Faculty Bibliography

BACKGROUND:Exposure to bisphenols and phthalates might influence bone health. We hypothesized that exposure to bisphenols and phthalates during fetal life has persistent effects on bone development. OBJECTIVES/OBJECTIVE:To analyze the associations of fetal exposure to bisphenols and phthalates with bone health in school-aged children. METHODS:Among 1,362 mother-child pairs participating in a population-based cohort study, we measured maternal urinary concentrations of bisphenols and phthalates at first, second and third trimester with high performance liquid chromatography electrospray ionization-tandem mass spectrometry. Total body bone mineral density (BMD) and bone area (BA) were measured using dual-energy X-ray absorptiometry (DXA) at 6 and 10 years, and were both used to calculate bone mineral content (BMC) and area-adjusted BMC (aBMC, a measure of volumetric BMD). RESULTS:and -0.12 (95% CI, -0.20 to -0.04) g). Maternal third trimester low molecular weight (LMW) phthalate concentrations were associated with higher aBMC at 6 years whereas, maternal third trimester di-n-octylphthalate (DNOP) concentrations were associated with lower aBMC at 10 years. However, these associations did not remain statistically significant after multiple testing correction. DISCUSSION/CONCLUSIONS:Maternal first trimester BPS concentrations are associated with lower BMD and aBMC in school-aged children. These findings should be considered as hypothesis generating and need further replication and exploration of potential underlying mechanisms.

BACKGROUND: Payors are increasingly recognizing that social determinants of health(SDH) impact on health outcomes and healthcare costs. Z codes can be used to document and stratify patients into risk pools according to SDH. We report on the impact of SDH screening implementation in a federally qualified health center network on the use of Z codes to document SDH. In this study, we describe the prevalence of SDH screening by department, the prevalence of documented SDH, and the prevalence of documented Z codes for each SDH.
METHOD(S): In October 2017, we initiated SDH screening throughout, but focusing on the internal medicine and women's health departments of a large FQHC network (12 service delivery sites) using the OCHIN tool embedded in the elecrtonic health record. In November 2019, we retrieved the following variables from record: % of all patients who were screened, number of patients screened annually by department, % of positive screens (+ response to any question), % abnormal screens(response that triggers a best practice alert to the treating provider), and documentation of a Z code for positive or abnormal screens.
RESULT(S): There were 624,007 encounters over a 2 year study period; 2,844 patients were screened: 194 in 2017, 1068 in 2018;1644 in 2019. Overall, there were 3052 screening events (some patients received multiple screens). The majority of screening events occurred in women's health [1961(64%)], followed by adult medicine[874(29%)]. Overall, 2350(77%) of screens were "positive", of which 433 had no "abnormal" results and hence did not trigger a best practice alert. Of these 433, the most common positive items were: social isolation(63%), stress(44%), financial resource strain(8%), moved 2+ times(7%). There were 1923(63%) abnormal screens. The top 10 abnormal items in Women's Health and Adult Medicine were: Education less than high school(36% and 37%), physical activity <140 minutes(23% and 25%), hard to pay for medicine/medical care(13% and 26%), hard to pay for utilities(14% and 23%), hard to pay for food(13% and 21%), hard to pay for health insurance(11% and 22%), concerns about housing quality(3% and 9%), hard to pay child care(5% and 5%), exposure to violence(4% and 3%), never get together with family/friends(3% and 3%). Overall, encounters with an SDH screen were more likely to have a documented Z code:26% vs. 1%. Z codes were documented for the following documented needs: insufficient social insurance(53%); lack of access to health care(51%), homelessness(49%), inadequate family support(40%), lack of physical exercise(37%), underachievement in school(34%), personal history of abuse(31%), lack of assistance for care at home(29%), inadequate food supply(1%).
CONCLUSION(S): Presence of a documented SDH screen was associated with documentation of Z codes, however documentation was missing more than half the time for most documented needs. The drivers of Z code documentation deserve further exploration. Qualitative interviews and focus groups with providers may be useful

BACKGROUND: Race, ethnicity, and language have been identified as factors impacting uptake of HIV testing. This project sought to compare testing rates between predominant and non-predominant ethnic, racial, or language populations within neighborhood FQHCs.
METHOD(S): We identified Family Health Center network locations at which more than 50% of patients served identified as the same race, and/ or had the same preferred language, and focused our analysis on these sites. We used Excel and SPSS to compare HIV testing rates between predominant and non-predominant population groups at each clinic.
RESULT(S): At 2 of 5 sites with a predominant non-English preferred language, speakers of the predominant language were more likely to receive an HIV test than speakers of other languages (p<0.001 for both sites). The other sites showed no difference by language. Of 2 clinics with a predominant racial population, there was no difference between predominant and non-predominant populations in terms of HIV testing. At all included sites, with one exception, Hispanic ethnicity was associated with a significantly higher rate of HIV testing.
CONCLUSION(S): Predominant/non-predominant race did not affect HIV testing rates, but language and ethnicity did. One mechanism for this may be increased trust associated with patient-provider language concordance, resulting in greater uptake of tests. There is a need for future research to further explore the factors associated with these findings

BACKGROUND: Patient Portals(PP) allow access to medical records and interaction with providers; however activation(PPA) and use (PPU) are limited by language barriers, low health/computer literacy, and poor internet access which are prevalent issues in Federally Qualified Health Centers(FQHC). Little is known of the drivers and patterns of PPA in such settings. We aimed to describe the prevalence of PPA and PPU in adult patients of an FQHC; describe PPU activity, and test demographic, condition, and utilization-related correlates of PPA and PPU.
METHOD(S):We conducted a retrospective chart review in an FQHC that launched a PP in September 2016. We extracted demographics, PPA status(active/not) at data pull, PPU activities, presence of a chronic condition on the problem list, # emergency department, inpatient, subspecialty visits over past year (utilization summed, dichotomized >1 vs. 0-1 visit). Missing values for homelessness were coded to majority category( 0). Analyses included descriptive statistics, bivariate analyses, then logistic regression to test odds of PPA and PPU by. demographics, chronic conditions, and utilization. We report [adjusted odds ratios(confidence interval)].
RESULT(S): Data were analyzed for 62,610 adults [mean age 45(SD 17), 21% Black, 47% Hispanic, 46% Medicaid, 25% Selfpay, speaking English( 60%), Spanish (31%), Chinese(6%), Other(3%), with: hypertension( 19%), diabetes(11%), depression(8%), asthma(6%), CVD(5%); 21% had utilization>1. Overall 23,104(37%) activated the PP. PPU included viewing test results(69%), medications(62% ), immunizations( 51%), billing (38%), asking advice (29%), and scheduling appointments( 16%). PPA and PPU varied by demographics, chronic condition, and utilization, but were consistently higher for females, those who were not Medicaid recipients or Self-pay, English speakers and those with asthma, hypertension, and depression.
CONCLUSION(S): PPA was lower for non-whites and poorer patients, but higher for patients speaking the predominant languages of this FQHC, suggesting that language concordance helps engage patients. Patients with chronic conditions and more healthcare utilization had greater odds of PPA and PPU. On the other hand, Spanish-speakers were less likely to actively use the portal for functions such as scheduling appointments, suggesting that improvements in language capabilities of the platform are needed

Research on early life adversity has begun a shift from cumulative risk approaches to more dimensional approaches. One such dimensional approach to understanding early life adversity uses dimensions of deprivation and threat to differentially predict developmental outcomes, however this framework has not been applied to the context of poverty-related adversity, which encompasses more than deprivation and threat and is characterized by high levels of both these dimensions. Previous studies have found that experiences of deprivation, but not threat, predict executive functions (EF). We propose a model of deprivation and threat as dimensions of poverty-related adversity, and we hypothesized that deprivation, but not threat, would mediate links between early life socioeconomic status (SES) and EF. Data come from the 15-, 24-, and 48-month visits of the Family Life Project (n=1,292). We used latent variables of deprivation and threat in a multiple mediation model with SES as the main predictor, deprivation and threat as mediators predicting 48 month EF. Lower SES was related to higher levels of both deprivation (beta=-0.597, p < 0.01) and threat (beta=-0.628, p < 0.01). Additionally, deprivation (beta=-0.916, p < 0.01), but not threat (beta= 0.307, p=0.112) was significantly negatively related to EF outcomes. The indirect effect of SES on EF through deprivation was significant (beta= 0.548, p =0.013). Finally, deprivation and threat together fully mediated the relationship between SES and EF. Implications for mental and physical health for children growing up in high-poverty contexts will be discussed

A growing body of research demonstrates that early-life stress exposure is linked to later-life health outcomes, with disparities in outcomes emerging as early as childhood. However, the mechanisms by which early stress might contribute to adverse health effects remain poorly understood. One likely mechanism is via altered glucocorticoid activity. Glucocorticoids (e.g., cortisol in humans) are essential for myriad physiological functions, including the maintenance of cardiovascular tone, provision of anti-inflammatory effects, and regulation of growth, behavior, and cognition. Here we assessed if glucocorticoid levels across infancy and toddlerhood were associated with impaired tissue sensitivity to glucocorticoids (glucocorticoid resistance) in early adolescence. Data come from the Family Life Project, a longitudinal study of 1,292 children and their caregivers living in predominantly low-income non-urban communities. Children's resting levels of cortisol were assayed via saliva samples collected in their home at 6, 15, 24, and 48 months of age. Glucocorticoid resistance at 11-12 years of age was assessed using a well-established protocol whereby whole blood was diluted in phosphate buffered saline and cultured with and without endotoxin lipopolysaccharide (LPS) at a range of concentrations of hydrocortisone. Glucocorticoid resistance was quantified by the difference in inflammatory cytokine (IL-6) levels in response to LPS alone versus LPS with the highest concentration of hydrocortisone. Structural equation modeling was used to assess direct effects of a latent variable of early childhood cortisol on glucocorticoid resistance in early adolescence. All models adjusted for demographic covariates, including infant's race, gender, age, and mother's age, as well as child's body mass index, health status, time of blood draw, and body temperature. Analyses revealed a significant positive association between cortisol levels and glucocorticoid resistance, such that higher cortisol in early childhood predicted increased glucocorticoid resistance in early adolescence (b=0.893, p=0.023). Our findings support the idea that prolonged elevation of glucocorticoids in early life may result in a dysregulated response such that the expression and/or function of glucocorticoid receptors become downregulated, leading to glucocorticoid resistance

Use of substances other than nicotine in e-cigarettes, especially marijuana, is becoming increasingly popular in the US. However, population-representative data on such poly-use (nicotine and marijuana) remains limited. We therefore conducted a cross-sectional logistic regression analysis of the 2018 Behavioral Risk Factor Surveillance System among 16 US states/territories with data on past 30-day marijuana use to describe the emerging dual nicotine and marijuana vaping population. We additionally examined trends in marijuana use, including marijuana vaping, from 2016 to 2018. Of the 131,807 participants studied, 3068 were current e-cigarette users, among whom 7.1% also vaped marijuana. Prevalence of nicotine-predominant, dual nicotine marijuana, and marijuana-predominant vaping was 3.36%, 0.38% and 1.09%, respectively. Compared to nicotine-predominant vapers, dual and marijuana-predominant vapers were older, had greater proportions of non-Whites, particularly Hispanics, and less likely to be current smokers (nicotine-predominant vs dual vs marijuana-predominant vaping: current tobacco use 44.7 vs 23.7 vs 11.1%). Proportion of dual vapers among current e-cigarette users was 8.6%, 2.6% and 7.1% for 2016, 2017 and 2018, respectively. Prevalence of marijuana use increased from 8.97% (2016) to 13.1% (2018) while no clear trend was observed for marijuana vaping. Dual nicotine and marijuana vaping is prevalent in the US, and compared to predominantly nicotine vapers such users have higher mean ages, and are more likely to be Blacks, Hispanics, and never cigarette smokers. Marijuana use overall increased from 2016 to 2018. Dual vapers represent a large and important emerging population that will require dedicated study of health effects and tailored regulatory strategies.

The chapters and reports in this book explore a wide variety of topics related to how health literacy can impact clinical practice and public health. While health literacy is relevant to healthcare issues across populations, it has unique implications in the field of pediatrics, where parents and other caregivers are responsible for managing their child's healthcare. Younger children have varying roles and involvement; over time, as children reach adolescence, they have an increasing understanding of and participation in their healthcare. This chapter will review the epidemiology of health literacy in parents, adolescents, and children, and how this compares to the general adult population. It will highlight unique considerations regarding health literacy and pediatric health. The chapter will then focus on the impact of health literacy and relevant health literacy-informed interventions on pediatric health. Finally, the chapter will discuss gaps in the literature and future directions.

Patient nonadherence to healthy lifestyle behaviors and medical treatments (like medication adherence) accounts for a significant portion of chronic disease burden. Despite the plethora of behavioral interventions to overcome key modifiable/nonmodifiable barriers and enable facilitators to adherence, short- and long-term adherence to healthy lifestyle behaviors and medical treatments is still poor. To optimize adherence, we aimed to provide a novel mobile health solution steeped in precision and personalized population health and a pantheoretical approach that increases the likelihood of adherence. We have described the stages of a pantheoretical approach utilizing tailoring, clustering/profiling, personalizing, and optimizing interventions/strategies to obtain adherence and highlight the minimal engineering needed to build such a solution.

Higher serum 6-bromotryptophan has been associated with lower risk of chronic kidney disease (CKD) progression, implicating mechanisms beyond renal clearance. We studied genetic determinants of urine 6-bromotryptophan and its association with CKD risk factors and incident end-stage kidney disease (ESKD) in 4,843 participants of the German Chronic Kidney Disease (GCKD) study. 6-bromotryptophan was measured from urine samples using mass spectrometry. Patients with higher levels of urine 6-bromotryptophan had higher baseline estimated glomerular filtration rate (eGFR, p < 0.001). A genome-wide association study of urine 6-bromotryptophan identified two significant loci possibly related to its tubular reabsorption, SLC6A19, and its production, ERO1A, which was also associated with serum 6-bromotryptophan in an independent study. The association between urine 6-bromotryptophan and time to ESKD was assessed using Cox regression. There were 216 ESKD events after four years of follow-up. Compared with patients with undetectable levels, higher 6-bromotryptophan levels were associated with lower risk of ESKD in models unadjusted and adjusted for ESKD risk factors other than eGFR (<median level: cause-specific hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.51 to 0.97; ≥median level: HR 0.50, 95% CI 0.34 to 0.74). Upon adjustment for baseline eGFR, this association became attenuated, suggesting that urine 6-bromotryptophan may represent a correlated marker of kidney health.