Daniel J. Tancredi

Pregnancy coercion, intimate partner violence and unintended pregnancy ☆

BACKGROUND Reproductive control including pregnancy coercion (coercion by male partners to become pregnant) and birth control sabotage (partner interference with contraception) may be associated with partner violence and risk for unintended pregnancy among young adult females utilizing family planning clinic services. STUDY DESIGN A cross-sectional survey was administered to females ages 16-29 years seeking care in five family planning clinics in Northern California (N=1278). RESULTS Fifty-three percent of respondents reported physical or sexual partner violence, 19% reported experiencing pregnancy coercion and 15% reported birth control sabotage. One third of respondents reporting partner violence (35%) also reported reproductive control. Both pregnancy coercion and birth control sabotage were associated with unintended pregnancy (AOR 1.83, 95% CI 1.36-2.46, and AOR 1.58, 95% CI 1.14-2.20, respectively). In analyses stratified by partner violence exposure, associations of reproductive control with unintended pregnancy persisted only among women with a history of partner violence. CONCLUSIONS Pregnancy coercion and birth control sabotage are common among young women utilizing family planning clinics, and in the context of partner violence, are associated with increased risk for unintended pregnancy.

Maternal periconceptional folic acid intake and risk of autism spectrum disorders and developmental delay in the CHARGE (CHildhood Autism Risks from Genetics and Environment) case-control study

BACKGROUND Periconceptional folate is essential for proper neurodevelopment. OBJECTIVE Maternal folic acid intake was examined in relation to the risk of autism spectrum disorder (ASD) and developmental delay (DD). DESIGN Families enrolled in the CHARGE (CHildhood Autism Risks from Genetics and Environment) Study from 2003 to 2009 were included if their child had a diagnosis of ASD (n = 429), DD (n = 130), or typical development (TD; n = 278) confirmed at the University of California Davis Medical Investigation of Neurodevelopmental Disorders Institute by using standardized clinical assessments. Average daily folic acid was quantified for each mother on the basis of dose, brands, and intake frequency of vitamins, supplements, and breakfast cereals reported through structured telephone interviews. RESULTS Mean (±SEM) folic acid intake was significantly greater for mothers of TD children than for mothers of children with ASD in the first month of pregnancy (P1; 779.0 ± 36.1 and 655.0 ± 28.7 μg, respectively; P < 0.01). A mean daily folic acid intake of ≥600 μg (compared with <600 μg) during P1 was associated with reduced ASD risk (adjusted OR: 0.62; 95% CI: 0.42, 0.92; P = 0.02), and risk estimates decreased with increased folic acid (P-trend = 0.001). The association between folic acid and reduced ASD risk was strongest for mothers and children with MTHFR 677 C>T variant genotypes. A trend toward an association between lower maternal folic acid intake during the 3 mo before pregnancy and DD was observed, but not after adjustment for confounders. CONCLUSIONS Periconceptional folic acid may reduce ASD risk in those with inefficient folate metabolism. The replication of these findings and investigations of mechanisms involved are warranted.

Prenatal vitamins, one-carbon metabolism gene variants, and risk for autism.

Background: Causes of autism are unknown. Associations with maternal nutritional factors and their interactions with gene variants have not been reported. Methods: Northern California families were enrolled from 2003 to 2009 in the CHARGE (CHildhood Autism Risks from Genetics and Environment) population-based case-control study. Children aged 24–60 months were evaluated and confirmed to have autism (n = 288), autism spectrum disorder (n = 141), or typical development (n = 278) at the University of California–Davis Medical Investigation of Neurodevelopmental Disorders Institute using standardized clinical assessments. We calculated adjusted odds ratios (ORs) for associations between autism and retrospectively collected data on maternal vitamin intake before and during pregnancy. We explored interaction effects with functional genetic variants involved in one-carbon metabolism (MTHFR, COMT, MTRR, BHMT, FOLR2, CBS, and TCN2) as carried by the mother or child. Results: Mothers of children with autism were less likely than those of typically developing children to report having taken prenatal vitamins during the 3 months before pregnancy or the first month of pregnancy (OR = 0.62 [95% confidence interval = 0.42–0.93]). Significant interaction effects were observed for maternal MTHFR 677 TT, CBS rs234715 GT + TT, and child COMT 472 AA genotypes, with greater risk for autism when mothers did not report taking prenatal vitamins periconceptionally (4.5 [1.4–14.6]; 2.6 [1.2–5.4]; and 7.2 [2.3–22.4], respectively). Greater risk was also observed for children whose mothers had other one-carbon metabolism pathway gene variants and reported no prenatal vitamin intake. Conclusions: Periconceptional use of prenatal vitamins may reduce the risk of having children with autism, especially for genetically susceptible mothers and children. Replication and mechanistic investigations are warranted.

Neurodevelopmental disorders and prenatal residential proximity to agricultural pesticides: the CHARGE study.

Background: Gestational exposure to several common agricultural pesticides can induce developmental neurotoxicity in humans, and has been associated with developmental delay and autism. Objectives: We evaluated whether residential proximity to agricultural pesticides during pregnancy is associated with autism spectrum disorders (ASD) or developmental delay (DD) in the Childhood Autism Risks from Genetics and Environment (CHARGE) study. Methods: The CHARGE study is a population-based case–control study of ASD, DD, and typical development. For 970 participants, commercial pesticide application data from the California Pesticide Use Report (1997–2008) were linked to the addresses during pregnancy. Pounds of active ingredient applied for organophophates, organochlorines, pyrethroids, and carbamates were aggregated within 1.25-km, 1.5-km, and 1.75-km buffer distances from the home. Multinomial logistic regression was used to estimate the odds ratio (OR) of exposure comparing confirmed cases of ASD (n = 486) or DD (n = 168) with typically developing referents (n = 316). Results: Approximately one-third of CHARGE study mothers lived, during pregnancy, within 1.5 km (just under 1 mile) of an agricultural pesticide application. Proximity to organophosphates at some point during gestation was associated with a 60% increased risk for ASD, higher for third-trimester exposures (OR = 2.0; 95% CI: 1.1, 3.6), and second-trimester chlorpyrifos applications (OR = 3.3; 95% CI: 1.5, 7.4). Children of mothers residing near pyrethroid insecticide applications just before conception or during third trimester were at greater risk for both ASD and DD, with ORs ranging from 1.7 to 2.3. Risk for DD was increased in those near carbamate applications, but no specific vulnerable period was identified. Conclusions: This study of ASD strengthens the evidence linking neurodevelopmental disorders with gestational pesticide exposures, particularly organophosphates, and provides novel results of ASD and DD associations with, respectively, pyrethroids and carbamates. Citation: Shelton JF, Geraghty EM, Tancredi DJ, Delwiche LD, Schmidt RJ, Ritz B, Hansen RL, Hertz-Picciotto I. 2014. Neurodevelopmental disorders and prenatal residential proximity to agricultural pesticides: the CHARGE study. Environ Health Perspect 122:1103–1109; http://dx.doi.org/10.1289/ehp.1307044

Independent and dependent contributions of advanced maternal and paternal ages to autism risk

Reports on autism and parental age have yielded conflicting results on whether mothers, fathers, or both, contribute to increased risk. We analyzed restricted strata of parental age in a 10‐year California birth cohort to determine the independent or dependent effect from each parent. Autism cases from California Department of Developmental Services records were linked to State birth files (1990–1999). Only singleton births with complete data on parental age and education were included (n=4,947,935, cases=12,159). In multivariate logistic regression models, advancing maternal age increased risk for autism monotonically regardless of the paternal age. Compared with mothers 25–29 years of age, the adjusted odds ratio (aOR) for mothers 40+ years was 1.51 (95% CI: 1.35–1.70), or compared with mothers <25 years of age, aOR=1.77 (95% CI, 1.56–2.00). In contrast, autism risk was associated with advancing paternal age primarily among mothers <30: aOR=1.59 (95% CI, 1.37–1.85) comparing fathers 40+ vs. 25–29 years of age. However, among mothers >30, the aOR was 1.13 (95% CI, 1.01–1.27) for fathers 40+ vs. 25–29 years of age, almost identical to the aOR for fathers <25 years. Based on the first examination of heterogeneity in parental age effects, it appears that womens risk for delivering a child who develops autism increases throughout their reproductive years whereas fathers age confers increased risk for autism when mothers are <30, but has little effect when mothers are past age 30. We also calculated that the recent trend towards delayed childbearing contributed approximately a 4.6% increase in autism diagnoses in California over the decade.

Evaluation of the predictive value of ICD-9-CM coded administrative data for venous thromboembolism in the United States

OBJECTIVE To determine the positive predictive value of International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) discharge codes for acute deep vein thrombosis or pulmonary embolism. MATERIALS AND METHODS Retrospective review of 3456 cases hospitalized between 2005 and 2007 that had a discharge code for venous thromboembolism, using 3 sample populations: a single academic hospital, 33 University HealthSystem Consortium hospitals, and 35 community hospitals in a national Joint Commission study. Analysis was stratified by position of the code in the principal versus a secondary position. RESULTS Among 1096 cases that had a thromboembolism code in the principal position the positive predictive value for any acute venous thrombosis was 95% (95%CI:93-97), whereas among 2360 cases that had a thromboembolism code in a secondary position the predictive value was lower, 75% (95%CI:71-80). The corresponding positive predictive values for lower extremity deep-vein thrombosis or pulmonary embolism were 91% (95%CI:86-95) and 50% (95%CI:41-58), respectively. More highly defined codes had higher predictive value. Among codes in a secondary position that were false positive, 22% (95%CI:16-27) had chronic/prior venous thrombosis, 15% (95%CI:10-19) had an upper extremity thrombosis, 6% (95%CI:4-8) had a superficial vein thrombosis, and 7% (95%CI:4-13) had no mention of any thrombosis. CONCLUSIONS ICD-9-CM codes for venous thromboembolism had high predictive value when present in the principal position, and lower predictive value when in a secondary position. New thromboembolism codes that were added in 2009 that specify chronic thrombosis, upper extremity thrombosis and superficial venous thrombosis should reduce the frequency of false-positive thromboembolism codes.

Mapping the SF-12 to the EuroQol EQ-5D Index in a national US sample.

Background . Preference scores for the Medical Outcomes Study (MOS) SF-12 would enable its use in cost-effectiveness analyses. Previous mapping studies of MOS instruments to preference-based instruments have not examined performance in national samples. Participants . 15,000 adults in the 2000 Medical Expenditure Panel Survey annual survey including the SF-12 and EQ-5D Index. Methods . Regression of the EQ-5D Index scores onto the physical and mental component summary scores of the SF-12, testing 2nd-4th degree polynomial and spline models, including and excluding sociodemographics. Results . A 2nd degree polynomial model explained 63% of the variance in EQ-5D scores, with robust internal and external validation. More complex models explained minimally additional variance. Compared with EQ-5D valuations, prediction models overestimated the lowest health states (6% of the population). Conclusions . The mapped SF-12 yields usable preference-scaled scores, with some caution for the lowest health states.

Immigration to the USA and risk for mood and anxiety disorders: Variation by origin and age at immigration

BACKGROUND Risk for mood and anxiety disorders associated with US-nativity may vary across immigrant groups. METHOD Using data from the National Epidemiological Study of Alcohol and Related Conditions (NESARC), we examined the association of lifetime risk for mood and anxiety disorders with US-nativity and age at immigration across seven subgroups of the US population defined by country or region of ancestral origin: Mexico, Puerto-Rico, Cuba, Central and South America, Western Europe, Eastern Europe, and Africa and the Caribbean. Discrete time survival models were used to compare lifetime risk between the US-born, immigrants who arrived in the USA prior to the age of 13 years and immigrants who arrived in the USA at the age of 13 years or older. RESULTS The association of risk for mood and anxiety disorders with US-nativity varies significantly across ancestral origin groups (p<0.001). Among people from Mexico, Eastern Europe, and Africa or the Caribbean, risk for disorders is lower relative to the US-born among immigrants who arrived at the age of 13 years or higher (odds ratios in the range 0.34-0.49) but not among immigrants who arrived prior to the age of 13 years. There is no association between US-nativity and risk for disorder among people from Western Europe and Puerto Rico. CONCLUSIONS Low risk among immigrants relative to the US-born is limited to groups among whom risk for mood and anxiety disorder is low in immigrants who spent their pre-adolescent years outside of the USA.

A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion

BACKGROUND This study examined the efficacy of a family-planning-clinic-based intervention to address intimate partner violence (IPV) and reproductive coercion. STUDY DESIGN Four free-standing urban family planning clinics in Northern California were randomized to intervention (trained family planning counselors) or standard of care. English-speaking and Spanish-speaking females ages 16-29 years (N = 906) completed audio computer-assisted surveys prior to a clinic visit and 12-24 weeks later (75% retention rate). Analyses included assessment of intervention effects on recent IPV, awareness of IPV services and reproductive coercion. RESULTS Among women reporting past-3-months IPV at baseline, there was a 71% reduction in the odds of pregnancy coercion among participants in intervention clinics compared to participants in the control clinics that provided standard of care. Women in the intervention arm were more likely to report ending a relationship because the relationship was unhealthy or because they felt unsafe regardless of IPV status (adjusted odds ratio = 1.63; 95% confidence interval=1.01-2.63). CONCLUSIONS Results of this pilot study suggest that this intervention may reduce the risk for reproductive coercion from abusive male partners among family planning clients and support such women to leave unsafe relationships.

How valid is the ICD-9-CM based AHRQ patient safety indicator for postoperative venous thromboembolism?

Background:Hospital administrative data are being used to identify patients with postoperative venous thromboembolism (VTE), either pulmonary embolism (PE) or deep-vein thrombosis (DVT). However, few studies have evaluated the accuracy of these ICD-9-CM codes across multiple hospitals. Methods and Materials:The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI)-12 was used to identify cases with postoperative VTE in 80 hospitals that volunteered for either an AHRQ or University HealthSystem Consortium (UHC) validation project. Trained abstractors using a standardized tool and guidelines retrospectively verified all coded VTE events. Results:In the combined samples, the positive predictive value of the set of prespecified VTE codes for any acute VTE at any time during the hospitalization was 451 of 573 = 79% (95% CI: 75%–82%). However, the positive predictive value for acute lower extremity DVT or PE diagnosed after an operation was 209 of 452 = 44% (95% CI: 37%–51%) in the UHC sample and 58 of 121 = 48% (95% CI: 42–67%) in the AHRQ sample. Fourteen percent of all cases had an acute upper extremity DVT, 6% had superficial vein thrombosis and 21% had no acute VTE, however, 61% of the latter had a documented prior/chronic VTE. In the UHC cohort, the sensitivity for any acute VTE was 95.5% (95% CI: 86.4%–100%); the specificity was 99.5% (95% CI: 99.4%–99.7%). Conclusion:Current PSI 12 criteria do not accurately identify patients with acute postoperative lower extremity DVT or PE. Modification of the ICD-9-CM codes and implementation of “present on admission” flags should improve the predictive value for clinically important VTE events.