Interpretation of the Pattern in Rate Ratios Across Strata

The pattern in the ratio of disease rates over strata is a summary statistic used to describe the changing risk of disease in one group relative to another. While patterns of the ratios of disease rates over strata appear to correspond to specific changes in disease rates, plots of the disease rates over strata seem to contradict the information yielded by the ratios. For example, if disease rates from populations A and B have identical rates of decline (parallel lines), the difference in the rates (A - B) at each strata remains constant, while the ratio of the rates (AIB) increases over strata. Through simple algebraic manipulation, one can show that the pattern of the rate ratio is a function of the rate difference relative to the endemic disease rate. Thus, rather than describing the behavior of the disease rates, ratio patterns reflect the importance of exposure relative to the disease rate in the unexposed population

Identifying factors affecting diabetes education program participation within a metro Detroit integrated health system

Diabetes self-management education and support (DSMES) can help people achieve optimal disease control, yet these services often remain underutilized. People referred to these programs by their provider can become disengaged in the program at several key steps. This study applies Classification and Regression Tree analysis to 3796 people with diabetes at a single health system based in the Detroit metropolitan area who were referred for DSMES provided by the health system to determine demographic patterns of those who were successfully contacted to schedule program intake appointments, those who did not attend their intake appointment, and those who began but did not complete their personalized DSMES program. White people \u3e 43 years of age, those with a prior A1C value \u3e 8.9 and those with Medicaid insurance had the highest rate of not being successfully contacted for their intake appointment. Those who did not attend their intake appointment tended to have Medicaid insurance, be younger than 48 years, and have A1C \u3e 8.1. Within the Medicare or private insurance groups, those who did not attend were more likely to be female, of Black race and not partnered. Older males with a lower A1C (≤8.3%) had the lowest rate (34.0%) of failing to complete their DSMES plan. The data showed that almost half of those referred were not successfully contacted. The overall low completion rate of 13.2% confirms the need to examine factors predictive of participation and completion. This study highlights process improvement changes to improve personalization of outreach and engagement

Increased risk of asthma at age 10 years for children sensitized to multiple allergens

BACKGROUND: Childhood sensitization patterns have been previously found to be related to variable risk of early life allergic disease in several birth cohorts. OBJECTIVE: To determine whether these risks persist into later childhood. METHODS: In the birth cohort of the Wayne County Health, Environment, Allergy and Asthma Longitudinal Study, previous latent class analysis based on sensitization to 10 allergens found the following 4 early life sensitization patterns at age 2 years: highly sensitized, milk/egg dominated, peanut and inhalant(s), and low to no sensitization. At an age 10 study-specific visit, children were evaluated by an allergist for current asthma and atopic dermatitis through a physical examination and interviews with the child and parent or guardian. Total and specific immunoglobulin E (IgE), spirometry, and methacholine challenge were also completed. RESULTS: Compared with children sensitized to none or 1 allergen, children sensitized to 4 or more food and inhalant allergens at age 2 had the highest risk of current asthma (relative risk [RR], 4.42; 95% confidence interval [CI], 2.58-7.59; P \u3c .001) and bronchial hyperresponsiveness (RR, 1.77; 95% CI, 1.29-2.42; P \u3c .001). In addition, they had the highest levels of total IgE (geometric mean, 800 IU/mL; 95% CI, 416-1536) among the 4 groups. Risk of current atopic dermatitis did not depend on pattern of sensitization but remained increased for children with any sensitization (RR, 2.23; 95% CI, 1.40-3.55; P \u3c .001). No differences in spirometry (forced expiratory volume in 1 second, forced expiratory flow between 25% and 75%, and forced expiratory volume in 1 second/forced vital capacity) were identified. CONCLUSION: The previously reported importance of a specific pattern of sensitization in early life (sensitization to ≥4 inhalant and food allergens) continues to be associated with an increased risk of asthma, bronchial hyperresponsiveness, and high total IgE at age 10 years

Exploring the impact of elevated depressive symptoms on the ability of a tailored asthma intervention to improve medication adherence among urban adolescents with asthma

BACKGROUND: In patients with asthma, medication adherence is a voluntary behavior that can be affected by numerous factors. Depression is an important co-morbidity in adolescents with asthma that may significantly impact their controller medication adherence and other asthma-related outcomes. The modifying effect of depressive symptoms on an asthma intervention’s ability to improve asthma controller medication adherence among urban adolescents with asthma has not yet been reported. OBJECTIVE: To assess self-reported symptoms of depression as an effect modifier of the relationship between randomization group and controller medication adherence at 6-month follow-up. METHODS: These analyses use data from a randomized controlled trial (RCT) conducted in Detroit high schools to evaluate a tailored asthma management program. The intervention included referrals to school or community resources for students reporting symptoms of depression and other issues. “Elevated depressive symptoms” was defined as a positive answer to ≥ 5 of 7 questions from a validated tool included on the baseline questionnaire. Self-reported adherence to controller medication was collected at intervention onset (session 1) and at 6-month follow up. Analyses were restricted to students with report of a controller medication at baseline. Logistic regression was used to assess elevated depressive symptoms as an effect modifier of the relationship between randomization group and 6-month adherence. RESULTS: Of the 422 students enrolled in the RCT, a controller medication was reported at intervention onset by n = 123 adolescents (29%). Analyzing this group, we observed an interaction between elevated depressive symptoms and adherence (p = 0.073). Stratified analysis showed better adherence in treatment group adolescents meeting criteria for elevated depressive symptoms at baseline as compared to the control group (adjusted Odds Ratio [aOR] = 9.50; p = 0.024). For adolescents without elevated depressive symptoms at baseline, differences in adherence by group assignment did not reach statistical significance (aOR 1.40, p = 0.49). CONCLUSIONS: In this sample of students reporting controller medications at baseline, report of elevated depressive symptoms at baseline and randomization to the intervention group was associated with significantly better adherence at 6-month follow up when compared to that of a control group. Larger studies are needed to evaluate the impact of depression on the relationship between adherence and asthma intervention effectiveness

Infant Feeding Practices and Subsequent Dietary Patterns of School-Aged Children in a US Birth Cohort

BACKGROUND: Infant feeding practices are thought to shape food acceptance and preferences. However, few studies have evaluated whether these affect child diet later in life. OBJECTIVE: The study objective was to examine the association between infant feeding practices and dietary patterns (DPs) in school-aged children. DESIGN: A secondary analysis of data from a diverse prospective birth cohort with 10 years of follow-up (WHEALS [Wayne County Health Environment Allergy and Asthma Longitudinal Study]) was conducted. PARTICIPANTS/SETTING: Children from the WHEALS (Detroit, MI, born 2003 through 2007) who completed a food screener at age 10 years were included (471 of 1,258 original participants). MAIN OUTCOME MEASURES: The main outcome was DPs at age 10 years, identified using the Block Kids Food Screener. STATISTICAL ANALYSIS PERFORMED: Latent class analysis was applied for DP identification. Breastfeeding and age at solid food introduction were associated with DPs using a 3-step approach for latent class modeling based on multinomial logistic regression models. RESULTS: The following childhood DPs were identified: processed/energy-dense food (35%), variety plus high intake (41%), and healthy (24%). After weighting for loss to follow-up and covariate adjustment, compared with formula-fed children at 1 month, breastfed children had 0.41 times lower odds of the processed/energy-dense food DP vs the healthy DP (95% CI 0.14 to 1.25) and 0.53 times lower odds of the variety plus high intake DP (95% CI 0.17 to 1.61), neither of which were statistically significant. Results were similar, but more imprecise, for breastfeeding at 6 months. In addition, the association between age at solid food introduction and DP was nonsignificant, with each 1-month increase in age at solid food introduction associated with 0.81 times lower odds of the processed/energy-dense food DP relative to the healthy DP (95% CI 0.64 to 1.02). CONCLUSIONS: A significant association between early life feeding practices and dietary patterns at school age was not detected. Large studies with follow-up beyond early childhood that can also adjust for the multitude of potential confounders associated with breastfeeding are needed

Association of citrulline concentration at birth with lower respiratory tract infection in infancy: Findings from a multi-site birth cohort study

Assessing the association of the newborn metabolic state with severity of subsequent respiratory tract infection may provide important insights on infection pathogenesis. In this multi-site birth cohort study, we identified newborn metabolites associated with lower respiratory tract infection (LRTI) in the first year of life in a discovery cohort and assessed for replication in two independent cohorts. Increased citrulline concentration was associated with decreased odds of LRTI (discovery cohort: aOR 0.83 [95% CI 0.70-0.99], p = 0.04; replication cohorts: aOR 0.58 [95% CI 0.28-1.22], p = 0.15). While our findings require further replication and investigation of mechanisms of action, they identify a novel target for LRTI prevention and treatment

Comparison of early-, late-, and non-participants in a school-based asthma management program for urban high school students

<p>Abstract</p> <p>Background</p> <p>To assess bias and generalizability of results in randomized controlled trials (RCT), investigators compare participants to non-participants or early- to late-participants. Comparisons can also inform the recruitment approach, especially when working with challenging populations, such as urban adolescents. In this paper, we describe characteristics by participant status of urban teens eligible to participate in a RCT of a school-based, web-based asthma management program.</p> <p>Methods</p> <p>The denominator for this analysis was all students found to be eligible to participate in the RCT. Data were analyzed for participants and non-participants of the RCT, as well as for students that enrolled during the initially scheduled recruitment period (early-participants) and persons that delayed enrollment until the following fall when recruitment was re-opened to increase sample size (late-participants). Full Time Equivalents (FTEs) of staff associated with recruitment were estimated.</p> <p>Results</p> <p>Of 1668 teens eligible for the RCT, 386 enrolled early, and 36 enrolled late, leaving 1246 non-participants. Participants were younger (p < 0.01), more likely to be diagnosed, use asthma medication, and have moderate-to-severe disease than non-participants, odds ratios (95% Confidence Intervals) = 2.1(1.7-2.8), 1.7(1.3-2.1), 1.4(1.0-1.8), respectively. ORs were elevated for the association of late-participation with Medicaid enrollment, 1.9(0.7-5.1) and extrinsic motivation to enroll, 1.7(0.6-5.0). Late-participation was inversely related to study compliance for teens and caregivers, ORs ranging from 0.1 to 0.3 (all p-values < 0.01). Early- and late-participants required 0.45 FTEs/100 and 3.3 FTEs/100, respectively.</p> <p>Conclusions</p> <p>Recruitment messages attracted youth with moderate-to-severe asthma, but extending enrollment was costly, resulting in potentially less motivated, and certainly less compliant, participants. Investigators must balance internal versus external validity in the decision to extend recruitment. Gains in sample size and external validity may be offset by the cost of additional staff time and the threat to internal validity caused by lower participant follow-up.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00201058">NCT00201058</a></p

Association Between Body Mass Index and Patient-Centered Outcomes After Hysterectomy.

OBJECTIVE: To assess whether body mass index (BMI) was associated with self-reported pain, well-being, or procedure satisfaction in the 3 months after hysterectomy. STUDY DESIGN: Prospective cohort study that recruited women undergoing hysterectomy. Data was collected over 1 year for 245 women. RESULTS: BMI was not associated with pain either at baseline or in the 3 months after surgery versus no pain; odds ratio [OR] = 1.0, 95% confidence interval [CI] 0.97-1.03, p = 0.88 for a 1 unit increase in BMI) or being fully satisfied with the procedure (versus not fully satisfied; OR = 1.01, 95% CI 0.97-1.04, p = 0.77 for a 1unit increase in BMI). Similarly, patient\u27s perception of well-being was also not influenced by BMI as reflected in their well-being score (0.98 increase in score, 95% CI 0.95-1.02, p = 0.40, for a 1-unit increase in BMI). CONCLUSION: The data from this prospectively studied cohort of women who had undergone hysterectomy suggest that BMI is not associated with self-report of pain, well-being, -or procedure satisfaction in the 3 month after surgery

Myomectomy to conserve fertility: seven-year follow-up

OBJECTIVE: To observe the occurrence of pregnancy in women undergoing minimally invasive and open myomectomy for symptoms attributed to uterine fibroids and who desire future pregnancy. METHODS: We performed a retrospective chart review of women who had undergone myomectomy at least two years previously within the Henry Ford Health System in Detroit, MI. We reviewed the subsequent fertility outcomes according to the fertility goals identified by each woman. RESULTS: During the seven-year observation window, 310 women underwent myomectomy and 124 (40%) of these women desired pregnancy. Forty-nine women desiring pregnancy (40%) conceived, and 30 (61% of those who conceived) delivered a viable infant from their first pregnancy. In addition, two women had a live birth after a miscarriage, and one had a live birth after an ectopic pregnancy. Five women had a second live-born baby. There were no differences in the occurrence of pregnancy or pregnancy outcome according to surgical approach, patient age or race, number of uterine incisions, or whether the endometrial cavity was entered. In addition, five of 186 women who did not have a fertility goal (3%) conceived, and one woman delivered two babies. CONCLUSION: Myomectomy performed to preserve fertility resulted in approximately one in four women having a live birth, independent of surgical technique