Antidepressant Exposure and DNA Methylation: Insights from a Methylome-Wide Association Study

Importance

Understanding antidepressant mechanisms could help design more effective and tolerated treatments.

Objective

Identify DNA methylation (DNAm) changes associated with antidepressant exposure.

Design

Case-control methylome-wide association studies (MWAS) of antidepressant exposure were performed from blood samples collected between 2006-2011 in Generation Scotland (GS). The summary statistics were tested for enrichment in specific tissues, gene ontologies and an independent MWAS in the Netherlands Study of Depression and Anxiety (NESDA). A methylation profile score (MPS) was derived and tested for its association with antidepressant exposure in eight independent cohorts, alongside prospective data from GS.

Setting

Cohorts; GS, NESDA, FTC, SHIP-Trend, FOR2107, LBC1936, MARS-UniDep, ALSPAC, E-Risk, and NTR.

Participants

Participants with DNAm data and self-report/prescription derived antidepressant exposure.

Main Outcomes and Measures

Whole-blood DNAm levels were assayed by the EPIC/450K Illumina array (9 studies, N exposed = 661, N unexposed = 9,575) alongside MBD-Seq in NESDA (N exposed = 398, N unexposed = 414). Antidepressant exposure was measured by self- report and/or antidepressant prescriptions.

Results

The self-report MWAS (N = 16,536, N exposed = 1,508, mean age = 48, 59% female) and the prescription-derived MWAS (N = 7,951, N exposed = 861, mean age = 47, 59% female), found hypermethylation at seven and four DNAm sites (p < 9.42x10 -8 ), respectively. The top locus was cg26277237 ( KANK1, p self-report = 9.3x10 -13 , p prescription = 6.1x10 -3 ). The self-report MWAS found a differentially methylated region, mapping to DGUOK-AS1 ( p adj = 5.0x10 -3 ) alongside significant enrichment for genes expressed in the amygdala, the "synaptic vesicle membrane" gene ontology and the top 1% of CpGs from the NESDA MWAS (OR = 1.39, p < 0.042). The MPS was associated with antidepressant exposure in meta-analysed data from external cohorts (N studies = 9, N = 10,236, N exposed = 661, f3 = 0.196, p < 1x10 -4 ).

Conclusions and Relevance

Antidepressant exposure is associated with changes in DNAm across different cohorts. Further investigation into these changes could inform on new targets for antidepressant treatments.

3 Key Points

Question: Is antidepressant exposure associated with differential whole blood DNA methylation?Findings: In this methylome-wide association study of 16,536 adults across Scotland, antidepressant exposure was significantly associated with hypermethylation at CpGs mapping to KANK1 and DGUOK-AS1. A methylation profile score trained on this sample was significantly associated with antidepressant exposure (pooled f3 [95%CI]=0.196 [0.105, 0.288], p < 1x10 -4 ) in a meta-analysis of external datasets. Meaning: Antidepressant exposure is associated with hypermethylation at KANK1 and DGUOK-AS1 , which have roles in mitochondrial metabolism and neurite outgrowth. If replicated in future studies, targeting these genes could inform the design of more effective and better tolerated treatments for depression.

Point prevalence and clinical course of proteinuria in dogs with idiopathic non-erosive immune-mediated polyarthritis

Objectives

To describe the point prevalence and clinical course of proteinuria in dogs diagnosed with idiopathic non‐erosive immune‐mediated polyarthritis.

Materials and Methods

Cases presenting to a single referral centre with a diagnosis of idiopathic non‐erosive immune‐mediated polyarthritis were retrospectively recruited from January 2009 to August 2018. Data including signalment, urinalysis, clinicopathological results, cytology from arthrocentesis, treatment and long‐term follow‐up were analysed. Dogs were defined as: non‐proteinuric (UPC <0.2), borderline proteinuric (UPC 0.2‐0.5) or overtly proteinuric (UPC >0.5).

Results

Fifty‐eight dogs met the inclusion criteria. Twenty‐two dogs were overtly proteinuric (38%), eight dogs were borderline proteinuric (14%) and 28 dogs were non‐proteinuric (48%). Repeated urinalysis was performed in nine of 12 dogs with UPC greater than 2.0. The UPC decreased in all nine dogs, with the UPC decreasing to less than 0.5 in 44% of dogs. A greater than 50% decrease in UPC was noted in 44% of dogs, despite seven of nine (77%) receiving prednisolone as either monotherapy or in conjunction with an adjunctive immunosuppressive medication.

Clinical Significance

Proteinuria was common in this cohort of dogs diagnosed with primary idiopathic non‐erosive immune‐mediated polyarthritis. The use of prednisolone does not appear to be contraindicated in proteinuric dogs with idiopathic non‐erosive immune‐mediated polyarthritis.

Systematic review of wastewater surveillance of antimicrobial resistance in human populations

OBJECTIVES

We systematically reviewed studies using wastewater for AMR surveillance in human populations, to determine: (i) evidence of concordance between wastewater-human AMR prevalence estimates, and (ii) methodological approaches which optimised identifying such an association, and which could be recommended as standard. We used Lin's concordance correlation coefficient (CCC) to quantify concordance between AMR prevalence estimates in wastewater and human compartments (where CCC = 1 reflects perfect concordance), and logistic regression to identify study features (e.g. sampling methods) associated with high agreement studies (defined as >70% of within-study wastewater-human AMR prevalence comparisons within ±10%).

RESULTS

Of 8,867 records and 441 full-text methods reviewed, 33 studies were included. AMR prevalence data was extractable from 24 studies conducting phenotypic-only (n = 7), genotypic-only (n = 1) or combined (n = 16) AMR detection. Overall concordance of wastewater-human AMR prevalence estimates was reasonably high for both phenotypic (CCC = 0.85 [95% CI 0.8-0.89]) and genotypic approaches (CCC = 0.88 (95% CI 0.84-0.9)) despite diverse study designs, bacterial species investigated and phenotypic/genotypic targets. No significant relationships between methodological approaches and high agreement studies were identified using logistic regression; however, this was limited by inconsistent reporting of study features, significant heterogeneity in approaches and limited sample size. Based on a secondary, descriptive synthesis, studies conducting composite sampling of wastewater influent, longitudinal sampling >12 months, and time-/location-matched sampling of wastewater and human compartments generally had higher agreement.

CONCLUSION

Wastewater-based surveillance of AMR appears promising, with high overall concordance between wastewater and human AMR prevalence estimates in studies irrespective of heterogenous approaches. However, our review suggests future work would benefit from: time-/location-matched sampling of wastewater and human populations, composite sampling of influent, and sampling >12 months for longitudinal studies. Further research and clear and consistent reporting of study methods is required to identify optimal practice.

Validation of the Prevention Impacts Simulation Model (PRISM)

Introduction

Demonstrating the validity of a public health simulation model helps to establish confidence in the accuracy and usefulness of a model’s results. In this study we evaluated the validity of the Prevention Impacts Simulation Model (PRISM), a system dynamics model that simulates health, mortality, and economic outcomes for the US population. PRISM primarily simulates outcomes related to cardiovascular disease but also includes outcomes related to other chronic diseases that share risk factors. PRISM is openly available through a web application.

Methods

We applied the model validation framework developed independently by the International Society of Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making modeling task force to validate PRISM. This framework included model review by external experts and quantitative data comparison by the study team.

Results

External expert review determined that PRISM is based on up-to-date science. One-way sensitivity analysis showed that no parameter affected results by more than 5%. Comparison with other published models, such as ModelHealth, showed that PRISM produces lower estimates of effects and cost savings. Comparison with surveillance data showed that projected model trends in risk factors and outcomes align closely with secular trends. Four measures did not align with surveillance data, and those were recalibrated.

Conclusion

PRISM is a useful tool to simulate the potential effects and costs of public health interventions. Results of this validation should help assure health policy leaders that PRISM can help support community health program planning and evaluation efforts.

Serological markers of gluten sensitivity in Border terriers with gall bladder mucocoeles

OBJECTIVES

To evaluate serological markers of gluten sensitivity in conjunction with cholecystokinin measurement in Border terriers with gall bladder mucocoeles.

MATERIALS AND METHODS

Medical records from two referral hospitals were obtained between 2011 and 2019 to identify Border terriers with gall bladder mucocoeles, non-Border terriers with gall bladder mucocoeles and control Border terriers with non-biliary diseases. Enzyme-linked immunosorbent assays were performed on stored fasted serum samples for anti-gliadin IgG, anti-canine transglutaminase-2-IgA autoantibodies and cholecystokinin. Statistical analysis was performed using the Kruskall-Wallis test to identify differences between the groups.

RESULTS

Fifteen Border terriers with gall bladder mucocoeles, 17 non-Border terriers with gall bladder mucocoeles and 14 control Border terriers with non-biliary diseases were recruited. Median transglutaminase-2-IgA autoantibodies in Border terriers with gall bladder mucocoeles was 0.73 (range: 0.18 to 1.67), which was significantly greater than in control Border terriers at 0.41 (0.07 to 1.14). Median cholecystokinin concentration in Border terriers with gall bladder mucocoeles was 13 pg/mL (6 to 45 pg/mL), which was significantly lower than in control Border terriers at 103 pg/mL (9 to 397 pg/mL). There was no difference in the anti-gliadin IgG between these groups. There was no difference observed in the non-Border terriers with gall bladder mucocoeles with either of the other groups.

CLINICAL SIGNIFICANCE

Reduced cholecystokinin and increased transglutaminase-2-IgA autoantibodies was detected in Border terriers with gall bladder mucocoeles; which is in part homologous to gall bladder disease identified in human coeliac disease. The results suggest an immunological disease with impaired cholecystokinin release may be affecting gall bladder motility and possibly contributing to mucocoele formation in Border terriers.

Identification of a predominant cognitive phenotype in patients with multiple sclerosis

BACKGROUND AND PURPOSE

Cognitive impairment occurs frequently in multiple sclerosis (MS). However, the prevalence and clinical characteristics of cognitive MS phenotype are not well established. The aim of the study was to characterize the clinical course and neurocognitive impairment of patients with MS meeting an Expanded Disability Status Scale (EDSS)-defined cognitive phenotype.

METHODS

A total of 2302 patients from the Comprehensive Longitudinal Investigation of Multiple Sclerosis at Brigham and Women's Hospital (CLIMB) study were studied. Predominant cognitive MS phenotype was defined as EDSS Cerebral Functional System (FS) subscore ≥3 and remaining EDSS FS subscores ≤2 on at least one clinical visit. Demographic/clinical characteristics, phenotype stability and neurocognitive domain impairment of these subjects were assessed.

RESULTS

A total of 60 of 2302 (2.6%) patients (age 52.8 ± 10.8 years, 68% female, 82% relapsing MS) met criteria for phenotype designation. A total of 29 of 60 (48%) were designated within 10 years of their presenting MS symptom. The mean cohort annualized relapse rate was 0.38 and EDSS score at last clinical assessment was 3.2 ± 1.3. Cognitive phenotype status was poorly sustained, with only 27% of subjects maintaining Cerebral FS score ≥2 throughout all follow-up. However, predominant cognitive phenotype subjects with clinical neuropsychiatric testing [n = 39/60 (65%)] frequently had cognitive impairment (1.5 SD below mean) in ≥1 domain [n = 30/39 (77%) of subjects] affecting memory, attention/executive function and processing speed. A total of 11 of 39 (28%) patients had severe-range cognitive impairment (3.0 SD below mean). Cognitive phenotype designation was associated with low rate of employment at last clinical assessment.

CONCLUSION

Predominant cognitive MS phenotype is rare, although an EDSS-based definition identifies patients with multidomain cognitive impairment and may serve as a practical screen for identification of patients who might warrant close monitoring of neurocognitive status.

Gall bladder mucoceles in Border terriers

Background

Gall bladder mucoceles (GBM) are a leading cause of biliary disease in dogs with several breeds, including the Shetland Sheepdog, American Cocker Spaniel, Chihuahua, Pomeranian, and Miniature Schnauzer apparently predisposed.

Objective

To determine risk factors, clinical features, and response to treatment of GBM in Border terriers (BT).

Animals

Medical records of 99 dogs (including 51 BT) with an ultrasonographic (±histopathologic) diagnosis of GBM from three referral centers in the United Kingdom were collected. A control group of 87 similar‐aged BT with no ultrasonographic evidence of gall bladder disease was selected for comparison.

Method

Retrospective case‐control study. Odds ratios were calculated to establish breed predisposition. Signalment, presence of endocrine disease, clinicopathologic results, and outcome were compared between the BT, other breeds, and control BTs.

Results

The odds of identifying a GBM in a BT in this hospital population was 85 times that of all other breeds (95% confidence interval 56.9‐126.8). BT had similar clinical signs and clinicopathologic changes to other breeds with GBM. There was no evidence that endocrinopathies were associated with GBM in BT.

Clinical Significance

A robust breed predisposition to GBM is established for the BT.

Chronic Disease Disparities by County Economic Status and Metropolitan Classification, Behavioral Risk Factor Surveillance System, 2013

INTRODUCTION

Racial/ethnic disparities have been studied extensively. However, the combined influence of geographic location and economic status on specific health outcomes is less well studied. This study's objective was to examine 1) the disparity in chronic disease prevalence in the United States by county economic status and metropolitan classification and 2) the social gradient by economic status. The association of hypertension, arthritis, and poor health with county economic status was also explored.

METHODS

We used 2013 Behavioral Risk Factor Surveillance System data. County economic status was categorized by using data on unemployment, poverty, and per capita market income. While controlling for sociodemographics and other covariates, we used multivariable logistic regression to evaluate the relationship between economic status and hypertension, arthritis, and self-rated health.

RESULTS

Prevalence of hypertension, arthritis, and poor health in the poorest counties was 9%, 13%, and 15% higher, respectively, than in the most affluent counties. After we controlled for covariates, poor counties still had a higher prevalence of the studied conditions.

CONCLUSION

We found that residents of poor counties had a higher prevalence of poor health outcomes than affluent counties, even after we controlled for known risk factors. Further, the prevalence of poor health outcomes decreased as county economics improved. Findings suggest that poor counties would benefit from targeted public health interventions, better access to health care services, and improved food and built environments.

But who will make the visits? A patient-related information system for management in district nursing

District nurses in Barnsley, UK, have for many years used a patient classification system based on ‘Criteria for Care’, whose value in practical management terms has established itself into the routine of the information system used. This is a descendant of FIP, now known as TCCS (Total Care Community System). ‘Criteria for Care’ was, however, hospital based and an independent validity check was required for community use. This was carried out in Belfast, Northern Ireland, where research produced a system for patient classification, workload analysis and skillmix analysis which was generated by nurses and acted both as a validity check and further development of the system used in Barnsley.

The management information matrix, which is the outcome of this paper, is generated from practitioners using guidelines agreed by them, and yields management information of a directly practical value.

The system presented is now implemented and uses data updated daily, if required, to produce a spreadsheet covering team workload index, a workload profile, and measures of pressure of work on each nurse, patient acuity [1], and a quality of care index. From this it is possible to adjust skillmix and staffing levels to create equity of pressure across teams and to match nursing skillmix to patient classification in the light of a quality index from each team.

From a GP attachment and a team perspective this information can be utilized in conjunction with contract monitoring data in order to review district nursing activity. This will enable workloads to be reviewed and could facilitate integrated team working within the practice.

Summarizing health-related quality of life (HRQOL): development and testing of a one-factor model

BACKGROUND

Health-related quality of life (HRQOL) is a multi-dimensional concept commonly used to examine the impact of health status on quality of life. HRQOL is often measured by four core questions that asked about general health status and number of unhealthy days in the Behavioral Risk Factor Surveillance System (BRFSS). Use of these measures individually, however, may not provide a cohesive picture of overall HRQOL. To address this concern, this study developed and tested a method for combining these four measures into a summary score.

METHODS

Exploratory and confirmatory factor analyses were performed using BRFSS 2013 data to determine potential numerical relationships among the four HRQOL items. We also examined the stability of our proposed one-factor model over time by using BRFSS 2001-2010 and BRFSS 2011-2013 data sets.

RESULTS

Both exploratory factor analysis and goodness of fit tests supported the notion that one summary factor could capture overall HRQOL. Confirmatory factor analysis indicated acceptable goodness of fit of this model. The predicted factor score showed good validity with all of the four HRQOL items. In addition, use of the one-factor model showed stability, with no changes being detected from 2001 to 2013.

CONCLUSION

Instead of using four individual items to measure HRQOL, it is feasible to study overall HRQOL via factor analysis with one underlying construct. The resulting summary score of HRQOL may be used for health evaluation, subgroup comparison, trend monitoring, and risk factor identification.

Association of Socioeconomic Position and Demographic Characteristics with Cardiovascular Disease Risk Factors and Healthcare Access among Adults Living in Pohnpei, Federated States of Micronesia

Background. The burden of cardiovascular disease (CVD) is increasing in low-to-middle income countries. We examined how socioeconomic and demographic characteristics may be associated with CVD risk factors and healthcare access in such countries. Methods. We extracted data from the World Health Organization's STEPwise approach to surveillance 2002 cross-sectional dataset from Pohnpei, Federated States of Micronesia (FSM). We used these data to estimate associations for socioeconomic position (education, income, and employment) and demographics (age, sex, and urban/rural) with CVD risk factors and with healthcare access, among a sample of 1638 adults (25-64 years). Results. In general, we found significantly higher proportions of daily tobacco use among men than women and respondents reporting primary-level education (<9 years) than among those with postsecondary education (>12 years). Results also revealed significant positive associations between paid employment and waist circumference and systolic blood pressure. Healthcare access did not differ significantly by socioeconomic position. Women reported significantly higher mean waist circumference than men. Conclusion. Our results suggest that socioeconomic position and demographic characteristics impact CVD risk factors and healthcare access in FSM. This understanding may help decision-makers tailor population-level policies and programs. The 2002 Pohnpei data provides a baseline; subsequent population health surveillance data might define trends.

Prevalence and incidence trends for diagnosed diabetes among adults aged 20 to 79 years, United States, 1980-2012

IMPORTANCE

Although the prevalence and incidence of diabetes have increased in the United States in recent decades, no studies have systematically examined long-term, national trends in the prevalence and incidence of diagnosed diabetes.

OBJECTIVE

To examine long-term trends in the prevalence and incidence of diagnosed diabetes to determine whether there have been periods of acceleration or deceleration in rates.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed 1980-2012 data for 664,969 adults aged 20 to 79 years from the National Health Interview Survey (NHIS) to estimate incidence and prevalence rates for the overall civilian, noninstitutionalized, US population and by demographic subgroups (age group, sex, race/ethnicity, and educational level).

MAIN OUTCOMES AND MEASURES

The annual percentage change (APC) in rates of the prevalence and incidence of diagnosed diabetes (type 1 and type 2 combined).

RESULTS

The APC for age-adjusted prevalence and incidence of diagnosed diabetes did not change significantly during the 1980s (for prevalence, 0.2% [95% CI, -0.9% to 1.4%], P = .69; for incidence, -0.1% [95% CI, -2.5% to 2.4%], P = .93), but each increased sharply during 1990-2008 (for prevalence, 4.5% [95% CI, 4.1% to 4.9%], P < .001; for incidence, 4.7% [95% CI, 3.8% to 5.6%], P < .001) before leveling off with no significant change during 2008-2012 (for prevalence, 0.6% [95% CI, -1.9% to 3.0%], P = .64; for incidence, -5.4% [95% CI, -11.3% to 0.9%], P = .09). The prevalence per 100 persons was 3.5 (95% CI, 3.2 to 3.9) in 1990, 7.9 (95% CI, 7.4 to 8.3) in 2008, and 8.3 (95% CI, 7.9 to 8.7) in 2012. The incidence per 1000 persons was 3.2 (95% CI, 2.2 to 4.1) in 1990, 8.8 (95% CI, 7.4 to 10.3) in 2008, and 7.1 (95% CI, 6.1 to 8.2) in 2012. Trends in many demographic subpopulations were similar to these overall trends. However, incidence rates among non-Hispanic black and Hispanic adults continued to increase (for interaction, P = .03 for non-Hispanic black adults and P = .01 for Hispanic adults) at rates significantly greater than for non-Hispanic white adults. In addition, the rate of increase in prevalence was higher for adults who had a high school education or less compared with those who had more than a high school education (for interaction, P = .006 for <high school and P < .001 for high school).

CONCLUSIONS AND RELEVANCE

Analyses of nationally representative data from 1980 to 2012 suggest a doubling of the incidence and prevalence of diabetes during 1990-2008, and a plateauing between 2008 and 2012. However, there appear to be continued increases in the prevalence or incidence of diabetes among subgroups, including non-Hispanic black and Hispanic subpopulations and those with a high school education or less.

The lifetime cost of diabetes and its implications for diabetes prevention

OBJECTIVE

To assess the cost implications of diabetes prevention, it is important to know the lifetime medical cost of people with diabetes relative to those without. We derived such estimates using data representative of the U.S. national population.

RESEARCH DESIGN AND METHODS

We aggregated annual medical expenditures from the age of diabetes diagnosis to death to determine lifetime medical expenditure. Annual medical expenditures were estimated by sex, age at diagnosis, and diabetes duration using data from 2006-2009 Medical Expenditure Panel Surveys, which were linked to data from 2005-2008 National Health Interview Surveys. We combined survival data from published studies with the estimated annual expenditures to calculate lifetime spending. We then compared lifetime spending for people with diabetes with that for those without diabetes. Future spending was discounted at 3% annually.

RESULTS

The discounted excess lifetime medical spending for people with diabetes was $124,600 ($211,400 if not discounted), $91,200 ($135,600), $53,800 ($70,200), and $35,900 ($43,900) when diagnosed with diabetes at ages 40, 50, 60, and 65 years, respectively. Younger age at diagnosis and female sex were associated with higher levels of lifetime excess medical spending attributed to diabetes.

CONCLUSIONS

Having diabetes is associated with substantially higher lifetime medical expenditures despite being associated with reduced life expectancy. If prevention costs can be kept sufficiently low, diabetes prevention may lead to a reduction in long-term medical costs.

Association between depression and functional vision loss in persons 20 years of age or older in the United States, NHANES 2005-2008

IMPORTANCE

This study provides further evidence from a national sample to generalize the relationship between depression and vision loss to adults across the age spectrum. Better recognition of depression among people reporting reduced ability to perform routine activities of daily living due to vision loss is warranted.

OBJECTIVES

To estimate, in a national survey of US adults 20 years of age or older, the prevalence of depression among adults reporting visual function loss and among those with visual acuity impairment. The relationship between depression and vision loss has not been reported in a nationally representative sample of US adults. Previous studies have been limited to specific cohorts and predominantly focused on the older population.

DESIGN

The National Health and Nutrition Examination Survey (NHANES) 2005-2008.

SETTING

A cross-sectional, nationally representative sample of adults, with prevalence estimates weighted to represent the civilian, noninstitutionalized US population.

PARTICIPANTS

A total of 10 480 US adults 20 years of age or older.

MAIN OUTCOME MEASURES

Depression, as measured by the 9-item Patient Health Questionnaire depression scale, and vision loss, as measured by visual function using a questionnaire and by visual acuity at examination.

RESULTS

In 2005-2008, the estimated crude prevalence of depression (9-item Patient Health Questionnaire score of ≥10) was 11.3% (95% CI, 9.7%-13.2%) among adults with self-reported visual function loss and 4.8% (95% CI, 4.0%-5.7%) among adults without. The estimated prevalence of depression was 10.7% (95% CI, 8.0%-14.3%) among adults with presenting visual acuity impairment (visual acuity worse than 20/40 in the better-seeing eye) compared with 6.8% (95% CI, 5.8%-7.8%) among adults with normal visual acuity. After controlling for age, sex, race/ethnicity, marital status, living alone or not, education, income, employment status, health insurance, body mass index, smoking, binge drinking, general health status, eyesight worry, and major chronic conditions, self-reported visual function loss remained significantly associated with depression (overall odds ratio, 1.9 [95% CI, 1.6-2.3]), whereas the association between presenting visual acuity impairment and depression was no longer statistically significant.

CONCLUSIONS AND RELEVANCE

Self-reported visual function loss, rather than loss of visual acuity, is significantly associated with depression. Health professionals should be aware of the risk of depression among persons reporting visual function loss.

Medical expenditures associated with major depressive disorder among privately insured working-age adults with diagnosed diabetes in the United States, 2008

AIM

We aimed at estimating excess medical expenditures associated with major depressive disorder (MDD) among working-age adults diagnosed with diabetes, disaggregated by treatment mode: insulin-treated diabetes (ITDM) or non-insulin-treated diabetes (NITDM).

METHODS

We analyzed data for over 500,000 individuals with diagnosed diabetes from the 2008 U.S. MarketScan claims database. We grouped diabetic patients first by treatment mode (ITDM or NITDM), then by MDD status (with or without MDD), and finally by whether those with MDD used antidepressant medication. We estimated annual mean excess outpatient, inpatient, prescription drug, and total expenditures using regression models, controlling for demographics, types of health coverage, and comorbidities.

RESULTS

Among persons having ITDM, the estimated annual total mean expenditure for those with no MDD (the comparison group) was $19,625. For those with MDD, the expenditures were $12,406 (63%) larger if using antidepressant medication and $7322 (37%) larger if not using antidepressant medication. Among persons having NITDM, the corresponding estimated expenditure for the comparison group was $10,746, the excess expenditures were $10,432 (97%) larger if using antidepressant medication and $5579 (52%) larger if not using antidepressant medication, respectively. Inpatient excess expenditures were the largest of total excess expenditure for those with ITDM and MDD treated with antidepressant medication; for all others with diabetes and MDD, outpatient expenditures were the largest excess expenditure.

CONCLUSIONS

Among working-age adults with diabetes, MDD was associated with substantial excess medical expenditures. Implementing the effective interventions demonstrated in clinical trials and treatment guidelines recommended by professional organizations might reduce the economic burden of MDD in this population.

Characteristics associated with poor glycemic control among adults with self-reported diagnosed diabetes--National Health and Nutrition Examination Survey, United States, 2007-2010

Nationally representative estimates indicate that 18.8 million adults in the United States have received a diagnosis with diabetes mellitus. When glycemic control is not optimized, diabetes imposes additional burdensome care requirements, health-care costs, and high risk of disabling complications, and this has been especially evident in socioeconomically disadvantaged and minority populations. For example, higher levels of glycated hemoglobin (A1c) have been associated with increased risk of diabetic retinopathy, increased risk of chronic kidney disease, and increased risk of cardiovascular disease. Reducing A1c levels through combined clinical and effective self-management has demonstrated reduced risk for microvascular complications. Although the most appropriate target A1c levels to achieve optimal health impact might vary among persons, the majority of adults with diabetes will benefit from reduction of A1c levels to ≤7%; targets for patients with a history of severe hypoglycemia, or with limited life expectancy, or with advanced complications, or with certain comorbid conditions might be higher. Nevertheless, an A1c level of 9% constitutes a clearly modifiable, high level of risk that few, if any, persons with diabetes should be exposed to. Accordingly, the Healthy People 2020 objectives include a 10% reduction in the proportion of the diabetes population that has poor glycemic control (A1c >9%) as a target.

Trends in death rates among U.S. adults with and without diabetes between 1997 and 2006: findings from the National Health Interview Survey

OBJECTIVE

To determine whether all-cause and cardiovascular disease (CVD) death rates declined between 1997 and 2006, a period of continued advances in treatment approaches and risk factor control, among U.S. adults with and without diabetes.

RESEARCH DESIGN AND METHODS

We compared 3-year death rates of four consecutive nationally representative samples (1997-1998, 1999-2000, 2001-2002, and 2003-2004) of U.S. adults aged 18 years and older using data from the National Health Interview Surveys linked to National Death Index.

RESULTS

Among diabetic adults, the CVD death rate declined by 40% (95% CI 23-54) and all-cause mortality declined by 23% (10-35) between the earliest and latest samples. There was no difference in the rates of decline in mortality between diabetic men and women. The excess CVD mortality rate associated with diabetes (i.e., compared with nondiabetic adults) decreased by 60% (from 5.8 to 2.3 CVD deaths per 1,000) while the excess all-cause mortality rate declined by 44% (from 10.8 to 6.1 deaths per 1,000).

CONCLUSIONS

Death rates among both U.S. men and women with diabetes declined substantially between 1997 and 2006, reducing the absolute difference between adults with and without diabetes. These encouraging findings, however, suggest that diabetes prevalence is likely to rise in the future if diabetes incidence is not curtailed.

Age at diagnosis of diabetes in Appalachia

BACKGROUND

Appalachia is a region of the United States noted for the poverty and poor health outcomes of its residents. Residents of the poorest Appalachian counties have a high prevalence of diabetes and risk factors (obesity, low income, low education, etc.) for type 2 diabetes. However, diabetes prevalence exceeds what these risk factors alone explain. Based on this, the history of poor health outcomes in Appalachia, and personally observed high rates of childhood obesity and lack of concern about prediabetes, we speculated that people in Appalachia with diagnosed diabetes might tend to be diagnosed younger than their non-Appalachian counterparts.

METHODS

We used data from the Behavioral Risk Factor Surveillance System (2006-2008). We compared age at diagnosis among counties by Appalachian Regional Commission-defined level of economic development. To account for risk differences, we constructed a model for average age at diagnosis of diabetes, adjusting for county economic development, obesity, income, sedentary lifestyle, and other covariates.

FINDINGS

After adjustment for risk factors for diabetes, people in distressed or at-risk counties (the least economically developed) had their diabetes diagnosed two to three years younger than comparable people in non-Appalachian counties. No significant differences between non-Appalachian counties and Appalachian counties at higher levels of economic development remained after adjusting.

CONCLUSIONS

People in distressed and at-risk counties have poor access to care, and are unlikely to develop diabetes at the same age as their non-Appalachian counterparts but be diagnosed sooner. Therefore, people in distressed and at-risk counties are likely developing diabetes at younger ages. We recommend that steps to reduce health disparities between the poorest Appalachian counties and non-Appalachian counties be considered.

Household income and cardiovascular disease risks in U.S. children and young adults: analyses from NHANES 1999-2008

OBJECTIVE

To assess the cardiovascular risk profile of youths across socioeconomic groups in the U.S.

RESEARCH DESIGN AND METHODS

Analysis of 1999-2008 National Health and Nutrition Examination Surveys (NHANES) including 16,085 nonpregnant 6- to 24-year-olds to estimate race/ethnicity-adjusted prevalence of obesity, central obesity, sedentary behaviors, tobacco exposure, elevated systolic blood pressure, glycated hemoglobin, non-HDL cholesterol (non-HDL-C), and high-sensitivity C-reactive protein according to age-group, sex, and poverty-income ratio (PIR) tertiles.

RESULTS

Among boys aged 6-11 years, 19.9% in the lowest PIR tertile were obese and 30.0% were centrally obese compared with 13.2 and 21.6%, respectively, in the highest-income tertile households (P(obesity) < 0.05 and P(central obesity) < 0.01). Boys aged 12-17 years in lowest-income households were more likely than their wealthiest family peers to be obese (20.6 vs. 15.6%, P < 0.05), sedentary (14.8 vs. 9.3%, P < 0.05), and exposed to tobacco (19.0 vs. 6.5%, P < 0.01). Compared with girls aged 12-17 years in highest-income households, lowest-income household girls had higher prevalence of obesity (17.9 vs. 13.1%, P < 0.05), central obesity (41.5 vs. 29.2%, P < 0.01), sedentary behaviors (20.4 vs. 9.4%, P < 0.01), and tobacco exposure (14.1 vs. 5.9%, P < 0.01). Apart from higher prevalence of elevated non-HDL-C among low-income women aged 18-24 years (23.4 vs. 15.8%, P < 0.05), no other cardiovascular disease risk factor prevalence differences were observed between lowest- and highest-income background young adults.

CONCLUSIONS

Independent of race/ethnicity, 6- to 17-year-olds from low-income families have higher prevalence of obesity, central obesity, sedentary behavior, and tobacco exposure. Multifaceted cardiovascular health promotion policies are needed to reduce health disparities between income groups.

Smoking and visual impairment among older adults with age-related eye diseases

INTRODUCTION

Tobacco use is the leading preventable cause of death in the United States. Visual impairment, a common cause of disability in the United States, is associated with shorter life expectancy and lower quality of life. The relationship between smoking and visual impairment is not clearly understood. We assessed the association between smoking and visual impairment among older adults with age-related eye diseases.

METHODS

We analyzed Behavioral Risk Factor Surveillance System data from 2005 through 2008 on older adults with age-related eye diseases (cataract, glaucoma, age-related macular degeneration, and diabetic retinopathy; age ≥50 y, N = 36,522). Visual impairment was defined by self-reported difficulty in recognizing a friend across the street or difficulty in reading print or numbers. Current smokers were respondents who reported having smoked at least 100 cigarettes ever and still smoked at the time of interview. Former smokers were respondents who reported having ever smoked at least 100 cigarettes but currently did not smoke. We used multivariate logistic regressions to examine the association and to adjust for potential confounders.

RESULTS

Among respondents with age-related eye diseases, the estimated prevalence of visual impairment was higher among current smokers (48%) than among former smokers (41%, P < .05) and respondents who had never smoked (42%, P < .05). After adjustment for age, sex, race/ethnicity, education, and general health status, current smokers with age-related eye diseases were more likely to have visual impairment than respondents with age-related eye diseases who had never smoked (odds ratio, 1.16, P < .05). Furthermore, respondents with cataract who were current smokers were more likely to have visual impairment than respondents with cataract who had never smoked (predictive margin, 44% vs 40%, P = .03), and the same was true for respondents with age-related macular degeneration (65% of current smokers vs 57% of never smokers, P = .02). This association did not hold true among respondents with glaucoma or diabetic retinopathy.

CONCLUSION

Smoking is linked to self-reported visual impairment among older adults with age-related eye diseases, particularly cataract and age-related macular degeneration. Longitudinal evaluation is needed to assess smoking cessation's effect on vision preservation.

Access to health care and undiagnosed diabetes along the United States-Mexico border

OBJECTIVE

To examine the relationship between access to health care and undiagnosed diabetes among the high-risk, vulnerable population in the border region between the United States of America and Mexico.

METHODS

Using survey and fasting plasma glucose data from Phase I of the U.S.-Mexico Border Diabetes Prevention and Control Project (February 2001 to October 2002), this epidemiological study identified 178 adults 18-64 years old with undiagnosed diabetes, 326 with diagnosed diabetes, and 2 966 without diabetes. Access to health care among that sample (n = 3,470), was assessed by type of health insurance coverage (including "none"), number of health care visits over the past year, routine pattern of health care utilization, and country of residence.

RESULTS

People with diabetes who had no insurance and no place to go for routine health care were more likely to be undiagnosed than those with insurance and a place for routine health care (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.0-6.6, and OR 4.5, 95% CI 1.4-14.1, respectively). When stratified by country, the survey data showed that on the U.S. side of the border there were more people with undiagnosed diabetes if they were 1) uninsured versus the insured (28.9%, 95% CI 11.5%-46.3%, versus 9.1%, 95% CI 1.5%-16.7%, respectively) and if they 2) had made no visits or 1-3 visits to a health care facility in the past year versus had made ≥ 4 visits (40.8%, 95% CI 19.6%-62.0%, and 23.4%, 95% CI 9.9%-36.9%, respectively, versus 2.4%, 95% CI -0.9%-5.7%) (all, P < 0.05). No similar pattern was found in Mexico.

CONCLUSIONS

Limited access to health care--especially not having health insurance and/or not having a place to receive routine health services--was significantly associated with undiagnosed diabetes in the U.S.-Mexico border region.

Medical expenditures associated with diabetes acute complications in privately insured U.S. youth

OBJECTIVE

To estimate medical expenditures attributable to diabetes ketoacidosis (DKA) and severe hypoglycemia among privately insured insulin-treated U.S. youth with diabetes.

RESEARCH DESIGN AND METHODS

We analyzed the insurance claims of 7,556 youth, age ≤ 19 years, with insulin-treated diabetes. The youth were continuously enrolled in fee-for-service health plans, and claims were obtained from the 2007 U.S. MarketScan Commercial Claims and Encounter database. We used regression models to estimate total medical expenditures and their subcomponents: outpatient, inpatient, and drug expenditures. The excess expenditures associated with DKA and severe hypoglycemia were estimated as the difference between predicted medical expenditures for youth who did/did not experience either DKA or severe hypoglycemia.

RESULTS

For youth with and without DKA, respectively, predicted mean annual total medical expenditures were $14,236 and $8,398 (an excess of $5,837 for those with DKA). The excess was statistically greater for those with one or more episodes of DKA ($8,455) than among those with only one episode ($3,554). Predicted mean annual total medical expenditures were $12,850 and $8,970 for youth with and without severe hypoglycemia, respectively (an excess of $3,880 for those with severe hypoglycemia). The excess was greater among those with one or more episodes ($5,929) than among those with only one ($2,888).

CONCLUSIONS

Medical expenditures for potentially preventable DKA and severe hypoglycemia in U.S. youth with insulin-treated diabetes are substantial. Improving the quality of care for these youth to prevent the development of these two complications could avert substantial U.S. health care expenditures.

Residence in a distressed county in Appalachia as a risk factor for diabetes, Behavioral Risk Factor Surveillance System, 2006-2007

INTRODUCTION

We compared the risk of diabetes for residents of Appalachian counties to that of residents of non-Appalachian counties after controlling for selected risk factors in states containing at least 1 Appalachian county.

METHODS

We combined Behavioral Risk Factor Surveillance System data from 2006 and 2007 and conducted a logistic regression analysis, with self-reported diabetes as the dependent variable. We considered county of residence (5 classifications for Appalachian counties, based on economic development, and 1 for non-Appalachian counties), age, sex, race/ethnicity, education, household income, smoking status, physical activity level, and obesity to be independent variables. The classification "distressed" refers to counties in the worst 10%, compared with the nation as a whole, in terms of 3-year unemployment rate, per capita income, and poverty.

RESULTS

Controlling for covariates, residents in distressed Appalachian counties had 33% higher odds (95% confidence interval, 1.10-1.60) of reporting diabetes than residents of non-Appalachian counties. We found no significant differences between other classifications of Appalachian counties and non-Appalachian counties.

CONCLUSION

Residents of distressed Appalachian counties are at higher risk of diabetes than are residents of other counties. States with distressed Appalachian counties should implement culturally sensitive programs to prevent diabetes.

Obesity prevention and diabetes screening at local health departments

OBJECTIVES

We assessed whether local health departments (LHDs) were conducting obesity prevention programs and diabetes screening programs, and we examined associations between LHD characteristics and whether they conducted these programs.

METHODS

We used the 2005 National Profile of Local Health Departments to conduct a cross-sectional analysis of 2300 LHDs nationwide. We used multivariate logistic regressions to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Approximately 56% of LHDs had obesity prevention programs, 51% had diabetes screening programs, and 34% had both. After controlling for other factors, we found that employing health educators was significantly associated with LHDs conducting obesity prevention programs (OR = 2.08; 95% CI = 1.54, 2.81) and diabetes screening programs (OR = 1.63; 95% CI = 1.23, 2.17). We also found that conducting chronic disease surveillance was significantly associated with LHDs conducting obesity prevention programs (OR = 1.66; 95% CI = 1.26, 2.20) and diabetes screening programs (OR = 2.44; 95% CI = 1.90, 3.15). LHDs with a higher burden of diabetes prevalence were more likely to conduct diabetes screening programs (OR = 1.20; 95% CI = 1.11, 1.31) but not obesity prevention programs.

CONCLUSIONS

The presence of obesity prevention and diabetes screening programs was significantly associated with LHD structural capacity and general performance. However, the effectiveness and cost-effectiveness of both types of programs remain unknown.

Case report: reconstruction of the distal tibia with porous tantalum spacer after resection for giant cell tumor

Treatment options for giant cell tumors of the distal tibia include curettage and cement packing, curettage and bone grafting, or resection and reconstruction for aggressive tumors. Curettage of aggressive tumors often leads to severe bone loss requiring reconstruction. Allograft and autograft may be effective options for reconstruction, but each is associated with drawbacks including the possibility of infection and collapse. We present a case of giant cell tumor of the distal tibia treated with curettage and arthrodesis using a porous tantalum spacer. Complete removal of the tumor and successful arthrodesis of the ankle were accomplished using the spacer. The patient returned to pain-free walking along with eradication of the giant cell tumor. We believe porous tantalum spacers are a reasonable option for reconstructing the distal tibia after curettage of a giant cell tumor with extensive bone loss.

Impact of state mandatory insurance coverage on the use of diabetes preventive care

BACKGROUND

46 U.S. states and the District of Columbia have passed laws and regulations mandating that health insurance plans cover diabetes treatment and preventive care. Previous research on state mandates suggested that these policies had little impact, since many health plans already covered the benefits. Here, we analyze the contents of and model the effect of state mandates. We examined how state mandates impacted the likelihood of using three types of diabetes preventive care: annual eye exams, annual foot exams, and performing daily self-monitoring of blood glucose (SMBG).

METHODS

We collected information on diabetes benefits specified in state mandates and time the mandates were enacted. To assess impact, we used data that the Behavioral Risk Factor Surveillance System gathered between 1996 and 2000. 4,797 individuals with self-reported diabetes and covered by private insurance were included; 3,195 of these resided in the 16 states that passed state mandates between 1997 and 1999; 1,602 resided in the 8 states or the District of Columbia without state mandates by 2000. Multivariate logistic regression models (with state fixed effect, controlling for patient demographic characteristics and socio-economic status, state characteristics, and time trend) were used to model the association between passing state mandates and the usage of the forms of diabetes preventive care, both individually and collectively.

RESULTS

All 16 states that passed mandates between 1997 and 1999 required coverage of diabetic monitors and strips, while 15 states required coverage of diabetes self management education. Only 1 state required coverage of periodic eye and foot exams. State mandates were positively associated with a 6.3 (P = 0.04) and a 5.8 (P = 0.03) percentage point increase in the probability of privately insured diabetic patient's performing SMBG and simultaneous receiving all three preventive care, respectively; state mandates were not significantly associated with receiving annual diabetic eye (0.05 percentage points decrease, P = 0.92) or foot exams (2.3 percentage points increase, P = 0.45).

CONCLUSIONS

Effects of state mandates varied by preventive care type, with state mandates being associated with a small increase in SMBG. We found no evidence that state mandates were effective in increasing receipt of annual eye or foot exams. The small or non-significant effects might be attributed to small numbers of insured people not having the benefits prior to the mandates' passage. If state mandates' purpose is to provide improved benefits to many persons, policy makers should consider determining the number of people who might benefit prior to passing the mandate.

Health insurance coverage and use of eye care services

OBJECTIVE

To compare realized access or use of eye care services in adults with self-reported vision problems in Canada and the United States.

METHODS

Using the Joint Canada/United States Survey of Health, we examined the differences in use of eye care services in 2018 Canadian respondents and 2930 American respondents with self-reported vision problems. We performed multivariate logistic regression analyses to estimate the probability that individuals with vision problems and various insurance categories would visit an eye care professional.

RESULTS

Approximately 8.2% of Americans with self-reported vision problems did not have health insurance. Americans without health insurance had the lowest age-adjusted rate of use of eye care services (42%) compared with Americans with private health insurance (67%) or public health insurance (55%) and Canadians (56%). The difference in use of eye care services between Americans without health insurance and Canadians narrowed when adjusted for income level and was almost eliminated when adjusted for having optional vision insurance. Individuals with optional vision insurance and those with higher income levels were more likely to use eye care services.

CONCLUSIONS

Americans with vision problems who had health insurance accessed eye care services at a rate higher than or equal to that of their Canadian counterparts. The gap in access between Canadians and Americans without health insurance narrowed after adjustments for income level and optional vision insurance.

Diabetes and anxiety in US adults: findings from the 2006 Behavioral Risk Factor Surveillance System

AIMS

Anxiety disorders may cause substantial impairment in patient functioning and well-being. Little is known about the relationship between diabetes and anxiety. We estimated the prevalence of lifetime diagnosis of anxiety in adults aged > or = 18 years with and without diabetes in the USA.

METHODS

We analysed data from the 2006 Behavioral Risk Factor Surveillance System (total, N = 201 575; 20 142 with diabetes; 39.4% men, 77.9% non-Hispanic Whites, 8.1% non-Hispanic Blacks and 7.7% Hispanics; mean age 52.4 years). Diabetes and lifetime diagnosis of anxiety were self-reported. A multivariable log-binomial model was used to estimate prevalence ratios (PR) and associated 95% confidence intervals (CI) of anxiety based on diabetes status.

RESULTS

The overall age-adjusted prevalence of lifetime diagnosis of anxiety was 19.5 and 10.9% in people with and without diabetes, respectively. After adjustment for educational level, marital status, employment status, current smoking, leisure-time physical activity and body mass index, people with diabetes had a 20% higher prevalence of lifetime diagnosis of anxiety than those without (PR 1.20; 95% CI 1.12, 1.30). There were no significant differences in the PR by gender (P = 0.06). However, the ratios differed significantly by age (P = 0.04) and by race/ethnicity (P < 0.01), indicating that people aged 18-29 years (PR 1.70; 95% CI 1.19, 2.43) and Hispanics (PR 1.69; 95% CI 1.33, 2.15) had a higher ratio than their counterparts.

CONCLUSION

Diabetes was significantly associated with anxiety in adults in this large population-based sample, particularly in Hispanics and young adults.

The National Violent Death Reporting System: an exciting new tool for public health surveillance

The US does not have a unified system for surveillance of violent deaths. This report describes the National Violent Death Reporting System (NVDRS), a system for collecting data on all violent deaths (homicides, suicides, accidental firearms deaths, deaths of undetermined intent, and deaths from legal intervention, excluding legal executions) in participating states. The NVDRS centralizes data from many sources, providing a more comprehensive picture of violent deaths than would otherwise be available. The NVDRS collects data on victims, suspects, and circumstances related to the violent deaths. Currently, 17 US states participate in the NVDRS; the intention is for the NVDRS to become a truly national system, representing all 50 states, the District of Columbia, and the US territories. This report describes the history of the NVDRS, provides an overview of how the NVDRS functions, and describes future directions.

Race/ethnicity, substance abuse, and mental illness among suicide victims in 13 US states: 2004 data from the National Violent Death Reporting System

OBJECTIVE

To calculate the prevalence of substance abuse and mental illness among suicide victims of different racial/ethnic groups and to identify race/ethnicity trends in mental health and substance abuse that may be used to improve suicide prevention.

METHODS

Data are from the National Violent Death Reporting System (NVDRS), a state-based data integration system that, for 2004, includes data from 13 US states. The NVDRS integrates medical examiner, toxicology, death certificate, and law enforcement data.

RESULTS

Within participating states, for data year 2004, 6865 suicide incidents in which race/ethnicity are known were identified. This included 5797 (84.4%) non-Hispanic whites, 501 (7.3%) non-Hispanic blacks, 257 (3.7%) Hispanics, and 310 (4.5%) persons from other racial/ethnic groups. At the time of the suicide event, non-Hispanic blacks had lower blood alcohol contents than other groups. Non-Hispanic whites had less cocaine but more antidepressants and opiates. There were no differences in the levels of amphetamines or marijuana by race/ethnicity. Hispanics were less likely to have been diagnosed with a mental illness or to have received treatment, although family reports of depression were comparable to non-Hispanic whites and other racial/ethnic groups. Non-Hispanic whites were more likely to be diagnosed with depression or bipolar disorder and non-Hispanic blacks with schizophrenia. Comorbid substance abuse and mental health problems were more likely among non-Hispanic whites and non-Hispanic blacks, while Hispanics were more likely to have a substance abuse problem without comorbid mental health problems.

CONCLUSION

The results support earlier research documenting differences in race/ethnicity, substance abuse, and mental health problems as they relate to completed suicide. The data suggest that suicide prevention efforts must address not only substance abuse and mental health problems in general, but the unique personal, family, and social characteristics of different racial/ethnic groups.

Gorlin's syndrome presenting with myolipoma of tongue base

OBJECTIVE

We report the first case of tongue base myolipoma associated with Gorlin's syndrome.

METHOD

Case report and review of world literature.

RESULTS

A 39-year-old man with known Gorlin's syndrome presented with progressive dysphagia. Subsequent magnetic resonance imaging scan and biopsy confirmed the rare diagnosis of myolipoma arising from the tongue base. In view of the benign nature of this mass, it was debulked rather than completely excised in order to preserve swallowing function.

CONCLUSION

To our knowledge, this is the first report of the coexistence of two rare conditions in an atypical fashion. This case appears to represent a new variant in the broad spectrum of features of Gorlin's syndrome.

Herd immunity and pneumococcal conjugate vaccine: A quantitative model

Invasive pneumococcal disease in older children and adults declined markedly after introduction in 2000 of the pneumococcal conjugate vaccine for young children. An empirical quantitative model was developed to estimate the herd (indirect) effects on the incidence of invasive disease among persons >or=5 years of age induced by vaccination of young children with 1, 2, or >or=3 doses of the pneumococcal conjugate vaccine, Prevnar (PCV7), containing serotypes 4, 6B, 9V, 14, 18C, 19F and 23F. From 1994 to 2003, cases of invasive pneumococcal disease were prospectively identified in Georgia Health District-3 (eight metropolitan Atlanta counties) by Active Bacterial Core surveillance (ABCs). From 2000 to 2003, vaccine coverage levels of PCV7 for children aged 19-35 months in Fulton and DeKalb counties (of Atlanta) were estimated from the National Immunization Survey (NIS). Based on incidence data and the estimated average number of doses received by 15 months of age, a Poisson regression model was fit, describing the trend in invasive pneumococcal disease in groups not targeted for vaccination (i.e., adults and older children) before and after the introduction of PCV7. Highly significant declines in all the serotypes contained in PCV7 in all unvaccinated populations (5-19, 20-39, 40-64, and >64 years) from 2000 to 2003 were found under the model. No significant change in incidence was seen from 1994 to 1999, indicating rates were stable prior to vaccine introduction. Among unvaccinated persons 5+ years of age, the modeled incidence of disease caused by PCV7 serotypes as a group dropped 38.4%, 62.0%, and 76.6% for 1, 2, and 3 doses, respectively, received on average by the population of children by the time they are 15 months of age. Incidence of serotypes 14 and 23F had consistent significant declines in all unvaccinated age groups. In contrast, the herd immunity effects on vaccine-related serotype 6A incidence were inconsistent. Increasing trends of non-vaccine serotypes, in particular 19A, were noted in most unvaccinated age groups, but these increases were substantially smaller than the concurrent decreases among the vaccine serotypes. Also, the model estimated PCV7 to have a greater (p=0.014) indirect impact on the incidence of invasive pneumococcal disease caused by all vaccine serotypes among African-Americans of all ages than for whites. Thus, conjugate vaccines may be able to induce herd effects even in situations where vaccine coverage is far from complete or with schedules using fewer than 3 or 4 doses. Because the model was based on incidence rates and PCV7 coverage in Atlanta, our findings should be validated in other geographic areas.