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BackgroundThe aim of our study was to evaluate the post-release outcomes of incarcerated individuals with opioid use disorder (OUD) treated with extended-release buprenorphine (XRB) in a rural county jail. Administrative data were collected from a pilot program within a jail in Maine that introduced XRB treatment in 2022 and a comparable jail utilizing sublingual buprenorphine (SLB) during the same period to compare post-release outcomes. Log-binomial regression models were used to estimate the risk ratio (RR) and 95% confidence interval (CI) for jail use of XRB vs. SLB on post-release community buprenorphine continuation.ResultsFrom September 2022 to September 2023, 70 individuals who received XRB were released from the pilot jail and 130 individuals who received SLB were released from the comparison jail. After adjusting for age, sex, and buprenorphine use at entry to jail, individuals released from the pilot jail were almost 3 times (adjusted RR = 2.67, 95% CI 1.84, 3.88) as likely to continue community buprenorphine treatment post-release relative to the comparison jail. In addition, utilization of XRB allowed for expanded access to OUD treatment, was well tolerated, and reduced medication diversion.ConclusionsIn this pilot program in Maine, XRB treatment during incarceration was associated with higher post-release community buprenorphine continuation when compared to individuals treated with SLB. These findings provide strong evidence for the superiority of XRB vs. SLB for the treatment of OUD in jail settings.Highlights• Utilization of extended-release buprenorphine (XRB) in jail reduced diversion. • Using XRB reduced staffing demands and expanded access to treatment.• XRB may have reduced post-release overdose deaths.• Those treated with XRB were 3 times as likely to continue buprenorphine post-release.

The activity of paraoxonase 1 (PON1), an antioxidant enzyme whose polymorphisms have been associated with cancer risk, may be associated with metals exposure. To evaluate PON1 activity in relation to cadmium, lead, and mercury levels in healthy, premenopausal women. Women from upstate New York were followed for ≥ two menstrual cycles. Repeated measures linear mixed models estimated the association between cadmium, lead, and mercury levels (by tertile: T1, T2, T3) and PON1 arylesterase (PON1A) and PON1 paraoxonase (PON1P) activity, separately. Analyses were stratified by PON1 Q192R phenotype and un-stratified. Median blood cadmium, lead, and mercury concentrations were 0.30 µg/L, 0.87 µg/dL, and 1.15 µg/L. In un-stratified analyses cadmium and mercury were associated with decreased PON1A activity (T2 vs. T1; not T3 vs. T1) but metals were not associated with PON1P. Phenotypes were distributed between QQ (n = 99), QR (n = 117), and RR (n = 34). Cadmium was associated with decreased PON1A activity for QR and RR phenotypes comparing T2 vs. T1 (-14.4% 95% confidence interval [CI] [-20.1, -8.4] and -27.9% [-39.5, -14.0],). Lead was associated with decreased PON1A (RR phenotype, T3 vs. T1 -18.9% [-32.5, -2.5]; T2 vs. T1 -19.6% [-32.4, -4.4]). Cadmium was associated with lower PON1P comparing T2 vs. T1 for the RR (-34.9% [-51.5, -12.5]) and QR phenotypes (-9.5% [-18.1, 0.0]) but not comparing T3 vs. T1. Cadmium was associated with increases in PON1P levels (QQ phenotype, T3 vs. T1 24.5% [7.0, 44.9]) and mercury was associated with increased PON1A levels (QQ phenotype, T3 vs. T1 6.2% [0.2, 12.6]). Mercury was associated with decreased PON1P (RR phenotype, T2 vs. T1 -22.8 [-37.8, -4.1]). Blood metals were associated with PON1 activity and these effects varied by phenotype. However, there was not a linear dose-response and these findings await replication.

Background Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity. Methods We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes. Discussion Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Objectives Early pregnancy detection is important for improving pregnancy outcomes as the first trimester is a critical window of fetal development; however, there has been no description of trends in timing of pregnancy awareness among US women. Methods We examined data from the 1995, 2002, 2006–2010 and 2011–2013 National Survey of Family Growth on self-reported timing of pregnancy awareness among women aged 15–44 years who reported at least one pregnancy in the 4 or 5 years prior to interview that did not result in induced abortion or adoption (n = 17, 406). We examined the associations between maternal characteristics and late pregnancy awareness (≥7 weeks’ gestation) using adjusted prevalence ratios from logistic regression models. Gestational age at time of pregnancy awareness (continuous) was regressed over year of pregnancy conception (1990–2012) in a linear model. Results Among all pregnancies reported, gestational age at time of pregnancy awareness was 5.5 weeks (standard error = 0.04) and the prevalence of late pregnancy awareness was 23 % (standard error = 1 %). Late pregnancy awareness decreased with maternal age, was more prevalent among non-Hispanic black and Hispanic women compared to non-Hispanic white women, and for unintended pregnancies versus those that were intended ( p  < 0.01). Mean time of pregnancy awareness did not change linearly over a 23-year time period after adjustment for maternal age at the time of conception ( p  < 0.16). Conclusions for Practice On average, timing of pregnancy awareness did not change linearly during 1990–2012 among US women and occurs later among certain groups of women who are at higher risk of adverse birth outcomes.

Placental dysfunction is related to many pregnancy complications, but collecting placental specimens for investigation in large scale epidemiologic studies is often infeasible. Standard procedures involving immediate collection after birth and snap freezing are often cost prohibitive. We aimed to collect pilot data regarding the feasibility and precision of a simpler approach, the collection of tissue samples following 24 hours of refrigeration of whole placentae at 4°C, as compared to the \"gold standard\" of snap freezing excised tissue within 40 minutes of delivery for the assessment of inflammatory cytokines. Placentae were collected from 12 women after delivering live-born singleton babies via uncomplicated vaginal delivery. Two placentae were utilized to establish laboratory tissue processing and assay protocols. The other 10 placentae were utilized in a comparison of three tissue collection conditions. Specifically, key inflammatory cytokines were measured in 3 sections, representing three collection conditions. Sections 1 (full thickness) and 2 (excised prior to freezing) were obtained within 40 minutes of delivery and snap frozen in liquid nitrogen, and section 3 (full thickness) was obtained after refrigerating the placenta at 4°C for 24 hours. IL-6, IL-10, and IL-8 all had comparable concentrations and variability overall in all three section types. Levels of tumor necrosis factor alpha (TNF-α) were too low among samples to reliably measure using immunoassay. Refrigeration of placentae prior to processing does not appear to compromise detection of these cytokines for purposes of large scale studies. These findings provide a framework and preliminary data for the study of inflammatory cytokines within the placenta in large scale and/or resource-limited settings.

Objectives. To determine if the introduction of New York State’s 8-week paid family leave policy on January 1, 2018, reduced rates of hospitalizations with respiratory syncytial virus (RSV) bronchiolitis or any acute lower respiratory tract infection among young infants. Methods. We conducted an interrupted time series analysis using New York State population-based, all-payer hospital discharge records, October 2015 to December 2019. We estimated the change in monthly hospitalization rates for RSV bronchiolitis and for any acute lower respiratory tract infection among infants aged 8 weeks or younger after the introduction of paid family leave while controlling for temporal trends and RSV seasonality. We modeled RSV hospitalization rates in infants aged 1 year as a control. Results. Hospitalization rates for RSV bronchiolitis and any acute lower respiratory tract infection decreased by 30% after the introduction of paid family leave (rate ratio [RR] = 0.71; 95% confidence interval [CI] = 0.54, 0.94; and RR = 0.72; 95% CI = 0.59, 0.88, respectively). There were no such reductions in infants aged 1 year (RR = 0.98; 95% CI = 0.72, 1.33; and RR = 1.17; 95% CI = 1.03, 1.32, respectively). Conclusions. State paid family leave was associated with fewer RSV-associated hospitalizations in young infants. (Am J Public Health. 2022;112(2):316–324. https://doi.org/10.2105/AJPH.2021.306559 )

BACKGROUND:Correlated data are ubiquitous in epidemiologic research, particularly in nutritional and environmental epidemiology where mixtures of factors are often studied. Our objectives are to demonstrate how highly correlated data arise in epidemiologic research and provide guidance, using a directed acyclic graph approach, on how to proceed analytically when faced with highly correlated data. METHODS:We identified three fundamental structural scenarios in which high correlation between a given variable and the exposure can ariseintermediates, confounders, and colliders. For each of these scenarios, we evaluated the consequences of increasing correlation between the given variable and the exposure on the bias and variance for the total effect of the exposure on the outcome using unadjusted and adjusted models. We derived closed-form solutions for continuous outcomes using linear regression and empirically present our findings for binary outcomes using logistic regression. RESULTS:For models properly specified, total effect estimates remained unbiased even when there was almost perfect correlation between the exposure and a given intermediate, confounder, or collider. In general, as the correlation increased, the variance of the parameter estimate for the exposure in the adjusted models increased, while in the unadjusted models, the variance increased to a lesser extent or decreased. CONCLUSION:Our findings highlight the importance of considering the causal framework under study when specifying regression models. Strategies that do not take into consideration the causal structure may lead to biased effect estimation for the original question of interest, even under high correlation.

Objectives. To compare blood lead levels (BLLs) among US children aged 1 to 5 years according to receipt of federal housing assistance. Methods. In our analyses, we used 2005 to 2012 data for National Health and Nutrition Examination Survey (NHANES) respondents that were linked to 1999 to 2014 administrative records from the US Department of Housing and Urban Development (HUD). After we restricted the analysis to children with family income-to-poverty ratios below 200%, we compared geometric mean BLLs and the prevalence of BLLs of 3 micrograms per deciliter or higher among children who were living in assisted housing at the time of their NHANES blood draw (n = 151) with data for children who did not receive housing assistance (n = 1099). Results. After adjustment, children living in assisted housing had a significantly lower geometric mean BLL (1.44 µg/dL; 95% confidence interval [CI] = 1.31, 1.57) than comparable children who did not receive housing assistance (1.79 µg/dL; 95% CI = 1.59, 2.01; P < .01). The prevalence ratio for BLLs of 3 micrograms per deciliter or higher was 0.51 (95% CI = 0.33, 0.81; P < .01). Conclusions. Children aged 1 to 5 years during 2005 to 2012 who were living in HUD-assisted housing had lower BLLs than expected given their demographic, socioeconomic, and family characteristics.

Objective To estimate trends in maternal opioid use disorder (OUD) and neonatal abstinence syndrome (NAS) in Maine using the most recent data available. Study design We used hospital discharge data to estimate the annual prevalence of maternal OUD and NAS between 2016 and 2022. In addition, we used birth certificate-linked Medicaid data to estimate related trends among Medicaid enrollees. Result From 2016 to 2022, the prevalence of maternal OUD decreased from 35.3 to 18.8 per 1000 deliveries and the prevalence of NAS decreased from 33.2 to 14.0 per 1000 newborns (linear trend p values <0.01). Decreasing trends were also found among Medicaid enrollees. Conclusion In Maine between 2016 and 2022, there was a decrease in maternal OUD and NAS diagnoses recorded in administrative datasets. These findings should be interpreted with caution due to changes in how OUD and NAS diagnoses are recorded and COVID-related changes in healthcare utilization.

BACKGROUND:Stress has been shown to suppress ovulation in experimental models, but its effect on human reproduction at the population level is unclear. METHODS:Healthy women (n = 259), aged 18–44 years from Western New York, were followed for 2 menstrual cycles (2005–2007). Women completed daily perceived stress assessments, a 4-item Perceived Stress Scale (PSS-4) up to 4 times each cycle, and a 14-item PSS at baseline. Mixed model analyses were used to assess effects of stress on log reproductive hormone concentrations and sporadic anovulation. RESULTS:High versus low daily stress was associated with lower estradiol (−9.5% [95% confidence interval (CI) = −15.6% to −3.0%]), free estradiol (−10.4% [−16.5% to −3.9%]), and luteinizing hormone (−14.8% [−21.3% to −7.7%]) and higher follicle-stimulating hormone (6.2% [95% CI = 2.0% to 10.5%]) after adjusting for age, race, percent body fat, depression score, and time-varying hormones and vigorous exercise. High versus low daily stress was also associated with lower luteal progesterone (−10.4% [95% CI = −19.7% to −0.10%]) and higher odds of anovulation (adjusted odds ratio = 2.2 [95% CI = 1.0 to 4.7]). For each unit increase in daily stress level, women had a 70% higher odds of an anovulatory episode (odds ratio = 1.7 [1.1 to 2.4]). Similar but attenuated results were found for the association between the PSS-4 and reproductive hormones, while null findings were found for the baseline PSS. CONCLUSION:Daily perceived stress does appear to interfere with menstrual cycle function among women with no known reproductive disorders, warranting further research to explore potential population-level impacts and causal biologic mechanisms.