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Importance: Obesity is associated with increased severity of COVID-19. Whether obesity is associated with an increased risk of post-acute sequelae of SARS-CoV-2 infection (PASC) among pediatric populations, independent of its association with acute infection severity, is unclear., Objective: To quantify the association of body mass index (BMI) status before SARS-CoV-2 infection with pediatric PASC risk, controlling for acute infection severity., Design, Setting, and Participants: This retrospective cohort study occurred at 26 US children's hospitals from March 2020 to May 2023 with a minimum follow-up of 179 days. Eligible participants included children and young adults aged 5 to 20 years with SARS-CoV-2 infection. Data analysis was conducted from October 2023 to January 2024., Exposures: BMI status assessed within 18 months before infection; the measure closest to the index date was selected. The BMI categories included healthy weight (≥5th to <85th percentile for those aged 5-19 years or ≥18.5 to <25 for those aged >19 years), overweight (≥85th to <95th percentile for those aged 5-19 years or ≥25 to <30 for for those aged >19 years), obesity (≥95th percentile to <120% of the 95th percentile for for those aged 5-19 years or ≥30 to <40 for those aged >19 years), and severe obesity (≥120% of the 95th percentile for those aged 5-19 years or ≥40 for those aged >19 years)., Main Outcomes and Measures: To identify PASC, a diagnostic code specific for post-COVID-19 conditions was used and a second approach used clusters of symptoms and conditions that constitute the PASC phenotype. Relative risk (RR) for the association of BMI with PASC was quantified by Poisson regression models, adjusting for sociodemographic, acute COVID severity, and other clinical factors., Results: A total of 172 136 participants (mean [SD] age at BMI assessment 12.6 [4.4] years; mean [SD] age at cohort entry, 13.1 [4.4] years; 90 187 female [52.4%]) were included. Compared with participants with healthy weight, those with obesity had a 25.4% increased risk of PASC (RR, 1.25; 95% CI, 1.06-1.48) and those with severe obesity had a 42.1% increased risk of PASC (RR, 1.42; 95% CI, 1.25-1.61) when identified using the diagnostic code. Compared with those with healthy weight, there was an increased risk for any occurrences of PASC symptoms and conditions among those with obesity (RR, 1.11; 95% CI, 1.06-1.15) and severe obesity (RR, 1.17; 95% CI, 1.14-1.21), and the association held when assessing total incident occurrences among those with overweight (RR, 1.05; 95% CI, 1.00-1.11), obesity (RR, 1.13; 95% CI, 1.09-1.19), and severe obesity (RR, 1.18; 95% CI, 1.14-1.22)., Conclusions and Relevance: In this cohort study, elevated BMI was associated with a significantly increased PASC risk in a dose-dependent manner, highlighting the need for targeted care to prevent chronic conditions in at-risk children and young adults.

Objectives: To investigate the relationship between herpes simplex virus (HSV) and hearing loss using comprehensive population-based research., Design: This cross-sectional study utilised data from the National Health and Nutrition Examination Survey (NHANES) to examine the relationship between HSV (types 1 and 2) and hearing loss. The final sample comprised 4608 participants aged 20-49 years. Weighted multivariate regression, subgroup and sensitivity analyses were employed for statistical evaluations., Setting: Utilising the NHANES data, this cross-sectional study provides insights into the American population aged 20-49 years., Participants: The study includes 4608 participants from the NHANES 2011-2012 and 2015-2016 cycles, focusing on those with complete data on HSV infection and hearing assessment., Interventions Exposure: The study analyses the association between HSV (types 1 and 2) infection and hearing loss, using weighted multivariate regression for statistical evaluations., Results: We observed an association between HSV-1 infection and an increased likelihood of hearing impairment (OR, 1.4 (95% CI 1.1 to 1.9)). A similar association was noted for those coinfected with HSV-1 and HSV-2 (OR, 1.6 (95% CI 1.1 to 2.3)). Similarly, higher grades of hearing loss and elevated pure-tone averages were more prevalent in these groups. Notably, the association between HSV-1 and hearing impairment was more pronounced in individuals aged 20-34 (OR, 2.1 (95% CI 1.4 to 3.3); P for interaction=0.020) and those with a body mass index (BMI) below 30 (OR, 1.8 (95% CI 1.1 to 2.8); P for interaction=0.028)., Conclusions: Our findings suggest an association between HSV-1 infection or coinfections with HSV-1 and HSV-2 and the presence of hearing impairment. The association appears particularly pronounced among younger individuals and those with a lower BMI. Further prospective research is needed to explore the causal impact of HSV on auditory function., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We aimed to explore the factors affecting the prognosis of patients with acute cerebrovascular occlusion with high National Institutes of Health Stroke Scale (NIHSS) scores treated with the SWIM (Solitaire™ stent retriever-assisted thrombectomy with immediate mechanical aspiration) technique using an intracranial support catheter., Methods: A retrospective analysis was conducted in 72 patients with acute cerebrovascular occlusion who underwent SWIM surgery in the Affiliated Hospital of Chengde Medical University in China between January 2020 and June 2022. The patients were divided into a good prognosis group (Modified Rankin Score [mRS] 0 to 2; n = 30) and a poor prognosis group (mRS score 3 to 6; n = 42) on their mRS scores 3 months after surgery. The THRIVE (TICI, hemorrhage, reocclusion, infarction, vessel, and embolism) score at different time points before and after the SWIM procedure and the postoperative revascularization rate were compared in the 2 NIHSS score groups. Univariate and logistic regression analyses were performed to identify the risk factors that affected the prognosis of patients with acute cerebrovascular occlusion treated with the SWIM procedure., Results: The NIHSS score difference at various time points after SWIM surgery in patients with low to moderate NIHSS scores was significantly higher than in patients with high NIHSS scores (P < .05). The postoperative revascularization rate in patients with high NIHSS scores was 74.36%, which was not significantly different from that in patients with low to moderate scores (84.85%; P > .05). The poor prognosis in patients with acute cerebrovascular occlusion after SWIM surgery was related to age, hypertension, NIHSS score, Glasgow Coma Scale (GCS) score, Essen Stroke Risk Score (ESRS), onset-to-treatment time (OTT) and Alberta Collateral Grading Scale (ACGS) score (P < .05). Logistic regression analysis showed that age, admission NIHSS score and ACGS score were independent risk factors that affected the prognosis in patients with acute cerebrovascular occlusion treated with the SWIM procedure (P < .05)., Conclusion: The prognosis in patients with acute cerebrovascular occlusion with high NIHSS scores after SWIM surgery was poor. Advanced age, high NIHSS score and ACGS score were independent risk factors that affected the prognosis in patients with acute cerebrovascular occlusion treated with the SWIM procedure. Overall, incorporating these findings into clinical practice promotes personalized approaches, interdisciplinary collaboration and timely interventions to optimize outcomes in patients undergoing the SWIM procedure for acute cerebrovascular occlusion.

The COVID-19 pandemic has sparked hostility against Chinese immigrants and sojourners in the U.S. and other countries. Making the situation worse, strong resentment against this group has also emerged in China due to the fear of returnees spreading the disease. Integrating research on acculturation and hostile media perception, we examined how such bilateral hostility along with different acculturation components (i.e., cultural identification, COVID-19-related media use, and individualistic-collectivistic value) influenced U.S.-dwelling Chinese's psychological well-being during the COVID-19 pandemic. Based on the results from a two-wave survey assessing the cultural identity and value, COVID-19-related media use, and psychological distress of a group of relatively young and highly educated U.S.-dwelling Chinese ( N = 1,256) between March and April 2020, we found that identification with both U.S. and Chinese cultures alleviated immigrants and sojourners' psychological distress. Further, COVID-19-related media use served as a stressor during the pandemic, and perceived hostility from China led to stronger psychological distress among U.S.-dwelling Chinese.

Objectives: We propose the origami plot, which maintains the original functionality of a radar chart and avoids potential misuse of its connected regions, with newly added features to better assist multicriteria decision-making., Study Design and Setting: Built upon a radar chart, the origami plot adds additional auxiliary axes and points such that the area of the connected region of all dots is invariant to the ordering of axes. As such, it enables ranking different individuals by the overall performance for multicriteria decision-making while maintaining the intuitive visual appeal of the radar chart. We develop extensions of the origami plot, including the weighted origami plot, which allows reweighting of each attribute to define the overall performance, and the pairwise origami plot, which highlights comparisons between two individuals., Results: We illustrate the different versions of origami plots using the hospital compare database developed by the Centers for Medicare & Medicaid Services (CMS). The plot shows individual hospital's performance on mortality, readmission, complication, and infection, as well as patient experience and timely and effective care, as well as their overall performance across these metrics. The weighted origami plot allows weighing the attributes differently when some are more important than others. We illustrate the potential use of the pairwise origami plot in electronic health records (EHR) system to monitor five clinical measures (body mass index [BMI]), fasting glucose level, blood pressure, triglycerides, and low-density lipoprotein ([LDL] cholesterol) of a patient across multiple hospital visits., Conclusion: The origami plot is a useful visualization tool to assist multicriteria decision making. It improves radar charts by avoiding potential misuse of the connected regions. It has several new features and allows flexible customization., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Identifying the onset age of cancer is essential for its early intervention. The aim of this study was to characterize the features and investigate the variation tendency of first primary colorectal cancer (CRC) onset age in the USA., Methods: For this retrospective population-based cohort analysis, data on patients diagnosed with first primary CRC (n = 330,977) between 1992 and 2017 were obtained from the Surveillance, Epidemiology, and End Results dataset. Annual percent changes (APC) and average APCs were calculated to examine the changes in average age at CRC diagnosis using the Joinpoint Regression Program., Results: From 1992 to 2017, the average age at CRC diagnosis decreased from 67.0 to 61.2 years, declining by 0.22% and 0.45% annually before and after 2000. The age at diagnosis was lower in the distal than in the proximal CRC cases and the age has the downward trends in all subgroups of sex, race, and stage. Over one-fifth of CRC patients were initially diagnosed with distantly metastatic CRC, with the age lower than that in localized CRC cases (63.5 vs 64.8 years)., Conclusions: The first primary CRC onset age has decreased significantly in the USA over the last 25 years and the modern lifestyle may be responsible for the decline. Specifically, the age of proximal CRC is invariably higher than that of distal CRC. Moreover, the age of advanced stage is lower than that of the early stage. Clinicians should adopt earlier screening age and more effective screening techniques for CRC., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Racial and ethnic disparities in adverse pregnancy outcomes (APOs) have been well-documented in the United States, but the extent to which the disparities are present in high-risk subgroups have not been studied. To address this problem, we first applied association rule mining to the clinical data derived from the prospective nuMoM2b study cohort to identify subgroups at increased risk of developing four APOs (gestational diabetes, hypertension acquired during pregnancy, preeclampsia, and preterm birth). We then quantified racial/ethnic disparities within the cohort as well as within high-risk subgroups to assess potential effects of risk-reduction strategies. We identify significant differences in distributions of major risk factors across racial/ethnic groups and find surprising heterogeneity in APO prevalence across these populations, both in the cohort and in its high-risk subgroups. Our results suggest that risk-reducing strategies that simultaneously reduce disparities may require targeting of high-risk subgroups with considerations for the population context.

Containing the COVID-19 pandemic while balancing the economy has proven to be quite a challenge for the world. We still have limited understanding of which combination of policies have been most effective in flattening the curve; given the challenges of the dynamic and evolving nature of the pandemic, lack of quality data etc. This paper introduces a novel data mining-based approach to understand the effects of different non-pharmaceutical interventions in containing the COVID-19 infection rate. We used the association rule mining approach to perform descriptive data mining on publicly available data for 50 states in the United States to understand the similarity and differences among various policies and underlying conditions that led to transitions between different infection growth curve phases. We used a multi-peak logistic growth model to label the different phases of infection growth curve. The common trends in the data were analyzed with respect to lockdowns, face mask mandates, mobility, and infection growth. We observed that face mask mandates combined with mobility reduction through moderate stay-at-home orders were most effective in reducing the number of COVID-19 cases across various states., (© 2021. The Author(s).)

In a large cohort of United States healthcare personnel without prior coronavirus disease 2019 (COVID-19) infection, 94 382 doses of messenger RNA (mRNA) COVID-19 vaccine were administered to 49 220 individuals. The adjusted vaccine effectiveness following 2 doses of each of the 2 available brands of mRNA vaccine exceeded 96%., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America.)

Human mobility plays an important role in the dynamics of infectious disease spread. Evidence from the initial nationwide lockdowns for COVID- 19 indicates that restricting human mobility is an effective strategy to contain the spread. While a direct correlation was observed early on, it is not known how mobility impacted COVID- 19 infection growth rates once lockdowns are lifted, primarily due to modulation by other factors such as face masks, social distancing, and the non-linear patterns of both mobility and infection growth. This paper introduces a piece-wise approach to better explore the phase-wise association between state-level COVID- 19 incidence data and anonymized mobile phone data for various states in the United States. Prior literature analyzed the linear correlation between mobility and the number of cases during the early stages of the pandemic. However, it is important to capture the non-linear dynamics of case growth and mobility to be usable for both tracking and forecasting COVID- 19 infections, which is accomplished by the piece-wise approach. The associations between mobility and case growth rate varied widely for various phases of the epidemic curve when the stay-at-home orders were lifted. The mobility growth patterns had a strong positive association of 0.7 with the growth in the number of cases, with a lag of 5 to 7 weeks, for the fast-growth phase of the pandemic, for only 20 states that had a peak between July 1st and September 30, 2020. Overall though, mobility cannot be used to predict the rise in the number of cases after initial lockdowns have been lifted. Our analysis explores the gradual diminishing value of mobility associations in the later stage of the outbreak. Our analysis indicates that the relationship between mobility and the increase in the number of cases, once lockdowns have been lifted, is tenuous at best and there is no strong relationship between these signals. But we identify the remnants of the last associations in specific phases of the growth curve., (© 2021. The Author(s).)

Objective: Integrating constructs from three prominent health behavior theories including the extended parallel process model, the health belief model, and the theory of planned behavior, this study seeks to identify sociopsychological factors that influenced American's intention to receive a COVID-19 vaccine., Method: An online survey was delivered to a U.S. sample (N = 934), assessing the influences of risk perception and fear associated with COVID-19, beliefs about and attitudes toward COVID-19 vaccines, self-efficacy, social and psychological contexts, and demographic characteristics on people's intention to get COVID-19 vaccines., Results: Most respondents intended to get vaccinated. However, they tended to underestimate their risks of contracting COVID-19. Disease exposure led to higher uptake intent via the mediation of fear. Safety concerns negatively influenced vaccination intention, while perceived community benefits were positively associated with vaccination intention. Positive attitudes toward vaccines and recent vaccine history were positively linked to vaccination intent., Conclusion: This study attests the effectiveness of HBT constructs in predicting people's intention to receive a COVID-19 vaccine., Practice Implications: The results point to the importance of fostering confidence in vaccine safety and countering overoptimism of individual susceptibility to the disease in interventions promoting COVID-19 vaccines uptake., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Fine particulate matter (PM 2.5 ) is suspected to increase the risk of colorectal cancer, but the mechanism remains unknown. We aimed to investigate the association between PM 2.5 exposure, genetic variants and colorectal cancer risk in the Prostate, Lung, Colon and Ovarian (PLCO) Cancer Screening trial., Methods: We included a prospective cohort of 139,534 cancer-free individuals from 10 United States research centers with over ten years of follow-up. We used a Cox regression model to assess the association between PM 2.5 exposure and colorectal cancer incidence by calculating the hazard ratio (HR) and 95% confidence interval (CI) with adjustment for potential confounders. The polygenic risk score (PRS) and genome-wide interaction analysis (GWIA) were used to evaluate the multiplicative interaction between PM 2.5 exposure and genetic variants in regard to colorectal cancer risk., Results: After a median of 10.43 years of follow-up, 1,666 participants had been diagnosed with colorectal cancer. PM 2.5 exposure was significantly associated with an increased risk of colorectal cancer (HR = 1.27; 95% CI = 1.17-1.37 per 5 μg/m 3 increase). Five independent susceptibility loci reached statistical significance at P < 1.22 × 10 -8 in the interaction analysis. Furthermore, a joint interaction was observed between PM 2.5 exposure and the PRS based on these five loci with colorectal cancer risk (P = 3.11 × 10 -29 ). The Gene Ontology analysis showed that the vascular endothelial growth factor (VEGF) receptor signaling pathway was involved in the biological process of colorectal cancer., Conclusions: Our large-scale analysis has shown for the first time that long-term PM 2.5 exposure potential increases colorectal cancer risk, which might be modified by genetic variants., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: Mandated social distancing has been applied globally to reduce the spread of coronavirus disease 2019 (COVID-19). However, the beneficial effects of this community-based intervention have not been proven or quantified for the COVID-19 pandemic., Study Design: This is a regional population-level observational study., Methods: Using publicly available data, we examined the effect of timing of mandated social distancing on the rate of COVID-19 cases in 119 geographic regions, derived from 41 states within the United States and 78 other countries. The highest number of new COVID-19 cases per day recorded within a geographic unit was the primary outcome. The total number of COVID-19 cases in regions where case numbers had reached the tail end of the outbreak was an exploratory outcome., Results: We found that the highest number of new COVID-19 cases per day per million persons was significantly associated with the total number of COVID-19 cases per million persons on the day before mandated social distancing (β = 0.66, P < 0.0001). These findings suggest that if mandated social distancing is not initiated until the number of existing COVID-19 cases has doubled, the eventual peak would result in 58% more COVID-19 cases per day. Subgroup analysis on those regions where the highest number of new COVID-19 cases per day has peaked showed increase in β values to 0.85 (P < 0.0001). The total number of cases during the outbreak in a region was strongly predicted by the total number of COVID-19 cases on the day before mandated social distancing (β = 0.97, P < 0.0001)., Conclusions: Initiating mandated social distancing when the numbers of COVID-19 cases are low within a region significantly reduces the number of new daily COVID-19 cases and perhaps also reduces the total number of cases in the region., (Copyright © 2020. Published by Elsevier Ltd.)

Climate change poses severe economic and public health threats to societies around the world. However, little is known about how selectively emphasizing its impacts on different issues and in different locations influence public engagement in climate change mitigation. Utilizing an experimental survey with adult participants, this study investigates the effect of issue framing and distance framing on risk perception and policy support related to climate change. The impacts of political ideology, environmental value, and belief in climate science on message effect are also examined. Based on the results of ANOVA (Analysis of Variance) and OLS (Ordinary Least Squares) regression, we found that compared with the economy frame, the public health frame led to greater polarization in risk perception and policy support between liberals and conservatives, and these relationships were mediated by environmental value and belief in climate science. Similarly, distance framing also increased ideological polarization in risk perception and policy support.

Coronavirus Disease 2019 (COVID-19) caused by the emerging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with a crude case fatality rate of about 0.5-10 % depending on locality. A few clinically approved drugs, such as remdesivir, chloroquine, hydroxychloroquine, nafamostat, camostat, and ivermectin, exhibited anti-SARS-CoV-2 activity in vitro and/or in a small number of patients. However, their clinical use may be limited by anti-SARS-CoV-2 50 % maximal effective concentrations (EC 50 ) that exceeded their achievable peak serum concentrations (Cmax), side effects, and/or availability. To find more immediately available COVID-19 antivirals, we established a two-tier drug screening system that combines SARS-CoV-2 enzyme-linked immunosorbent assay and cell viability assay, and applied it to screen a library consisting 1528 FDA-approved drugs. Cetilistat (anti-pancreatic lipase), diiodohydroxyquinoline (anti-parasitic), abiraterone acetate (synthetic androstane steroid), and bexarotene (antineoplastic retinoid) exhibited potent in vitro anti-SARS-CoV-2 activity (EC 50 1.13-2.01 μM). Bexarotene demonstrated the highest Cmax:EC 50 ratio (1.69) which was higher than those of chloroquine, hydroxychloroquine, and ivermectin. These results demonstrated the efficacy of the two-tier screening system and identified potential COVID-19 treatments which can achieve effective levels if given by inhalation or systemically depending on their pharmacokinetics., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Traumatic spinal cord injury (SCI) is a life-altering event. Motor vehicle accidents and falls are common causes of traumatic SCI, and SCI outcomes may be affected by patients' ages and injury sites. This study aimed to investigate the factors associated with unfavorable in-hospital outcomes, focusing on the impact of patients' ages and SCI lesion sites., Methods: Data of 25,988 patients hospitalized with traumatic SCI in the US National Inpatient Sample (NIS) database from 2005 to 2014 were extracted and analyzed. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with SCI outcomes, including in-hospital deaths, adverse discharge, and prolonged hospital stays., Results: Multivariate analysis revealed that the oldest ages (>65 years) were significantly associated with increased in-hospital mortality compared with the youngest ages at all lesion sites (cervical, odds ratio [OR]: 5.474, 95% confidence interval [CI]: 4.465 to 6.709; thoracic, OR: 5.940, 95% CI: 3.881 to 9.091; and lumbosacral, OR: 6.254, 95% CI: 2.920 to 13.394). Older ages were also significantly associated with increased adverse outcomes at all sites (cervical, OR: 2.460, 95% CI: 2.180 to 2.777; thoracic, OR: 2.347, 95% CI: 1.900 to 2.900; and lumbosacral, OR: 2.743, 95% CI: 2.133 to 3.527). Intermediate ages (35 to 64) were also significantly associated with increased in-hospital death and adverse discharge at cervical and thoracic SCIs, but not at lumbosacral sites., Discussion: For hospitalized patients with traumatic SCI, older age independently predicts worse in-hospital outcomes, with greatest effects seen in patients aged 65 years and older. Study findings suggest that extra vigilance and targeted management strategies are warranted in managing SCI patients aged 65 years and older during hospitalization.

Severe fever with thrombocytopenia syndrome virus (SFTSV) is an emerging tick-borne bunyavirus that causes severe disease in humans with case-fatality rates of up to 30%. There are currently very limited treatment options for SFTSV infection. We conducted a drug repurposing program by establishing a two-tier test system to rapidly screen a Food and Drug Administration- (FDA)-approved drug library for drug compounds with anti-SFTSV activity in vitro. We identified five drug compounds that inhibited SFTSV replication at low micromolar concentrations, including hexachlorophene, triclosan, regorafenib, eltrombopag, and broxyquinoline. Among them, hexachlorophene was the most potent with an IC 50 of 1.3 ± 0.3 µM and a selectivity index of 18.7. Mechanistic studies suggested that hexachlorophene was a virus entry inhibitor, which impaired SFTSV entry into host cells by interfering with cell membrane fusion. Molecular docking analysis predicted that the binding of hexachlorophene with the hydrophobic pocket between domain I and domain III of the SFTSV Gc glycoprotein was highly stable. The novel antiviral activity and mechanism of hexachlorophene in this study would facilitate the use of hexachlorophene as a lead compound to develop more entry inhibitors with higher anti-SFTSV potency and lower toxicity.

Objective: To quantify how changes in reporting of specific causes of death and of selecting underlying cause from among multiple causes of death contribute to trends in mortality from unintentional injury in Americans aged 65 years or older., Methods: We extracted age-standardized unintentional injury mortality data in the United States Centers for Disease Control and Prevention online databases from 1999 to 2016. We used an attribution method to calculate two indicators: the proportion of mortality with specific codes out of all mortality; and the proportion of mortality with underlying cause of death selected from multiple causes of death. We conducted a linear regression to examine the changes over time in these proportions and in reported and age-adjusted mortality., Findings: From 1999 through 2016, the proportion of cause-specific unintentional injury mortality in this age group increased from 74% in 1999 (136.9 out of 185.0 per 100 000 population) to 85% in 2016 (143.0 out of 169.1 per 100 000 population) based on multiple causes of death codes. The proportions of mortality with underlying cause of death selected out of multiple causes of death rose in all specific causes of unintentional injury except motor vehicle crash. Age-standardized mortality attributed to reporting changes increased steadily between 1999 and 2016. The increases for overall unintentional injury, fall, motor vehicle crash, suffocation, poisoning and fire or hot object were 24.2, 13.5, 2.1, 2.3, 1.6 and 0.4 deaths per 100 000 persons, respectively., Conclusion: Changes in data reporting affect trends in overall and specific unintentional injury mortality over time for older Americans.

Objectives: Cellphone use behaviours can vary demographically in the USA. This study examined whether legislation restricting cellphone use while driving was associated with lower self-reported hand-held cellphone conversations or texting behaviours among adult drivers of different ages (19-24, 25-39, 40-59,≥60 years), sex, race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, Other) or rurality (urban, rural)., Design: Cross-sectional study., Setting: USA., Participants: Individuals ≥19 years of age who indicated they were a current driver and participated in the 2011-2014 Traffic Safety Culture Index Surveys (n=9706)., Primary Outcome: The exposure was the presence of a hand-held calling or texting ban applicable to all drivers (ie, universal) at time of survey. Modified Poisson regression with robust SE was used to estimate the risk of engaging in these self-reported behaviours., Results: In fully adjusted models, universal texting bans were not associated with lower texting behaviours (adjusted risk ratio [aRR]=0.92; 95% CI 0.84, 1.01). In stratified, fully adjusted models, men and those of other racial/ethnic origin were 13% and 33% less likely, respectively (aRR=0.87; 95% CI 0.77, 0.98; aRR=0.67; 95% CI 0.46, 0.97), to engage in texting behaviours if a universal texting ban was effective in their state. Conversely, universal hand-held calling bans were associated with lower self-reported hand-held cellphone conversations across every sub-group. In fully adjusted models, the presence of a hand-held calling ban was associated with 40% lower (aRR=0.60, 95% CI 0.54, 0.67) self-reported hand-held cellphone conversations while driving., Conclusions: Universal hand-held calling bans were associated with lower self-reported cellphone conversations for adult drivers. More interventional work targeting adult drivers may be needed to reduce texting while driving., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Globalization prompts remote acculturation toward U.S. culture in Jamaica; this study used a bioecological systems approach to examine its proximal impact on nutrition through U.S. cable TV consumption, and maternal influences in the home. Overall, 330 randomly selected adolescent-mother dyads from schools in Kingston, Jamaica (M adolescent&#95;age  = 13.8 years, SD adolescent&#95;age  = 1.8) completed questionnaires reporting American identity and behavioral preferences, daily time spent watching U.S.-produced TV programs, and frequency of eating unhealthy foods. Actor-partner interdependence models revealed that girls' American identity/behavior directly predicted their unhealthy eating, whereas girls' mothers and boys' American identity/behavior indirectly predicted unhealthy eating as mediated by their U.S. TV hours. Additionally, mothers' American identity/behavior predicted daughters' unhealthy eating as mediated by mothers' U.S. TV hours. Remote acculturation theory may facilitate more targeted research and prevention/intervention., (© 2017 The Authors. Child Development © 2017 Society for Research in Child Development, Inc.)

Purpose: The relationship between cellphone use while driving legislation and self-reported adolescent driver behavior is poorly understood, especially across demographic subgroups. This study investigated the relationship between statewide cellphone legislation and cellphone use behaviors across adolescent driver subgroups, including age (16/17 vs. 18), sex, race/ethnicity (white non-Hispanic and others), and rurality (urban or rural)., Methods: Data from the 2011-2014 Traffic Safety Culture Index Surveys were combined with state legislation. The outcomes were self-reported texting and handheld cellphone conversations. The exposure was the presence of a texting or handheld cellphone ban applicable to all drivers (i.e., universal) in the drivers' state of residence. A multilevel, modified Poisson regression model was used to estimate the risk of engaging in these behaviors., Results: Approximately 34% of respondents reported to have driven while conversing, and 37% texted and drove in the 30 days before the survey. Universal handheld calling bans were associated with lower occurrences of cellphone conversations across all groups except rural drivers. Overall, handheld cellphone bans were associated with 55% lower (adjusted risk ratio .45, 95% confidence interval .32-.63) occurrences of cellphone conversations. However, universal texting bans were not associated with fewer texting behaviors in any subgroup., Conclusions: Universal handheld calling bans may discourage adolescents from engaging in handheld phone conversations, whereas universal texting bans may not fully discourage texting behaviors. More interventional or educational work is necessary, particularly addressing texting while driving., (Copyright © 2018 The Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Unlike the United States, where human papillomavirus (HPV) vaccines have been available for decades, China recently approved its first HPV vaccines. Setting up a baseline comparison between these two countries, this study examines the influence of message framing, motivational orientation, cultural worldview, knowledge, and gender on young adults' intentions to get vaccinated. Compared to the U.S. participants, Chinese participants perceived HPV as a more severe risk and were more willing to get the vaccine. However, they were also more skeptical about vaccine safety. Inconsistencies with previous research emerged regarding the moderating effects of motivational orientation and cultural worldview. Findings from this study offer important implications for HPV vaccine promotion in China.

Background: To illustrate the 10-year risks of urinary adverse events (UAEs) among men diagnosed with prostate cancer and treated with different types of therapy, accounting for the competing risk of death., Methods: Prostate cancer is the second most common malignancy among adult males in the United States. Few studies have reported the long-term post-treatment risk of UAEs and those that have, have not appropriately accounted for competing deaths. This paper conducts an inverse probability of treatment (IPT) weighted competing risks analysis to estimate the effects of different prostate cancer treatments on the risk of UAE, using a matched-cohort of prostate cancer/non-cancer control patients from the Surveillance, Epidemiology and End Results (SEER) Medicare database., Results: Study dataset included men age 66 years or older that are 83% white and had a median follow-up time of 4.14 years. Patients that underwent combination radical prostatectomy and external beam radiotherapy experienced the highest risk of UAE (IPT-weighted competing risks: HR 3.65 with 95% CI (3.28, 4.07); 10-yr. cumulative incidence = 36.5%)., Conclusions: Findings suggest that IPT-weighted competing risks analysis provides an accurate estimator of the cumulative incidence of UAE taking into account the competing deaths as well as measured confounding bias.

Purpose: Cervical cancer treatment is associated with a risk of urinary adverse events (UAEs) such as ureteral stricture and vesicovaginal fistula. We sought to measure the long-term UAE risk after surgery and radiation therapy (RT), with confounding controlled through propensity-weighted models., Methods and Materials: From the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified women ≥66 years old with nonmetastatic cervical cancer treated with simple surgery (SS), radical hysterectomy (RH), external beam RT plus brachytherapy (EBRT+BT), or RT+surgery. We matched them to noncancer controls 1:3. Differences in demographic and cancer characteristics were balanced by propensity weighting. Grade 3 to 4 UAEs were identified by diagnosis codes plus treatment codes. Cumulative incidence was measured using Kaplan-Meier methods. The hazard associated with different cancer treatments was compared using Cox models., Results: UAEs occurred in 272 of 1808 cases (17%) and 222 of 5424 (4%) controls; most (62%) were ureteral strictures. The raw cumulative incidence of UAEs was highest in advanced cancers. UAEs occurred in 31% of patients after EBRT+BT, 25% of patients after RT+surgery, and 15% of patients after RH; however, after propensity weighting, the incidence was similar. In adjusted Cox models (reference = controls), the UAE risk was highest after RT+surgery (hazard ratio [HR], 5.07; 95% confidence interval [CI], 2.32-11.07), followed by EBRT+BT (HR, 3.33; 95% CI, 1.45-7.65), RH (HR, 3.65; 95% CI, 1.41-9.46) and SS (HR, 0.99; 95% CI, 0.32-3.01). The higher risk after RT+surgery versus EBRT+BT was statistically significant, whereas, EBRT+BT and RH were not significantly different from each other., Conclusions: UAEs are common after cervical cancer treatment, particularly in patients with advanced cancers. UAEs are more common after RT, but these women tend to have the advanced cancers. After propensity weighting, the risk after RT was similar to that after surgery., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Prostate cancer is the second most common cancer in men and has high survivorship, yet little is known about the long-term risk of urinary adverse events (UAEs) after treatment., Objective: To compare the long-term UAE incidence across treatment and control groups., Design, Setting, and Participants: Using a matched-cohort design, we identified elderly men treated with external-beam radiotherapy (EBRT; n=44 318), brachytherapy (BT; n=14 259), EBRT+BT (n=11 835), radical prostatectomy (RP; n=26 970), RP+EBRT (n=1557), or cryotherapy (n=2115) for non-metastatic prostate cancer and 144 816 non-cancer control individuals from the population-based Surveillance, Epidemiology, and End Results-Medicare linked data from 1992-2007 with follow-up through 2009., Outcome Measures and Statistical Analysis: The incidence of treated UAEs and time from cancer treatment to first UAE were analyzed in terms of propensity-weighted survival., Results: Median follow-up was 4.14 yr. At 10 yr, all treatment groups experienced higher propensity-weighted cumulative UAE incidence than the control group (16.1%; hazard risk [HR] 1.0), with the highest incidence for RP+EBRT (37.8%; HR 3.19, 95% confidence interval [CI] 2.79-3.66), followed by BT+EBRT (28.4%; HR 1.97, CI 1.85-2.10), RP (26.6%; HR 2.44, CI 2.34-2.55), cryotherapy (23.4%; HR 1.56, CI 1.30-1.87), BT (19.8%; HR 1.43, CI 1.33-1.53), and EBRT (19.7%; HR 1.11, CI 1.07-1.16). Bladder outlet obstruction was the most common event., Conclusions: Men undergoing RP, RP+EBRT, and BT+EBRT experienced the highest UAE risk at 10 yr, although UAEs accrued differently over extended follow-up. The significant background UAE rate among non-cancer control individuals yields a risk attributable to prostate cancer treatment that is 17% lower than prior estimates., Patient Summary: We show that treatment for prostate cancer, especially combinations of two treatments such as radiation and surgery, carries a significant risk of urinary adverse events such as urethral stricture. This risk increases with time since treatment, emphasizing that treatments have long-term effects., (Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Allergic sensitization is a risk factor for asthma and allergic diseases. The relationship between ambient air pollution and allergic sensitization is unclear., Objective: To investigate the relationship between ambient air pollution and allergic sensitization in a nationally representative sample of the US population., Methods: We linked annual average concentrations of nitrogen dioxide (NO2), particulate matter ≤10 μm (PM10), particulate matter ≤2.5 μm (PM2.5), and summer concentrations of ozone (O3), to allergen-specific immunoglobulin E (IgE) data for participants in the 2005-2006 National Health and Nutrition Examination Survey (NHANES). In addition to the monitor-based air pollution estimates, we used the Community Multiscale Air Quality (CMAQ) model to increase the representation of rural participants in our sample. Logistic regression with population-based sampling weights was used to calculate adjusted prevalence odds ratios per 10 ppb increase in O3 and NO2, per 10 μg/m(3) increase in PM10, and per 5 μg/m(3) increase in PM2.5 adjusting for race, gender, age, socioeconomic status, smoking, and urban/rural status., Results: Using CMAQ data, increased levels of NO2 were associated with positive IgE to any (OR 1.15, 95% CI 1.04, 1.27), inhalant (OR 1.17, 95% CI 1.02, 1.33), and indoor (OR 1.16, 95% CI 1.03, 1.31) allergens. Higher PM2.5 levels were associated with positivity to indoor allergen-specific IgE (OR 1.24, 95% CI 1.13, 1.36). Effect estimates were similar using monitored data., Conclusions: Increased ambient NO2 was consistently associated with increased prevalence of allergic sensitization., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Our goal was to study the prevalence of systemic sclerosis (SSc) subtypes, autoantibody profile, and pulmonary fibrosis in a large group of Han Chinese. Chinese SSc patients (n = 419) were recruited from a multicenter study including hospitals and outpatient clinics in China. All patients met the American College of Rheumatology classification criteria for SSc. Anti-topoisomerase (ATA), anti-centromere (ACA), anti-RNA polymerase III (anti-RNAP3), and anti-U1-ribonucleoprotein (anti-U1RNP) were detected utilizing commercially available kits. The clinical and autoantibody information in Chinese patients was compared to that in the US Caucasian patients (n = 834), recruited from the Genetics versus Environment in Scleroderma Outcome Study and Scleroderma Family Registry. Chi-square test was utilized for the abovementioned comparisons. Chinese patients showed 40.3 % limited (lcSSc) and 59.7 % diffuse (dcSSc) forms of SSc. ATA was found in 59.9 %, ACA in 13.4 %, anti-RNAP3 in 1.3 %, and anti-U1RNP in 18 % of Chinese SSc patients. Compared to US patients (65.1 % lcSSc, 34.9 % dcSSc, ATA in 18.7 %, ACA in 32.4 %, anti-RNAP3 in 17.4 %, and anti-U1RNP in 2.8 %), Chinese SSc patients are significantly higher in dcSSc and the frequencies of ATA and anti-U1RNP, but lower in ACA and anti-RNAP3. In addition, pulmonary fibrosis was observed in 78 % Chinese SSc patients and was strongly associated with the presence of ATA. The present study represents the first report of SSc features in a large group of Chinese patients. Clinical subtypes and the frequencies of SSc-related autoantibodies in Chinese SSc patients are significantly different from those in SSc patients of the US Caucasian descent.

We employed the parametric G formula to analyze lung cancer mortality in a cohort of textile manufacturing workers who were occupationally exposed to asbestos in South Carolina. A total of 3,002 adults with a median age of 24 years at enrollment (58% male, 81% Caucasian) were followed for 117,471 person-years between 1940 and 2001, and 195 lung cancer deaths were observed. Chrysotile asbestos exposure was measured in fiber-years per milliliter of air, and annual occupational exposures were estimated on the basis of detailed work histories. Sixteen percent of person-years involved exposure to asbestos, with a median exposure of 3.30 fiber-years/mL among those exposed. Lung cancer mortality by age 90 years under the observed asbestos exposure was 9.44%. In comparison with observed asbestos exposure, if the facility had operated under the current Occupational Safety and Health Administration asbestos exposure standard of <0.1 fibers/mL, we estimate that the cohort would have experienced 24% less lung cancer mortality by age 90 years (mortality ratio = 0.76, 95% confidence interval: 0.62, 0.94). A further reduction in asbestos exposure to a standard of <0.05 fibers/mL was estimated to have resulted in a minimal additional reduction in lung cancer mortality by age 90 years (mortality ratio = 0.75, 95% confidence interval: 0.61, 0.92).

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.

Study Objective: We examine whether using public National Hospital Ambulatory Medical Care Survey (NHAMCS) data with masked design variables produces different estimates, standard errors, and confidence intervals (CIs) for the temporal trend of overall and injury-related emergency department (ED) visits compared with using unmasked data housed at the Centers for Disease Control and Prevention., Methods: We obtained counts of ED visits with their standard errors for unmasked data from published summaries from 1999 through 2006. Public files with masked design variables were used to estimate visit counts and rates with standard errors for each year, using the Taylor series linearization method. Weighted least squares linear regressions were used for trend analysis to estimate the annual change in visits., Results: Compared with using unmasked data, using masked data produced similar estimates of overall ED visit counts and rates for each year from 1999 through 2006 but overestimated standard errors by 27% on average (range 12% to 45%). According to unmasked data, overall ED visit counts increased by 1.973 million annually (standard error 0.747; 95% CI 0.505 to 3.440 million [corrected] ). With masked data, the estimated change was 1.977 million visits annually (standard error 0.894; 95% CI -0.221 to 3.733 million [corrected] ). As for injury-related ED visit counts, masked data overestimated the standard error by 16% for trend. Although neither unmasked nor masked data suggested a statistically significant annual increase of overall or injury-related ED visit rate, masked data overestimated the standard error by 16%., Conclusion: Using masked public data overestimated standard errors for trend of counts and rates for overall and injury-related ED visits and resulted in wider CIs., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

In occupational case-control studies, work-related exposure assessments are often fallible measures of the true underlying exposure. In lieu of a gold standard, often more than 2 imperfect measurements (e.g. triads) are used to assess exposure. While methods exist to assess the diagnostic accuracy in the absence of a gold standard, these methods are infrequently used to correct for measurement error in exposure-disease associations in occupational case-control studies. Here, we present a likelihood-based approach that (a) provides evidence regarding whether the misclassification of tests is differential or nondifferential; (b) provides evidence whether the misclassification of tests is independent or dependent conditional on latent exposure status, and (c) estimates the measurement error-corrected exposure-disease association. These approaches use information from all imperfect assessments simultaneously in a unified manner, which in turn can provide a more accurate estimate of exposure-disease association than that based on individual assessments. The performance of this method is investigated through simulation studies and applied to the National Occupational Hazard Survey, a case-control study assessing the association between asbestos exposure and mesothelioma.

The widely used Cox proportional hazards regression model for the analysis of censored survival data has limited utility when either hazard functions themselves are of primary interest, or when relative times instead of relative hazards are the relevant measures of association. Parametric regression models are an attractive option in situations such as this, although the choice of a particular model from the available families of distributions can be problematic. The generalized gamma (GG) distribution is an extensive family that contains nearly all of the most commonly used distributions, including the exponential, Weibull, log normal and gamma. More importantly, the GG family includes all four of the most common types of hazard function: monotonically increasing and decreasing, as well as bathtub and arc-shaped hazards. We present here a taxonomy of the hazard functions of the GG family, which includes various special distributions and allows depiction of effects of exposures on hazard functions. We applied the proposed taxonomy to study survival after a diagnosis of clinical AIDS during different eras of HIV therapy, where proportionality of hazard functions was clearly not fulfilled and flexibility in estimating hazards with very different shapes was needed. Comparisons of survival after AIDS in different eras of therapy are presented in terms of both relative times and relative hazards. Standard errors for these and other derived quantities are computed using the delta method and checked using the bootstrap. Description of standard statistical software (Stata, SAS and S-Plus) for the computations is included and available at http://statepi.jhsph.edu/software.

Prevalent biologic specimens can be used to estimate human immunodeficiency virus (HIV) incidence using a two-stage immunologic testing algorithm that hinges on the average time, T, between testing HIV-positive on highly sensitive enzyme immunoassays and testing HIV-positive on less sensitive enzyme immunoassays. Common approaches to confidence interval (CI) estimation for this incidence measure have included 1) ignoring the random error in T or 2) employing a Bonferroni adjustment of the box method. The authors present alternative Monte Carlo-based CIs for this incidence measure, as well as CIs for the biomarker-based incidence difference; standard approaches to CIs are typically appropriate for the incidence ratio. Using American Red Cross blood donor data as an example, the authors found that ignoring the random error in T provides a 95% CI for incidence as much as 0.26 times the width of the Monte Carlo CI, while the Bonferroni-box method provides a 95% CI as much as 1.57 times the width of the Monte Carlo CI. Further research is needed to understand under what circumstances the proposed Monte Carlo methods fail to provide valid CIs. The Monte Carlo-based CI may be preferable to competing methods because of the ease of extension to the incidence difference or to exploration of departures from assumptions.

Background: The authors show how information collected on retrospective occurrence times may be combined with prospective occurrence times in the analysis of recurrent events from cohort studies., Methods: We demonstrate how the observed data can be expanded from one to two records per participant and account for the within-individual dependence when estimating variances. We illustrate our methods using data from the Women's Interagency HIV Study, which recorded 384 retrospective and 352 prospective occurrences of pneumonia in 9478 retrospective and 7857 prospective person-years among 2610 adult women., Results: The hazard of non-Pneumocystis carinii pneumonia among the 2056 HIV-1 infected women was 2.24 times (95% confidence limits: 1.74, 2.89) that of the 554 uninfected women, independent of age. This hazard ratio was homogeneous across retrospective and prospective occurrences (P for interaction = 0.96) and combining occurrence types increased the precision by reducing the standard error by about a fourth., Conclusions: As expected, HIV-1 infection increases the hazard of pneumonia, with more precise inference obtained by combining information available on bidirectional occurrences. The proposed method for the analysis of bidirectional occurrence times will improve precision when the estimated associations are homogeneous across occurrence types, or may provide added insight into either the data collection or disease process when the estimated associations are heterogeneous.

Study Objective: To assess whether HIV RNA levels (log(10) scale) in highly active antiretroviral therapy (HAART) treated population have a bimodal distribution, suggesting optimal or suboptimal response to HAART., Methods: The study population from two ongoing cohort studies comprised 564 men (4785 person visits) and 1173 women (8675 person visits) with known dates of HAART initiation and with HIV RNA measurements before and after initiation. Values below detection limit of assays were treated in the analysis as left censored. Maximum likelihood methods were used to estimate parameters and to determine possible bimodality of HIV RNA distributions., Results: A two component mixture model fitted HIV RNA levels significantly better than did a single component distribution at different years from HAART initiation in both therapy experienced and therapy naive patients. In the fifth year after HAART initiation, 32% of men and 44% of women had HIV RNA in the higher component with medians of 5247 and 9253 copies/ml, respectively, suggesting suboptimal virological response to HAART, which was associated with poor adherence and lower frequency of CCR5 heterozygous genotype., Conclusion: The bimodal distribution of HIV RNA persisted during the years after HAART initiation. The high occurrence of suboptimal virological response at the fifth year after HAART initiation underscore the needs for careful monitoring and patient education about the importance of treatment adherence. This data analysis overcomes limitations of measurement techniques of observations having values below detection limits and serves to characterise the dynamics of the virological response to therapies.

The authors evaluated population- and individual-level CD4-positive T-lymphocyte (CD4 cell) count trajectories over a 7-year period (July 1995-March 2004) following initiation of highly active antiretroviral therapy (HAART) in the Multicenter AIDS Cohort Study and the Women's Interagency HIV Study. The study population included 404 human immunodeficiency virus (HIV)-infected men and 609 HIV-infected women who 1) had a CD4 cell count measurement available from their last pre-HAART study visit, 2) provided at least four post-HAART CD4 cell count measurements, and 3) reported HAART usage for at least 80% of the post-HAART visits. The CD4 cell count trajectory was analyzed by means of a Bayesian random change-point model. The results indicated that CD4 cell count trajectories for long-term frequent HAART users can be well modeled with change points at both the population and individual levels. At the population level, regardless of CD4 cell count before HAART initiation, the gains in CD4 cell count ended approximately 2 years after HAART initiation in both men and women. At the individual level, 35% of men in the Multicenter AIDS Cohort Study versus 25% of women in the Women's Interagency HIV Study had a statistically significant change in CD4 cell count trajectory within 7 years after HAART initiation.

Context: In the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS)-Thrombolysis in Myocardial Infarction (TIMI) 18 trial, patients with either unstable angina or non-ST-segment elevation myocardial infarction (UA/NSTEMI) treated with the platelet glycoprotein (Gp IIb/IIIa) inhibitor tirofiban had a significantly reduced rate of major cardiac events at 6 months with an early invasive vs a conservative strategy., Objective: To examine total 6-month costs and long-term cost-effectiveness of an invasive vs a conservative strategy., Design: Randomized controlled trial including a priori economic end points., Setting: Hospitalization for UA/NSTEMI with 6-month follow-up period., Patients: A total of 2220 patients with UA/NSTEMI; economic data from 1722 patients at US-non-VA hospitals., Intervention: Early invasive strategy with routine catheterization and revascularization as appropriate vs a conservative strategy with catheterization performed only for recurrent ischemia or a positive stress test., Main Outcome Measure: Total 6-month costs and incremental cost-effectiveness ratio., Results: The average initial hospitalization costs among those in the invasive strategy group were $15714 vs $14047 among those in the conservative strategy group, a difference of $1667 (95% confidence interval [CI], $387-3091). The in-hospital costs were offset significantly at the 6-month follow-up, with an average cost in the invasive group of $6098 vs $7180 in the conservative group, a difference of $1082 (95% CI, -$2051 to $76). The average total costs at 6 months, including productivity costs, for the invasive group was $21 813 vs $21 227 for the conservative group, a $586 difference (95% CI, -$1087 to $2486). The average 6-month costs excluding productivity costs in the invasive group was $19 780 vs $19 111 in the conservative group, a difference of $670, 95% CI; (-$1035 to $2321). Estimated cost per year of life gained for the invasive strategy, based on projected life expectancy, was $12739 for the base case, and ranged from $8371 to $25769, based on model assumptions., Conclusions: In patients with UA/NSTEMI treated with the Gp IIb/IIIa inhibitor tirofiban, the clinical benefit of an early invasive strategy was achieved with a small increase in cost, yielding favorable projected estimates of cost per year of life gained. These results support the broader use of an early invasive strategy in these patients.

Objective: To determine the percentage of patients in the multicenter Lipid Treatment Assessment Project receiving lipid-lowering therapy who are achieving low-density lipoprotein cholesterol (LDL-C) goals as defined by National Cholesterol Education Program (NCEP) guidelines., Methods: Adult patients with dyslipidemia, who had been receiving the same lipid-lowering therapy for at least 3 months, were assessed at investigation sites. Lipid levels were determined once in each patient at the time of enrollment. The primary end point was the success rate, defined as the proportion of patients who achieved their LDL-C target level as specified by NCEP guidelines., Results: A total of 4888 patients from 5 regions of the United States were studied. Of these, 23% had fewer than 2 risk factors for coronary heart disease (CHD) and no evidence of CHD (low-risk group), 47% had 2 or more risk factors and no evidence of CHD (high-risk group), and 30% had established CHD. Overall, only 38% of patients achieved NCEP-specified LDL-C target levels; success rates were 68% among low-risk patients, 37% among high-risk patents, and 18% among patients with CHD. Drug therapy was significantly (P< or =.001) more effective than nondrug therapy in all patient risk groups. However, many patients treated with lipid-lowering drugs did not achieve LDL-C target levels., Conclusions: Large proportions of dyslipidemic patients receiving lipid-lowering therapy are not achieving NCEP LDL-C target levels. These findings indicate that more aggressive treatment of dyslipidemia is needed to attain goals established by NCEP guidelines.