Publications by authors named "Mari Palta"

119 Publications

A preliminary epidemiologic study of social (pragmatic) communication disorder in the context of developmental language disorder.

Int J Lang Commun Disord 2021 Aug 12. Epub 2021 Aug 12.

Department of Population Health Sciences and Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA.

Background: There is extremely limited population-based research on social (pragmatic) communication disorder (SCD). Population-based samples have the potential to better characterize the SCD phenotype by mitigating confounds and biases that are typical of convenience and clinical samples.

Aims: The aims of this preliminary epidemiologic study were to advance our understanding of the SCD phenotype relative to developmental language disorder (DLD), obtain an estimate of prevalence, identify risk factors and lay the groundwork for future population level research of SCD.

Methods & Procedures: We analysed existing data from the EpiSLI Database to examine social communication skills in 393 8th grade (13-14 years) children with and without a history of DLD. The primary measure used to evaluate SCD was the Children's Communication Checklist (CCC-2). Two case definitions of SCD reflecting DSM-5 criteria were examined. Both definitions involved significant pragmatic impairment, employing a commonly adopted clinical cut-point of 1.5 SD. In one case, pragmatic deficits could occur along with structural language deficits and, in the other case (established using principal component analysis), pragmatic and social skills were disproportionately lower than structural language abilities.

Outcomes & Results: When using the first case definition, SCD was much more common in children with a history of DLD than without DLD and history of language disorder at kindergarten was a significant risk factor for SCD in adolescence. However, it is important to note that SCD could be found in children with no prior deficits in other aspects of language. When the second definition was employed, SCD was equally distributed across children with and without a history of DLD. Male sex was a significant risk factor using this case definition of SCD. The estimated prevalence of SCD ranged from 7% (SE = 1.5%) to 11% (SE = 1.7%), acknowledging that prevalence depends on the cut-point selected to determine communication disorder.

Conclusions & Implications: These findings contribute to our understanding of the association between SCD and DLD by recognizing varying profiles of pragmatic and social communication difficulties, which in turn may help refine our diagnostic categories. Preliminary prevalence estimates of SCD can serve as an initial guidepost for identification and planning for intervention services for this condition.

What This Paper Adds: What is already known on this subject There is considerable debate about the diagnostic category of SCD and its relation to other neurodevelopmental disorders. What this study adds to existing knowledge Using data from a US-based epidemiologic sample of DLD, this study offers new information about the association between SCD and DLD, provides preliminary estimates of SCD prevalence, and identifies risk factors for SCD. Clinical implications of this study Improved understanding of possible profiles of pragmatic and social communication deficits will help to clarify diagnostic categories and preliminary prevalence estimates may assist with ensuring availability of adequate intervention services.
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http://dx.doi.org/10.1111/1460-6984.12664DOI Listing
August 2021

Decreased ventricular size and mass mediate the reduced exercise capacity in adolescents and adults born premature.

Early Hum Dev 2021 Sep 24;160:105426. Epub 2021 Jul 24.

Department of Pediatrics, Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI, United States of America.

Background: Premature birth is associated with lower levels of cardiorespiratory fitness (CRF) but the underlying mechanisms responsible remain unclear. This study assessed whether differences in cardiac morphology or function mediate differences in CRF among adolescents and young adults born preterm.

Methods: Adolescents and young adults born moderately to extremely premature (gestational age ≤ 32 weeks or birth weight < 1500 g) and age-matched term born participants underwent resting cardiac MRI and maximal exercise testing. Mediation analysis assessed whether individual cardiovascular variables accounted for a significant proportion of the difference in maximal aerobic capacity between groups.

Results: Individuals born preterm had lower VO2max than those born term (41.7 ± 8.6 v 47.5 ± 8.7, p < 0.01). Several variables differed between term and preterm born subjects, including systolic and diastolic blood pressure, mean pulmonary artery pressure, indexed left ventricular end-diastolic volume (LVEDVi), right ventricular end-diastolic volume (RVEDVi), LV mass (LVMi), LV stroke volume index (LVSVi), and LV strain (p < 0.05 for all). Of these variables, LVEDVi, RVEDVi, LVSVi, LVMi, and LV longitudinal strain were significantly related to VO2max (p < 0.05 for all). Significant portions of the difference in VO2max between term and preterm born subjects were mediated by LVEDVi (74.3%, p = 0.010), RVEDVi (50.6%, p = 0.016), and LVMi (43.0%, p = 0.036).

Conclusions: Lower levels of CRF in adolescents and young adults born preterm are mediated by differences in LVEDVi, RVEDVi, and LVMi. This may represent greater risk for long-term cardiac morbidity and mortality in preterm born individuals.
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http://dx.doi.org/10.1016/j.earlhumdev.2021.105426DOI Listing
September 2021

Polysomnographic indicators of restorative sleep and body mass trajectories in the Wisconsin Sleep Cohort Study.

Sleep 2021 Aug;44(8)

Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA.

Study Objectives: Previous research suggests that reductions in restorative, slow-wave (N3), and rapid eye movement (REM) sleep are associated with weight gain and obesity in mid-to-late life. We extend prior work by examining how within-person (WP) changes and between-person (BP) differences in restorative sleep over several years are associated with body mass trajectories among participants in the Wisconsin Sleep Cohort Study (WSCS).

Methods: We used data from 4,862 polysomnographic (PSG) sleep studies and physical exams collected from 1,187 WSCS participants over an average duration of 14.9 years. Primary measures of interest included body mass index (BMI = kg/m2) and the percentages of time spent in N3 and REM sleep. We estimated a series of linear mixed regression models to examine how WP changes and BP differences in N3 and REM sleep affected BMI trajectories, controlling for other sleep measures, demographic characteristics, and health behaviors as potential confounders.

Results: Women in the WSCS experienced more rapid BMI gain than men. With some variation by sex, we found that (1) below-average N3 and REM sleep is associated with above-average BMI, and (2) within-person decreases in N3 and REM sleep over time are associated with gains in BMI. These findings persisted after adjustment for sleep duration and other potential confounders.

Conclusions: Our findings highlight the importance of PSG indices of restorative sleep in mid-to-late life, suggesting that future clinical treatments and public health policies will benefit from heightened attention to sleep quality.
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http://dx.doi.org/10.1093/sleep/zsab031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361330PMC
August 2021

The Survey of the Health of Wisconsin (SHOW) Program: An infrastructure for Advancing Population Health Sciences.

medRxiv 2021 Apr 7. Epub 2021 Apr 7.

Purpose: The Survey of the Health of Wisconsin (SHOW) was established in 2008 by the University of Wisconsin (UW) School of Medicine and Public Health (SMPH) with the goals of 1) providing a timely and accurate picture of the health of the state residents; and 2) serving as an agile resource infrastructure for ancillary studies. Today SHOW continues to serve as a vital population health research infrastructure.

Participants: SHOW currently includes 5,846 adult and 980 minor participants recruited between 2008-2019 in four primary waves. WAVE I (2008-2013) includes annual statewide representative samples of 3,380 adults ages 21 to 74 years. WAVE II (2014-2016) is a triannual statewide sample of 1957 adults (age ≥18 years) and 645 children. WAVE III (2017) consists of follow-up of 725 adults from the WAVE I and baseline surveys of 222 children in selected households. WAVEs II and III include stool samples collected as part of an ancillary study in a subset of 784 individuals. WAVE IV consist of 517 adults and 113 children recruited from traditionally under-represented populations in biomedical research including African Americans and Hispanics in Milwaukee county, WI.

Findings To Date: The SHOW provides extensive data to examine the intersectionality of multiple social determinants and population health. SHOW includes a large biorepository and extensive health data collected in a geographically diverse urban and rural population. Over 60 studies have been published covering a broad range of topics including, urban and rural disparities in cardio-metabolic disease and cancer, objective physical activity, sleep, green-space and mental health, transcriptomics, the gut microbiome, antibiotic resistance, air pollution, concentrated animal feeding operations and heavy metal exposures.

Future Plans: The SHOW cohort is available for continued longitudinal follow-up and ancillary studies including genetic, multi-omic and translational environmental health, aging, microbiome and COVID-19 research.

Article Summary: The Survey of the Health of Wisconsin (SHOW) is an infrastructure to advance population health sciences including biological sample collection and broader data on individual and neighborhood social and environmental determinants of health.The extensive data from diverse urban and rural populations offers a unique study sample to compare how socio-economic gradients shape health outcomes in different contexts.The objective health data supports novel interdisciplinary research initiatives and is especially suited for research in causes and consequences of environmental exposures (physical, chemical, social) across the life course on cardiometabolic health, immunity, and aging related conditions.The extensive biorepository supports novel omics research into common biological mechanisms underlying numerous complex chronic conditions including inflammation, oxidative stress, metabolomics, and epigenetic modulation.Ancillary studies, such as the Wisconsin Microbiome Study, have expanded the utility of the study to examine human susceptibility to environmental exposures and opportunities for investigations of the role of microbiome in health and disease.Long-standing partnerships and recent participation among traditionally under-represented populations in biomedical research offer numerous opportunities to support community-driven health equity work.No biological samples were collected among children.The statewide sampling frame may limit generalizability to other regions in the United States.
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http://dx.doi.org/10.1101/2021.03.15.21253478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043470PMC
April 2021

Reproductive health at conflict borders: a cross-sectional survey of human rights violations and perinatal outcomes at the Thai-Myanmar border.

Confl Health 2021 Mar 10;15(1):15. Epub 2021 Mar 10.

Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Background: Human rights violations (HRVs) are common in conflict and displacement contexts. Women are especially vulnerable to HRVs in these contexts, and perinatal health is acutely sensitive to related stressors and health care barriers. However, how HRVs affect immediate and long-term perinatal health in chronic displacement settings has not been closely investigated. Furthermore, it remains unclear whether and how HRVs in these contexts are tied directly to displacement circumstances or other marginalizing factors affecting local migrant and minority populations generally.

Methods: We investigated these questions using novel survey data from 577 women at the northern Thai-Myanmar border, where thousands of people have fled conflict in Shan State, Myanmar, for refuge in a range of precarious settings in Thailand, including unofficial refugee camps, villages, and worksites. We compared HRV exposures by ethnicity, country of birth, legal documentation, and residential setting. We then analyzed perinatal outcomes associated with HRV frequency, timing, and type.

Results: Birth in Myanmar, and ethnic minority and precarious legal status more broadly, predicted higher HRV prevalence. HRV frequency significantly predicted unmet antenatal care and lower birth weight, along with HRVs related to labor exploitation and violence or conflict. HRVs timed closer to pregnancies were more adversely associated with perinatal outcomes. Resource/property deprivation was the strongest predictor of pregnancy complications.

Conclusions: Human rights must be urgently attended to, through expanded HRV screenings and responsive care, and policy changes to further protect migrant workers, displaced persons, and others in precarious legal status situations.
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http://dx.doi.org/10.1186/s13031-021-00347-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945312PMC
March 2021

Influences of health and environmental deprivation on family relationships among children with chronic disease.

Qual Life Res 2021 May 26;30(5):1337-1346. Epub 2021 Jan 26.

Department of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA.

Purpose: Families play a key role in managing chronic illness. Among chronically ill children, we describe the Patient-Reported Outcomes Measurement Information System (PROMIS) Family Relationships measure over time and its associations with sociodemographics, environmental deprivation, and health.

Methods: Parents of children aged 8-18 years with asthma (n = 171), type 1 diabetes (n = 199), or sickle cell disease (n = 135), recruited in pediatric clinics and emergency departments (ED), completed demographic surveys. Every six months for up to three years, children completed PROMIS Family Relationships, Anxiety, and Depressive Symptoms short forms (T-scores; mean 50, SD = 10), and a 5-level health status item. Linear mixed models were fit to estimate associations.

Results: Older baseline age was associated with weaker family relationships. For example, for each 3-year higher baseline age, relationships were 3 points weaker for males (- 3.0; 95%CI - 5.7 to - .0.2) and females (- 3.1; 95%CI - 6.0 to - 0.3) with asthma recruited in the ED. For each 1-unit higher mean overall health, relationships were 4.6 points (95%CI 3.2-6.1) stronger for children with diabetes and about 2 points stronger for children with asthma (2.3; 0.7-3.9) and sickle cell disease (2.1; 0.3-3.9). Family relationships were 0.3-0.5 points weaker for each 1-unit increment in mean anxiety or depressive symptoms across all three diseases. Relationships were not significantly associated with environmental deprivation and generally stable over time.

Conclusions: Family relationships were weaker among older children and generally stable over time, yet fluctuated with physical and mental health. Monitoring PROMIS Family Relationships scores may facilitate referrals for chronically ill children who need support.
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http://dx.doi.org/10.1007/s11136-020-02737-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076063PMC
May 2021

Sustaining Gains in Diabetic Eye Screening: Outcomes from a Stakeholder-Based Implementation Program for Teleophthalmology in Primary Care.

Telemed J E Health 2021 09 19;27(9):1021-1028. Epub 2020 Nov 19.

Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Teleophthalmology is a validated method for diabetic eye screening that is underutilized in U.S. primary care clinics. Even when made available to patients, its long-term effectiveness for increasing screening rates is often limited. We hypothesized that a stakeholder-based implementation program could increase teleophthalmology use and sustain improvements in diabetic eye screening. NIATx Model p p p p p Our stakeholder-based implementation program achieved a significant increase in overall teleophthalmology use and maintained increased post-teleophthalmology diabetic eye screening rates. Stakeholder-based implementation may increase the long-term reach and effectiveness of teleophthalmology to reduce vision loss from diabetes. Our approach may improve integration of telehealth interventions into primary care.
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http://dx.doi.org/10.1089/tmj.2020.0270DOI Listing
September 2021

Blunted cardiac output response to exercise in adolescents born preterm.

Eur J Appl Physiol 2020 Nov 30;120(11):2547-2554. Epub 2020 Aug 30.

Department of Pediatrics, University of Wisconsin-Madison, Madison, USA.

Purpose: Premature birth is associated with lasting effects, including lower exercise capacity and pulmonary function, and is acknowledged as a risk factor for cardiovascular disease. The aim was to evaluate factors affecting exercise capacity in adolescents born preterm, including the cardiovascular and pulmonary responses to exercise, activity level and strength.

Methods: 21 preterm-born and 20 term-born adolescents (age 12-14 years) underwent strength and maximal exercise testing with thoracic bioimpedance monitoring. Baseline variables were compared between groups and ANCOVA was used to compare heart rate, cardiac output (Q) and stroke volume (SV) during exercise between groups while adjusting for body surface area.

Results: Preterm-borns had lower maximal aerobic capacity than term-borns (2.0 ± 0.5 vs. 2.5 ± 0.5 L/min, p = 0.01) and lower maximal power (124 ± 26 vs. 153 ± 33 watts, p < 0.01), despite similar physical activity scores. Pulmonary function and muscular strength did not differ significantly. Although baseline Q and SV did not differ between groups, preterm adolescents had significantly lower cardiac index (Qi) at 50, 75 and 100% of maximal time to exhaustion, driven by SV volume index (SVi, 50% max time: 53.0 ± 9.0 vs. 61.6 ± 11.4; 75%: 51.7 ± 8.4 vs. 64.3 ± 11.1; 100%: 51.2 ± 9.3 vs. 64.3 ± 11.5 ml/m, all p < 0.01), with similar heart rates.

Conclusion: Otherwise healthy and physically active adolescents born very preterm exhibit lower exercise capacity than term-born adolescents. Despite similar baseline cardiovascular values, preterm-born adolescents demonstrate significantly reduced Qi and SVi during incremental and maximal exercise.
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http://dx.doi.org/10.1007/s00421-020-04480-9DOI Listing
November 2020

Likelihood of hospital readmission in Medicare Advantage and Fee-For-Service within same hospital.

Health Serv Res 2020 08 1;55(4):587-595. Epub 2020 Jul 1.

Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.

Objective: To assess the extent to which all-cause 30-day readmission rate varies by Medicare program within the same hospitals.

Study Design: We used conditional logistic regression clustered by hospital and generalized estimating equations to compare the odds of unplanned all-cause 30-day readmission between Medicare Fee-for-Service (FFS) and Medicare Advantage (MA).

Data Collection: Wisconsin Health Information Organization collects claims data from various payers including private insurance, Medicare, and Medicaid, twice a year.

Principal Findings: For 62 of 66 hospitals, hospital-level readmission rates for MA were lower than those for Medicare FFS. The odds of 30-day readmission in MA were 0.92 times lower than Medicare FFS within the same hospital (odds ratio, 0.93; 95 percent confidence interval, 0.89-0.98). The adjusted overall readmission rates of Medicare FFS and MA were 14.9 percent and 11.9 percent, respectively.

Conclusion: These findings provide additional evidence of potential variations in readmission risk by payer and support the need for improved monitoring systems in hospitals that incorporate payer-specific data. Further research is needed to delineate specific care delivery factors that contribute to differential readmission risk by payer source.
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http://dx.doi.org/10.1111/1475-6773.13315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375992PMC
August 2020

Increased aortic stiffness and elevated blood pressure in response to exercise in adult survivors of prematurity.

Physiol Rep 2020 06;8(12):e14462

Department of Health and Human Physiology, University of Iowa, Iowa City, IA, USA.

Objectives: Adults born prematurely have an increased risk of early heart failure. The impact of prematurity on left and right ventricular function has been well documented, but little is known about the impact on the systemic vasculature. The goals of this study were to measure aortic stiffness and the blood pressure response to physiological stressors; in particular, normoxic and hypoxic exercise.

Methods: Preterm participants (n = 10) were recruited from the Newborn Lung Project Cohort and matched with term-born, age-matched subjects (n = 12). Aortic pulse wave velocity was derived from the brachial arterial waveform and the heart rate and blood pressure responses to incremental exercise in normoxia (21% O ) or hypoxia (12% O ) were evaluated.

Results: Aortic pulse wave velocity was higher in the preterm groups. Additionally, heart rate, systolic blood pressure, and pulse pressure were higher throughout the normoxic exercise bout, consistent with higher conduit artery stiffness. Hypoxic exercise caused a decline in diastolic pressure in this group, but not in term-born controls.

Conclusions: In this first report of the blood pressure response to exercise in adults born prematurely, we found exercise-induced hypertension relative to a term-born control group that is associated with increased large artery stiffness. These experiments performed in hypoxia reveal abnormalities in vascular function in adult survivors of prematurity that may further deteriorate as this population ages.
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http://dx.doi.org/10.14814/phy2.14462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305240PMC
June 2020

Association Between Preterm Birth and Arrested Cardiac Growth in Adolescents and Young Adults.

JAMA Cardiol 2020 Aug;5(8):910-919

Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison.

Importance: Premature birth is associated with substantially higher lifetime risk for cardiovascular disease, including arrhythmia, ischemic disease, and heart failure, although the underlying mechanisms are poorly understood.

Objective: To characterize cardiac structure and function in adolescents and young adults born preterm using cardiac magnetic resonance imaging (MRI).

Design, Setting, And Participants: This cross-sectional cohort study at an academic medical center included adolescents and young adults born moderately to extremely premature (20 in the adolescent cohort born from 2003 to 2004 and 38 in the young adult cohort born in the 1980s and 1990s) and 52 age-matched participants who were born at term and underwent cardiac MRI. The dates of analysis were February 2016 to October 2019.

Exposures: Premature birth (gestational age ≤32 weeks) or birth weight less than 1500 g.

Main Outcomes And Measures: Main study outcomes included MRI measures of biventricular volume, mass, and strain.

Results: Of 40 adolescents (24 [60%] girls), the mean (SD) age of participants in the term and preterm groups was 13.3 (0.7) years and 13.0 (0.7) years, respectively. Of 70 adults (43 [61%] women), the mean (SD) age of participants in the term and preterm groups was 25.4 (2.9) years and 26.5 (3.5) years, respectively. Participants from both age cohorts who were born prematurely had statistically significantly smaller biventricular cardiac chamber size compared with participants in the term group: the mean (SD) left ventricular end-diastolic volume index was 72 (7) vs 80 (9) and 80 (10) vs 92 (15) mL/m2 for adolescents and adults in the preterm group compared with age-matched participants in the term group, respectively (P < .001), and the mean (SD) left ventricular end-systolic volume index was 30 (4) vs 34 (6) and 32 (7) vs 38 (8) mL/m2, respectively (P < .001). Stroke volume index was also reduced in adolescent vs adult participants in the preterm group vs age-matched participants in the term group, with a mean (SD) of 42 (7) vs 46 (7) and 48 (7) vs 54 (9) mL/m2, respectively (P < .001), although biventricular ejection fractions were preserved. Biventricular mass was statistically significantly lower in adolescents and adults born preterm: the mean (SD) left ventricular mass index was 39.6 (5.9) vs 44.4 (7.5) and 40.7 (7.3) vs 49.8 (14.0), respectively (P < .001). Cardiac strain analyses demonstrated a hypercontractile heart, primarily in the right ventricle, in adults born prematurely.

Conclusions And Relevance: In this cross-sectional study, adolescents and young adults born prematurely had statistically significantly smaller biventricular cardiac chamber size and decreased cardiac mass. Although function was preserved in both age groups, these morphologic differences may be associated with elevated lifetime cardiovascular disease risk after premature birth.
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http://dx.doi.org/10.1001/jamacardio.2020.1511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240643PMC
August 2020

One-year changes in self-reported napping behaviors across the retirement transition.

Sleep Health 2019 12 11;5(6):639-646. Epub 2019 Nov 11.

Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI. Electronic address:

Objective: To estimate associations of retirement with self-reported frequency and duration of naps.

Design: Prospective cohort study.

Setting: Population-based.

Participants: 1359 current and former Wisconsin state employees, aged 54-69.

Measurements: Four annual surveys mailed between 2010 and 2014 elicited employment status and nap characteristics. Changes in employment status and nap characteristics were identified from survey pairs measured 1 year apart (up to 3 survey pairs per subject). General linear mixed models with repeated measures were used to estimate changes in minutes napped per week (MNPW), weekly nap frequency, and individual nap duration as predicted by retirement transitions vs stable employment status. All models were adjusted for demographic characteristics, self-rated health, medical diagnoses, sleep problems, circadian preference, and change in nocturnal sleep duration.

Results: There were 3101 survey pairs in the analytic sample. Full retirement (transition from working ≥35 h/wk to not working for pay) over a 1-year period predicted a statistically significantly larger mean change in MNPW than stable employment status: mean (95% confidence interval) = +48 (+16, +80) MNPW. Associations between staged retirement transitions (from full-time to part-time work, or from part-time work to full retirement) and 1-year changes in MNPW were not statistically significant. The MNPW changes associated with full retirement were attributable to nap frequency increase of +0.4 (+0.1, +0.8) d/wk; nap duration did not change significantly.

Conclusions: Compared with stable employment status, full retirement is associated with an average 1-year increase of +48 MNPW. This change is attributable to a frequency gain of 0.4 d/wk napped. Changes in nap duration were negligible.
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http://dx.doi.org/10.1016/j.sleh.2019.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962139PMC
December 2019

Reliability and validity of PROMIS® pediatric family relationships short form in children 8-17 years of age with chronic disease.

Qual Life Res 2020 Jan 10;29(1):191-199. Epub 2019 Aug 10.

Department of Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226-3522, USA.

Purpose: Families play a key role in managing pediatric chronic illness. The PROMIS® pediatric family relationships measure was developed primarily within the general pediatric population. We evaluated the Family Relationships short form in the context of pediatric chronic diseases.

Methods: Children aged 8-17 years with asthma (n = 73), type 1 diabetes (n = 122), or sickle cell disease (n = 80) completed the Family Relationships 8a short form and the PROMIS Pediatric Profile-25's six domains representing physical, mental, and social health. Parents (N = 275) of these children completed the parent versions of the same measures. We evaluated reliability of the Family Relationships measure using Cronbach's alpha and IRT-based marginal reliability, and the standard error of measurement (SEM). Convergent/discriminant validity were assessed from correlations between the Family Relationships domain and the PROMIS-25 domains.

Results: SEM increased for scores above the normative mean of 50. Cronbach's alpha and IRT-estimated marginal reliabilities exceeded 0.80 for children and parents across diseases, except in asthma, where marginal reliability was 0.75 for parents. Scores displayed small to large correlations in the expected directions with social and mental health domains. The largest correlations occurred with parents' proxy reports of children's depressive symptoms in sickle cell disease and asthma, r = - 0.60 (95% CI - 0.74, - 0.48) and r = - 0.58 (95% CI - 0.68, - 0.48) respectively.

Conclusions: The Family Relationships 8-item short form demonstrated adequate reliability and convergent/discriminant validity for use in pediatric chronic conditions, though scores above the mean displayed greater uncertainty. Evidence of the measure's reliability and validity in multiple contexts furthers the case for its use.
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http://dx.doi.org/10.1007/s11136-019-02266-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980213PMC
January 2020

Impact of family-centered tailoring of pediatric diabetes self-management resources.

Pediatr Diabetes 2019 11 8;20(7):1016-1024. Epub 2019 Aug 8.

Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background: The American Diabetes Association recommends a family-centered approach that addresses each family's specific type 1 diabetes self-management barriers.

Objective: To assess an intervention that tailored delivery of self-management resources to families' specific self-management barriers.

Subjects: At two sites, 214 children 8-16 years old with type 1 diabetes and their parent(s) were randomized to receive tailored self-management resources (intervention, n = 106) or usual care (n = 108).

Methods: Our intervention (1) identified families' self-management barriers with a validated survey, (2) tailored self-management resources to identified barriers, and (3) delivered the resources as four group sessions coordinated with diabetes visits. Mixed effects models with repeated measures were fit to A1c as well as parent and child QOL during the intervention and 1 year thereafter.

Results: Participants were 44% youth (8-12 years) and 56% teens (13-16 years). No intervention effect on A1c or QOL was shown, combining data from sites and age groups. Analyzing results by site and age group, post-intervention A1c for teens at one site declined by 0.06 more per month for intervention teens compared to usual care (P < 0.05). In this group, post-intervention A1c declined significantly when baseline A1c was >8.5 (-0.08, P < 0.05), with an even larger decline when baseline A1c was >10 (-0.19, P < 0.05). In addition, for these teens, the significant improvements in A1c resulted from addressing barriers related to motivation to self-manage. Also at this site, mean QOL increased by 0.61 points per month more during the intervention for parents of intervention youth than for usual care youth (P < 0.05).

Conclusions: Tailored self-management resources may improve outcomes among specific populations, suggesting the need to consider families' self-management barriers and patient characteristics before implementing self-management resources.
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http://dx.doi.org/10.1111/pedi.12899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827338PMC
November 2019

Pyuria as a Marker of Urinary Tract Infection in Neurogenic Bladder: Is It Reliable?

Pediatr Infect Dis J 2019 08;38(8):804-807

Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin.

Objective: The utility of the urinalysis as a potential marker to diagnose urinary tract infection (UTI) in patients with neurogenic bladder is controversial. We assessed the baseline urine characteristics and intraindividual variance of pyuria in a cohort of asymptomatic children with neurogenic bladder followed longitudinally.

Study Design: A cohort of 54 children with neurogenic bladder was followed from 2004 to 2015 at a single institution's multidisciplinary clinic. Urine data obtained from 529 routine urology visits were reviewed. Urine obtained within 2 weeks before or after treatment for UTI were excluded. Bladder surgery was defined as any operation that altered the bladder as a closed or sterile system. The effects of age, gender, catheterization, and bladder surgery on pyuria were evaluated using mixed-model regression analysis.

Results: Fifty patients with 305 urine samples had a mean length of follow-up of 3.2 years. Only 16/50 patients (32%) never had pyuria, and these patients had shorter follow-up compared with the group who ever had pyuria (≥5 white blood cells per high powered field) (1.7 vs. 3.8 years; P = 0.008). Catheterization was associated with a 15% increase in pyuria (P = 0.21). Surgery was associated with a 120% increase in pyuria (P < 0.001). The test-to-test variance of pyuria within an individual was consistently greater than between individuals (P < 0.001).

Conclusions: Bladder surgery is associated with significant increases in pyuria among children with neurogenic bladder. The substantial test-to-test variation in pyuria in asymptomatic individuals indicates the low reliability of pyuria, when positive, as a marker for UTI in neurogenic bladder and the need to search for either methods to reduce this variability or alternative biomarkers of UTI in this population.
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http://dx.doi.org/10.1097/INF.0000000000002370DOI Listing
August 2019

Heart rate recovery after maximal exercise is impaired in healthy young adults born preterm.

Eur J Appl Physiol 2019 Apr 11;119(4):857-866. Epub 2019 Jan 11.

Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA.

Purpose: The long-term implications of premature birth on autonomic nervous system (ANS) function are unclear. Heart rate recovery (HRR) following maximal exercise is a simple tool to evaluate ANS function and is a strong predictor of cardiovascular disease. Our objective was to determine whether HRR is impaired in young adults born preterm (PYA).

Methods: Individuals born between 1989 and 1991 were recruited from the Newborn Lung Project, a prospectively followed cohort of subjects born preterm weighing < 1500 g with an average gestational age of 28 weeks. Age-matched term-born controls were recruited from the local population. HRR was measured for 2 min following maximal exercise testing on an upright cycle ergometer in normoxia and hypoxia, and maximal aerobic capacity (VO) was measured.

Results: Preterms had lower VO than controls (34.88 ± 5.24 v 46.15 ± 10.21 ml/kg/min, respectively, p < 0.05), and exhibited slower HRR compared to controls after 1 and 2 min of recovery in normoxia (absolute drop of 20 ± 4 v 31 ± 10 and 41 ± 7 v 54 ± 11 beats per minute (bpm), respectively, p < 0.01) and hypoxia (19 ± 5 v 26 ± 8 and 39 ± 7 v 49 ± 13 bpm, respectively, p < 0.05). After adjusting for VO, HRR remained slower in preterms at 1 and 2 min of recovery in normoxia (21 ± 2 v 30 ± 2 and 42 ± 3 v 52 ± 3 bpm, respectively, p < 0.05), but not hypoxia (19 ± 3 v 25 ± 2 and 40 ± 4 v 47 ± 3 bpm, respectively, p > 0.05).

Conclusions: Autonomic dysfunction as seen in this study has been associated with increased rates of cardiovascular disease in non-preterm populations, suggesting further study of the mechanisms of autonomic dysfunction after preterm birth.
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http://dx.doi.org/10.1007/s00421-019-04075-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7100254PMC
April 2019

Early Pulmonary Vascular Disease in Young Adults Born Preterm.

Am J Respir Crit Care Med 2018 12;198(12):1549-1558

Department of Pediatrics.

Premature birth affects 10% of live births in the United States and is associated with alveolar simplification and altered pulmonary microvascular development. However, little is known about the long-term impact prematurity has on the pulmonary vasculature. Determine the long-term effects of prematurity on right ventricular and pulmonary vascular hemodynamics. Preterm subjects ( = 11) were recruited from the Newborn Lung Project, a prospectively followed cohort at the University of Wisconsin-Madison, born preterm with very low birth weight (≤1,500 g; average gestational age, 28 wk) between 1988 and 1991. Control subjects ( = 10) from the same birth years were recruited from the general population. All subjects had no known adult cardiopulmonary disease. Right heart catheterization was performed to assess right ventricular and pulmonary vascular hemodynamics at rest and during hypoxic and exercise stress. Preterm subjects had higher mean pulmonary arterial pressures (mPAPs), with 27% (3 of 11) meeting criteria for borderline pulmonary hypertension (mPAP, 19-24 mm Hg) and 18% (2 of 11) meeting criteria for overt pulmonary hypertension (mPAP ≥ 25 mm Hg). Pulmonary vascular resistance and elastance were higher at rest and during exercise, suggesting a stiffer vascular bed. Preterm subjects were significantly less able to augment cardiac index or right ventricular stroke work during exercise. Among neonatal characteristics, total ventilatory support days was the strongest predictor of adult pulmonary pressure. Young adults born preterm demonstrate early pulmonary vascular disease, characterized by elevated pulmonary pressures, a stiffer pulmonary vascular bed, and right ventricular dysfunction, consistent with an increased risk of developing pulmonary hypertension.
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http://dx.doi.org/10.1164/rccm.201710-2016OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6298636PMC
December 2018

Hypertension control after an initial cardiac event among Medicare patients with diabetes mellitus: A multidisciplinary group practice observational study.

J Clin Hypertens (Greenwich) 2018 05 23;20(5):891-901. Epub 2018 Apr 23.

Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Patients with diabetes mellitus and cardiovascular disease have a high risk of mortality and/or recurrent cardiovascular events. Hypertension control is critical for secondary prevention of cardiovascular events. The objective was to determine rates and predictors of achieving hypertension control among Medicare patients with diabetes and uncontrolled hypertension after hospital discharge for an initial cardiac event. A retrospective analysis of linked electronic health record and Medicare data was performed. The primary outcome was hypertension control within 1 year after hospital discharge for an initial cardiac event. Cox proportional hazard models assessed sociodemographics, medications, utilization, and comorbidities as predictors of control. Medicare patients with diabetes were more likely to achieve hypertension control when prescribed beta-blockers at discharge or with a history of more specialty visits. Adults ≥ 80 were more likely to achieve control with diuretics. These findings demonstrate the importance of implementing guideline-directed multidisciplinary care in this complex and high-risk population.
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http://dx.doi.org/10.1111/jch.13282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109367PMC
May 2018

Impaired autonomic function in adolescents born preterm.

Physiol Rep 2018 03;6(6):e13620

Department of Pediatrics, University of Wisconsin, Madison, Wisconsin.

Preterm birth temporarily disrupts autonomic nervous system (ANS) development, and the long-term impacts of disrupted fetal development are unclear in children. Abnormal cardiac ANS function is associated with worse health outcomes, and has been identified as a risk factor for cardiovascular disease. We used heart rate variability (HRV) in the time domain (standard deviation of RR intervals, SDRR; and root means squared of successive differences, RMSSD) and frequency domain (high frequency, HF; and low frequency, LF) at rest, as well as heart rate recovery (HRR) following maximal exercise, to assess autonomic function in adolescent children born preterm. Adolescents born preterm (less than 36 weeks gestation at birth) in 2003 and 2004 and healthy age-matched full-term controls participated. Wilcoxon Rank Sum tests were used to compare variables between control and preterm groups. Twenty-one adolescents born preterm and 20 term-born controls enrolled in the study. Preterm-born subjects had lower time-domain HRV, including SDRR (69.1 ± 33.8 vs. 110.1 ± 33.0 msec, respectively, P = 0.008) and RMSSD (58.8 ± 38.2 vs. 101.5 ± 36.2 msec, respectively, P = 0.012), with higher LF variability in preterm subjects. HRR after maximal exercise was slower in preterm-born subjects at 1 min (30 ± 12 vs. 39 ± 9 bpm, respectively, P = 0.013) and 2 min (52 ± 10 vs. 60 ± 10 bpm, respectively, P = 0.016). This study is the first report of autonomic dysfunction in adolescents born premature. Given prior association of impaired HRV with adult cardiovascular disease, additional investigations into the mechanisms of autonomic dysfunction in this population are warranted.
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http://dx.doi.org/10.14814/phy2.13620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875539PMC
March 2018

Associations between Food Security Status and Dietary Inflammatory Potential within Lower-Income Adults from the United States National Health and Nutrition Examination Survey, Cycles 2007 to 2014.

J Acad Nutr Diet 2018 06 13;118(6):994-1005. Epub 2018 Feb 13.

Background: Evidence suggests both that chronic inflammation mediates the association of food insecurity with adverse health outcomes and that diet may be a significant source of inflammation among food insecure individuals.

Objective: To examine whether food security status is associated with dietary inflammatory potential.

Design And Participants: Cross-sectional data came from the National Health and Nutrition Examination Survey (NHANES), cycles 2007 to 2014 (n=10,630). The analysis sample is representative of noninstitutionalized US adults with an income-to-poverty ratio ≤3.00.

Main Outcome: Dietary Inflammatory Index (DII) score, calculated using the average of two 24-hour dietary recalls, was the main outcome measure.

Statistical Analysis: Type III F tests or χ tests compared population characteristics by food security status, defined using the US Food Security Survey Module. Multivariable linear regression was used to estimate the association between food security status and the DII score and moderation by demographic factors. Survey weighting procedures accounted for the effects of stratification and clustering used in the NHANES study design.

Results: When accounting for socioeconomic status, demographic factors, and health status, DII score was higher at greater levels of food insecurity (P=0.0033). Those with very low food security had a 0.31 (95% CI=0.12 to 0.49) higher DII score than those with high food security. Age moderated the association between food security status and DII score (interaction P=0.0103), where the magnitude of the association between DII score and severity of food insecurity was higher for those >65 years than for younger age groups.

Conclusion: Food security status may be associated with dietary inflammatory potential, which is hypothesized to play a role in multiple chronic health conditions. Further research is needed to determine the causal nature of this relationship and evaluate how best to implement programs designed to address health disparities within food insecure populations.
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http://dx.doi.org/10.1016/j.jand.2017.12.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5971121PMC
June 2018

Higher Pretransplantation Hemoglobin A1c Is Associated With Greater Risk of Posttransplant Diabetes Mellitus.

Kidney Int Rep 2017 Nov 22;2(6):1076-1087. Epub 2017 Jun 22.

Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Introduction: Posttransplantation diabetes mellitus (PTDM) is a common complication among kidney transplant recipients and is associated with a higher risk of cardiovascular events and poorer graft and patient survival. The association of pretransplantation hemoglobin A1c (HbA1c) with PTDM remains unclear. Identifying recipients at greatest risk for PTDM may help guide monitoring and treatment strategies to prevent or delay the onset of PTDM.

Methods: We analyzed data from 1499 nondiabetic primary kidney transplant recipients with available pretransplantation HbA1c values in the United States Renal Data System (USRDS) from 2005 to 2011. Recipients with pretransplantation diabetes diagnosis or HbA1c ≥ 6.5% were excluded. We assessed the association of pretransplantation HbA1c with PTDM using Cox proportional hazards models. Pretransplantation HbA1c level as a continuous variable was modeled using restricted cubic splines with knots at the 25th, 50th, and 75th percentiles. Based on results from this model, pretransplantation HbA1c was further modeled using a linear spline with a single knot at 5.4%.

Results: A total of 395 recipients (26.4%) developed PTDM over a median follow-up of 1.8 years. Pretransplantation HbA1c was not significantly associated with risk of PTDM below 5.4%, whereas each 1% higher HbA1c above 5.4% was associated with an adjusted hazard ratio of 1.84 (95% confidence interval = 1.28, 2.66; for change in slope = 0.04).

Discussion: Higher pretransplantation HbA1c above 5.4% is independently associated with greater risk of PTDM among kidney transplant recipients. A continuous relationship between pretransplantation HbA1c and risk of PTDM suggests that increased risk starts at HbA1c levels well below current thresholds for prediabetes.
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http://dx.doi.org/10.1016/j.ekir.2017.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733678PMC
November 2017

Participation in the Supplemental Nutrition Assistance Program and maternal depressive symptoms: Moderation by program perception.

Soc Sci Med 2018 01 22;197:1-8. Epub 2017 Nov 22.

University of Wisconsin-Madison, Madison, WI 53706, United States.

Rationale: Previous studies have observed an association between participation in the Supplemental Nutrition Assistance Program (SNAP) and depression, which is contrary to SNAP's potential to alleviate food insecurity and financial strain.

Objective: This study investigated the impact of change in SNAP participation status on maternal depression, and whether perceptions of government assistance moderate this association.

Methods: Data were from the Fragile Families and Child Wellbeing Study (FFCWS). Logistic regression models with individual-specific fixed-effects, were fit to SNAP-eligible mothers who changed SNAP participation and depression status (N = 256) during waves 2 to 4. Perceptions of government assistance were defined as feelings of humiliation or loss of freedom and tested for interactions with SNAP participation.

Results: Perceptions of government assistance moderated the association between SNAP participation and depression (p-interaction = 0.0208). Those with positive perceptions of welfare had 0.27 (95% CI = 0.08 to 0.89) times lower odds of depression when enrolled vs. not enrolled in SNAP. Among those with negative perceptions of welfare, SNAP enrollment was not associated with depression (OR = 1.13; 95% CI = 0.85 to 1.51).

Conclusion: Evidence suggests that SNAP mental health benefits may be context specific. SNAP's capacity to improve mental health may depend on individual perceptions of government assistance. More research is needed to determine whether interventions aimed at mitigating negative perceptions of programs like SNAP could ameliorate poor mental health among program participants.
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http://dx.doi.org/10.1016/j.socscimed.2017.11.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5763005PMC
January 2018

Design and baseline data from a PCORI-funded randomized controlled trial of family-centered tailoring of diabetes self-management resources.

Contemp Clin Trials 2017 07 24;58:58-65. Epub 2017 Apr 24.

Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA. Electronic address:

This article describes the methodology, recruitment, participant characteristics, and sustained, intensive stakeholder engagement for Project ACE (Achieving control, Connecting resources, Empowering families). Project ACE is a randomized controlled trial of children and youth ages 8-16 with type 1 diabetes evaluating the impact of tailored self-management resources on hemoglobin A1c (A1c) and quality of life (QOL). Despite strong evidence that controlling A1c reduces long-term complications, <25% of US youth with type 1 diabetes meet A1c targets. Many interventions are efficacious in improving A1c and QOL for these youth, whose families often struggle with the substantial demands of the treatment regimen. However, most such interventions are ineffective in the real world due to lack of uptake by families and limited healthcare system resources. Project ACE is a multi-site trial designed to improve diabetes outcomes by tailoring existing, evidence-based interventions to meet families' needs and preferences. We hypothesize that this family-centered approach will result in better A1c and QOL than usual care. Project ACE has recruited and randomized 214 eligible 8-16year old youth and their parents. The 9-month intervention consisted of 4 group sessions tailored to families' self-management barriers as identified by a validated instrument. Outcomes including A1c and QOL for parents and youth will be assessed for 1year after the intervention. Stakeholder engagement was used to enhance this trial's recruitment, retention and integration into routine clinical care. Findings will inform implementation and dissemination of family-centered approaches to address self-management barriers.

Trial Registration Number: NCT02024750 Trial Registrar: Clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT02024750.
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http://dx.doi.org/10.1016/j.cct.2017.04.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5535788PMC
July 2017

Can Claims Data Algorithms Identify the Physician of Record?

Med Care 2018 03;56(3):e16-e20

Departments of Population Health Sciences.

Background: Claims-based algorithms based on administrative claims data are frequently used to identify an individual's primary care physician (PCP). The validity of these algorithms in the US Medicare population has not been assessed.

Objective: To determine the agreement of the PCP identified by claims algorithms with the PCP of record in electronic health record data.

Data: Electronic health record and Medicare claims data from older adults with diabetes.

Subjects: Medicare fee-for-service beneficiaries with diabetes (N=3658) ages 65 years and older as of January 1, 2008, and medically housed at a large academic health system.

Measures: Assignment algorithms based on the plurality and majority of visits and tie breakers determined by either last visit, cost, or time from first to last visit.

Results: The study sample included 15,624 patient-years from 3658 older adults with diabetes. Agreement was higher for algorithms based on primary care visits (range, 78.0% for majority match without a tie breaker to 85.9% for majority match with the longest time from first to last visit) than for claims to all visits (range, 25.4% for majority match without a tie breaker to 63.3% for majority match with the amount billed tie breaker). Percent agreement was lower for nonwhite individuals, those enrolled in Medicaid, individuals experiencing a PCP change, and those with >10 physician visits.

Conclusions: Researchers may be more likely to identify a patient's PCP when focusing on primary care visits only; however, these algorithms perform less well among vulnerable populations and those experiencing fragmented care.
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http://dx.doi.org/10.1097/MLR.0000000000000709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5601011PMC
March 2018

Sleep-disordered breathing and the menopausal transition among participants in the Sleep in Midlife Women Study.

Menopause 2017 02;24(2):157-162

1Medical Scientist Training Program, University of Wisconsin School of Medicine and Public Health, Madison, WI 2Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI 3Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Objective: Menopause is widely believed to be an established cause of sleep disorders, but evidence for this theory is inconclusive. Attributing any sleep problem to normal processes of menopause may lead to underdiagnosis of treatable sleep disorders in midlife women. This study uses detailed longitudinal data on sleep and menopausal health from participants in the Sleep in Midlife Women Study to investigate whether risk and severity of sleep-disordered breathing increase with progression through menopause, accounting for changes in age and body habitus.

Methods: A total of 219 women aged 38 to 62 years were recruited from participants in the Wisconsin Sleep Cohort Study. Menopause status was determined from daily diaries in which participants reported menstrual flow, hot flashes, and use of hormonal medications. Each participant underwent in-home polysomnography studies every 6 months, to measure the apnea-hypopnea index (AHI) (N = 1,667 studies). Linear models with empirical standard errors were fit for logarithm of AHI on menopause status and years in menopause, adjusting for age, body mass index, waist girth, and neck girth.

Results: Compared with women in premenopause, AHI was 21% higher among participants in perimenopause (95% CI, -4 to 54), 31% higher among participants in postmenopause (95% CI, 2-68), and 41% higher among participants whose menopausal stage could not be distinguished between peri- and postmenopause (95% CI, 8-82). Among women who had begun perimenopause, each additional year in menopause was associated with 4% greater AHI (95% CI, 2-6).

Conclusions: Progression through menopause is associated with greater sleep-disordered breathing severity. This association is independent of aging and changes in body habitus.
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http://dx.doi.org/10.1097/GME.0000000000000744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266663PMC
February 2017

Women's Sexual Function, Satisfaction, and Perceptions After Starting Long-Acting Reversible Contraceptives.

Obstet Gynecol 2016 11;128(5):1143-1151

University of Wisconsin, Madison, Wisconsin; and the University of Utah, Salt Lake City, Utah.

Objective: To document how long-acting reversible contraception (LARC) affects women's sexual outcomes.

Methods: In this prospective, observational cohort study, we enrolled new-start intrauterine device and contraceptive implant users attending four family planning clinics. Data collection occurred at baseline, 1 month, and 3 months. Primary outcomes were the Female Sexual Function Index, New Sexual Satisfaction Scale, and perceived sexual effects of method (positive, negative, or none). Secondary outcomes included other factors associated with LARC's sexual acceptability, including the ability to "let go" in sex, sense of control over pregnancy, and bleeding changes. Chi square and F-tests assessed differences between method groups at baseline. Mixed-effects models, robust Wald χ tests, and conditional logistic regression documented differences from baseline and trends over time.

Results: In December 2014 to April 2015, 200 patients consented and enrolled in the study. Among 159 women who completed three survey rounds, 20% selected copper intrauterine devices, 46% levonorgestrel intrauterine devices, and 34% implants. Sexual functioning and satisfaction scores did not change over time. However, across methods, participants were more likely to report improvements to their sexual lives compared with baseline (χ P<.001). By 3 months, 40% (n=64) reported positive changes and 17% (n=27) negative changes. Positive sexual changes were associated with one's sense of control over pregnancy and one's ability to "let go" in sex. Negative sexual changes were largely attributable to increased vaginal bleeding.

Conclusion: Although new LARC users reported no measurable objective change in sexual function or satisfaction, a sizable minority reported perceived positive, method-related sexual changes.

Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT02734199.
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http://dx.doi.org/10.1097/AOG.0000000000001655DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5082420PMC
November 2016

Differences in Receipt of Three Preventive Health Care Services by Race/Ethnicity in Medicare Advantage Plans: Tracking the Impact of Pay for Performance, 2010 and 2013.

Prev Chronic Dis 2016 09 8;13:E125. Epub 2016 Sep 8.

University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Introduction: In 2012, the Centers for Medicare and Medicaid Services (CMS) introduced the Quality Bonus Payment Demonstration, a pay-for-performance (P4P) program, into Medicare Advantage plans. Previous studies documented racial/ethnic disparities in receipt of care among participants in these plans. The objective of this study was to determine whether P4P incentives have affected these disparities in Medicare Advantage plans.

Methods: We studied 411 Medicare Advantage health plans that participated in the Medicare Health Outcome Survey in 2010 and 2013. Preventive health care was defined as self-reported receipt of health care provider communication or treatment to reduce risk of falling, improve bladder control, and monitor physical activity among individuals reporting these problems. Logistic regression stratified by health care plan was used to examine racial/ethnic disparities in receipt of preventive health care before and after the introduction of the P4P program in 2012.

Results: We found similar racial/ethnic differences in receipt of preventive health care before and after the introduction of P4P. Blacks and Asians were less likely than whites to receive advice to improve bladder control and more likely to receive advice to reduce risk of falling and improve physical activity. Hispanics were more likely to report receiving advice about all 3 health issues than whites. After the introduction of P4P, the gap decreased between Hispanics and whites for improving bladder control and monitoring physical activity and increased between blacks and whites for monitoring physical activity.

Conclusion: Racial/ethnic differences in receipt of preventive health care are not always in the expected direction. CMS should consider developing a separate measure of equity in preventive health care services to encourage health plans to reduce gaps among racial/ethnic groups in receiving preventive care services.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027847PMC
http://dx.doi.org/10.5888/pcd13.160047DOI Listing
September 2016

Shiftwork, Sleep Habits, and Metabolic Disparities: Results from the Survey of the Health of Wisconsin.

Sleep Health 2015 Jun;1(2):115-120

Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, 53726, USA.

Background: With the expanding demand for a 24-hour society, the prevalence of sleep deprivation and other sleep-related health problems is increasing. Shiftwork is an occupational health risk of growing significance because of its high prevalence and because of its potential role as a determinant of socioeconomic-related health disparities.

Aims: The aim of this study was to examine the associations of shiftwork with overweight status and type 2 diabetes, and explore whether a history of sleep problems mediates or modifies these associations.

Participants And Methods: A cross-sectional study was conducted among 1,593 participants in the Survey of the Health of Wisconsin (2008-12) who were employed and reported work characteristics (traditional schedule or shiftwork) and sleep habits and history of sleep problems (insomnia, insufficient sleep, wake time sleepiness). Objective measures of body mass index (BMI) and type 2 diabetes were used.

Results: Shiftworkers were more overweight than traditional-schedule workers (83% vs. 71% with BMI≥25) and reported more sleep problems, such as insomnia symptoms (24% vs. 16%), insufficient sleep (53% vs.43%), and sleepiness (32% vs. 24%). The associations between shiftwork and being overweight or diabetic were stronger among those reporting insufficient sleep, but the interaction was not statistically significant.

Conclusions: Shiftworkers face disparities in metabolic health, particularly those with insufficient sleep. Improved understanding of the relationship between sleep and metabolic states can inform healthcare providers' and employers' efforts to screen high-risk individuals and intervene with workplace wellness initiatives to address these disparities.
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http://dx.doi.org/10.1016/j.sleh.2015.04.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755509PMC
June 2015

Examining systemic steroid Use in older inflammatory bowel disease patients using hurdle models: a cohort study.

BMC Pharmacol Toxicol 2015 Dec 8;16:34. Epub 2015 Dec 8.

Department of Biostatistics & Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Background: Interpreting clinical guideline adherence and the appropriateness of medication regimens requires consideration of individual patient and caregiver factors. Factors leading to initiation of a medication may differ from those determining continued use. We believe this is the case for systemic steroid therapy in inflammatory bowel disease (IBD), resulting in a need to apply methods that separately consider factors associated with initiation and duration of therapy. To evaluate the relationship between patient characteristics and the frequency and duration of incident steroid use we apply a 2-part hurdle model to Medicare data. We do so in older patients with tumor necrosis factor antagonist (anti-TNFs) contraindications, as they are of special interest for compliance with Medicare-adopted, quality metrics calling for anti-TNFs and nonbiologic immune therapies to reduce steroid utilization. Many older patients have contraindications to anti-TNFs. However, nonbiologics cause adverse events that are concerning in older adults, limiting their use in this population and increasing reliance on systemic steroids.

Methods: We used a national Medicare sample for 2006-2009 including patients with 12 months or greater of Parts A and B and 6 months or greater of Part D coverage, IBD confirmed with at least 2 claims for ICD-9CM 555.xx or 556.xx, anti-TNF contraindications and without contraindications to nonbiologic agents. We applied a negative binomial-logit hurdle model to examine patient characteristics associated with systemic steroid utilization.

Results: Among the 1,216 IBD patients without baseline steroid use, 21% used systemic steroids. Odds of receiving systemic steroids were greater in those younger, rural, and those receiving other agents. Available patient characteristics failed to predict longer steroid treatment duration.

Conclusions: Our study identified differences in predictors of frequency and duration of medication use and suggests the utility of two-part models to examine drug utilization patterns. Applying such a model to Medicare data, we determined that despite medical consensus that systemic steroid use should be minimized, its use was substantial. Findings indicate anticipated difficulties in implementing recently adopted quality measures to avoid systemic steroids.
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http://dx.doi.org/10.1186/s40360-015-0034-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672478PMC
December 2015

The Association Between Renin-Angiotensin System Blockade and Long-term Outcomes in Renal Transplant Recipients: The Wisconsin Allograft Recipient Database (WisARD).

Transplantation 2016 07;100(7):1541-9

1 Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI. 2 Department of Population Health Sciences, Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI. 3 Department of Medicine, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. 4 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI. 5 Department of Medicine, Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Background: Renin-angiotensin system (RAS) blockade reduces mortality in the general population and among non-dialysis-dependent patients with chronic kidney disease. The RAS blockade also decreases proteinuria and protects renal function in non-transplant patients with chronic kidney disease. It remains controversial, however, whether this translates to improved patient or graft survival among transplant recipients.

Methods: We analyzed 2684 primary kidney transplant recipients at the University of Wisconsin in 1994 to 2010 who had a functioning graft at 6 months after transplantation. We assessed the association of RAS blockade with patient and graft survival using time-dependent Cox and marginal structural models.

Results: Three hundred seventy-seven deaths and 329 graft failures before death (638 total graft losses) occurred during a median of 5.4 years of follow-up. The RAS blockade was associated with an adjusted-hazard ratio of 0.63 (95% confidence interval, 0.53-0.75) for total graft loss, 0.69 (0.55-0.86) for death, and 0.62 (0.49-0.78) for death-censored graft failure. The associations of RAS blockade with a lower risk of total graft loss and mortality were stronger with more severe proteinuria. The RAS blockade was associated with a 2-fold higher risk of hyperkalemia.

Conclusions: Our findings suggest RAS blockade is associated with better patient and graft survival in renal transplant recipients.
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http://dx.doi.org/10.1097/TP.0000000000000938DOI Listing
July 2016
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