Faculty Bibliography

We examined interactions between baseline hypothalamic "pituitary" adrenal (HPA) axis and parasympathetic nervous system (PNS) activity in relation to executive functions (EF) in a sample (n=1,005) of children in low wealth, nonurban communities at age 48 months. Salivary cortisol and respiratory sinus arrhythmia (RSA) represented baseline HPA axis and PNS activity, respectively. The interaction between RSA and cortisol predicted EF such that children with either lower RSA and lower cortisol, or higher RSA and higher cortisol had higher EF scores. These findings suggest a potential compensatory relation in which the PNS and HPA axis counterbalance each other to support cognition.

IMPORTANCE:Determining whether the previously reported decreased stroke incidence rates from 1987 to 2011 among US adults 65 years and older in the Atherosclerosis Risk in Communities (ARIC) study continued to decrease subsequently can help guide policy and planning efforts. OBJECTIVE:To evaluate whether stroke incidence declines among older adults in the ARIC study continued after 2011. DESIGN, SETTING, AND PARTICIPANTS:ARIC is a community-based prospective cohort study including 15 792 individuals aged 45 to 64 years at baseline (1987-1989), selected by probability sampling from residents of Forsyth County, North Carolina; Jackson, Mississippi (black individuals only); the northwestern suburbs of Minneapolis, Minneapolis; and Washington County, Maryland (ie, center). The present study included ARIC participants free of stroke at baseline, followed up through December 31, 2017. Data were collected through personal interviews and physical examinations during study visits, annual/semiannual telephone interviews, and active surveillance of discharges from local hospitals. Stroke events were adjudicated by study-physicians reviewers. Analysis began September 2018. MAIN OUTCOMES AND MEASURES:The main outcome was stroke incidence rates, which were computed with 95% CIs stratifying the analysis by age and calendar time. Trends in adjusted incidence rates were assessed using Poisson regression incidence rate ratios. Models included calendar time, age, sex, race/center, and time-varying risk factors (hypertension, diabetes, coronary heart disease, cholesterol-lowering medication use, and smoking). RESULTS:Of 14 357 ARIC participants with 326 654 person-years of follow-up, the mean (SD) age at baseline was 54.1 (5.8) years and 7955 (55.4%) were women. From 1987 to 2017, a total of 1340 incident strokes occurred among ARIC participants, and among them, 1028 (76.7%) occurred in participants 65 years and older. Crude incidence rates of stroke for participants 65 years and older decreased progressively from 1987 to 2017. Incidence rates, adjusted for age, sex, race/center, and time-varying risk factors, decreased by 32% (95% CI, 23%-40%) per 10 years in participants 65 years and older. Findings were consistent across decades, sex, and race. CONCLUSIONS AND RELEVANCE:Validated total stroke incidence rates in adults 65 years and older decreased over the last 30 years in the ARIC cohort. The decrease in rates previously reported for 1987 to 2011 extends for the subsequent 6 years in men and women as well as in white and black individuals.

Satisfaction greatly impacts decisions about where and how to access healthcare. This cross-sectional study uses data gathered from young adult gay men in New York City. Findings indicate that participants who experienced discrimination in a healthcare setting were less likely to prefer coordinated healthcare. Participants who disclosed their sexual orientation and were comfortable discussing sexual activity with their provider were more likely to agree that their healthcare needs were adequately addressed. The healthcare system does not fully address the healthcare needs of gay men. Preferences for coordination of care, nondisclosure of sexual orientation, and low levels of satisfaction with services further discourage healthcare usage among this population.

INTRODUCTION/BACKGROUND:Perfluoroalkyl substances (PFAS) were among various persistent organic pollutants suspected to have been released during the collapse of the World Trade Center (WTC) on 9/11. Evidence suggests PFAS may have cardiometabolic effects, including alterations in lipid profiles. This study evaluated the association between cord PFAS and lipids in a population prenatally exposed to the WTC disaster. STUDY POPULATION/METHODS:222 pregnant women in the Columbia University WTC birth cohort enrolled between December 13, 2001 and June 26, 2002 at hospitals located near the WTC site: Beth Israel, St. Vincent's, and New York University Downtown. METHODS:We evaluated the association between five cord blood PFAS (perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), perfluorohexanesulfonic acid (PFHxS), perfluorononanoic acid (PFNA), perfluorodecane sulfonate (PFDS)) and cord blood lipids (total lipids, total cholesterol, triglycerides). RESULTS:Median (interquartile range (IQR)) concentrations of PFAS were 6.32 (4.58-8.57), 2.46 (1.77, 3.24), 0.38 (0.25, 0.74), 0.66 (0.48, 0.95) and 0.11 (0.09, 0.16) ng/mL for PFOS, PFOA, PFNA, PFHxS and PFDS, respectively. Median (IQR) for lipids were 59.0 (51.5, 68.5) mg/dL for total cholesterol, 196.5 (170.5, 221.2) mg/dL for total lipids and 33.1 (24.2, 43.9) mg/dL for triglycerides. In fully adjusted models, several PFAS were associated with higher lipid levels, including evidence of a strong linear trend between triglycerides and both PFOA and PFHxS. CONCLUSIONS:Findings support previous evidence of an association between PFAS exposure and altered lipid profiles and add novel information on this relationship in cord blood, as well as for an understudied PFAS, PFDS.

Schwarz's Bayesian information criterion (BIC) is one of the most popular criteria for model selection, that was derived under the assumption of independent and identical distribution. For correlated data in longitudinal studies, Jones (Statistics in Medicine, 30, 3050-3056, 2011) modified the BIC to select the best linear mixed effects model based on the effective sample size where the number of parameters in covariance structure was not considered. In this paper, we propose an extended Jones' modified BIC by considering covariance parameters. We conducted simulation studies under a variety of parameter configurations for linear mixed effects models. Our simulation study indicates that our proposed BIC performs better in model selection than Schwarz's BIC and Jones' modified BIC do in most scenarios. We also illustrate an example of smoking data using a longitudinal cohort of cancer patients.

BACKGROUND/OBJECTIVE/OBJECTIVE:Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. Here, we examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Fee-for-service Medicare data, 2012 to 2015. PARTICIPANTS/METHODS:Beneficiaries, aged 65 years and older, hospitalized with HF who were subsequently discharged to SNF and then discharged home. MEASUREMENTS/METHODS:The primary outcome was unplanned readmission within 30 days of discharge to home from SNF. We compared time to readmission between those with and without HHC services using a Cox model. RESULTS:Of 67 585 HF hospitalizations discharged to SNFs and subsequently discharged home, 13 257 (19.6%) were discharged with HHC, and 54 328 (80.4%) were discharged without HHC. Patients discharged home from SNFs with HHC had lower 30-day readmission rates than patients discharged without HHC (22.8% vs 24.5%; P < .0001) and a longer time to readmission. In an adjusted model, the hazard for readmission was 0.91 (0.86-0.95) with receipt of HHC. CONCLUSIONS:Recipients of HHC were less likely to be readmitted within 30 days vs those discharged home without HHC. This is unexpected, as patients discharged with HHC likely have more functional impairments. Since patients requiring a SNF stay after hospital discharge may have additional needs, they may particularly benefit from restorative therapy through HHC; however, only approximately 20% received such services.

Decreased prostate-specific antigen screening since 2008 has generated much concern, including report of recent increase in metastatic prostate cancer incidence among older men. Although increased metastatic disease was temporally proceeded by decreased screening and decreased localized prostate cancer at diagnosis, it is unclear whether the 2 trends are geographically connected. We therefore used the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database to assess geographic-specific associations between changes in localized (2008-2011) and later changes in metastatic prostate cancer incidence (2012-2015). We examined trends from 200 health-care service areas (HSAs) within SEER 18 registries. While on average for each HSA, localized incidence decreased by 27.4 and metastatic incidence increased by 2.3 per 100 000 men per year, individual HSA-level changes in localized incidence did not correlate with later changes in metastatic disease. Decreased detection of localized disease may not fully explain the recent increase in metastatic disease at diagnosis.