Faculty Bibliography

OBJECTIVE:The use of financial incentives to promote physical activity (PA) has grown in popularity due in part to technological advances that make it easier to track and reward PA. The purpose of this study was to update the evidence on the effects of incentives on PA in adults. DATA SOURCES/METHODS:Medline, PubMed, Embase, PsychINFO, CCTR, CINAHL and COCH. ELIGIBILITY CRITERIA/UNASSIGNED:Randomised controlled trials (RCT) published between 2012 and May 2018 examining the impact of incentives on PA. DESIGN/METHODS:A simple count of studies with positive and null effects ('vote counting') was conducted. Random-effects meta-analyses were also undertaken for studies reporting steps per day for intervention and post-intervention periods. RESULTS:23 studies involving 6074 participants were included (64.42% female, mean age = 41.20 years). 20 out of 22 studies reported positive intervention effects and four out of 18 reported post-intervention (after incentives withdrawn) benefits. Among the 12 of 23 studies included in the meta-analysis, incentives were associated with increased mean daily step counts during the intervention period (pooled mean difference (MD), 607.1; 95% CI: 422.1 to 792.1). Among the nine of 12 studies with post-intervention daily step count data incentives were associated with increased mean daily step counts (pooled MD, 513.8; 95% CI:312.7 to 714.9). CONCLUSION/CONCLUSIONS:after incentives were removed, though post-intervention 'vote counting' and pooled results did not align. Nonetheless, and contrary to what has been previously reported, these findings suggest a short-term incentive 'dose' may promote sustained PA.

Rationale & Objective/UNASSIGNED:Evaluation of glomerular filtration rate (GFR) is challenging in adults undergoing bariatric surgery because creatinine and cystatin C levels are influenced by changes in muscle and fat mass. Additionally, indexing of GFR by body surface area (BSA) may by affected by decreases in BSA. Study Design/UNASSIGNED:Prospective observational study. Setting & Participants/UNASSIGNED:who underwent measurement of GFR before and after bariatric surgery. Outcomes/UNASSIGNED:Indexed and nonindexed GFRs measured (mGFRs) using plasma iohexol clearance, indexed and nonindexed estimated GFR (eGFR) based on levels of creatinine, cystatin C, or both from Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Analytic Approach/UNASSIGNED:) for estimating equations were examined. Results/UNASSIGNED:was unbiased before (median bias, -6.0 [95% CI, -11.0 to 1.0] mL/min) and after surgery (-2.0 [95% CI, -8.8 to 4.9] mL/min). Findings were similar for indexed eGFR compared with indexed mGFR. Limitations/UNASSIGNED:Small, mostly white sample. Conclusions/UNASSIGNED:because of opposite biases in estimating mGFR.

OBJECTIVE:To assess relationships between material hardships, shortened sleep duration, and suboptimal sleep practices across infancy and toddlerhood in low-income Hispanic families. METHODS:We analyzed longitudinal data of 451 low-income Hispanic mother-child pairs from a child obesity prevention trial. During infancy and toddlerhood, we used adjusted linear regression to assess associations between material hardship (financial difficulty, food insecurity, housing disrepair, multiple hardships), sleep duration (24-hour, night), and the number of suboptimal sleep practices (e.g., later bedtime, co-sleeping). We used adjusted linear regression to assess the longitudinal association between the number of suboptimal sleep practices in infancy and toddlerhood, and tested whether specific or multiple hardships moderated this association. RESULTS:In infants, financial difficulty and multiple hardships were associated with decreased night sleep (B=-0.59 hours, 95% CI: -1.04, -0.14; and B=-0.54 hours, 95% CI: -1.00, -0.08). Housing disrepair was associated with decreased 24-hour sleep (B=-0.64 hours, 95% CI: -1.29, -0.01). In toddlers, each additional suboptimal sleep practice was associated with a decrease in night sleep (B=-0.19 hours, 95% CI: -0.29, -0.09). Each additional suboptimal sleep practice in infancy was associated with a 0.30 increase in the number of suboptimal sleep practices in toddlerhood (p<0.001), with greater increases for those with food insecurity or multiple hardships. CONCLUSION/CONCLUSIONS:Specific and multiple hardships shortened sleep duration during infancy, and moderated the increase of suboptimal sleep behaviors between infancy and toddlerhood. Future studies should consider these early critically sensitive periods for interventions to mitigate material hardships and establish healthy sleep practices.

OBJECTIVE:This study examined the extent to which maternal immune activity during pregnancy is associated with childhood adiposity, and if so, whether associations at birth differ from those in infancy and childhood. Sex-specific associations were also examined. METHODS:Participants were 1,366 singleton pregnancies from the Collaborative Perinatal Project (1959-1966). Interleukin-1β (IL-1β), IL-6, TNF-α, IL-8, and IL-10 in maternal sera were assayed repeatedly during pregnancy. Children's BMI was calculated repeatedly from birth through age 8 and derived age- and sex-normalized BMI z scores (BMIz). Linear mixed models were used to estimate the cumulative concentration of each cytokine in the second and third trimesters and then related this concentration to child BMIz. RESULTS:Children exposed to higher IL-1β, IL-6, IL-8, and IL-10 concentrations had lower BMIz at birth but higher BMIz during childhood. Higher concentrations of IL-8 and IL-1β were also associated with higher BMIz during infancy (B per log increase in IL-8 = 0.04; 95% CI: 0.02 to 0.07; B per log increase in IL-1β = 0.03; 95% CI: 0.001 to 0.06). The associations between TNF-α and BMIz were in opposing directions in boys (B = -0.13; 95% CI: -0.31 to 0.04) and girls (B = 0.14; 95% CI: 0.02 to 0.26) during childhood. CONCLUSIONS:Maternal prenatal inflammation contributes to the age- and sex-specific programming of obesity risk in childhood.

OBJECTIVE:To understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's (NCCN) guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. METHODS:We implemented the CROC at VA New York Harbor Healthcare System (VANYHHS) from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VHANYHHS before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. RESULTS:57% (117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. CONCLUSION/CONCLUSIONS:While the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a CPRS-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.

BACKGROUND AND PURPOSE:Data on the significance of combined white matter hyperintensities (WMH)/lacunar brain infarcts, and their progression over time for the prediction of stroke are scarce. We studied associations between the progression in combined measures of microvascular brain disease and risk of stroke in the ARIC study (Atherosclerosis Risk in Communities). METHODS:Prospective analysis of 907 stroke-free ARIC participants who underwent a brain magnetic resonance imaging (MRI) in 1993 to 1995, a second brain MRI in 2004 to 2006, and were subsequently followed for stroke incidence through December 31, 2017 (median [25%-75%] follow-up 12.6 [8.9-13.4] years). A combined measure of microvascular brain disease was defined at each visit and categorized by progression from first to second brain MRI as no progression; mild progression (increase of ≥1 unit in WMH grade or new lacune), and moderate progression (increase of ≥1 unit in WMH grade and new lacune). All definite/probable ischemic or hemorrhagic incident strokes occurring after this second MRI, and through 2017, were included. Associations between microvascular brain disease, progression in the combined measures, and stroke incidence were studied with Cox proportional hazard models, adjusting for age, sex, race, education level, time from first to second MRI, body mass index, smoking, hypertension, diabetes mellitus, and coronary heart disease. RESULTS:At the second brain MRI (mean age 72), the distribution of the combined measure was 37% WMH grade <2 and no lacune; 57% WMH grade ≥2 or lacune; and 6% WMH grade ≥2 and lacune. No progression in the combined measures was observed in 38% of participants, 57% showed mild progression and 5% showed moderate progression. Sixty-four incident strokes occurred during the follow-up period. Compared with no change in the combined measure, moderate progression of microvascular brain disease was significantly associated with higher risk of stroke (adjusted hazard ratio, 3.00 [95% CI, 1.30-6.94]). CONCLUSIONS:Progression of microvascular brain disease, manifesting as both new lacunes and increase in WMHs grade, is related to substantial increase in long-term risk of stroke.

BACKGROUND:Reduced fetal growth increases the risk for adverse health outcomes. Growing evidence suggests that metal exposures contribute to reduced fetal growth, but little is known about the effects of complex metal mixtures. OBJECTIVES/OBJECTIVE:We investigated the impact of a complex mixture of metals on birth weight for gestational age (BW for GA) in the Maternal and Developmental Risks from Environmental and Social Stressors study, a predominately lower-income Hispanic pregnancy cohort in Los Angeles, California. METHODS: RESULTS:In primary analyses, Hg and Ni ranked highest as predictors of BW for GA. An inverse linear association was estimated for Hg, whereas a positive association was estimated for Ni at low-to-moderate concentrations. A potential interaction between Hg and Ni was also identified. In our exploratory analysis, Sb ranked highest as a predictor of BW for GA, followed by Hg and Ni. CONCLUSIONS:Our findings suggest that in this understudied population, Hg may reduce fetal growth, whereas Ni may promote fetal growth. We also identified Sb as a potential metal of concern for this population, which merits additional investigation. https://doi.org/10.1289/EHP7201.

OBJECTIVE:Scalable, accessible forms of behavioral therapy for migraine prevention are needed. We assessed the feasibility and acceptability of progressive muscle relaxation (PMR) delivered by a smartphone application (app) in the Primary Care setting. METHODS:This pilot study was a non-blinded, randomized, parallel-arm controlled trial of adults with migraine and 4+ headache days/month. Eligible participants spoke English and owned a smartphone. All participants were given the RELAXaHEAD app which includes an electronic headache diary. Participants were randomized to receive 1 of the 2 versions of the app-one with PMR and the other without PMR. The primary outcomes were measures of feasibility (adherence to the intervention and diary entries during the 90-day interval) and acceptability (satisfaction levels). We conducted exploratory analyses to determine whether there was a change in Migraine Disability Assessment Scale (MIDAS) scores or a change in headache days. RESULTS:Of 139 participants (77 PMR, 62 control), 116 (83%) were female, mean age was 41.7 ± 12.8 years. Most patients 108/139 (78%) had moderate-severe disability. Using a 1-5 Likert scale, participants found the app easy to use (mean 4.2 ± 0.7) and stated that they would be happy to engage in the PMR intervention again (mean 4.3 ± 0.6). For the first 6 weeks, participants practiced PMR 2-4 days/week. Mean per session duration was 11.1 ± 8.3 minutes. Relative to the diary-only group, the PMR group showed a greater non-significant decline in mean MIDAS scores (-8.7 vs -22.7, P = .100) corresponding to a small-moderate mean effect size (Cohen's d = 0.38). CONCLUSION/CONCLUSIONS:Smartphone-delivered PMR may be an acceptable, accessible form of therapy for migraine. Mean effects show a small-moderate mean effect size in disability scores.