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Objectives: Structural racism (SR) is viewed as a root cause of racial and ethnic disparities in maternal health outcomes. However, evidence linking SR to increased odds of severe adverse maternal outcomes (SAMO) is scant. This study assessed the association between state-level indicators of SR and SAMO during childbirth. Methods: Data for non-Hispanic Black and non-Hispanic white women came from the US Natality file, 2017–2018. The exposures were state-level Black-to-white inequity ratios for lower education level, unemployment, and prison incarceration. The outcome was patient-level SAMO, including eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Adjusted odds ratios (aORs) of SAMO associated with each ratio were estimated using multilevel models adjusting for patient, hospital, and state characteristics. Results: A total of 4,804,488 birth certificates were analyzed, with 22.5% for Black women. SAMO incidence was 106.4 per 10,000 (95% CI 104.5, 108.4) for Black women, and 72.7 per 10,000 (95% CI 71.8, 73.6) for white women. Odds of SAMO increased 35% per 1-unit increase in the unemployment ratio for Black women (aOR 1.35; 95% CI 1.04, 1.73), and 16% for white women (aOR 1.16; 95% CI 1.01, 1.33). Odds of SAMO increased 6% per 1-unit increase in the incarceration ratio for Black women (aOR 1.06; 95% CI 1.03, 1.10), and 4% for white women (aOR 1.04; 95% CI 1.02, 1.06). No significant association was observed between SAMO and the lower education level ratio. Conclusions for Practice: State-level Black-to-white inequity ratios for unemployment and incarceration are associated with significantly increased odds of SAMO. Significance: What is already known on this subject? Structural racism is viewed as a root cause of racial and ethnic disparities in maternal health outcomes, independent of socioeconomic determinants of health. However, supporting evidence is scant. What this study adds? In this population-based study in 2017–2018, state-level Black-to-white inequities in unemployment and incarceration are associated with significantly increased odds of severe adverse maternal outcomes (i.e., blood transfusion, hysterectomy, and ICU admission) during childbirth for non-Hispanic Black women, and to a lesser extent, for non-Hispanic white women. Addressing structural racism in maternal care may contribute to improving maternal health equity. [ABSTRACT FROM AUTHOR]

Background: Polypharmacy use among older adults is of increasing concern for driving safety. This study assesses the individual and joint effects of benzodiazepines and prescription opioids on the incidence of hard braking events in older drivers. Methods: Data for this study came from the Longitudinal Research on Aging Drivers project—a multisite, prospective cohort study of 2990 drivers aged 65–79 years at enrollment (2015–2017). Adjusted incidence rate ratios (aIRRs) and 95% confidence intervals (CIs) of hard braking events (defined as maneuvers with deceleration rates ≥0.4 g and commonly known as near‐crashes) were estimated through multivariable negative binominal modeling. Results: Of the 2929 drivers studied, 167 (5.7%) were taking benzodiazepines, 163 (5.6%) prescription opioids, and 23 (0.8%) both drugs at baseline. The incidence rates of hard braking events per 1000 miles driven were 1.14 (95% CI 1.10–1.18) for drivers using neither benzodiazepines nor prescription opioids, 1.25 (95% CI 1.07–1.43) for those using benzodiazepines only, 1.55 (95% CI 1.35–1.76) for those using prescription opioids only, and 1.63 (95% CI 1.11–2.16) for those using both medications. Multivariable modeling revealed that the use of prescription opioids was associated with a 19% increased risk of hard braking events (aIRR 1.19, 95% CI 1.03–1.36). There existed a positive interaction between the two drugs on the additive scale but not on the multiplicative scale. Conclusion: Concurrent use of benzodiazepines and prescription opioids by older drivers appears to affect driving safety through increased incidence of hard braking events. [ABSTRACT FROM AUTHOR]

Recent research indicates that children with autism are at increased risk of maltreatment. We examined news media reports on homicide incidents involving children with autism as victims in the United States between 2000 and 2019. Of the 52 victims studied, 47 (90.4%) were male. Age of victims ranged from 2 to 20 years (mean = 10.4 ± 5.3 years). Parents and other caregivers accounted for 63.5% and 13.5% of the perpetrators, respectively. The leading injury mechanism was gunshot wounds (23.1%), followed by drowning (19.2%), and suffocation, strangulation, or asphyxiation (19.2%). The most commonly cited contributing factor (47.1%) was overwhelming stress from caring for the autistic child. These results underscore the importance of supporting services for caregivers of children with autism. [ABSTRACT FROM AUTHOR]

Background: The cost-benefit of stocking dantrolene in maternity units for treating malignant hyperthermia (MH) has been recently questioned because of the low incidence of MH crisis in the general population and the low utilization of general anesthesia in obstetrics. However, no study has examined the prevalence of MH susceptibility in obstetrics. This study aimed to assess the prevalence of MH diagnosis and associated factors in obstetric patients. Methods: Data for this study came from the National Inpatient Sample from 2003 to 2014, a 20% nationally representative sample of discharge records from community hospitals. A diagnosis of MH due to anesthesia was identified using the International Classification of Diseases, Ninth Revision, Clinical Modification code 995.86. MH prevalence was estimated according to the delivery mode and patient and hospital characteristics. Results: During the 12-year study period, 47,178,322 delivery-related discharges [including 15,175,127 (32.2%) cesarean deliveries] were identified. Of them, 215 recorded a diagnosis of MH, yielding a prevalence of 0.46 per 100,000 [95% confidence interval (CI), 0.40 to 0.52]. The prevalence of MH diagnosis in cesarean deliveries was 0.81 per 100,000 (95% CI, 0.67 to 0.97), compared with 0.29 per 100,000 (95% CI, 0.23 to 0.35) in vaginal deliveries (P < 0.001). Multivariable logistic regression revealed that cesarean delivery was associated with a significantly increased risk of MH diagnosis [adjusted rate ratio (aOR) 2.88; 95% CI, 2.19 to 3.80]. Prevalence of MH diagnosis was lower in Hispanics than in non-Hispanic whites (aOR 0.47; 95% CI, 0.29 to 0.76) and higher in the South than in the Northeast census regions (aOR 2.44; 95% CI, 1.50 to 3.96). Conclusion: The prevalence of MH-susceptibility is about 1 in 125,000 in cesarean deliveries, similar to the prevalence reported in non-obstetrical surgery inpatients. The findings of this study suggest that stocking dantrolene in maternity units is justified. [ABSTRACT FROM AUTHOR]

Purpose: Analyses compared older drivers from urban, suburban, and rural areas on perceived importance of continuing to drive and potential impact that driving cessation would have on what they want and need to do. Methods: The AAA LongROAD Study is a prospective study of driving behaviors, patterns, and outcomes of older adults. A cohort of 2,990 women and men 65‐79 years of age was recruited during 2015‐2017 from health systems or primary care practices near 5 study sites in different parts of the United States. Participants were classified as living in urban, surburban, or rural areas and were asked to rate the importance of driving and potential impact of driving cessation. Logistic regression models adjusted for sociodemographic and driving‐related characteristics. Findings: The percentages of older drivers rating driving as "completely important" were 76.9%, 79.0%, and 83.8% for urban, suburban, and rural drivers, respectively (P =.009). The rural drivers were also most likely to indicate driving cessation would have a high impact on what they want or need to do (P <.001). After adjustment for sociodemographic and driving‐related characteristics, there was a 2‐fold difference for rural versus urban older drivers in odds that driving cessation would have a high impact on what they need to do (OR = 2.03; 95% CI: 1.60‐2.58). Conclusions: Older drivers from rural areas were more likely to rate driving as highly important and the prospect of driving cessation as very impactful. Strategies to enhance both the ability to drive safely and the accessibility of alternative sources of transportation may be especially important for older rural adults. [ABSTRACT FROM AUTHOR]

Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid-related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time. [ABSTRACT FROM AUTHOR]

Objectives. To assess cohort effects in prescription opioid and heroin overdose mortality in the United States. Methods. Using the National Center for Health Statistics' multiple-cause-of-death file for 1999 to 2014, we performed an age-period-cohort analysis of drug overdose mortality in the United States. Results. Compared with those born in 1977 and 1978, individuals born between 1947 and 1964 experienced excess risks of prescription opioid overdose death (e.g., for the 1955-1956 birth cohort, rate ratio [RR] = 1.27; 95% confidence interval [CI] = 1.09, 1.48) and of heroin overdose death (e.g., for the 1953-1954 birth cohort, RR = 1.32; 95% CI = 1.11, 1.57). Those born between 1979 and 1992 also experienced an increased risk of heroin overdose death (e.g., for the 1989-1990 birth cohort, RR = 1.23; 95% CI = 1.01, 1.50). The cohort effects were consistent between sexes. Conclusions. Individuals born between 1947 and 1964 and between 1979 and 1992 are particularly afflicted by the opioid epidemic. Intervention programs are needed to reduce the excess overdose mortality in these specific demographic groups. [ABSTRACT FROM AUTHOR]

Background: Drug overdose is a public health crisis in the United States, due in part to the unintended consequences of increases in prescribing of opioid analgesics. Many clinicians evaluate risk markers for opioid-related harms when prescribing opioids for chronic pain; however, more data on predictive risk markers are needed. Risk markers are attributes (modifiable and non-modifiable) that are associated with increased probability of an outcome. This review aims to identify risk markers associated with fatal and non-fatal prescription drug overdose by synthesizing findings in the existing peer-reviewed and grey literature. Eligible cohort, case-control, cross-sectional, and case-cohort studies were reviewed and data were extracted for qualitative and quantitative synthesis. Findings: Summary odds ratios (SOR) were estimated from 29 studies for six risk markers: sex, age, race, psychiatric disorders, substance use disorder (SUD), and urban/rural residence. Heterogeneity was assessed and effect estimates were stratified by study characteristics. Of the six risk markers identified, SUD had the strongest association with drug overdose death (SOR = 5.24, 95% confidence interval (CI) = 3.53 - 7.76), followed by psychiatric disorders (SOR = 3.94, 95% CI = 3.09 - 5.01), white race (SOR = 2.28, 95% CI = 1.93 - 2.70), the 35-44 year age group relative to the 25-34 year reference group (SOR = 1.52, 95% CI = 1.31 - 1.76), and male sex (SOR = 1.33, 95% CI = 1.17 - 1.51). Conclusions: This review highlights fatal and non-fatal prescription drug risk markers most frequently assessed in peer-reviewed and grey literature. There is a need to better understand modifiable risk markers and underlying reasons for drug misuse in order to inform interventions that may prevent future drug overdoses. [ABSTRACT FROM AUTHOR]

Drugged driving is a safety issue of increasing public concern. Using data from the Fatality Analysis Reporting System for 1999–2010, we assessed trends in alcohol and other drugs detected in drivers who were killed within 1 hour of a motor vehicle crash in 6 US states (California, Hawaii, Illinois, New Hampshire, Rhode Island, and West Virginia) that routinely performed toxicological testing on drivers involved in such crashes. Of the 23,591 drivers studied, 39.7% tested positive for alcohol and 24.8% for other drugs. During the study period, the prevalence of positive results for nonalcohol drugs rose from 16.6% in 1999 to 28.3% in 2010 (Z = −10.19, P < 0.0001), whereas the prevalence of positive results for alcohol remained stable. The most commonly detected nonalcohol drug was cannabinol, the prevalence of which increased from 4.2% in 1999 to 12.2% in 2010 (Z = −13.63, P < 0.0001). The increase in the prevalence of nonalcohol drugs was observed in all age groups and both sexes. These results indicate that nonalcohol drugs, particularly marijuana, are increasingly detected in fatally injured drivers. [ABSTRACT FROM PUBLISHER]

Objective Graduated Driver Licensing (GDL) has been implemented in Australia, Canada, New Zealand, USA and Israel. We conducted an exploratory summary of available data to estimate whether GDL effects varied with age. Methods We searched MEDLINE and other sources from 1991-2011. GDL evaluation studies with crashes resulting in injuries or deaths were eligible. They had to provide age-specific incidence rate ratios with CI or information for calculating these quantities. We included studies from individual states or provinces, but excluded national studies. We examined rates based on person-years, not license-years. Results Of 1397 papers, 144 were screened by abstract and 47 were reviewed. Twelve studies from 11 US states and one Canadian province were selected for meta-analysis for age 16, eight were selected for age 17, and four for age 18. Adjusted rate ratios were pooled using random effects models. The pooled adjusted rate ratios for the association of GDL presence with crash rates was 0.78 (95% CI 0.72 to 0.84) for age 16 years, 0.94 (95% CI 0.93 to 0.96) for 17 and 1.00 (95% CI 0.95 to 1.04) for 18. The difference between these three rate ratios was statistically significant: p<0.001. Conclusions GDL policies were associated with a 22% reduction in crash rates among 16-year-old drivers, but only a 6% reduction for 17-year-old drivers. GDL showed no association with crashes among 18-year-old drivers. Because we had few studies to summarise, particularly for older adolescents, our findings should be considered exploratory. [ABSTRACT FROM AUTHOR]

Objective To determine the prevalence of alcohol involvement and impairment in fatal crashes in the USA involving Mexican and Canadian drivers. Methods Drivers in fatal crashes in the USA were identified during 1998 to 2008 from the Fatality Analysis Reporting System, and the prevalence of alcohol involvement and impairment (defined as blood alcohol concentrations ≥0.01 g/dl and ≥0.08 g/dl, respectively) was compared among drivers licensed in Mexico (n=687), Canada (n=598), and the USA (n=561 908). Results The prevalence of alcohol involvement was 27% for US drivers, 27% for Mexican drivers, and 11% for Canadian drivers. Alcohol impairment was found in 23% of US drivers, 23% of Mexican drivers, and 8% of Canadian drivers. With adjustment for driver demographic characteristics and survival status and for crash circumstances, the prevalence of alcohol involvement was significantly lower for Canadian drivers (adjusted prevalence ratio (PR) 0.63, 95% CI 0.49 to 0.80) than for US drivers, and was similar between Mexican and US drivers (adjusted PR 0.91, 95% CI 0.81 to 1.02). Conclusions Alcohol involvement in fatal motor vehicle crashes in the USA is similarly prevalent in US and Mexican drivers, but is substantially less common in Canadian drivers. INSETS: Salesperson tripped by own dog to receive workers¿ compensation;School held liable for student¿s injured eye. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims Studies of the relationship between social norms and marijuana use have generally focused on individual attitudes, leaving the influence of larger societal-level attitudes unknown. The present study investigated societal-level disapproval of marijuana use defined by birth cohort or by time-period. Design Combined analysis of nationally representative annual surveys of secondary school students in the United States conducted from 1976 to 2007 as part of the Monitoring the Future study. Setting In-school surveys completed by adolescents in the United States. Participants A total of 986 003 adolescents in grades 8, 10 and 12. Measurements Main predictors included the percentage of students who disapproved of marijuana in each birth cohort and time-period. Multi-level models with individuals clustered in time-periods of observation and birth cohorts were modeled, with past-year marijuana use as the outcome. Findings Results indicated a significant and strong effect of birth cohort disapproval of marijuana use in predicting individual risk of marijuana use, after controlling for individual-level disapproval, perceived norms towards marijuana and other characteristics. Compared to birth cohorts in which most (87-90.9%) adolescents disapproved of marijuana use, odds of marijuana use were 3.53 times higher in cohorts where fewer than half (42-46.9%) disapproved (99% confidence interval: 2.75, 4.53). Conclusions Individuals in birth cohorts that are more disapproving of marijuana use are less likely to use, independent of their personal attitudes towards marijuana use. Social norms and attitudes regarding marijuana use cluster in birth cohorts, and this clustering has a direct effect on marijuana use even after controlling for individual attitudes and perceptions of norms. [ABSTRACT FROM AUTHOR]

Aims In the United States, transportation employees who are suspected of using alcohol and drugs are subject to reasonable-cause testing. This study aims to assess the validity of suspected alcohol and drug violations in aviation employees. Methods Using reasonable-cause testing and random testing data from the Federal Aviation Administration for the years 1995-2005, we calculated the positive predictive value (PPV) and positive likelihood ratio (LR+) of suspected alcohol and drug violations. The true status of violations was based on testing results, with an alcohol violation being defined as a blood alcohol concentration of ≥0.04 mg/dl and a drug violation as a test positive for marijuana, cocaine, amphetamines, phencyclidine or opiates. Results During the 11-year study period, a total of 2284 alcohol tests and 2015 drug tests were performed under the reasonable-cause testing program. The PPV was 37.7% [95% confidence interval (CI), 35.7-39.7%] for suspected alcohol violations and 12.6% (95% CI, 11.2-14.1%) for suspected drug violations. Random testing revealed an overall prevalence of 0.09% for alcohol violations and 0.6% for drug violations. The LR+ was 653.6 (95% CI, 581.7-734.3) for suspected alcohol violations and 22.5 (95% CI, 19.6-25.7) for suspected drug violations. Conclusion The discriminative power of reasonable-cause testing suggests that, despite its limited positive predictive value, physical and behavioral observation represents an efficient screening method for detecting alcohol and drug violations. The limited positive predictive value of reasonable-cause testing in aviation employees is due in part to the very low prevalence of alcohol and drug violations. [ABSTRACT FROM AUTHOR]

Aim To conduct a comprehensive analysis of the conflicting evidence on substance use and misuse following mass traumas such as terrorist incidents. Methods We reviewed and synthesized evidence from 31 population-based studies using Bayesian meta-analysis and meta-regression. Results The majority of the studied were conducted in the aftermath of the terrorist attacks of 11 September 2001. Controlling for exposure, type of incident and time since the event occurred, 7.3% [95% credible interval (CrI) 1.1–32.5%] of a population can be expected to report increased alcohol consumption in the first 2 years following a terrorist event. There is, however, a 20% probability that the prevalence will be as high as 14%. The unadjusted prevalence of increased cigarette smoking following a terrorist event is 6.8% (95% Cr I 2.6–16.5%). Unadjusted reports of mixed drug use (including narcotics and prescription medications) was 16.3% (95% Cr I 1.3–72.5%). Conclusions These results underscore the potentially pervasive behavioral health effects of mass terrorism, and suggest that public health interventions may usefully consider substance use as an area of focus after such events. [ABSTRACT FROM AUTHOR]

The authors analyzed homicide mortality data for the United States from 1935 to 1994, to delineate temporal trends and birth cohort patterns. This study included 850, 822 homicide-attributed deaths documented by the National Center for Health Statistics, and incorporated graphical presentation, median polish, and Poisson regression modeling in an age-period-cohort analysis. Death rates from homicide in the United States doubled in the past four decades, with most of the increase having occurred during the 1960s and early 1970s. Poisson regression models confirmed that the rise of homicide mortality in both men and women was largely attributable to a significant period effect between 1960 and 1974. No discernible cohort patterns were found among women. However, homicide rates for recent male birth cohorts appeared to peak at younger ages and at higher levels. A significant increase in homicide mortality risk beginning with males born around 1965 was found by examining the residuals of median polish, and the second-order changes in the regression coefficients from the age-period-cohort model. The hike of homicide mortality during 1985 and 1994 was explained by this cohort effect. Increased prevalence of substance abuse and availability of firearms are two likely factors underlying this disturbing cohort pattern. Am J Epidemiol 1999; 150: 1213-22. [ABSTRACT FROM PUBLISHER]

Objective: Although a popular endeavor, boxing has fallen under increased scrutiny because of its association with traumatic brain injury. However, few studies have investigated the overall epidemiology of boxing injuries from representative samples, and no study has ever documented the incidence of injuries in female boxers. This study is a review of professional boxing data from the state of Nevada from September 2001 through March 2003. Materials and Methods: Medical and outcome data for all professional boxing matches occurring in Nevada between September 2001 and March 2003 (n = 524 matches) were analyzed on the basis of a pair-matched, case-control design. Cases were boxers who received an injury during the boxing matches. Boxers who were not injured served as control subjects. Both conditional and unconditional logistic regression models were used to assess risk factors for injury. Results; The overall incidence rate of injury was 17.1 per 100 boxer-matches, or 3.4 per 100 boxer-rounds. Facial laceration accounted for 51% of all injuries, followed by hand injury (17%), eye injury (14%). and nose injury (5%). Male boxers were significantly more likely than female boxers to receive injuries (3.6 versus 1.2 per 100 boxer-rounds. P = 0.01). Male boxing matches also ended in knockouts and technical knockouts more often than did female matches (P < 0.001). The risk of injury for those who lost the matches was nearly twice the risk for the winners. Those who lost by knockout had double the risk of injury compared with those who lost by other means. Neither age nor weight was significantly associated with the risk of injury. Conclusions: The injury rate in professional boxing matches is high, particularly among male boxers. Superficial facial lacerations are the most common injury reported. Male boxers have a higher rate of knockout and technical knockouts than female boxers. Further research is necessary to determine the outcomes of injury, particularly the long-term neurologic outcome differences between sexes. [ABSTRACT FROM AUTHOR]

Abstract: The Federal Aviation Administration conducts background checking for driving-while-intoxicated (DWI) convictions on all pilots. This study examined the association between DWI history and crash risk in a cohort of 335,672 general aviation pilots. These pilots were followed up from 1994 to 2000 through the aviation crash surveillance system of the National Transportation Safety Board. At baseline, 3.4% of the pilots had a DWI history. DWI history was associated with a 43% increased risk of crash involvement (adjusted relative risk: 1.43; 95% confidence interval: 1.15–1.77). The population-attributable risk fraction for DWI history was estimated as 1.4%. In addition to DWI history, male gender, older age, and inexperience were associated with significantly increased risk of crash involvement. The results of this study support DWI history as a valid risk marker for general aviation pilots. The safety benefit of background checking for DWI history needs to be further evaluated. [Copyright &y& Elsevier]

Objectives. We analyzed age, time period, and cohort effects on trends in adolescent cigarette smoking in California from 1990 to 1999. Methods. Data from subjects aged 12 to 17 years (n = 26 536; 50.4% male) from the California Tobacco Survey and the California Youth Tobacco Survey were analyzed, and never smokers were used as the outcome measure. Results. The proportion of never smokers increased from 60% for males and 66% for females in 1990 to around 70% for both sexes in 1999. Respondents were more likely to be never smokers if born in 1978 or later (i.e., aged 12 years or younger in 1990, when most tobacco control programs started in California). Conclusions. The statewide antitobacco programs prevented adolescents from starting to smoke, primarily through a cohort effect. (Am J Public Health. 2003;93: 2099-2104) [ABSTRACT FROM AUTHOR]

Focuses on the epidemiology of substance abuse among trauma patients. Recognition of substance abuse as the leading health problem in the United States; Information on substance abuse in the general population; Details of surveys on the incidence of substance abuse.

Discusses the study designed to determine whether passengers who accompany teenage automobile drivers increase the risk of fatal accidents in the United States. Mortality rates which increase with the number of passengers; Design and setting of study; Conclusion which includes that fatal injuries occur in relation to the number of passengers in the vehicle.

Background: Despite updated playground equipment and improved industry standards, playgrounds remain a common source of childhood injury. Fractures account for 35% of all playground injuries presenting to emergency departments (EDs). We aimed to examine the time trends and epidemiologic patterns of playground equipment-related extremity fractures in children in the United States. Methods: We analyzed data from the National Electronic Injury Surveillance System. Children ≤14 years presenting to US emergency departments from 2006 to 2016 with playground equipment-related injuries were included. We used weighted complex survey analysis to describe the epidemiologic patterns and severity of playground equipment-related extremity fractures and Joinpoint linear weighted regression analysis to determine trends in extremity fractures. Results: An annual average of 72,889 children were treated in US EDs for playground equipment-related extremity fractures, yielding a national annual incidence rate of 119.2 per 100,000 children. Playground equipment-related extremity fractures accounted for 33.9% of ED presentations and 78.7% of hospitalizations for playground equipment-related injuries. Of patients with playground equipment-related extremity fractures, 11.2% had severe fractures requiring hospitalization. The annual rate of ED visits due to playground equipment-related extremity fractures remained stable (annual rate of change = 0.74, p = 0.14) from 2006 to 2016. Adjusted for age, injuries on monkey bars or climbing gyms were associated with significantly increased odds of extremity fractures in comparison to injuries from other playground equipment (adjusted odds ratio [aOR]: 2.0; 95% CI: 1.9–2.1). Overall, 49.8% of extremity fractures and 54.7% of severe extremity fractures (i.e. those requiring hospitalization) occurred on monkey bars or climbing gyms. Conclusions: Despite enhanced playground safety standards, national rates of playground equipment-related extremity fractures have remained stable in the US. Extremity fractures remain the most common type of playground injury presenting to EDs and most commonly occur on monkey bars and climbing gyms. [ABSTRACT FROM AUTHOR]

Objective: To synthesize the empirical research evidence about the association between Medicaid expansion under the Affordable Care Act (ACA) and increasing perinatal care access and utilization among low-income women.Data Sources: We searched MEDLINE through PubMed (1966-present), EMBASE (Ovid), the Cumulative Index to Nursing and Allied Health (1982-present), PAIS Index (ProQuest), Web of Science (1900-present), and the Cochrane Central Register of Controlled Trials. Our review focuses on the association between Medicaid expansion under the ACA and perinatal care access and utilization, which cannot be subjected to randomized controlled trials, therefore ClinicalTrials.gov was not included in our search.Methods Of Study Selection: A comprehensive search of the research literature was performed using Covidence. Studies were eligible if they were based on population data and research designs ensuring that the exposure (ie, Medicaid expansion under the ACA) preceded the perinatal care access or utilization outcome, had an appropriate comparison group, presented quantitative data, and examined pregnant or postpartum women. The search in six bibliographic databases returned 1,243 records, with 855 abstracts reviewed, 34 full-text articles screened for eligibility, and nine eligible studies included in the systematic review.Tabulation, Integration, and Results: Stata 16 software was used to generate summary estimates, forest plots, funnel plots, and heterogeneity statistics. Random effects modeling based on pooled data revealed that Medicaid expansion was associated with a 6.1% increase in Medicaid enrollment for pregnant women (95% CI 1.3-10.9%) and a 3.3% increase in perinatal care utilization (95% CI 0.2-6.3%).Conclusion: Medicaid expansion under the ACA is associated with a modest and statistically significant increase in perinatal care access and utilization among low-income women. [ABSTRACT FROM AUTHOR]

Focuses on child injuries and fatalities from alcohol-related motor vehicle crashes. Argument for a zero-tolerance policy in the United States in regards to drinking and driving; Highlights from other articles in the May 3, 2000 issue of 'The Journal of the American Medical Association' that deal with children and alcohol-related crashes; Groups of alcohol offenders that emerged from these studies; Need for change in current US laws regarding the legal blood alcohol concentration (BAC) level.

Purpose: Safe Routes to School (SRTS) was a federally funded transportation program for facilitating physically active commuting to and from school in children through improvements of the built environment. There is evidence that SRTS programs increase walking and bicycling in school-age children, but their impact on pedestrian and bicyclist safety has not been adequately examined. We investigate the impact and effects of the SRTS program on school-age pedestrian and bicyclist injuries in a nationwide sample in the United States.Methods: Data were crash records for school-age children (5-19 years) and adults (30-64 years), in 18 U.S. states for a 16-year period (1995-2010). Multilevel negative binomial models were used to examine the association between SRTS intervention and the risk of pedestrian and bicyclist injury in children aged 5-19 years.Results: SRTS was associated with an approximately 23% reduction (incidence rate ratio = 0.77, 95% confidence interval = 0.65-0.92) in pedestrian/bicyclist injury risk and a 20% reduction in pedestrian/bicyclist fatality risk (incidence rate ratio = 0.80, 95% confidence interval = 0.68-0.94) in school-age children compared to adults aged 30-64 years.Conclusions: Implementation of the SRTS program appears to have contributed to improving traffic safety for school-age children in the United States. [ABSTRACT FROM AUTHOR]

1. Describe the effect of state palliative care laws on place of death. To improve end-of-life care, some states have enacted legislation intended to facilitate palliative care (PC) delivery for seriously ill patients, but it is unknown whether these laws have any measurable impact on patient outcomes. Determining whether state PC legislation is associated with place of death (POD). Natural experimental study using collected information about states' legislation combined with US death certificate data of all 50 states from 2005-2017. We included decedents with cancer listed as underlying cause of death. Exposure was classified as presence of nonprescriptive (PC-related without prescribing particular clinician actions) or prescriptive (requiring clinicians to offer patients care options) PC law in the state-year where POD occurred. Multilevel relative risk (RR) regression, with state modeled as random-effect, was used to estimate the likelihood of dying at home or hospice for decedents dying in state-years with a PC law compared to decedents in state-years without it. Of 7,547,907 decedents from cancer as a primary cause of death, 3,780,918 (50.1%) died at home or in hospice. Most died in state-years without a PC law (70.8%), 15.7% died in state-years with a nonprescriptive law, and 13.5% died in state-years with a prescriptive law. Compared with state-years without a law, the likelihood of dying at home or in hospice increased 12% for decedents in state-years with a nonprescriptive law (RR 1.12, 95% CI 1.08-1.16) and 18% for decedents in state-years with a prescriptive law (RR 1.18, 95% CI 1.11-1.26). State PC laws were associated with an increased likelihood of dying at home or in hospice for decedents from cancer. Passage of state legislation promoting palliative and end-of-life care may be an effective policy intervention to improve quality-of-care delivery for seriously ill patients. [ABSTRACT FROM AUTHOR]

Objective: Reintubation after liberation from mechanical ventilation is viewed as an adverse event in ICUs. We sought to describe the frequency of reintubations across U.S. ICUs and to propose a standard, appropriate time cutoff for reporting of reintubation events.Design and Setting: We conducted a cohort study using data from the Project IMPACT database of 185 diverse ICUs in the United States.Patients: We included patients who received mechanical ventilation and excluded patients who received a tracheostomy, had a do-not-resuscitate order placed, or died prior to first extubation.Measurements and Main Results: We assessed the percentage of patients extubated who were reintubated; the cumulative probability of reintubation, with death and do-not-resuscitate orders after extubation modeled as competing risks, and time to reintubation. Among 98,367 patients who received mechanical ventilation without death or tracheostomy prior to extubation, 9,907 (10.1%) were reintubated, with a cumulative probability of 10.0%. Median time to reintubation was 15 hours (interquartile range, 2-45 hr). Of patients who required reintubation in the ICU, 90% did so within the first 96 hours after initial extubation; this was consistent across various patient subtypes (89.3% for electives surgical patients up to 94.8% for trauma patients) and ICU subtypes (88.6% for cardiothoracic ICUs to 93.5% for medical ICUs).Conclusions: The reintubation rate for ICU patients liberated from mechanical ventilation in U.S. ICUs is approximately 10%. We propose a time cutoff of 96 hours for reintubation definitions and benchmarking efforts, as it captures 90% of ICU reintubation events. Reintubation rates can be reported as simple percentages, without regard for deaths or changes in goals of care that might occur. [ABSTRACT FROM AUTHOR]

Background: Use of intensive care after major surgical procedures and whether routinely admitting patients to intensive care units (ICUs) improve outcomes or increase costs is unknown.Methods: The authors examined frequency of admission to an ICU during the hospital stay for Medicare beneficiaries undergoing selected major surgical procedures: elective endovascular abdominal aortic aneurysm (AAA) repair, cystectomy, pancreaticoduodenectomy, esophagectomy, and elective open AAA repair. The authors compared hospital mortality, length of stay, and Medicare payments for patients receiving each procedure in hospitals admitting patients to the ICU less than 50% of the time (low use), 50 to 89% (moderate use), and 90% or greater (high use), adjusting for patient and hospital factors.Results: The cohort ranged from 7,878 patients in 162 hospitals for esophagectomies to 69,989 patients in 866 hospitals for endovascular AAA. Overall admission to ICU ranged from 35.6% (endovascular AAA) to 71.3% (open AAA). Admission to ICU across hospitals ranged from less than 5% to 100% of patients for each surgical procedure. There was no association between hospital use of intensive care and mortality for any of the five surgical procedures. There was a consistent association between high use of intensive care with longer length of hospital stay and higher Medicare payments only for endovascular AAA.Conclusions: There is little consensus regarding the need for intensive care for patients undergoing major surgical procedures and no relationship between a hospital's use of intensive care and hospital mortality. There is also no consistent relationship across surgical procedures between use of intensive care and either length of hospital stay or payments for care. [ABSTRACT FROM AUTHOR]

Abstract: Analysts often use different conceptual definitions of a cohort effect, and therefore different statistical methods, which lead to differing empirical results. A definition often used in sociology assumes that cohorts have unique characteristics confounded by age and period effects, whereas epidemiologists often conceive that period and age effects interact to produce cohort effects. The present study aims to illustrate these differences by estimating age, period, and cohort (APC) effects on obesity prevalence in the U.S. from 1971 to 2006 using both conceptual approaches. Data were drawn from seven cross-sectional waves of the National Health and Nutrition Examination Survey. Obesity was defined as BMI≥30 for adults and ≥95th percentile for children under the age of 20. APC effects were estimated using the classic constraint-based method (first-order effects estimated and interpreted), the Holford method (first-order effects estimated but second-order effects interpreted), and median polish method (second-order effects are estimated and interpreted). Results indicated that all methods report significant age and period effects, with lower obesity prevalence in early life as well as increasing prevalence in successive surveys. Positive cohort effects for more recently born cohorts emerged based on the constraint-based model; when cohort effects were considered second-order estimates, no significant effects emerged. First-order estimates of age–period–cohort effects are often criticized because of their reliance on arbitrary constraints, but may be conceptually meaningful for sociological research questions. Second-order estimates are statistically estimable and produce conceptually meaningful results for epidemiological research questions. Age–period–cohort analysts should explicitly state the definition of a cohort effect under consideration. Our analyses suggest that the prevalence of obesity in the U.S. in the latter part of the 20th century rose across all birth cohorts, in the manner expected based on estimated age and period effects. As such, the absence or presence of cohort effects depends on the conceptual definition and therefore statistical method used. [Copyright &y& Elsevier]

Purpose Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality. Methods Using data from the New York Statewide Planning and Research Cooperative System for 2006–2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18–64 years and subsequent PDO death. Results The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50–5.34) for those with two ED visits, 16.61 (95% CI: 14.72–18.75) for those with three ED visits, and 48.24 (95% CI: 43.23–53.83) for those with four ED visits or more. Conclusions Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality. [ABSTRACT FROM AUTHOR]

Background: Providing continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent's plan until age 26 yr, was associated with increased labor neuraxial analgesia use., Methods: This study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 U.S. states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and postintervention periods (January 2009 to August 2010 and September 2010 to December 2013, respectively). The exposure was women's age, categorized as exposed (21 to 25 yr) and unexposed (27 to 31 yr). The outcome was the labor neuraxial analgesia utilization rate., Results: Of the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 68.9% during the postintervention period (difference, 4.0%; 95% CI, 3.9 to 4.2). For women aged 27 to 31 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 67.7% during the postintervention period (difference, 2.8%; 95% CI, 2.7 to 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI, 0.8 to 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 yr compared with women aged 27 to 31 yr. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women., Conclusions: Implementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size is unlikely of clinical significance., (Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved.)

Background: Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization., Objective: This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence., Study Design: This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics., Results: Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low)., Conclusion: Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Aims: The American Society for Gastrointestinal Endoscopy (ASGE) has developed a complexity-grading system for endoscopic retrograde cholangiopancreatography (ERCP) to predict technical success and adverse events. This study aimed to assess the association between the degree of difficulty for ERCP and the rates of success and adverse event, in turn demonstrating the validity and practicality of this system., Methods: ERCP procedures performed in the First Affiliated Hospital of Nanchang University from January 2011 to December 2020 were retrospectively reviewed. Procedural success and adverse events were recorded based on difficulty level according to the ASGE-grading system., Results: A total of 20,652 ERCP procedures performed during the study period were analyzed, including 1908 procedures considered grade 1(9.2%), 10,170 procedures considered grade 2 (49.2%), 7764 procedures considered grade 3 (37.6%), 810 procedures considered grade 4 (3.9%). The overall success rate increased from 92.8% in 2011-2015 to 94.0% in 2016-2020, while the distribution of procedures and the incidence of complications showed little variation. The success rate revealed a significantly decreasing trend with increasing difficulty (ranging from 55.6 to 98.6%), mainly for biliary diseases. In addition, the difficulty scale was not associated with any differences in the rate of adverse event, except for the pancreatitis for grade 1 procedures, which had a low incidence., Conclusions: The ASGE-grading system can help predict the success rate of ERCP procedures but showed poor performance in predicting adverse events. Further exploration may be required to improve the grading system by adjusting or including certain clinical parameters, and to validate the system for extrapolation to other endoscopy units., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Utilization of extracorporeal membrane oxygenation (ECMO) for adult critically ill patients is increasing, but data in obstetric cohorts are scant. This study analyzed ECMO utilization and maternal outcomes in obstetric patients in the United States., Methods: Data were abstracted from the 1999-2014 National Inpatient Sample (NIS), a 20% US national representative sample. ECMO hospitalizations (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 39.65) in patients ≥15 years of age were categorized into obstetric ECMO and nonobstetric ECMO. Obstetric patients included 4 categories: (1) loss or termination of pregnancy, (2) delivery (term or preterm), (3) postdelivery hospitalization, and (4) pregnancy without an obstetrical outcome. Possible underlying causes for obstetric ECMO were identified by analysis of ICD-9-CM codes in individual records. In-hospital death was abstracted from the NIS, and ECMO complications were identified using ICD-9-CM algorithms. Statistical significance in time-effect was assessed using weighted regression models., Results: During the 16-year study period, 20,454 adult ECMO cases were identified, of which 331 occurred in obstetric patients (1.6%; 95% confidence interval [CI], 1.4-1.8). Obstetric ECMO utilization rate was 4.7 per million obstetric discharges (95% CI, 4.2-5.2). The top 3 possible indications were sepsis (22.1%), cardiomyopathy (16.6%), and aspiration pneumonia (9.7%). Obstetric ECMO utilization rate increased significantly during the study period from 1.1 per million obstetric discharges in 1999-2002 (95% CI, 0.6-1.7) to 11.2 in 2011-2014 (95% CI, 9.6-12.9), corresponding to a 144.7% increase per 4-year period (95% CI, 115.3-178.1). Compared with nonobstetric ECMO, obstetric ECMO was associated with decreased in-hospital all-cause mortality (adjusted odds ratio [aOR] 0.78; 95% CI, 0.66-0.93). In-hospital all-cause mortality for obstetric ECMO decreased from 73.7% in 1999-2002 (95% CI, 48.8-90.8) to 31.9% in 2011-2014 (95% CI, 25.2-39.1), corresponding to a 26.1% decrease per 4-year period (95% CI, 10.1-39.3). Compared with nonobstetric ECMO, obstetric ECMO was associated with significantly increased risk of both venous thromboembolism without associated pulmonary embolism (aOR 1.83; 95% CI, 1.06-3.15) and of nontraumatic hemoperitoneum (aOR 4.32; 95% CI, 2.41-7.74)., Conclusions: During the study period, obstetric ECMO utilization has increased significantly and maternal prognosis improved., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: In the United States, New York State's health care system experienced unprecedented stress as an early epicenter of the coronavirus disease 2019 (COVID-19) pandemic. This study aims to assess the level of hopelessness in New York State physicians working on the frontlines during the first wave of the COVID-19 outbreak., Methods: A confidential online survey sent to New York State health care workers by the state health commissioner's office was used to gather demographic and hopelessness data as captured by a brief Hopelessness Scale. Adjusted linear regression models were used to assess the associations of physician age, sex, and number of triage decisions made, with level of hopelessness., Results: In total, 1330 physicians were included, of whom 684 were male (51.4%). Their average age was 52.4 years (SD=12.7), with the majority of respondents aged 50 years and older (55.2%). Almost half of the physician respondents (46.3%) worked directly with COVID-19 patients, and 163 (12.3%) were involved in COVID-19-related triage decisions. On adjusted analysis, physicians aged 40 to 49 years had significantly higher levels of hopelessness compared with those aged 50 years or more (μ=0.441, SD=0.152, P=0.004). Those involved in 1 to 5 COVID-19-related triage decisions had a significantly lower mean hopelessness score (μ=-0.572, SD=0.208, P=0.006) compared with physicians involved in none of these decisions., Conclusion: Self-reported hopelessness was significantly higher among physicians aged 40 to 49 years and those who had not yet been involved in a life or death triage decision. Further work is needed to identify strategies to support physicians at high risk for adverse mental health outcomes during public health emergencies such as the COVID-19 pandemic., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Medicaid expansions under the Affordable Care Act have increased insurance coverage and prenatal care utilization in low-income women. However, it is not clear whether they are associated with any measurable improvement in maternal health outcomes. In this study, we compared the changes in the incidence of severe maternal morbidity (SMM) during delivery hospitalizations between low- and high-income women associated with the 2014 Medicaid expansion in New York State., Methods: Data for this retrospective cohort study came from the 2006-2016 New York State Inpatient Database, a census of discharge records from community hospitals. The outcome was SMM during delivery hospitalizations, as defined by the Centers for Disease Control and Prevention. We used regression coefficients (β) from multivariable logistic models: (1) to compare independently in low-income women and in high-income women the changes in slopes in the incidence of SMM before (2006-2013) and after (2014-2016) the expansion, and (2) to compare low- and high-income women for the changes in slopes in the incidence of SMM before and after the expansion., Results: A total of 2,286,975 delivery hospitalizations were analyzed. The proportion of Medicaid beneficiaries in parturients increased a relative 12.1% (95% confidence interval [CI], 11.8-12.4), from 42.9% in the preexpansion period to 48.1% in the postexpansion period, whereas the proportion of the uninsured decreased a relative 4.8% (95% CI, 2.8-6.8). Multivariable logistic modeling revealed that implementation of the 2014 Medicaid expansion was associated with a decreased slope during the postexpansion period both in low-income women (β = -0.0161 or 1.6% decrease; 95% CI, -0.0190 to -0.0132) and in high-income women (β = -0.0111 or 1.1% decrease; 95% CI, -0.0130 to -0.0091). The decrease in slope during the postexpansion period was greater in low- than in high-income women (β = -0.0042 or 0.42% difference; 95% CI, -0.0076 to -0.0007)., Conclusions: Implementation of the Medicaid expansion in 2014 in New York State is associated with a small but statistically significant reduction in the incidence of SMM in low-income women compared with high-income women., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Objective: To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends., Methods: This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed., Results: During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period., Conclusion: Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

When older adults reduce their driving, there can be subsequent decreases in life satisfaction. In this cross-sectional study, we used baseline data from the multi-site Longitudinal Research on Aging Drivers (LongROAD) study to examine whether social support moderates the negative association between reduced driving and life satisfaction. The outcome variable was life satisfaction, and the main predictor variable was past-year reduced driving (yes/no). Emotional, instrumental, and informational social support were measured using PROMIS v2.0 (Patient-Reported Outcomes Measurement Information System) items. We used generalized linear regression models to examine how social support moderated the association between reduced driving and life satisfaction. Statistical adjustment for social support attenuated the negative effect of reduced driving on life satisfaction by ~10% for all three types of social support.

Background: Some recent clinical studies have found that early childhood exposure to anesthesia is associated with increased risks of behavioral deficits and clinical diagnoses of attention deficit hyperactivity disorder (ADHD). While diagnoses in claims data may be subject to inaccuracies, pharmacy claims are highly accurate in reflecting medication use. This study examines the association between exposure to surgery and anesthesia and subsequent ADHD medication use., Methods: Longitudinal data for children enrolled in Texas and New York Medicaid from 1999 to 2010 were used. We assessed the association between a single exposure to anesthesia before age 5 years for 1 of 4 common pediatric surgical procedures (pyloromyotomy, inguinal hernia repair, circumcisions outside the perinatal period, and tonsillectomy and/or adenoidectomy) and persistent ADHD medication use (event defined as the initial ADHD medication prescription, and persistent use defined as filling 2 or more ≥30-day prescriptions between 6 months following surgery until censoring). Exposed children (n = 42,687) were matched on propensity score (ie, the probability of receiving surgery) estimated in logistic regression including sociodemographic and clinical covariates, to children without anesthesia exposure before age 5 years (n = 213,435). Cox proportional hazards models were used to evaluate the hazard ratio (HR) of ADHD medication use following exposure. Nonpsychotropic medications served as negative controls to determine if exposed children simply had higher overall medication use., Results: Children with a single exposure to surgery and anesthesia were 37% more likely than unexposed children to persistently use ADHD medication (HR, 1.37; 95% confidence interval [CI], 1.30-1.44). The estimated HRs for common nonpsychotropic medication use following a single anesthetic exposure were 1.06 (95% CI, 1.04-1.07) for amoxicillin, 1.10 (95% CI, 1.08-1.12) for azithromycin, and 1.08 (95% CI, 1.05-1.11) for diphenhydramine. In comparison, the risk of using other psychotropic medication to treat conditions besides ADHD was also significantly higher, with HRs of 1.37 (95% CI, 1.24-1.51) for sedative/anxiolytics, 1.40 (95% CI, 1.25-1.58) for antidepressants, 1.31 (95% CI, 1.20-1.44) for antipsychotics, and 1.24 (95% CI, 1.10-1.40) for mood stabilizers., Conclusions: Medicaid-enrolled children receiving anesthesia for a single common pediatric surgical procedure under age 5 years were 37% more likely to require subsequent persistent use of ADHD medications than unexposed children. Because the increased use of ADHD medication is disproportionately higher than that of nonpsychotropic medications, unmeasured confounding may not account for all of the increase in ADHD medication use. By evaluating Medicaid data, this study assesses children who may be particularly vulnerable to neurotoxic exposures.

Objective: To evaluate healthcare utilization in Medicaid enrolled children with neonatal abstinence syndrome (NAS) in the first 2 years of life., Study Design: A retrospective, longitudinal cohort study evaluating Medicaid enrolled children born in New York (1999-2011) and Texas (1999-2010) was performed. Healthcare utilization, including inpatient days, emergency department and outpatient visits, and filled prescriptions in children after birth hospitalization was assessed. A tapered propensity-matching methodology was used, matching each child with NAS with 5 children without NAS, first on demographics, then on both demographics and clinical covariates (clinical diagnoses and congenital anomalies at birth). Poisson and negative binomial regression were used to calculate healthcare utilization ratios (HUR)., Results: In the first 2 years of life, children with NAS (n = 3799) had increased healthcare utilization with more inpatient days and emergency department visits than demographically similar children without NAS. This increased utilization however did not persist after matching on clinical covariates and performing multiple comparisons adjustment (inpatient days [HUR, 1.01; 95% CI, 0.88-1.16; P = .89], total emergency department visits [HUR, 1.06; 95% CI, 1.01-1.11; P = .02]). Children with NAS conversely had 9% fewer outpatient office visits (HUR, 0.91; 95% CI, 0.87-0.95; P < .0001)., Conclusions: A diagnosis of NAS does not appear to be an independent predictor of increased healthcare utilization in the first 2 years of life. These results differ from some other published studies, but may suggest that the increased healthcare utilization observed in children with NAS is due to higher incidences of perinatal complications and congenital anomalies in children with prenatal drug exposures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: State governments in the United States are increasingly viewing marijuana legalization as a policy option for controlling the opioid epidemic under the premise that marijuana is a less harmful substitute for opioids. The purpose of this study is to assess whether marijuana use is associated with decreased odds of prescription opioid use., Methods: A cross-sectional study design was applied to toxicological testing data from two national samples of drivers: 1) the 2011-2016 Fatality Analysis Reporting System (FARS) and 2) the 2013-2014 National Roadside Survey of Alcohol and Drug Use by Drivers (NRS). Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) estimated from multivariable logistic regression models were used to assess the associations of marijuana use with prescription opioid use and alcohol use., Results: Among the 47,602 drivers from the FARS, 15.7% tested positive for marijuana and 6.9% positive for prescription opioids. Compared with drivers testing negative for marijuana, those testing positive for marijuana were 28% more likely to test positive for prescription opioids (adjusted OR = 1.28, 95% CI = 1.15-1.42). Among the 7881 drivers from the NRS, 7.9% tested positive for marijuana and 4.5% positive for prescription opioids. Relative to drivers testing negative for marijuana, those testing positive for marijuana were twice as likely to test positive for prescription opioids (adjusted OR = 2.03, 95% CI = 1.29-3.20). In both study samples, marijuana use was associated with significantly increased odds of alcohol positivity., Conclusions: Drivers who test positive for marijuana are significantly more likely to test positive for prescription opioids. Longitudinal studies with rigorous designs and toxicological testing data are needed to further address the substitution hypothesis between marijuana and prescription opioids.

Background and Objectives: Balancing both driver mobility and safety is important for the well-being of older adults. However, research on the association of physical function with these 2 driving outcomes has yielded inconsistent findings. This study examined whether physical functioning of older drivers, as measured by the Short Physical Performance Battery (SPPB), is associated with either driving space or crash involvement., Methods: Using cross-sectional data of active drivers aged 65-79 years from the AAA Longitudinal Research on Aging Drivers (LongROAD) study (n = 2,990), we used multivariate log-binomial and logistic regressions to estimate the associations of the SPPB with either self-reported restricted driving space in the prior 3 months or any crashes in the past year. Interaction with gender was assessed using likelihood ratio tests., Results: After adjustment, older drivers with higher SPPB scores (higher physical functioning) had lower prevalence of restricted driving space (8-10 vs. 0-7, prevalence ratio [PR] = 0.88, 95% confidence interval [CI]: 0.78-0.99; 11-12 vs. 0-7, PR = 0.78, 95% CI: 0.61-0.99). Fair (8-10), but not good (11-12), scores were significantly associated with reduced crash involvement (8-10 vs. 0-7, odds ratio [OR] = 0.71, 95% CI: 0.60-0.84). Gender was not a significant effect modifier., Discussion and Implications: This study provides evidence that higher physical functioning is associated with better driving mobility and safety and that the SPPB may be useful for identifying at-risk drivers. Further research is needed to understand physical functioning's longitudinal effects and the SPPB's role in older driver intervention programs., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Simple febrile seizure (SFS) affects 2% to 4% of children under 6 years of age. The purpose of this study is to examine the epidemiologic patterns and resource utilization of SFS-associated hospitalizations in children aged younger than 6 years of age in the United States., Materials and Methods: This study is a serial, retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Databases for the years 2003, 2006, 2009, and 2012. SFS-associated hospitalizations were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis code 780.31. We calculated the proportion of hospitalizations in pediatric patients under 6 years of age due to SFS and all other nonbirth causes, the rate of SFS-associated hospitalizations per 100,000 population, the mean length of stay and inflation-adjusted hospital costs of SFS-associated hospitalizations, as well as patient demographics and hospital characteristics., Results: From 2003 to 2012, the weighted proportion of hospitalizations due to SFS declined from 0.83% to 0.41% (P<0.01) and the annual rate of SFS-associated hospitalizations per 100,000 population decreased from 48.0 to 18.7 (P<0.01). However, use of computed tomography, electroencephalogram, and lumbar puncture in SFS-associated hospitalizations decreased significantly (all P<0.001), but the utilization rate of magnetic resonance imaging remained stable (P=0.53). The mean length of stay for SFS-associated hospitalizations decreased from 2.03 days in 2003 to 1.74 days in 2012, and the mean hospital costs (exclusive of professional payment) decreased from $3830 in 2003 to $3223 in 2012 (both P<0.001)., Conclusions: SFS-associated hospitalizations and resource utilization in children under 6 years of age have decreased markedly in the United States, probably due to improved clinical adherence to the practice parameters set forth by the American Academy of Pediatrics for managing patients with SFS.

Background: There are approximately 42 million licensed drivers aged 65 years or older in the United States, who face unique age-related risks while driving. While physical activity affects several chronic conditions thought to be associated with motor vehicle crashes (MVCs), it is unclear if increased physical activity leads to fewer MVCs. This study explores whether self-reported vigorous and moderate physical activity is associated with MVCs in the previous year. Methods: Using cross-sectional data from the LongROAD study, a large multisite prospective cohort study of 2990 older adult drivers, we examined variables related to physical activity and performed a multivariate regression analysis to examine the association of physical activity health behaviors with self-reported MVCs. Results: Overall, 41.2% of participants reported vigorous and 69.6% of participants reported moderate exercise at least once per week. Eleven percent of participants reported at least 1 MVC in the previous year. Neither vigorous nor moderate physical activity was significantly associated with self-reported MVCs in the previous year. Select variables that were significantly associated with self-reported MVC included self-reported unsafe driving practices (odds ratio [OR] 1.55, confidence interval [CI] 1.05-2.29), and fall in the past 12 months (OR 1.46, CI 1.14-1.85). Conclusions: We were unable to detect a significant association between self-reported physical activity and MVCs in the past year among this group of older drivers. Use of objective measures of activity may better clarify this relationship.

We surveyed self-reported lifetime health conditions (using National Health and Aging Trends Study questions) and related driving reduction in a large multi-site older driver cohort (n = 2990) from the AAA Longitudinal Research on Aging Drivers (LongROAD) Study's baseline assessment. Those reporting reduced driving (n = 337) largely attributed reduction to musculoskeletal (29%), neurologic (13%), and ophthalmologic (10%) conditions. Women reported health condition-related driving reduction more often than men (14% versus 8%, p<.001). Mobility affects well-being; health professionals should consider that health conditions may cause older adults to reduce driving. Gender differences deserve attention in future research and education efforts.

Background: In 1997, the International Classification of Diseases (ICD), 9th Revision Clinical Modification (ICD-9) coding system introduced the code for malignant hyperthermia (MH) (995.86). The aim of this study was to estimate the accuracy of coding for MH in hospital discharge records., Methods: An expert panel of anesthesiologists reviewed medical records for patients with a discharge diagnosis of MH based on ICD-9 or ICD-10 codes from January 1, 2006 to December 31, 2008 at six tertiary care medical centers in North America. All cases were categorized as possible, probable, or fulminant MH, history of MH (family or personal) or other., Results: A total of 47 medical records with MH diagnoses were reviewed; 68.1% had a documented surgical procedure and general anesthesia, and 23.4% (95% CI, 12.3-38.0%) had a possible, probable, or fulminant MH event. Dantrolene was given in 81% of the MH events. All patients judged to have an incident MH event survived to discharge. Family and personal history of MH accounted for 46.8% of cases. High fever without evidence of MH during admission accounted for 23.4%, and the reason for MH coding was unclear in 6.4% of cases., Conclusions: Approximately one quarter of ICD-9 or ICD-10 coded MH diagnoses in hospital discharge records refer to incident MH episodes and an additional 47% to MH susceptibility (including personal history or family history). Information such as surgical procedure, anesthesia billing data, and dantrolene administration may aid in identifying incident MH cases among those with an ICD-9 or ICD-10 coded MH diagnosis in their hospital discharge records.

Objective: In the United States, per-capita opioid dispensing has increased concurrently with analgesic-related mortality and morbidity since the 1990s. To deter diversion and abuse of controlled substances, most states have implemented electronic prescription drug monitoring programs (PDMPs). We evaluated the impact of state PDMPs on opioid dispensing., Methods: We acquired data on opioids dispensed in a given quarter of the year for each state and the District of Columbia from 1999 to 2008 from the Automation of Reports and Consolidated Orders System and converted them to morphine milligram equivalents (MMEs). We used multivariable linear regression modeling with generalized estimating equations to assess the effect of state PDMPs on per-capita dispensing of MMEs., Results: The annual MMEs dispensed per capita increased progressively until 2007 before stabilizing. Adjusting for temporal trends and demographic characteristics, implementation of state PDMPs was associated with a 3% decrease in MMEs dispensed per capita (p=0.68). The impact of PDMPs on MMEs dispensed per capita varied markedly by state, from a 66% decrease in Colorado to a 61% increase in Connecticut., Conclusions: Implementation of state PDMPs up to 2008 did not show a significant impact on per-capita opioids dispensed. To control the diversion and abuse of prescription drugs, state PDMPs may need to improve their usability, implement requirements for committee oversight of the PDMP, and increase data sharing with neighboring states.

Rationale: Use of triggers for palliative care consultation has been advocated in intensive care units (ICUs) to ensure appropriate specialist involvement for patients at high risk of unmet palliative care needs. The volume of patients meeting these triggers, and thus the potential workload for providers, is unknown., Objectives: To estimate the prevalence of ICU admissions who met criteria for palliative care consultation using different sets of triggers., Methods: Retrospective cohort study of ICU admissions from Project IMPACT for 2001-2008. We assessed the prevalence of ICU admissions meeting one or more primary palliative care triggers, and prevalence meeting any of multiple sets of triggers., Measurements and Main Results: Overall, 53,124 (13.8%) ICU admissions met one or more primary triggers for palliative care consultation. Variation in prevalence was minimal across different types of units (mean 13.3% in medical ICUs to 15.8% in trauma/burn ICUs; P = 0.41) and individual units (mean 13.8%, median 13.0%, interquartile range, 10.2-16.5%). A comprehensive model combining multiple sets of triggers identified a total of 75,923 (19.7%) ICU admissions requiring palliative care consultation; of them, 85.4% were captured by five triggers: (1) ICU admission after hospital stay greater than or equal to 10 days, (2) multisystem organ failure greater than or equal to three systems, (3) stage IV malignancy, (4) status post cardiac arrest, and (5) intracerebral hemorrhage requiring mechanical ventilation., Conclusions: Approximately one in seven ICU admissions met triggers for palliative care consultation using a single set of triggers, with an upper estimate of one in five patients using multiple sets of triggers; these estimates were consistent across different types of ICUs and individual units. These results may inform staffing requirements for providers to ensure delivery of specialized palliative care to ICU patients nationally.

Drugged driving is a serious safety concern, but its role in motor vehicle crashes has not been adequately studied. Using a case-control design, the authors assessed the association between drug use and fatal crash risk. Cases (n=737) were drivers who were involved in fatal motor vehicle crashes in the continental United States during specific time periods in 2007, and controls (n=7719) were participants of the 2007 National Roadside Survey of Alcohol and Drug Use by Drivers. Overall, 31.9% of the cases and 13.7% of the controls tested positive for at least one non-alcohol drug. The estimated odds ratios of fatal crash involvement associated with specific drug categories were 1.83 [95% confidence interval (CI): 1.39, 2.39] for marijuana, 3.03 (95% CI: 2.00, 4.48) for narcotics, 3.57 (95% CI: 2.63, 4.76) for stimulants, and 4.83 (95% CI: 3.18, 7.21) for depressants. Drivers who tested positive for both alcohol and drugs were at substantially heightened risk relative to those using neither alcohol nor drugs (Odds Ratio=23.24; 95% CI: 17.79, 30.28). These results indicate that drug use is associated with a significantly increased risk of fatal crash involvement, particularly when used in combination with alcohol., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Graduated Driver Licensing (GDL) has been implemented in Australia, Canada, New Zealand, USA and Israel. We conducted an exploratory summary of available data to estimate whether GDL effects varied with age., Methods: We searched MEDLINE and other sources from 1991-2011. GDL evaluation studies with crashes resulting in injuries or deaths were eligible. They had to provide age-specific incidence rate ratios with CI or information for calculating these quantities. We included studies from individual states or provinces, but excluded national studies. We examined rates based on person-years, not license-years., Results: Of 1397 papers, 144 were screened by abstract and 47 were reviewed. Twelve studies from 11 US states and one Canadian province were selected for meta-analysis for age 16, eight were selected for age 17, and four for age 18. Adjusted rate ratios were pooled using random effects models. The pooled adjusted rate ratios for the association of GDL presence with crash rates was 0.78 (95% CI 0.72 to 0.84) for age 16 years, 0.94 (95% CI 0.93 to 0.96) for 17 and 1.00 (95% CI 0.95 to 1.04) for 18. The difference between these three rate ratios was statistically significant: p<0.001., Conclusions: GDL policies were associated with a 22% reduction in crash rates among 16-year-old drivers, but only a 6% reduction for 17-year-old drivers. GDL showed no association with crashes among 18-year-old drivers. Because we had few studies to summarise, particularly for older adolescents, our findings should be considered exploratory.