynamic response following pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension
No full textBACKGROUND: In patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing pulmonary thromboendarterectomy (PTE), obstructive disease burden predicts positive hemodynamic responsiveness. However, the effect of disease location (upper, middle, or lower lobes) and lung laterality (right or left) has not been studied.
OBJECTIVES: Examine the effect of obstructive disease location and laterality on hemodynamic response following PTE.
METHODS: This analysis is a retrospective cohort study of 56 consecutive patients diagnosed with CTEPH who underwent PTE at the University of Michigan Hospital between August 2019 and July 2022. Disease burden, location, and laterality were assessed on invasive pulmonary angiography (IPA), and lobar segments were assigned a score based on these features and correlated with an absolute change in pulmonary vascular resistance (PVR) following PTE. The relationship between disease burden and hemodynamic responsiveness was modeled using linear regressions with R (2) reported as a measure of correlation.
RESULTS: Most patients were World Health Organization (WHO) class III or IV (n = 47; 83.9%) and had a history of acute pulmonary embolism (n = 51; 91.1%). A modest correlation between patients\u27 overall disease burden and absolute change in PVR was noted, with the strongest contributions from the right lower lobe (RLL), right middle lobe (RML), and left lower lobe (LLL) (R (2) = 0.16, 0.10, and 0.03, respectively).
CONCLUSION: Disease location in the RLL, RML, and LLL may predict hemodynamic improvement in patients with CTEPH undergoing PTE
Feasibility, Efficacy, and Safety of the Mitral Annulo-TRIpsy in eXtreme Risk Patients
No full textBackground: Severe calcific mitral stenosis is common and therapeutically challenging. Intravascular lithotripsy (IVL) can facilitate percutaneous balloon mitral valvuloplasty in patients not amenable to conventional therapies. We describe a modified technique using larger IVL balloons to ensure maximal annular contact and delivery of ultrasonic shockwaves to restore mitral leaflet pliability and reduce transvalvular gradients without the need for noncompliant valvuloplasty balloons.
Methods: Seven patients underwent the Mitral Annulo-TRIpsy in eXtreme risk patients (MATRIX) procedure at 3 tertiary structural heart disease centers in the United States. Transcatheter mitral valve replacement was contraindicated due to prohibitive risk of left ventricular outflow tract obstruction or insufficient annular calcification for anchoring of a balloon-expandable valve. IVL balloons were delivered using a large-bore transseptal sheath over three 0.014 wires. Runs of delivery of IVL therapy were repeated until satisfactory results in terms of mean mitral gradient (mMG) reduction were achieved.
Results: Median age was 78 years, and 14.3% were female. All patients presented with progressive New York Heart Association class III-IV symptoms and functional limitations. Pre-MATRIX mMG was 9.0 mmHg. The final mMG was 3.0 mmHg (absolute difference 6.3 mmHg; 95% CI 2.6-10.1 mmHg; p \u3c 0.01). No conventional valvuloplasty balloons were used after IVL. All patients successfully underwent MATRIX. No major periprocedural complications were observed including death, stroke, major bleeding, or reintervention. No patients experienced worsening mitral regurgitation. All patients were discharged alive.
Conclusions: This small multicenter series demonstrates that IVL of calcified mitral stenosis using the MATRIX technique is feasible and safe and associated with effective reductions in mMG
Do not resuscitate (DNR) emergency medical services (EMS) protocol variation in the United States
No full textBACKGROUND: Do Not Resuscitate (DNR) orders are essential for ensuring that critically ill patients receive care from Emergency Medical Service (EMS) aligned with their preferences. However, significant variations exist in EMS protocols regarding acceptable DNR documentation leading to discordant care, moral distress, and ethical dilemmas.
OBJECTIVE: To characterize the variation of DNR documentation in EMS protocols.
METHODS: We performed a structured review of available statewide EMS protocols and of the 50 most populous U.S. cities to identify DNR protocols. We categorized the most common forms of DNR documentation: advance directives, living wills, jewelry/bracelets, portable medical orders (e.g. POLST), and verbal DNRs. Each type of DNR documentation was classified according to whether it is accepted, not mentioned, explicitly disallowed or required direct medical oversight (DMO) contact.
RESULTS: A total of 63 EMS protocols were included in this review; 31/51 (61 %) were statewide and 33/50 (67 %) were citywide protocols. Of available protocols 86 % (54/63) had a specific DNR protocol. Of available reviewed EMS DNR protocols, 50.0 % (27/54) permitted use of Advanced Directives, 13.0 % (7/54) Living Wills, 61.1 % (33/54) DNR Jewelry and 76.0 % (41/54) Portable Medical Orders. Notably, 38.5 % (21/52) of EMS protocols did not specify or disallowed verbal DNRs while 11.5 % (6/52) required DMO contact. Verbal DNRs were accepted from healthcare providers in 18.5 % (10/54) and from non-healthcare providers 26.6 % (16/54) of EMS protocols.
CONCLUSIONS: Although most EMS protocols have dedicated DNR protocols, this is not universal and there is significant variability in types of documentation recognized as valid. Documentation that is concise, portable, and designed for EMS use, such as the POLST is preferred. Future research should assess the effectiveness of these different documentation types and consider the expanding the use of verbal DNRs to ensure goal-concordant care in the out of hospital setting
Epidemiology of Hip Dislocations in the United States From 1990 to 2019: A Temporal Study Using the Global Burden of Disease Database
No full textIntroduction: Hip dislocations are devastating injuries that require urgent intervention to minimize the development of severe complications. This study aimed to evaluate the epidemiology of hip dislocations in the United States (U.S.) from 1990 to 2019.
Methods: This study is a descriptive retrospective epidemiological study. The Global Burden of Disease (GBD) database was used to collect epidemiological data on hip dislocation in the U.S. from 1990 to 2019. Data included years lived with disability (YLDs), prevalence, and incidence rates per 100,000 people. Data were regionally stratified into Northeast, Midwest, South, and West by the U.S. Census definition. Bartlett\u27s test was used to assess equal variance. Welch\u27s ANOVA was performed to assess regional differences to compare the means of different groups without assuming equal variances or equal sample sizes. The Games-Howell post hoc test was used to compare regions. Independent t-tests were performed to compare the means of each measure between males and females. Statistical significance was defined as p\u3c 0.05, and analyses were performed using IBM SPSS Statistics software, version 29.0.2.0 (IBM Corp., Armonk, NY).
Results: From 1990 to 2019, the U.S. saw a 1.67% decrease in the mean rate of YLDs, a 0.32% decrease in the mean prevalence rate, and a 4.74% decrease in the mean incidence rate of hip dislocations over the 29 years. Nationally, men experienced higher mean rates of YLDs, incidence, and prevalence compared to women, though only incidence was statistically significant (p\u3c 0.001). The Western region had the highest mean rates of YLDs, prevalence, and incidence rates of hip dislocation, while the Northeastern region experienced the lowest. Men had higher mean rates of YLDs in the Midwest (p=0.001), South (p\u3c 0.001), and West (p=0.004) regions. Men had a higher mean prevalence rate in the South (p=0.007), but not in other regions.
Conclusions: From 1990 to 2019, the U.S. experienced an overall drop in mean incidence, prevalence, and disease burden of hip dislocations, with men consistently showing higher rates across all measures compared to women. Regionally, the Western U.S. had the highest mean rates, while the Northeastern U.S. had the lowest. Our overall findings on the regional and sex-based disparities highlight the need for further targeted prevention strategies
Nodal metastasis in surgically treated sinonasal squamous cell carcinoma
No full textOBJECTIVES: Tumor factors such as subsite and stage impact the risk of lymph node metastasis (LNM) and overall risk in sinonasal squamous cell carcinoma (SNSCC). We sought to identify the rates of patients presenting with or without clinical LNM for different tumor subsites and stages of surgically-treated SNSCC, determine the concordance between clinical and pathologic LNM after neck dissection (ND), and identify predictors of occult LNM.
METHODS: The National Cancer Database was queried for patients with surgically-treated SNSCC from 2004 to 2016. For patients presenting with clinical LNM, rates of pathologic LNM and node negativity were determined following ND. For patients without clinical LNM, rates of elective neck dissection (END) and occult LNM were calculated. Predictors of occult LNM were identified using multivariate logistic regression.
RESULTS: 1,964 patients were included; primary tumor subsites included nasal cavity (55.7%), maxillary (37.8%), and ethmoid sinuses (6.5%). Clinical LNM rates at presentation were 14.3% overall and 25.3% for the maxillary sinus; clinical LNM rates increased with tumor stage. 30.8% of patients with clinical LNM were pN0 following ND. Only 15.3% of patients underwent END; advanced age (\u3e 75 years) (OR 8.17 [1.59-64.7]), presence of lymphovascular invasion (LVI) (OR 8.68 [2.63-30.2]) and unknown LVI status (OR 4.48 [1.17-16.2]) were associated with significantly higher risk of occult LNM.
CONCLUSIONS: Rates of occult LNM differed by subsite and tumor stage for surgically managed SNSCC. Rates of occult LNM were increased with older age and presence of LVI. Additional studies are necessary to determine the benefit of END in SNSCC
Environmental Risk Factors and Asthma Primary Prevention: from Birth Cohort Studies to Clinical Trials
No full textWith the prevalence of pediatric asthma and allergy rising substantially since last mid-century, birth cohort studies starting in pregnancy have been pivotal in identifying prenatal and early life environmental factors that influence risk of these diseases. With these findings, researchers have been able to identify biological mechanisms at play with the eventual goal of engineering tailored interventions to optimize immune system development and decrease the risk of allergic disorders. In this review, we describe the critical role birth cohort studies have played in starting to disentangle the environmental epidemiology and etiology of childhood-onset asthma and other allergic diseases, and how these studies have guided ongoing clinical trials for asthma and allergy prevention. Lastly, we highlight important questions that remain unanswered and potential approaches to help fill these gaps in knowledge
