Higher Serrated Polyp Detection Rates Are Associated With Lower Risk of Postcolonoscopy Colorectal Cancer: Data From the New Hampshire Colonoscopy Registry

INTRODUCTION

We used New Hampshire Colonoscopy Registry data to examine the association between postcolonoscopy colorectal cancer (PCCRC) and sessile serrated detection rates (SSLDRs).

METHODS

We included patients with either a colonoscopy or a CRC diagnosis in the NH State Cancer Registry. PCCRC was any CRC diagnosed ≥ 6 months after index examination.

RESULTS

Of 26,901 patients, 162 were diagnosed with PCCRC. The hazard ratio for PCCRC was lowest for patients whose endoscopists had the highest SSLDR quintile (≥6%) (hazard ratio 0.29; 95% confidence interval 0.16-0.50).

DISCUSSION

Endoscopists with higher SSLDRs had lower risks of PCCRC. These data validate SSLDR as a clinically relevant quality measure.

A Survey of Cancer Risk Behaviors, Beliefs, and Social Drivers of Health in New Hampshire and Vermont

Compared with urban areas, rural areas have higher cancer mortality and have experienced substantially smaller declines in cancer incidence in recent years. In a New Hampshire (NH) and Vermont (VT) survey, we explored the roles of rurality and educational attainment on cancer risk behaviors, beliefs, and other social drivers of health. In February-March 2022, two survey panels in NH and VT were sent an online questionnaire. Responses were analyzed by rurality and educational attainment. Respondents (N = 1,717, 22%) mostly lived in rural areas (55%); 45% of rural and 25% of urban residents had high school education or less and this difference was statistically significant. After adjustment for rurality, lower educational attainment was associated with smoking, difficulty paying for basic necessities, greater financial difficulty during the COVID-19 pandemic, struggling to pay for gas (P < 0.01), fatalistic attitudes toward cancer prevention, and susceptibility to information overload about cancer prevention. Among the 33% of respondents who delayed getting medical care in the past year, this was more often due to lack of transportation in those with lower educational attainment (21% vs. 3%, P = 0.02 adjusted for rurality) and more often due to concerns about catching COVID-19 among urban than rural residents (52% vs. 21%; P < 0.001 adjusted for education). In conclusion, in NH/VT, smoking, financial hardship, and beliefs about cancer prevention are independently associated with lower educational attainment but not rural residence. These findings have implications for the design of interventions to address cancer risk in rural areas.

Significance

In NH and VT, the finding that some associations between cancer risk factors and rural residence are more closely tied to educational attainment than rurality suggest that the design of interventions to address cancer risk should take educational attainment into account.

Cystic Echinococcosis in Northern New Hampshire, USA

In April 2022 and December 2022, the New Hampshire Department of Health and Human Services confirmed 2 cases of locally acquired human pulmonary cystic echinococcosis caused by Echinococcus granulosus tapeworms. Both patients reported dressing locally hunted moose and exposure to dogs.

Clinically significant serrated polyp detection rates and risk for postcolonoscopy colorectal cancer: data from the New Hampshire Colonoscopy Registry

BACKGROUND AND AIMS

Higher adenoma detection rates reduce the risk of postcolonoscopy colorectal cancer (PCCRC). Clinically significant serrated polyps (CSSPs; defined as any sessile serrated polyp, traditional serrated adenoma, large [≥1 cm] or proximal hyperplastic polyp >5 mm) also lead to PCCRC, but there are no data on associated CSSP detection rates (CSSDRs). We used data from the New Hampshire Colonoscopy Registry (NHCR) to investigate the association between PCCRC risk and endoscopist CSSDR.

METHODS

We included NHCR patients with 1 or more follow-up events: either a colonoscopy or a colorectal cancer (CRC) diagnosis identified through linkage with the New Hampshire State Cancer Registry. We defined our outcome, PCCRC, in 3 time periods: CRC diagnosed 6 to 36 months, 6 to 60 months, or all examinations (6 months or longer) after an index examination. We excluded patients with CRC diagnosed at or within 6 months of the index examination, with incomplete examinations, or with inflammatory bowel disease. The exposure variable was endoscopist CSSDR at the index colonoscopy. Cox regression was used to model the hazard of PCCRC on CSSDR controlling for age, sex, index findings, year of examination, personal history of colorectal neoplasia, and having more than 1 surveillance examination.

RESULTS

One hundred twenty-eight patients with CRC diagnosed at least 6 months after their index examination were included. Our cohort included 142 endoscopists (92 gastroenterologists). We observed that the risk for PCCRC 6 months or longer after the index examination was significantly lower for examinations performed by endoscopists with CSSDRs of 3% to <9% (hazard ratio [HR], .57; 95% confidence interval [CI], .39-.83) or 9% or higher (HR, .39; 95% CI, .20-.78) relative to those with CSSDRs under 3%.

CONCLUSIONS

Our study is the first to demonstrate a lower PCCRC risk after examinations performed by endoscopists with higher CSSDRs. Both CSSDRs of 9% and 3% to <9% had statistically lower risk of PCCRC than CSSDRs of <3%. These data validate CSSDR as a clinically relevant quality measure for endoscopists.

Colonoscopy Findings in FIT+ and mt-sDNA+ Patients versus in Colonoscopy-only Patients: New Hampshire Colonoscopy Registry Data

Few studies compare fecal immunochemical test (FIT) and multi-target stool DNA (mt-sDNA) outcomes in practice. We compared colonoscopy yield following FIT+ or mt-sDNA+ tests to colonoscopies without preceding stool tests in the comprehensive population-based New Hampshire Colonoscopy Registry (NHCR). Outcomes were any neoplasia and an ordered outcome: adenocarcinoma, advanced neoplasia (adenoma/serrated polyp ≥ 1 cm/villous/high-grade dysplasia), nonadvanced neoplasia, or normal. Our total sample included 306 mt-sDNA+ (average age ± SD 67.0 ± 7.9), 276 FIT+ (66.6 ± 8.7), and 50,990 colonoscopy-only patients (61.8 ± 8.1). Among average-risk patients (N = 240 mt-sDNA+, N = 194 FIT+, N = 26,221 colonoscopy only), mt-sDNA+ patients had a higher risk for any neoplasia (67.1%) compared with FIT+ (54.6%, P = 0.00098) or colonoscopy (40.8%, P < 0.0001). Severity of findings and histology subtypes differed across the three groups (P < 0.0001 for both), with a higher yield of advanced findings in mt-sDNA+ patients. In particular, clinically relevant serrated polyps (hyperplastic polyps ≥10 mm/traditional serrated adenomas/sessile serrated polyps) were detected at a higher frequency in mt-sDNA+ patients as compared with FIT+ or colonoscopy-only patients. Even after adjustment, patients with positive mt-sDNA [OR = 2.82; 95% confidence interval (CI), 2.00-4.02] or FIT+ tests (OR = 1.67; 95% CI, 1.19-2.36) were more likely to have histologically more advanced findings than colonoscopy alone. At follow-up colonoscopy, mt-sDNA+ tests were more likely to predict neoplasia than FIT+, largely due to increased detection of serrated polyps. Prevention Relevance: Colorectal cancer screening options include colonoscopy and stool-based tests, including the fecal immunochemical test (FIT) and the multi-target stool DNA (mt-sDNA) test which, if positive, must be followed by a colonoscopy. Assessing "real-world" outcomes of colonoscopies following positive stool tests can inform their clinical use. See related Spotlight, p. 417.

Assessing tobacco smoke exposure in pregnancy from self-report, urinary cotinine and NNAL: a validation study using the New Hampshire Birth Cohort Study

OBJECTIVES

Accurate assessment of tobacco smoke exposure is key to evaluate its effects. We sought to validate and establish cut-offs for self-reported smoking and secondhand smoke (SHS) exposure during pregnancy using urinary cotinine and 4-(methylnitrosamino)-1-(-3-pyridyl)-1-butanol (NNAL) in a large contemporary prospective study from the USA, with lower smoking prevalence than has previously been evaluated.

DESIGN

Prospective birth cohort.

SETTING

Pregnancy clinics in New Hampshire and Vermont, USA.

PARTICIPANTS

1396 women enrolled in the New Hampshire Birth Cohort Study with self-reported smoking, urinary cotinine, NNAL and pregnancy outcomes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cut-offs for urinary cotinine and NNAL concentrations were estimated from logistic regression models using Youden's method to predict SHS and active smoking. Cotinine and NNAL were each used as the exposure in separate multifactorial models for pregnancy outcomes.

RESULTS

Self-reported maternal smoking was: 72% non-smokers, 5.7% ex-smokers, 6.4% SHS exposure, 6.2% currently smoked, 10% unreported. Cotinine and NNAL levels were low and highly intercorrelated (r=0.91). Geometric mean cotinine, NNAL were 0.99 ng/mL, 0.05 pmol/mL, respectively. Cotinine cut-offs for SHS, current smoking were 1.2 ng/mL and 1.8 ng/mL (area under curve (AUC) 95% CI: 0.52 (0.47 to 0.57), 0.90 (0.85 to 0.94)). NNAL cut-off for current smoking was 0.09 pmol/mL (AUC=0.82 (95% CI 0.77 to 0.87)). Using cotinine and NNAL cut-offs combined gave similar AUC to cotinine alone, 0.87 (95% CI 0.82 to 0.91). Cotinine and NNAL gave almost identical effect estimates when modelling pregnancy outcomes.

CONCLUSIONS

In this population, we observed high concordance between self-complete questionnaire smoking data and urinary cotinine and NNAL. With respect to biomarkers, either cotinine or NNAL can be used as a measure of tobacco smoke exposure overall but only cotinine can be used to detect SHS.

Use of Cervid Serosurveys to Monitor Eastern Equine Encephalitis Virus Activity in Northern New England, United States, 2009-2017

Vertebrate surveillance for eastern equine encephalitis virus (EEEV) activity usually focuses on three types of vertebrates: horses, passerine birds, and sentinel chicken flocks. However, there is a variety of wild vertebrates that are exposed to EEEV infections and can be used to track EEEV activity. In 2009, we initiated a pilot study in northern New England, United States, to evaluate the effectiveness of using wild cervids (free-ranging white-tailed deer and moose) as spatial sentinels for EEEV activity. In Maine, New Hampshire, and Vermont during 2009-2017, we collected blood samples from hunter-harvested cervids at tagging stations and obtained harvest location information from hunters. U.S. Centers for Disease Control and Prevention processed the samples for EEEV antibodies using plaque reduction neutralization tests (PRNTs). We detected EEEV antibodies in 6 to 17% of cervid samples in the different states and mapped cervid EEEV seropositivity in northern New England. EEEV antibody-positive cervids were the first detections of EEEV activity in the state of Vermont, in northern Maine, and northern New Hampshire. Our key result was the detection of the antibodies in areas far outside the extent of documented wild bird, mosquito, human case, or veterinary case reports of EEEV activity in Maine, New Hampshire, and Vermont. These findings showed that cervid (deer and moose) serosurveys can be used to characterize the geographic extent of EEEV activity, especially in areas with low EEEV activity or with little or no EEEV surveillance. Cervid EEEV serosurveys can be a useful tool for mapping EEEV activity in areas of North America in addition to northern New England.

Prenatal exposure to arsenic and lung function in children from the New Hampshire Birth Cohort Study

Prenatal arsenic exposure is associated with an increased risk of lung cancer along with multiple non-carcinogenic outcomes, including respiratory diseases in arsenic-contaminated areas. Limited epidemiologic data exist on whether in utero arsenic exposure influences lung development and subsequent respiratory health. We investigated the association between gestational arsenic exposure and childhood lung function in the New Hampshire Birth Cohort Study. Urinary arsenic speciation including inorganic arsenic (iAs), monomethylarsonic acid (MMA), dimethylarsinic acid (DMA) and arsenobetaine was measured in maternal urine samples collected during pregnancy and spirometry was performed in offspring at a median age of 7.4 years. Forced vital capacity (FVC), forced expiratory volume in the first second of exhalation (FEV1), and forced expiratory flow between 25% and 75% of FVC (FEF25-75) standardized z-scores were assessed in linear models as dependent variables with the log2-transformed summation of urinary arsenic species (ΣAs = iAs + MMA + DMA) corrected for specific gravity as an independent variable and with adjustment for maternal smoking status, children's age, sex and height. Among the 358 children in the study, a doubling of ΣAs was associated with a -0.08 (ß) decrease in FVC z-scores (95% confidence interval (CI) from -0.14 to -0.01) and -0.10 (ß) (95% CI from -0.18 to -0.02) decrease in FEV1 z-scores. The inverse association appeared stronger among those mothers with lower secondary methylation index (urinary DMA/MMA), especially among girls. No association was observed for FEF25-75 z-scores. Our results suggest that gestation arsenic exposure at levels relevant to the general US population during the vulnerable period of lung formation may adversely affect lung function in childhood.

Modeling Hepatitis C Elimination Among People Who Inject Drugs in New Hampshire

Importance

The success of direct-acting antiviral therapies for chronic hepatitis C virus (HCV) infection led the World Health Organization to set elimination targets by 2030. For the United States to achieve these benchmarks, public health responses must target high-risk populations, such as people who inject drugs (PWID), a group with high rates of HCV incidence and low rates of treatment uptake.

Objective

To evaluate potential improvements in the HCV care cascade among PWID, focusing on improved testing, treatment uptake, and access to harm reduction.

Design, Setting, and Participants

This decision analytic model used a differential equation-based dynamic transmission model based on data from New Hampshire, an illustrative state with a large number of PWID and limited HCV treatment infrastructure. Surveillance data through 2020 was used for model parameterization, and the final analysis was conducted in May 2021.

Main Outcomes and Measures

Model forecasts of chronic HCV cases and advanced-stage HCV outcomes from 2022 to 2045.

Results

A total of 6 scenarios were tested: (1) the base case, (2) improved harm reduction, (3) improved testing, (4) improved treatment, (5) improved testing and treatment, and (6) improved testing, treatment, and harm reduction. All scenarios with improved testing, treatment uptake, and/or access to harm reduction were associated with decreases in forecasted HCV prevalence and HCV-associated mortality compared with the base case. Improving harm reduction, testing, and treatment individually were forecast to reduce prevalence of HCV in 2045 from 69.7% in the base case to 62.8%, 45.7%, and 35.5%, respectively. Combining treatment and testing improvements was associated with a 2045 prevalence of 0.3%; adding harm reduction improvements was associated with further reductions in prevalence forecasts (to 0.2%), with fewer total treatments (10 960 vs 13 219 from 2022-2045).

Conclusions and Relevance

In this modeling study, no single intervention was projected to achieve World Health Organization HCV elimination targets. Scenarios with improvements in both testing and treatment were associated with a prevalence of less than 3% by 2030 and achieved elimination targets. Adding improvements in harm reduction was associated with faster reductions in prevalence and fewer treatments.

Rural barriers to early lung cancer detection: Exploring access to lung cancer screening programs in New Hampshire and Vermont

BACKGROUND

Rural populations face many health disadvantages compared to urban areas. There is a critical need to better understand the current lung cancer screening landscape in these communities to identify targeted areas to improve the impact of this proven tool.

METHODS

Data from the County Health Rankings of New Hampshire and Vermont was reviewed for population density, distribution of adult smokers, and level of education compared to the distribution of Lung Cancer Screening Facilities throughout these two states.

RESULTS

Screening programs in southern counties of Vermont with lower levels of education have decreased access. In New Hampshire, there are no programs within 30 miles of the areas with the largest distribution of smokers, and decreased access in some areas with the lowest levels of education.

CONCLUSIONS

Improving equitable access to high-quality screening services in rural regions and the creation of targeted interventions to address decreased access in areas of high tobacco use and low education is vital to decreasing the incidence of latestage presentations of lung cancer within these populations.

Association of Recreational Cannabis Legalization With Maternal Cannabis Use in the Preconception, Prenatal, and Postpartum Periods

IMPORTANCE

Recent studies have revealed increases in population-level cannabis use after legalization of recreational cannabis. However, the association of cannabis legalization with maternal cannabis use during important life stages remains unknown.

OBJECTIVE

To investigate the association of legalization of recreational cannabis with maternal cannabis use during the preconception, prenatal, and postpartum periods.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study used state-level data on women who delivered live-born infants in the US from the Pregnancy Risk Assessment Monitoring System from January 2004 to December 2018. Data from 2 states that had legalized recreational cannabis (Alaska and Maine) and 2 states that had not legalized recreational cannabis (New Hampshire and Vermont) were used. Women completed surveys 2 to 6 months after delivery, reporting preconception, prenatal, and postpartum cannabis use.

EXPOSURE

State recreational cannabis legalization.

MAIN OUTCOMES AND MEASURES

The 3 primary outcomes were self-reported cannabis use during the 12 months before pregnancy (preconception), during pregnancy (prenatal), and the 2 to 6 months after pregnancy (postpartum). A difference-in-differences analysis was used to compare changes in the prevalence of maternal cannabis use during each period before and after state legalization of recreational cannabis, controlling for maternal characteristics (age, race/ethnicity, educational level, income, cigarette smoking, and breastfeeding) and state fixed effects. State-specific survey weights were used.

RESULTS

The analytic sample included 23 082 women in the preconception period, 23 859 in the prenatal period, and 26 610 in the postpartum period. In each analysis, most women were married (range among all groups, 63.9%-64.8%), aged 25 to 34 years (preconception, 55.4%; prenatal, 55.9%; postpartum, 56.1%), and had an annual household income less than $50 000 (preconception, 55.7%; prenatal, 56.3%; postpartum, 55.5%). In adjusted analyses, preconception and postpartum cannabis use increased significantly in states that had legalized recreational cannabis compared with states that had not legalized it (preconception risk difference, 0.0457 [95% CI, 0.0013-0.0900]; P = .04; postpartum risk difference, 0.0539 [95% CI, 0.0259-0.0818]; P < .001). The risk difference for prenatal cannabis use was not significant (0.0070; 95% CI, -0.0120 to 0.0260; P = .47).

CONCLUSIONS AND RELEVANCE

In this repeated cross-sectional study, recreational cannabis legalization was associated with changes in maternal cannabis use before and after pregnancy. The findings suggest that future studies should undertake an interdisciplinary approach to maximize benefit and application of findings to future public health, health care, and policy sectors.

Patient and physician factors associated with Oncotype DX and adjuvant chemotherapy utilization for breast cancer patients in New Hampshire, 2010-2016

BACKGROUND

Oncotype DX® (ODX) is used to assess risk of disease recurrence in hormone receptor positive, HER2-negative breast cancer and to guide decisions regarding adjuvant chemotherapy. Little is known about how physician factors impact treatment decisions. The purpose of this study was to examine patient and physician factors associated with ODX testing and adjuvant chemotherapy for breast cancer patients in New Hampshire.

METHODS

We examined New Hampshire State Cancer Registry data on 5630 female breast cancer patients diagnosed from 2010 to 2016. We performed unadjusted and adjusted hierarchical logistic regression to identify factors associated with a patient's receipt of ODX, being recommended and receiving chemotherapy, and refusing chemotherapy. We calculated intraclass correlation coefficients (ICCs) to examine the proportion of variance in clinical decisions explained by between-physician and between-hospital variation.

RESULTS

Over the study period, 1512 breast cancer patients received ODX. After adjustment for patient and tumor characteristics, we found that patients seen by a male medical oncologist were less likely to be recommended chemotherapy following ODX (OR = 0.50 (95% CI = 0.34-0.74), p < 0.01). Medical oncologists with more clinical experience (reference: less than 10 years) were more likely to recommend chemotherapy (20-29 years: OR = 4.05 (95% CI = 1.57-10.43), p < 0.01; > 29 years: OR = 4.48 (95% CI = 1.68-11.95), p < 0.01). A substantial amount of the variation in receiving chemotherapy was due to variation between physicians, particularly among low risk patients (ICC = 0.33).

CONCLUSIONS

In addition to patient clinicopathologic characteristics, physician gender and clinical experience were associated with chemotherapy treatment following ODX testing. The significant variation between physicians indicates the potential for interventions to reduce variation in care.

Increased risk of metachronous large serrated polyps in individuals with 5- to 9-mm proximal hyperplastic polyps: data from the New Hampshire Colonoscopy Registry

BACKGROUND AND AIMS

Because data on metachronous risk for patients with index proximal 5- to 9-mm hyperplastic polyps (HPs) are limited, the clinical significance of these polyps is unclear. Conversely, published data suggest that sessile serrated polyps (SSPs), traditional serrated adenomas (TSAs), and large (≥1 cm) HPs are high-risk lesions requiring close surveillance. We used data from the New Hampshire Colonoscopy Registry (NHCR) to examine the risk of metachronous large SPs and advanced neoplasias (ANs) in patients with 5- to 9-mm proximal HPs.

METHODS

We included adults with at least 1 polyp resected at index colonoscopy and a surveillance examination 12 months or more after index. Outcomes were risk for metachronous large (≥1 cm) SPs and ANs (≥1 cm, villous elements, high-grade dysplasia, or colorectal cancer [CRC]). Individuals were hierarchically stratified by the most significant index SP. The risks for adults with proximal 5- to 9-mm HPs at index examination were compared with individuals with index findings of large (≥1 cm) HPs or any SSPs or TSAs, nonsignificant HPs (<1 cm in rectosigmoid or <5 mm anywhere in colon), high-risk adenomas (AAs or ≥3 adenomas, no SPs), and low-risk adenomas (no SPs). We present absolute and adjusted risks of metachronous polyps from a regression model that included age, sex, body mass index, smoking, previous polyp history, family history of CRC, year of diagnosis, endoscopist SP detection rates, and months to surveillance examination.

RESULTS

A total of 8560 NHCR participants were included (44.8% women; average age, 59.0 years; standard deviation, 9.1). Similar to those with large HPs or any SSPs/TSAs at index examination (odds ratio, 7.63; 95% confidence interval, 4.78-12.20), individuals with proximal 5- to 9-mm HPs had an elevated risk for metachronous large SPs (odds ratio, 4.77; 95% confidence interval, 2.54-8.94) as compared with adults with low-risk conventional adenomas.

CONCLUSIONS

NHCR data suggest that similar to adults with large HPs or any SSPs or TSAs at index examination, individuals with index 5- to 9-mm HPs proximal to the sigmoid are at an increased risk for metachronous large SPs. These novel data suggest that close surveillance intervals may be appropriate for patients with 5- to 9-mm proximal HPs.

Feasibility and Acceptability of a Checklist and Learning Collaborative to Promote Quality and Safety in the Perinatal Care of Women with Opioid Use Disorders

INTRODUCTION

Perinatal opioid use disorder (OUD) represents a maternal-child health crisis in the United States. Untreated, OUD is associated with maternal and neonatal morbidity due to infectious disease, polysubstance use, co-occurring mental health conditions, prematurity, neonatal opioid withdrawal, and maternal mortality from overdose. Although national guidelines exist to optimize perinatal care for women with OUD, wide variation persists in health care providers' experience caring for this population and in the quality of care delivered.

PROCESS

We conducted a pilot study to determine whether the use of a checklist summarizing best practice could improve perinatal care for women with OUD. Implementation was supported by a learning collaborative of maternity care providers at 8 diverse sites across Vermont, New Hampshire, and Maine. Outcomes before and after implementation were compared to determine whether practice change occurred.

OUTCOMES

Data were collected from the records of 223 women with OUD who received prenatal care at pilot sites. All sites endorsed use of the checklist as a practice guide, and it was integrated in 78% of records reviewed. Across sites, significant improvement occurred in key elements of care, including increasing the proportion of women with access to the lifesaving drug naloxone (10.9% vs 36.3%, P < .001), receiving counseling about the benefits of breastfeeding (50.9% vs 72.0%, P < .01), and treating with nicotine replacement when indicated (9.1% vs 26.8%, P = .01). No significant change occurred in rates of prematurity, low birth weight, or breastfeeding at hospital discharge.

DISCUSSION

Implementation of a checklist to facilitate best practice in the care of pregnant women with OUD is feasible, acceptable to maternity care providers, and represents a promising approach to improving quality of care for this vulnerable population. Additional research is needed to determine whether improvement in quality can transform perinatal outcomes.

Young adults and metachronous neoplasia: risks for future advanced adenomas and large serrated polyps compared with older adults

BACKGROUND AND AIMS

Recent increases in colorectal cancer (CRC) incidence in adults younger than 50 years of age have led to more colonoscopies in this age group. As a result, there may be an increasing number of adults <50 years old with polyps detected. There is concern that younger adults may require closer follow-up. Our goal was to use data from the New Hampshire Colonoscopy Registry (NHCR) to examine the risk for metachronous advanced adenomas (AAs) and large (>1 cm) serrated polyps in younger versus older adults who return for a follow-up colonoscopy.

METHODS

Our cohort consisted of NHCR participants with at least 1 polyp on index examination and a follow-up colonoscopy at least 1 year after the index examination. Outcomes were the risks for metachronous AAs (adenomas ≥1 cm, with villous elements or high-grade dysplasia, or CRC) and large (≥1 cm) serrated polyps. We present absolute risk and adjusted risks from a logistic regression model stratified by age at index colonoscopy (<40, 40-49, 50-59, and 60+ [reference]). Covariates included index findings, endoscopist adenoma detection rates, sex, smoking, body mass index, follow-up time (months), bowel preparation quality, and family history of CRC.

RESULTS

In our sample of 12,380 adults, absolute risk for metachronous AA was lower for younger patients than for patients aged ≥60. After adjusting for covariates, when comparing with the 60+ group (reference), the lowest risk was observed in those younger than 40 years (odds ratio, .19; 95% confidence interval, .05-.80). Of note, similar risks were observed in the 40 to 49 age group (odds ratio, .61; 95% confidence interval, .41-.92) and 50 to 59 age group (odds ratio, .71; 95% confidence interval, .58-.86). The risk for large metachronous serrated polyps was not associated with age.

CONCLUSIONS

Younger adults aged <40 with index adenomas had a lower risk for metachronous AAs than those aged ≥60. The 40- to 49-year age group was found to have metachronous risk similar to the 50- to 59-year age group, with both less than the ≥60 age group. These data suggest that current surveillance interval guidelines for patients aged ≥50 years may appropriately be used with younger adults.

Maternal urinary cadmium, glucose intolerance and gestational diabetes in the New Hampshire Birth Cohort Study

BACKGROUND

Exposure to cadmium may contribute to the risk of gestational diabetes mellitus (GDM) and glucose intolerance during pregnancy.

METHODS

We examined 917 women enrolled from 2009 to 2017 in the New Hampshire Birth Cohort Study. Lifestyle, diet, demographic factors and pregnancy outcomes were collected by questionnaire and medical record review. Cadmium concentrations were measured in urine samples collected at 24-28 weeks gestation. Women were classified as normal (n = 815), glucose intolerant (n = 86), or GDM (n = 16) based on clinical data (i.e., glucose challenge test, oral glucose challenge test). We calculated odds ratios (OR) and 95% confidence intervals (CI), adjusting for potential confounders, using multinomial logistic regression to examine disease severity (normal, glucose intolerant, GDM) and logistic regression to examine the combined outcome of gestational hyperglycemia.

RESULTS

Little to no association was observed for glucose intolerance (OR = 1.11, 95%CI 0.85-1.45) or GDM (OR = 0.86, 95% CI 0.51-1.44) with a doubling of urinary cadmium as compared to normal women. The combined outcome of gestational hyperglycemia yielded similar results (OR = 1.07, 95% CI 0.84-1.35). However, when stratified by pre-pregnancy body mass index (BMI), there was a slight association with the combined outcome in normal weight women (OR = 1.32, 95% CI 0.88-1.98) and no association in the overweight or obese women. This positive association remained in restricted analyses of only women with no exposure to smoking during pregnancy and those who had never smoked.

CONCLUSIONS

Cadmium exposure was suggestively associated with increased risk of gestational hyperglycemia among women not already at increased risk of GDM due to being overweight or obese; however, associations of cadmium with gestational hyperglycemia were not statistically significant.

Treating perinatal opioid use disorder in rural settings: Challenges and opportunities

Perinatal opioid use disorder (OUD) is a life-threatening condition that significantly impacts women in rural areas. Medication assisted treatment (MAT) is the recommended treatment but can be difficult to access. Pregnant women may initially present for treatment of OUD in the emergency department, on labor and delivery units, or in an office setting, each of which presents unique challenges. Initiation of MAT in the appropriate setting, based on accurate assessment of gestational age, is a centrally important component of care for perinatal OUD. However, initiating treatment may present challenges to providers who lack experience treating this disorder. Vermont and New Hampshire are predominantly rural states which have focused on expanding MAT access for pregnant women using two different approaches to integrating treatment with maternity care.

Prenatal exposure to mercury in relation to infant infections and respiratory symptoms in the New Hampshire Birth Cohort Study

BACKGROUND

Mechanistic studies support the potential for mercury (Hg) to alter immunity, including via in utero exposure. As yet, there are few prospective studies of in utero Hg exposure and subsequent immune-related outcomes, especially in infancy.

OBJECTIVES

We investigated the association of biomarkers of prenatal Hg exposure and maternal silver-mercury dental amalgams with the occurrence of infant allergy, respiratory infection, and respiratory symptoms in the first year of life.

METHODS

The New Hampshire Birth Cohort Study (NHBCS) ascertained information on infant allergies, infections and symptoms through telephone interviews at 4, 8 and 12 months postpartum and measured total Hg in maternal toenails collected at ~28-30 weeks gestation. Information on maternal fish consumption and presence of dental amalgams was obtained from a questionnaire administered at study enrollment at 24-28 weeks. A total of 1321 NHBCS mother-infant pairs had at least one Hg exposure measure (toenail Hg or information on dental amalgams) and information on dietary fish intake. Generalized linear models and generalized estimating equation models with Poisson regression adjusted for potential confounders (maternal age, level of education, parity, smoking, alternative Healthy Eating Index-2010, infant sex, gestational age, feeding mode, and day care attendance) were used to assess the association between infant outcomes and prenatal toenail Hg levels. We subsetted this analysis on mothers who consumed fish (n = 706) as a measure of in utero methylmercury (MeHg) exposure. Associations between infant outcomes and dental amalgams as a measure of in utero inorganic Hg exposure were assessed among mothers who did not consume fish (n = 218).

RESULTS

Among women who ate fish during pregnancy, higher maternal toenail Hg concentrations were associated with an increased risk of lower respiratory infections and respiratory symptoms requiring a doctor visit among infants age 9-12 months (relative risk (RR) 1.4 (95% CI: 1.1, 1.9) and 1.2 (95% CI: 1.0, 1.4) respectively), whereas a reduced risk of lower respiratory infections was observed among infants 0-4 months of age (RR = 0.7 (95% CI: 0.5, 1.0). We found little to no evidence of associations of toenail Hg with upper respiratory infections, allergy or eczema at any age to one year. Among infants of mothers who did not consume fish, we found an elevated risk of upper respiratory infections requiring a doctor visit in relation to having dental amalgams during pregnancy (RR = 1.5 (95% CI: 1.1, 2.1)). Overall, weaker associations were observed with lower respiratory infections, respiratory symptoms, and medically confirmed allergies, and there was no association with eczema.

CONCLUSIONS

Our analyses of a US birth cohort, along with prior mechanistic work, raise the possibility that gestational Hg exposure through fish/seafood consumption and dental amalgams may alter respiratory infections and respiratory symptoms in infants.

Prenatal lead exposure and elevated blood pressure in children

Growing evidence suggests that environmental exposures can influence blood pressure over the course of a lifetime. Exposure to toxic metals, such as lead (Pb) and arsenic (As), has been associated with increased blood pressure in adults, but few studies have examined the impacts of in utero and early life toxic metals exposure on blood pressure in childhood. As subclinical vascular changes are thought to begin early in life, it is possible that in utero toxic metals exposure may play a role in blood pressure homeostasis. In the ongoing New Hampshire Birth Cohort Study, we investigated whether in utero exposure to Pb and As was associated with measures of blood pressure in a total of 323 young children (mean age 5.5 years, SD 0.4). Pb and As were measured in maternal toenail samples collected at ~28 weeks gestation (n = 257) and/or 6 weeks postpartum (n = 285), which represent exposures ~6 to 12 months prior to collection and therefore reflect the early prenatal and late prenatal exposures, respectively. Five measurements of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were averaged for each child using a standardized technique. In linear regression analyses, where log2-transformed prenatal toenail Pb and As were modeled jointly and adjusted for child age, sex, height, weight and maternal smoking during pregnancy, we observed that a doubling of maternal prenatal toenail Pb was associated with statistically significant increases in child SBP (β: 0.58 mm Hg, 95% CI: 0.05, 1.11). We did not observe any association of prenatal or postpartum As, or postpartum Pb, with SBP or DBP. Exploratory sex-stratified analyses suggest that associations of prenatal Pb with BP may be stronger among boys (SBP β: 0.72 mm Hg: 95% CI: -0.01, 1.44; DBP β: 0.37; 95% CI: -0.09, 0.84), compared to girls (SBP β: 0.48 mm Hg: 95% CI: -0.31, 1.26; DBP β: -0.05; 95% CI: -0.52, 0.41), though tests for interaction did not reach statistical significance (p-interaction SBP = 0.059; DBP = 0.057). Our preliminary results suggest that in utero toxic metals exposures may be associated with early life increases in blood pressure in children, which could have consequences for long-term health.

Heroin uncertainties: Exploring users' perceptions of fentanyl-adulterated and -substituted 'heroin'

BACKGROUND

The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use.

METHODS

A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin.

RESULTS

(1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports.

CONCLUSION

Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.

Use of Emergency Department Data to Monitor and Respond to an Increase in Opioid Overdoses in New Hampshire, 2011-2015

OBJECTIVES

Opioid-related overdoses and deaths in New Hampshire have increased substantially in recent years, similar to increases observed across the United States. We queried emergency department (ED) data in New Hampshire to monitor opioid-related ED encounters as part of the public health response to this health problem.

METHODS

We obtained data on opioid-related ED encounters for the period January 1, 2011, through December 31, 2015, from New Hampshire's syndromic surveillance ED data system by querying for (1) chief complaint text related to the words "fentanyl," "heroin," "opiate," and "opioid" and (2) opioid-related International Classification of Diseases ( ICD) codes. We then analyzed the data to calculate frequencies of opioid-related ED encounters by age, sex, residence, chief complaint text values, and ICD codes.

RESULTS

Opioid-related ED encounters increased by 70% during the study period, from 3300 in 2011 to 5603 in 2015; the largest increases occurred in adults aged 18-29 and in males. Of 20 994 total opioid-related ED visits, we identified 18 554 (88%) using ICD code alone, 690 (3%) using chief complaint text alone, and 1750 (8%) using both chief complaint text and ICD code. For those encounters identified by ICD code only, the corresponding chief complaint text included varied and nonspecific words, with the most common being "pain" (n = 3335, 18%), "overdose" (n = 1555, 8%), "suicidal" (n = 816, 4%), "drug" (n = 803, 4%), and "detox" (n = 750, 4%). Heroin-specific encounters increased by 827%, from 4% of opioid-related encounters in 2011 to 24% of encounters in 2015.

CONCLUSIONS

Opioid-related ED encounters in New Hampshire increased substantially from 2011 to 2015. Data from New Hampshire's ED syndromic surveillance system provided timely situational awareness to public health partners to support the overall response to the opioid epidemic.

Prospective Comparison of Diagnostic Accuracy Between Point-of-Care and Conventional Ultrasound in a General Diagnostic Department: Implications for Resource-Limited Settings

OBJECTIVES

To compare the diagnostic accuracy of hand-held point-of-care (POC) versus conventional sonography in a general diagnostic setting with the intention to inform medical providers or clinicians on the rational use of POC ultrasound in resource limited settings.

METHODS

Over 3 months in 2010, 47 patients were prospectively enrolled at a single academic center to obtain 54 clinical conventional ultrasound examinations and 54 study-only POC ultrasound examinations. Indications were 48% abdominal, 26% retroperitoneal, and 24% obstetrical. Nine blinded readers (sonographers, residents, and attending radiologists) sequentially assigned diagnoses to POC and then conventional studies, yielding 476 interpreted study pairs. Diagnostic accuracy was obtained by comparing POC and conventional diagnoses to a reference diagnosis established by the unblinded, senior author. Analysis was stratified by study type, body mass index (BMI), diagnostic confidence, and image quality.

RESULTS

The mean diagnostic accuracy of conventional sonography was 84% compared with 74% for POC (P < .001). This difference was constant regardless of reader, exam type, or BMI. The sensitivity and specificity to detect abnormalities with conventional was 85 and 83%, compared with 75 and 68% for POC. The POC sonography demonstrated greater variability in image quality and diagnostic confidence, and this accounted for lower diagnostic accuracy. When image quality and diagnostic confidence were similar between POC and conventional examinations, there was no difference in accuracy.

CONCLUSIONS

Point-of-care was nearly as accurate as conventional sonography for basic, focused examinations. Observed differences in accuracy were attributed to greater variation in POC image quality.

Maternal and infant inflammatory markers in relation to prenatal arsenic exposure in a U.S. pregnancy cohort

INTRODUCTION

Accumulating evidence indicates that arsenic (As), a potent environmental toxicant, may increase cardiovascular disease risk and adversely affect endothelial function at high levels of exposure. Pregnancy is a vulnerable time for both mother and child; however, studies examining the association between prenatal As exposure and plasma biomarkers of inflammation and endothelial function in mothers and newborns are lacking.

METHODS

We examined maternal urinary As levels at gestational weeks 24-28 and levels of inflammatory biomarkers in plasma from 563 pregnant women and 500 infants' cord blood. We assessed a multiplexed panel of circulating inflammatory and endothelial function markers, including tumor necrosis factor alpha (TNFα), monocyte chemoattractant protein 1 (MCP1), intercellular adhesion molecule (ICAM1) and vascular cell adhesion molecule (VCAM1).

RESULTS

Compared with the bottom tertile, the highest tertile of maternal urinary As during pregnancy was associated with a 145.2ng/ml (95% CI 4.1, 286.3; p=0.04) increase in cord blood ICAM1 and 557.3ng/ml (95% CI -56.4, 1171.1; p=0.09) increase in cord blood VCAM1. Among mothers, the highest tertile of maternal urinary As during pregnancy was related to a 141.8ng/ml (95% CI 26.1, 257.5; p=0.02) increase maternal plasma VCAM1 levels. Urinary As was unrelated to MCP1 or TNFα in maternal plasma and cord blood. In structural equation models, the association between maternal urinary As and infant VCAM was mediated by maternal levels of VCAM (βmediation: 0.024, 95% CI: 0.002, 0.050).

CONCLUSION

Our observations indicate that As exposure during pregnancy may affect markers of vascular health and endothelial function in both pregnant women and children, and suggest further investigation of the potential impacts on cardiovascular health in these susceptible populations.

Maternal arsenic exposure and gestational diabetes and glucose intolerance in the New Hampshire birth cohort study

BACKGROUND

Gestational diabetes mellitus (GDM) is a major pregnancy complication with detrimental effects for both mothers and their children. Accumulating evidence has suggested a potential role for arsenic (As) exposure in the development of GDM, but current studies have not assessed As exposure from water, urine or toenail samples.

METHODS

We investigated the association between As exposure and risk of glucose intolerance and GDM among 1151 women enrolled in the New Hampshire Birth Cohort Study. Arsenic was measured in home well water and via biomarkers (i.e., maternal urine collected ~24-28 weeks gestation and toenail clippings collected 2 weeks postpartum).

RESULTS

A total of 105 (9.1 %) of women were diagnosed with glucose intolerance and 14 (1.2 %) of women were diagnosed with GDM. A total of 10.3 % of women had water As levels above 10 μg/L, with a mean As level of 4.2. Each 5 μg/L increase in As concentration in home well water was associated with a ~10 % increased odds of GDM (OR: 1.1, 95 % CI 1.0, 1.2). A positive and statistically significant association also was observed between toenail As and GDM (OR: 4.5, 95 % CI 1.2, 16.6), but not urinary arsenic (OR: 0.8, 95 % CI 0.3, 2.4). In a stratified analysis, the association between water As and GDM and glucose intolerance was largely limited to obese women (OR: 1.7, 95 % CI 1.0, 2.8).

CONCLUSIONS

Our findings support the role of As exposure via water from private wells in the incidence of GDM and that this association may be modified by body composition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Relation between in Utero Arsenic Exposure and Birth Outcomes in a Cohort of Mothers and Their Newborns from New Hampshire

BACKGROUND

Studies suggest that arsenic exposure influences birth outcomes; however, findings are mixed.

OBJECTIVE

We assessed in utero arsenic exposure in relation to birth outcomes and whether maternal prepregnancy weight and infant sex modified the associations.

METHODS

Among 706 mother-infant pairs exposed to low levels of arsenic through drinking water and diet, we assessed in utero arsenic exposure using maternal second-trimester urinary arsenic, maternal prepregnancy weight through self-report, and birth outcomes from medical records.

RESULTS

Median (interquartile range) of total urinary arsenic [tAs; inorganic arsenic (iAs) + monomethylarsonic acid (MMA) + dimethylarsinic acid (DMA)] was 3.4 μg/L (1.7-6.0). In adjusted linear models, each doubling of tAs was associated with a 0.10-cm decrease (95% CI: -0.19, -0.01) in head circumference. Results were similar for MMA and DMA. Ln(tAs) and ln(DMA) were positively associated with birth length in infant males only; among males, each doubling of tAs was associated with a 0.28-cm increase (95% CI: 0.09, 0.46) in birth length (pinteraction = 0.04). Results were similar for DMA. Additionally, arsenic exposure was inversely related to ponderal index, and associations differed by maternal weight. Each ln(tAs) doubling of tAs was associated with a 0.55-kg/m3 lower (95% CI: -0.82, -0.28, p < 0.001) ponderal index for infants of overweight/obese, but not normal-weight, mothers (pinteraction < 0.01). Finally, there was a significant interaction between maternal weight status, infant sex, and arsenic exposure on birth weight (pinteraction = 0.03). In girls born of overweight/obese mothers, each doubling of tAs was associated with a 62.9-g decrease (95% CI: -111.6, -14.2) in birth weight, though the association was null in the other strata.

CONCLUSIONS

Low-level arsenic exposure may affect fetal growth, and the associations may be modified by maternal weight status and infant sex.

CITATION

Gilbert-Diamond D, Emond JA, Baker ER, Korrick SA, Karagas MR. 2016. Relation between in utero arsenic exposure and birth outcomes in a cohort of mothers and their newborns from New Hampshire. Environ Health Perspect 124:1299-1307; http://dx.doi.org/10.1289/ehp.1510065.

Epigenome-Wide Assessment of DNA Methylation in the Placenta and Arsenic Exposure in the New Hampshire Birth Cohort Study (USA)

BACKGROUND

Arsenic is one of the most commonly encountered environmental toxicants, and research from model systems has suggested that one mode of its toxic activity may be through alterations in DNA methylation. In utero exposure to arsenic can affect fetal, newborn, and infant health, resulting in a range of phenotypic outcomes.

OBJECTIVES

This study examined variation in placental DNA methylation and its relationship to arsenic exposure in 343 individuals enrolled in the New Hampshire Birth Cohort Study.

METHODS

Linear regression models using a reference-free correction to account for cellular composition were employed to determine CpG loci affected by arsenic levels.

RESULTS

Total arsenic measured in maternal urine during the second trimester was not associated with methylation in the placenta, whereas arsenic levels quantified through maternal toenail collected at birth were associated with methylation at a single CpG locus (p = 4.1 × 10-8). Placenta arsenic levels were associated with 163 differentially methylated loci (false discovery rate < 0.05), with 11 probes within the LYRM2 gene reaching genome-wide significance (p < 10-8). Measurement of LYRM2 mRNA levels indicated that methylation was weakly to moderately correlated with expression (r = 0.15, p < 0.06). In addition, we identified pathways suggesting changes in placental cell subpopulation proportions associated with arsenic exposure.

CONCLUSIONS

These data demonstrate the potential for arsenic, even at levels commonly experienced in a U.S. population, to have effects on the DNA methylation status of specific genes in the placenta and thus supports a potentially novel mechanism for arsenic to affect long-term children's health.

CITATION

Green BB, Karagas MR, Punshon T, Jackson BP, Robbins DJ, Houseman EA, Marsit CJ. 2016. Epigenome-wide assessment of DNA methylation in the placenta and arsenic exposure in the New Hampshire Birth Cohort Study (USA). Environ Health Perspect 124:1253-1260; http://dx.doi.org/10.1289/ehp.1510437.

Human polyomaviruses and incidence of cutaneous squamous cell carcinoma in the New Hampshire skin cancer study

Squamous cell carcinoma (SCC) of the skin is a malignancy arising from epithelial keratinocytes. Experimental and epidemiologic evidence raise the possibility that human polyomaviruses (PyV) may be associated with the occurrence of SCC. To investigate whether the risk for SCC was associated with PyV infection, seropositivity to 10 PyV types was assessed following diagnosis in a population-based case-control study conducted in the United States. A total of 253 SCC cases and 460 age group and gender-matched controls were included. Antibody response against each PyV was measured using a multiplex serology-based glutathione S-transferase capture assay of recombinantly expressed VP1 capsid proteins. Odds ratios (OR) for SCC associated with seropositivity to each PyV type were estimated using logistic regression, with adjustment for potentially confounding factors. SCC cases were seropositive for a greater number of PyVs than controls (P = 0.049). Those who were JC seropositive had increased odds of SCC when compared to those who were JC seronegative (OR = 1.37, 95% CI: 0.98-1.90), with an increasing trend in SCC risk with increasing quartiles of seroreactivity (P for trend = 0.04). There were no clear associations between SCC risk and serostatus for other PyV types. This study provides limited evidence that infection with certain PyVs may be related to the occurrence of SCC in the general population of the United States.

Oral Health Status of Older Adults Attending Senior Centers and Congregate Meal Sites in New Hampshire

PURPOSE

This study assessed the oral health status of older adults in randomly selected New Hampshire senior centers and congregate meal sites for the purpose of future planning, implementation and evaluation of targeted public health programs.

METHODS

A cross-sectional surveillance project was developed. Registered dental hygienists visually assessed denture use, number of natural teeth, teeth mobility, untreated caries, root fragments, gingivitis, need for care and treatment urgency among randomly selected active older adults living within New Hampshire communities.

RESULTS

Altogether, 610 adults 60 years old and older attending 25 senior centers and congregate meal sites participated. Sixteen percent were edentulous and 42% reported having a removable upper or lower denture. Among edentulous adults, 5% had no dentures at all. Among 513 dentate participants, 22% had untreated caries, 14% had root fragments, 9% had gingivitis and 7% presented with obviously mobile teeth. Overall, 19% required early or urgent dental care. Differences were detected by sex, age group, urban versus rural location of the site and by the participation in a federal nutritional program for older adults.

CONCLUSION

Baseline information about oral health needs of older adults in New Hampshire was gathered. Overall needs as well as existing oral health disparities will be addressed through the collaboration of public and private partners.

Emerging Cases of Powassan Virus Encephalitis in New England: Clinical Presentation, Imaging, and Review of the Literature

BACKGROUND

Powassan virus (POWV) is a rarely diagnosed cause of encephalitis in the United States. In the Northeast, it is transmitted by Ixodes scapularis, the same vector that transmits Lyme disease. The prevalence of POWV among animal hosts and vectors has been increasing. We present 8 cases of POWV encephalitis from Massachusetts and New Hampshire in 2013-2015.

METHODS

We abstracted clinical and epidemiological information for patients with POWV encephalitis diagnosed at 2 hospitals in Massachusetts from 2013 to 2015. We compared their brain imaging with those in published findings from Powassan and other viral encephalitides.

RESULTS

The patients ranged in age from 21 to 82 years, were, for the most part, previously healthy, and presented with syndromes of fever, headache, and altered consciousness. Infections occurred from May to September and were often associated with known tick exposures. In all patients, cerebrospinal fluid analyses showed pleocytosis with elevated protein. In 7 of 8 patients, brain magnetic resonance imaging demonstrated deep foci of increased T2/fluid-attenuation inversion recovery signal intensity.

CONCLUSIONS

We describe 8 cases of POWV encephalitis in Massachusetts and New Hampshire in 2013-2015. Prior to this, there had been only 2 cases of POWV encephalitis identified in Massachusetts. These cases may represent emergence of this virus in a region where its vector, I. scapularis, is known to be prevalent or may represent the emerging diagnosis of an underappreciated pathogen. We recommend testing for POWV in patients who present with encephalitis in the spring to fall in New England.

Clinical Importance and Natural History of Biliary Sludge in Outpatients

OBJECTIVES

Gallbladder sludge is a common diagnosis on routine abdominal sonography, yet its clinical importance is uncertain, especially in outpatients. To determine its natural history and potential future complications in this setting, we reviewed the imaging and clinical histories of nonhospitalized patients with a diagnosis of sludge on sonography.

METHODS

We conducted a retrospective search of our institutional radiology information system for all sonographic reports using the key words "biliary sludge without gallstones" over a 3-year period. For each of the 104 patients with isolated biliary sludge on initial sonography, we reviewed the electronic medical records and all imaging for the development of pancreaticobiliary complications.

RESULTS

We found an overall prevalence of biliary sludge in outpatients of 1.8%. Of the 104 patients reviewed with a mean follow up of 630 days (21 months), 25 developed a pancreaticobiliary complication, including cholelithiasis, cholecystitis, choledocholithiasis, and pancreatitis. The most frequent complication was cholecystitis, with a total of 14 diagnoses (12 chronic acalculous and 2 acute with gallstones). An additional 6 patients developed gallstones without cholecystitis features; 4 patients developed pancreatitis; and 1 developed choledocholithiasis. Biliary sludge remained quiescent or resolved in 76% of patients.

CONCLUSIONS

Biliary sludge always represents a pathologic process, but its clinical implications among outpatients have not been previously investigated. Our ambulatory population developed pancreaticobiliary complications at similar rates as prior mixed-patient setting studies. Regardless of the patient setting, biliary sludge is likely of more clinical importance than previously regarded.

Association between Early Childhood Caries, Feeding Practices and an Established Dental Home

PURPOSE

Early Childhood Caries (ECC) is a significant public health concern disproportionately affecting low-income children. The purpose of this study was to assess the association between the establishment of a dental home and ECC prevalence in a group of Medicaid-enrolled preschool children, and to explore feeding practices associated with an increased prevalence of ECC in Medicaid-enrolled preschool children with an established dental home was evaluated.

METHODS

A cross-sectional survey was conducted among Medicaid-enrolled children (n=132) between 2 and 5 years of age with an established dental home and no dental home to compare feeding practices, parental knowledge of caries risk factors and oral health status.

RESULTS

Children with an established dental home had lower rates of biofilm (p<0.05), gingivitis (p<0.05) and mean decayed, missing and filled teeth (DMFT) scores (p<0.05). Children with no dental home consumed more soda and juice (p<0.05) daily, and ate more sticky fruit snacks (p<0.05) than children with an established dental home. Establishment of a dental home had a strong protective effect on caries and DMFT index (odds ratio=0.22) in both univariate and confounding adjusted analyses.

CONCLUSION

The results suggest establishment of a dental home, especially among high-risk, low-income populations, decreases the prevalence of ECC and reduces the practice of cariogenic feeding behaviors.

Seroepidemiology of Human Polyomaviruses in a US Population

Polyomaviruses (PyV) are potentially tumorigenic in humans. However, limited data exist on the population seroprevalence of PyVs and individual characteristics that relate to seropositivity. Using multiplex serology, we determined the seroprevalence of 10 human PyVs (BK, JC, KI, WU, MCV, HPyV6, HPyV7, TSV, HPyV9, and HPyV10) among controls from a population-based skin cancer case-control study (n = 460) conducted in New Hampshire between 1993 and 1995. On a subset of participants (n = 194), methylation at CpG dinucleotides across the genome was measured in peripheral blood using the Illumina Infinium HumanMethylation27 BeadChip array (Illumina Inc., San Diego, California), from which lymphocyte subtype proportions were inferred. All participants were seropositive for at least 1 PyV, with seroprevalences ranging from 17.6% (HPyV9) to 99.1% (HPyV10). Seropositivity to JC, MCV, and HPyV7 increased with age. JC and TSV seropositivity were more common among men than among women. Smokers were more likely to be HPyV9-seropositive but MCV-seronegative, and HPyV7 seropositivity was associated with prolonged glucocorticoid use. Based on DNA methylation profiles, differences were observed in CD8-positive T- and B-cell proportions by BK, JC, and HPyV9 seropositivity. Our findings suggest that PyV seropositivity is common in the United States and varies by sociodemographic and biological characteristics, including those related to immune function.

Placental arsenic concentrations in relation to both maternal and infant biomarkers of exposure in a US cohort

Arsenic crosses the placenta and may have adverse consequences in utero and later in life. At present, little is known about arsenic concentrations in placenta and their relation to maternal and infant exposures particularly at common levels of exposure. We measured placenta arsenic in a US cohort potentially exposed via drinking water from private wells, and evaluated the relationships between placenta and maternal and infant biomarker arsenic concentrations. We measured total arsenic concentrations in placental samples from women enrolled in the New Hampshire Birth Cohort Study (N=766). We compared these data to maternal urinary arsenic (total arsenic and individual species) collected at approximately 24-28 week gestation, along with maternal post-partum toenails and infant toenails using non-parametric multivariate analysis of log10-transformed data. We also examined the association between placental arsenic and household drinking water arsenic. Placenta arsenic concentrations were related to arsenic concentrations in maternal urine (β 0.55, P value <0.0001), maternal (β 0.30, P value 0.0196) and infant toenails (β 0.40, P value 0.0293) and household drinking water (β 0.09, P value <0.0001). Thus, our data suggest that placenta arsenic concentrations reflect both maternal and infant exposures.

Validation of the Out-of-School-Time Snacks, Beverages, and Physical Activity Questionnaire

BACKGROUND

Recent research has highlighted the potential for out-of-school-time (OST) environments to impact children's energy balance. Expanding upon this evidence requires validated measures to assess nutrition and physical activity (PA) environments across large samples of OST programs. The aim of this study was to assess the criterion validity of the Out-of-School-Time Snacks, Beverages, and Physical Activity Questionnaire (OST-SBPA), an online questionnaire designed to measure OST nutrition and PA environments by program leaders' reports.

METHODS

The study consisted of two samples of OST programs (total n=65). Objective data across program meetings were compared to program leaders' reports of usual snack, beverage, and PA offerings. All 65 programs provided snack and beverage data; PA data were available from 31 programs. Validity was assessed using percent agreement, Cohen's kappa, and Spearman's correlations.

RESULTS

All OST-SBPA items demonstrated agreement above 60% when dichotomized (e.g., none/some versus most/all of the time for frequency items). Most OST-SBPA items were significantly correlated with objective data, including how often fresh and processed fruits and vegetables, salty snacks, sweet snacks, protein snacks, milk, juice, and sweetened beverages were offered and four PA measures (r=0.43-0.78; p<0.01), whereas one item, the frequency that water was offered, was not (r=0.13; p=0.37). The water item demonstrated validity once water from water fountains was recoded and not considered a program-provided beverage.

CONCLUSIONS

These findings fill a gap in the literature through the validation of a brief questionnaire that can be used to assess OST nutrition and PA environments. The current results support the use of the OST-SBPA in studies aiming to assess and impact these environments.

Preliminary analysis of in utero low-level arsenic exposure and fetal growth using biometric measurements extracted from fetal ultrasound reports

BACKGROUND

Early life exposure to arsenic is associated with decreased birth weight in highly exposed populations but little is known about effects of low-level arsenic exposure on growth in utero.

METHODS

Using a sample of 272 pregnancies from New Hampshire we obtained biometric measurements directly from fetal ultrasound reports commonly found in electronic medical records. We used information extraction methods to develop and validate an automated approach for mining biometric measurements from the text of clinical reports. As a preliminary analysis, we examined associations between in utero low-level arsenic exposure (as measured by maternal urinary arsenic concentration) and fetal growth measures (converted to Z-scores based on reference populations for estimated fetal weight, head, and other body measures) at approximately 18 weeks of gestation.

RESULTS

In a preliminary cross-sectional analysis of 223 out of 272 pregnancies, maternal urinary arsenic concentration (excluding arsenobetaine) was associated with a reduction in head circumference Z-score (Spearman correlation coefficient, rs = -0.08, p-value = 0.21) and a stronger association was observed among female fetuses at approximately 18 weeks of gestation (rs = - 0.21, p-value < 0.05). Although, associations were attenuated in adjusted analyses - among female fetuses a 1 μg/L increase in maternal urinary arsenic concentration was associated with a decrease of 0.047 (95% CI: -0.115, 0.021) in head circumference and 0.072 (95% CI: -0.151, 0.007) decrease in biparietal head diameter Z-score.

CONCLUSIONS

Our study demonstrates that useful data can be extracted directly from electronic medical records for epidemiologic research. We also found evidence that exposure to low-level arsenic may be associated with reduced head circumference in a sex dependent manner that warrants further investigation.

Cancer-related pain and symptoms among nursing home residents: a systematic review

CONTEXT

Many older nursing home (NH) residents with cancer experience pain and distressing symptoms. Although some develop cancer during their time in the institution, an increasing number are admitted during their final stages of their lives. Numerous studies have evaluated various treatment approaches, but how pain and symptoms are assessed and managed in people with cancer with and without dementia is unclear.

OBJECTIVES

The objective of this review was to summarize the evidence on cancer-related symptoms among NH residents with and without dementia.

METHODS

We systematically searched the PubMed (1946-2012), Embase (1974-2012), CINAHL (1981-2012), AgeLine, and Cochrane Library (1998-2012) databases using the search terms neoplasms, cancer, tumor, and nursing home. The inclusion criteria were studies including NH residents with a diagnosis of cancer and outcome measures including pain and cancer-related symptoms.

RESULTS

We identified 11 studies (cross-sectional, longitudinal, clinical trial, and qualitative studies). Ten studies investigated the prevalence and treatment of cancer-related symptoms such as vomiting, nausea, urinary tract infections, and depression. Studies clearly report a high prevalence of pain and reduced prescribing and treatment, regardless of the cognitive status. Only one small study included people with cancer and a diagnosis of dementia. Studies of new cancer diagnoses in NHs could not be identified.

CONCLUSION

This review clearly reports a high prevalence of pain and reduced drug prescribing and treatment among NH residents with cancer. This issue appears to be most critical among people with severe dementia, emphasizing the need for better guidance and evidence on pain assessment for these individuals.

A population-based case-control study of urinary arsenic species and squamous cell carcinoma in New Hampshire, USA

BACKGROUND

Chronic high arsenic exposure is associated with squamous cell carcinoma (SCC) of the skin, and inorganic arsenic (iAs) metabolites may play an important role in this association. However, little is known about the carcinogenicity of arsenic at levels commonly observed in the United States.

OBJECTIVE

We estimated associations between total urinary arsenic and arsenic species and SCC in a U.S. population.

METHODS

We conducted a population-based case-control SCC study (470 cases, 447 controls) in a U.S. region with moderate arsenic exposure through private well water and diet. We measured urinary iAs, monomethylarsonic acid (MMA), and dimethylarsinic acid (DMA), and summed these arsenic species (ΣAs). Because seafood contains arsenolipids and arsenosugars that metabolize into DMA through alternate pathways, participants who reported seafood consumption within 2 days before urine collection were excluded from the analyses.

RESULTS

In adjusted logistic regression analyses (323 cases, 319 controls), the SCC odds ratio (OR) was 1.37 for each ln-transformed microgram per liter increase in ln-transformed ΣAs concentration [ln(ΣAs)] (95% CI: 1.04, 1.80). Urinary ln(MMA) and ln(DMA) also were positively associated with SCC (OR = 1.34; 95% CI: 1.04, 1.71 and OR = 1.34; 95% CI: 1.03, 1.74, respectively). A similar trend was observed for ln(iAs) (OR = 1.20; 95% CI: 0.97, 1.49). Percent iAs, MMA, and DMA were not associated with SCC.

CONCLUSIONS

These results suggest that arsenic exposure at levels common in the United States relates to SCC and that arsenic metabolism ability does not modify the association.

In utero arsenic exposure and infant infection in a United States cohort: a prospective study

Arsenic (As), a ubiquitous environmental toxicant, has recently been linked to disrupted immune function and enhanced infection susceptibility in highly exposed populations. In drinking water, as levels above the EPA maximum contaminant level occur in our US study area and are a particular health concern for pregnant women and infants. As a part of the New Hampshire Birth Cohort Study, we investigated whether in utero exposure to As affects risk of infant infections. We prospectively obtained information on 4-month-old infants (n=214) using a parental telephone survey on infant infections and symptoms, including respiratory infections, diarrhea and specific illnesses, as well as the duration and severity of infections. Using logistic regression and Poisson models, we evaluated the association between maternal urinary As during pregnancy and infection risks adjusted for potentially confounding factors. Maternal urinary As concentrations were related to total number of infections requiring a physician visit (relative risk (RR) per one-fold increase in As in urine=1.5; 95% confidence interval (CI)=1.0, 2.1) or prescription medication (RR=1.6; 95% CI=1.1, 2.4), as well as lower respiratory infections treated with prescription medication (RR=3.3; 95% CI=1.2, 9.0). Associations were observed with respiratory symptoms (RR=4.0; 95% CI=1.0, 15.8), upper respiratory infections (RR=1.6; 95% CI=1.0, 2.5), and colds treated with prescription medication (RR=2.3; 95% CI=1.0, 5.2). Our results provide initial evidence that in utero As exposure may be related to infant infection and infection severity and provide insight into the early life impacts of fetal As exposure.

Differential DNA methylation in umbilical cord blood of infants exposed to low levels of arsenic in utero

BACKGROUND

There is increasing epidemiologic evidence that arsenic exposure in utero, even at low levels found throughout much of the world, is associated with adverse reproductive outcomes and may contribute to long-term health effects. Animal models, in vitro studies, and human cancer data suggest that arsenic may induce epigenetic alterations, specifically by altering patterns of DNA methylation.

OBJECTIVES

In this study we aimed to identify differences in DNA methylation in cord blood samples of infants with in utero, low-level arsenic exposure.

METHODS

DNA methylation of cord-blood derived DNA from 134 infants involved in a prospective birth cohort in New Hampshire was profiled using the Illumina Infinium Methylation450K array. In utero arsenic exposure was estimated using maternal urine samples collected at 24-28 weeks gestation. We used a novel cell mixture deconvolution methodology for examining the association between inferred white blood cell mixtures in infant cord blood and in utero arsenic exposure; we also examined the association between methylation at individual CpG loci and arsenic exposure levels.

RESULTS

We found an association between urinary inorganic arsenic concentration and the estimated proportion of CD8+ T lymphocytes (1.18; 95% CI: 0.12, 2.23). Among the top 100 CpG loci with the lowest p-values based on their association with urinary arsenic levels, there was a statistically significant enrichment of these loci in CpG islands (p = 0.009). Of those in CpG islands (n = 44), most (75%) exhibited higher methylation levels in the highest exposed group compared with the lowest exposed group. Also, several CpG loci exhibited a linear dose-dependent relationship between methylation and arsenic exposure.

CONCLUSIONS

Our findings suggest that in utero exposure to low levels of arsenic may affect the epigenome. Long-term follow-up is planned to determine whether the observed changes are associated with health outcomes.

Incidence of oral cavity and pharynx cancer in New Hampshire, 1990-2007

OBJECTIVE

The purpose of this study is to describe trends of the statewide cancer and treatment-related characteristics of oral cavity and pharynx (OCP) cancer and prevalence of risk factors in New Hampshire residents from 1990-2007.

STUDY DESIGN

This is a descriptive study on oral cavity and pharynx cancer using a state cancer registry dataset for 1990- 2007. The age-adjusted rates with 95% confidence intervals for cancer incidence rates and standard proportions for stage, treatment, and risk factors were calculated. The Joinpoint regression model was used for assessing linear trends for cancer rates. The overall differences for the period under study between age, female and male rate, and stage were analyzed using the test.

RESULTS

During 1990-2007, oral cavity and pharynx cancer incidence rates for New Hampshire residents have remained stable. The cancer incidence rates have decreased for older age groups (greater than 59) and the 50-59 age group has shown increase in incidence rate of OCP cancer since 1990. There is significant increase in the late-stage diagnoses from 1990-2007.

CONCLUSION

Early detection through periodic medical and dental examinations can reduce the risk of these cancers. Public health strategies that address the gaps identified by this study can reduce OCP cancer and protect the health of the New Hampshire population.

The effects of opt-out legislation on data collection and surveillance of birth defects by the New Hampshire Birth Conditions Program, New Hampshire, United States, 2007-2009

BACKGROUND

The New Hampshire Birth Conditions Program (NHBCP) is a population-based, active case ascertainment surveillance system that monitors the occurrence of 45 birth defects across the state. A 2008 law requires a new opt-out procedure whereby legal guardians can choose whether or not to have identifiable information retained in the NHBCP database. The purpose of this study was to determine the effects of implementing this opt-out legislation on data collection and surveillance of birth defects by the NHBCP.

METHODS

Using surveillance data collected following implementation of the opt out legislation for the period January 1, 2007, through December 31, 2009, 2 opt-out groups were created: the identifiable information retained (IIR) group, consisting of families who did not choose to opt out, and the de-identified information retained group (DIIR), consisting of those who either chose to opt out or were treated as opt-out birth defect cases because their opt-out package was undeliverable. Descriptive statistics were calculated for each group, and chi-square or Fisher's exact tests were used to compare the proportion of select sociodemographic and medical characteristics between the 2 opt-out groups.

RESULTS

Of 776 infants, 120 (15.5%) fell into the DIIR group. Differences were observed by race/ethnicity (among non-Hispanic whites, 15% were in the DIIR group and among Hispanics, 33% were in the DIIR group; p=0.01) and by maternal age (among women 30-34 years of age, 11% were in the DIIR group, and among those 25 years of age or younger, 22% were in the DIIR group; p=0.05). Birth outcomes, payer source, county of residence, and common birth defect diagnoses did not differ between the opt-out groups.

CONCLUSION

This study demonstrated that there were significant differences in race/ethnicity and maternal age between parents who had de-identified information included in the NHBCP compared with those who did not choose to opt out. Although the surveillance of birth defects is not affected, the opportunities for certain types of research will be limited.

Adolescent weight status and receptivity to food TV advertisements

OBJECTIVE

This study examined the relationship between adolescent weight status and food advertisement receptivity.

DESIGN

Survey-based evaluation with data collected at baseline (initial and at 2 months), and at follow-up (11 months).

SETTING

New Hampshire and Vermont.

PARTICIPANTS

Students (n = 2,281) aged 10-13 in 2002-2005.

MAIN OUTCOME MEASURE

Overweight.

ANALYSIS

Generalized estimating equations to model the relationship between identifying a food advertisement as their favorite and being overweight.

RESULTS

Overall, 35.9% of the adolescents were overweight. Less than one fifth named a food advertisement as their favorite (16.1%). Most of the food advertisements were for less-healthful food (89.6%). After controlling for school, age, sex, sociodemographics, physical activity, number of TV sessions watched, and having a TV in the bedroom, overweight adolescents were significantly less likely to be receptive to food advertisements (relative risk = 0.83, 95% confidence interval 0.70, 0.98) compared to non-overweight adolescents.

CONCLUSIONS AND IMPLICATIONS

This study provides preliminary evidence that normal-weight adolescents are receptive to unhealthful food advertisements. Longitudinal studies are needed to evaluate whether consistent exposure to advertisements for unhealthful food, particularly if they are promoted with healthful behaviors such as being physically active, influence adolescents' food choices, and ultimately their body mass index, over the long term.

Estimating water supply arsenic levels in the New England Bladder Cancer Study

BACKGROUND

Ingestion of inorganic arsenic in drinking water is recognized as a cause of bladder cancer when levels are relatively high (≥ 150 µg/L). The epidemiologic evidence is less clear at the low-to-moderate concentrations typically observed in the United States. Accurate retrospective exposure assessment over a long time period is a major challenge in conducting epidemiologic studies of environmental factors and diseases with long latency, such as cancer.

OBJECTIVE

We estimated arsenic concentrations in the water supplies of 2,611 participants in a population-based case-control study in northern New England.

METHODS

Estimates covered the lifetimes of most study participants and were based on a combination of arsenic measurements at the homes of the participants and statistical modeling of arsenic concentrations in the water supply of both past and current homes. We assigned a residential water supply arsenic concentration for 165,138 (95%) of the total 173,361 lifetime exposure years (EYs) and a workplace water supply arsenic level for 85,195 EYs (86% of reported occupational years).

RESULTS

Three methods accounted for 93% of the residential estimates of arsenic concentration: direct measurement of water samples (27%; median, 0.3 µg/L; range, 0.1-11.5), statistical models of water utility measurement data (49%; median, 0.4 µg/L; range, 0.3-3.3), and statistical models of arsenic concentrations in wells using aquifers in New England (17%; median, 1.6 µg/L; range, 0.6-22.4).

CONCLUSIONS

We used a different validation procedure for each of the three methods, and found our estimated levels to be comparable with available measured concentrations. This methodology allowed us to calculate potential drinking water exposure over long periods.

Skeletal health in men with chronic lung disease: rates of testing, treatment, and fractures

To advance our understanding of the burden of fractures among men, we studied a group of men at high risk for low bone strength due to lung disease. We found high rates of fractures but low rates of bone density testing that could predict fracture before it occurs.

INTRODUCTION

To advance understanding of the burden of fragility fractures and attention to bone health among men with chronic obstructive lung disease (COPD), we quantified rates of fragility fracture, bone density testing, and anti-resorptive treatment and calculated the number needed to screen (NNS) to prevent one hip fracture in a cohort of men with COPD.

METHODS

Veterans Administration (VA) and VA-Medicare administrative data permitted a retrospective cohort study of 87,360 men aged 50 and older, newly diagnosed with COPD between 1999 and 2003. Logistic regression models including patient characteristics, morbidities, and medication use assessed the effect of covariates on fracture and probability of testing or treatment.

RESULTS

Mean age was 66.8. Hip and wrist fracture rates were 3.99 and 1.31 per 1,000 person years, respectively. Mean follow-up was 2.67 years; 4.4% underwent bone densitometry; 2.8% filled anti-resorptive prescriptions. Age, white race/ethnicity, more COPD exacerbations, barbiturate use, and anti-Parkinson's drug use were significantly associated with fracture. Age, and systemic corticosteroids were most significantly associated with testing or treatment. Based on published adherence and treatment effects, the cohort's calculated NNS to prevent one hip fracture is 432.

CONCLUSIONS

Fracture rate was high and testing and treatment uncommon. The NNS of 432 to prevent one hip fracture is smaller than 731, the NNS for women aged 65-69 for whom universal screening is recommended. Attention to the bone health of this population is warranted. Future research must determine how testing and treatment impact overall quality of life and mortality of men with COPD.

Bilateral oophorectomy in relation to risk of postmenopausal breast cancer: confounding by nonmalignant indications for surgery?

Bilateral oophorectomy is often performed during hysterectomy for benign conditions and can reduce breast cancer risk by 20%-50% when performed at younger ages. Accuracy of estimating the decrease in breast cancer risk associated with bilateral oophorectomy could be affected by common conditions that lead to surgery, such as uterine fibroids or endometriosis. The authors examined the potential for confounding by nonmalignant indications for surgery on breast cancer risk estimates in a population-based case-control study of invasive breast cancer newly diagnosed in 1992-1995. Breast cancer cases (N = 4,935) aged 50-79 years were identified from Wisconsin, Massachusetts, and New Hampshire tumor registries; similarly aged controls (N = 5,111) were selected from driver's license and Medicare lists. Reproductive and medical history was obtained from structured telephone interviews. Odds ratios and 95% confidence intervals were estimated with multivariate logistic regression. Women who underwent bilateral oophorectomy with hysterectomy at age ≤ 40 years had significantly reduced odds of breast cancer (odds ratio = 0.74, 95% confidence interval: 0.60, 0.90) compared with women with intact ovaries and uterus. Effect estimates were virtually unchanged after adjustment for uterine fibroids or endometriosis history. Results indicate that breast cancer risk reductions conferred by bilateral oophorectomy are not strongly confounded by failure to account for nonmalignant indications for surgery.

Correlates of the preoperative level of CA125 at presentation of ovarian cancer

OBJECTIVE

CA125 at presentation of ovarian cancer carries important prognostic significance; but, other than tumor characteristics, little is known about factors that influence CA125 levels. We examined the effect of epidemiologic variables and tumor features on CA125 at diagnosis and their effects on survival.

METHODS

CA125 levels before treatment, tumor features, and questionnaire data from 805 women with ovarian cancer receiving care at Partners Hospitals were recorded. CA125 values were log-normalized and generalized linear, logistic, or Cox proportional hazards models used to identify predictors of CA125 and influence on survival in the subset of women with invasive, nonmucinous tumors.

RESULTS

The importance of histology, grade, stage, laterality, and presence of ascites on CA125 level was confirmed. For nonmucinous invasive cancers, Jewish ethnicity, parity, prior breast cancer, and family history of breast or ovarian cancer predicted higher CA125, and greater body mass index (BMI), recurrent yeast infections, colitis, and appendectomy predicted lower CA125. A quadratic model best described the relationship between CA125 and age with lower levels in youngest and oldest women. In multivariate modeling, stage, ascites, and prior breast cancer were the strongest predictors of high CA125 and appendectomy and yeast infections strongest predictors of low CA125. A model with these variables plus CA125 revealed high CA125 remains a predictor of poorer survival.

CONCLUSIONS

Ovarian tumor features and presence of ascites are key determinants of CA125 at diagnosis, but epidemiologic features such as BMI, parity, prior breast cancer, and history of inflammatory conditions of the genitourinary or gastrointestinal tracts may also play a role.

A novel survival multifactor dimensionality reduction method for detecting gene-gene interactions with application to bladder cancer prognosis

The widespread use of high-throughput methods of single nucleotide polymorphism (SNP) genotyping has created a number of computational and statistical challenges. The problem of identifying SNP-SNP interactions in case-control studies has been studied extensively, and a number of new techniques have been developed. Little progress has been made, however, in the analysis of SNP-SNP interactions in relation to time-to-event data, such as patient survival time or time to cancer relapse. We present an extension of the two class multifactor dimensionality reduction (MDR) algorithm that enables detection and characterization of epistatic SNP-SNP interactions in the context of survival analysis. The proposed Survival MDR (Surv-MDR) method handles survival data by modifying MDR's constructive induction algorithm to use the log-rank test. Surv-MDR replaces balanced accuracy with log-rank test statistics as the score to determine the best models. We simulated datasets with a survival outcome related to two loci in the absence of any marginal effects. We compared Surv-MDR with Cox-regression for their ability to identify the true predictive loci in these simulated data. We also used this simulation to construct the empirical distribution of Surv-MDR's testing score. We then applied Surv-MDR to genetic data from a population-based epidemiologic study to find prognostic markers of survival time following a bladder cancer diagnosis. We identified several two-loci SNP combinations that have strong associations with patients' survival outcome. Surv-MDR is capable of detecting interaction models with weak main effects. These epistatic models tend to be dropped by traditional Cox regression approaches to evaluating interactions. With improved efficiency to handle genome wide datasets, Surv-MDR will play an important role in a research strategy that embraces the complexity of the genotype-phenotype mapping relationship since epistatic interactions are an important component of the genetic basis of disease.

Improving the quality of industry and occupation data at a central cancer registry

BACKGROUND

Central cancer registries are required to collect industry and occupation (I/O) information when available, but the data reported are often incomplete.

METHODS

We audited the completeness of I/O data in the New Hampshire State Cancer Registry (NHSCR) database for diagnosis year 2005, and reviewed medical records for a convenience sample of 474 of these cases. We compared I/O data quality before and after a statewide registrar training session on occupationally related cancers.

RESULTS

The original 2005 data contained both I/O data in 11.5% of cases, and lacked any I/O data in 74.5%. Corresponding figures for cases selected for audit were 15.2% and 77.2%, which improved to 54.2% and 11.8% after medical record review. After registrar training, 47% of reports contained both I/O data, and only 14.4% of cases lacked any I/O data.

CONCLUSIONS

Statewide training to highlight the importance of I/O data is an effective method to improve I/O data quality.