Publications

BACKGROUND

Medications that may increase risk of birth defects if used during pregnancy or immediately preconception are dispensed to approximately half of female Veterans who fill prescriptions at a VA pharmacy.

OBJECTIVE

To assess receipt of counseling about risk of medication-induced birth defects among female Veterans of reproductive age and to examine Veterans' confidence that their healthcare provider would counsel them about teratogenic risks.

DESIGN AND PARTICIPANTS

Cross-sectional analysis of data provided by 286 female Veterans of Operation Iraqi Freedom and/or Operation Enduring Freedom who completed a mailed survey between July 2008 and October 2010.

MAIN MEASURES

We examined associations between demographic, reproductive, and health service utilization variables and female Veterans' receipt of counseling and confidence that they would receive such counseling.

KEY RESULTS

The response rate was 11 %; the large majority (89 %) of responding female Veterans reported use of a prescription medication in the last 12 months. Most (90 %) of the 286 female Veterans who reported medication use were confident that they would be told by their healthcare provider if a medication might cause a birth defect. However, only 24 % of women who received prescription medications reported they had been warned of teratogenic risks. Female Veterans who used medications that are known to be teratogenic were not more likely than women using other medications to report having been warned about risks of medication-induced birth defects, and fewer were confident that their health care providers would provide teratogenic risk counseling when needed.

CONCLUSIONS

Female Veterans may not receive appropriate counseling when medications that can cause birth defects are prescribed.

OBJECTIVE

To estimate the U.S. maternal health burden from current breastfeeding rates both in terms of premature death as well as economic costs.

METHODS

Using literature on associations between lactation and maternal health, we modeled the health outcomes and costs expected for a U.S. cohort of 15-year-old females followed to age 70 years. In 2002, this cohort included 1.88 million individuals. Using Monte Carlo simulations, we compared the outcomes expected if 90% of mothers were able to breastfeed for at least 1 year after each birth with outcomes under the current 1-year breastfeeding rate of 23%. We modeled cases of breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction considering direct costs, indirect costs, and cost of premature death (before age 70 years) expressed in 2011 dollars.

RESULTS

If observed associations between breastfeeding duration and maternal health are causal, we estimate that current breastfeeding rates result in 4,981 excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction compared with a cohort of 1.88 million U.S. women who optimally breastfed. Using a 3% discount rate, suboptimal breastfeeding incurs a total of $17.4 billion in cost to society resulting from premature death (95% confidence interval [CI] $4.38-24.68 billion), $733.7 million in direct costs (95% CI $612.9-859.7 million), and $126.1 million indirect morbidity costs (95% CI $99.00-153.22 million). We found a nonsignificant difference in number of deaths before age 70 years under current breastfeeding rates (4,396 additional premature deaths, 95% CI -810-7,918).

CONCLUSIONS

Suboptimal breastfeeding may increase U.S. maternal morbidity and health care costs. Thus, investigating whether the observed associations between suboptimal breastfeeding and adverse maternal health outcomes are causal should be a research priority.

OBJECTIVE

Positive affect can improve survival, but the mechanisms responsible for this association are unknown. We sought to evaluate the association between positive affect and mortality in patients with stable coronary heart disease and to determine biological and behavioral factors that might explain this association.

METHOD

The Heart and Soul Study is a prospective cohort study of 1,018 outpatients with stable coronary heart disease. Participants were recruited between September 11, 2000, and December 20, 2002, and were followed up to June 2011. Baseline positive affect was assessed by using the 10-item positive affect subscale of the Positive and Negative Affect Schedule. Cox proportional hazards regression was used to estimate the risk of mortality (primary outcome measure) and cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack) associated with positive affect, adjusting for baseline cardiac disease severity and depression. We also evaluated the extent to which these associations were explained by potential biological and behavioral mediators.

RESULTS

A total of 369 patients (36%) died during a mean ± SD follow-up period of 7.1 ± 2.5 years. Positive affect was not significantly associated with cardiovascular events (hazard ratio [HR]: 0.89; 95% CI, 0.79-1.00; P = .06). However, each standard deviation (8.8-point) increase in positive affect score was associated with a 16% decreased risk of all-cause mortality (HR: 0.84; 95% CI, 0.76-0.92; P = .001). After adjustment for cardiac disease severity and depressive symptoms, positive affect remained significantly associated with improved survival (HR: 0.87; 95% CI, 0.78-0.97; P = .01). The association was no longer significant after adjustment for behavioral factors, and particularly physical activity (HR: 0.92; 95% CI, 0.82-1.03; P = .16). Further adjustment for C-reactive protein and omega-3 fatty acids did not result in any meaningful changes (HR: 0.94; 95% CI, 0.84-1.06; P = .31).

CONCLUSIONS

In this sample of outpatients with coronary heart disease, positive affect was associated with improved survival. This association was largely explained by physical activity.