Faculty Bibliography

Introduction/UNASSIGNED:Infants and young children may be at an increased risk for second- and thirdhand exposure to tobacco smoke because of increased respiration rate and exposure to surface residue. However, relatively fewer studies have examined biomarkers of exposure (cotinine) in children under age 4 years. This study examines the magnitude and chronicity of exposure across early childhood among children from low-income families in order to better characterize contextual risk factors associated with exposure. Methods/UNASSIGNED:A total of 1292 families were recruited in six nonurban counties of Pennsylvania and North Carolina. Cotinine was assayed from infant saliva at 6, 15, 24, and 48 months of age (N = 1218), and categorized as low (≤0.45 ng/mL), moderate (0.46-12 ng/mL), or high (≥12 ng/mL) at each time point. Categories were highly correlated across time. Latent class analysis was used to summarize patterns of exposure categories across time. Results/UNASSIGNED:Magnitude of exposure in this sample was high, with approximately 12% of infants registering cotinine values at least 12 ng/mL, consistent with active smoking in adults. Greater exposure was associated with lower income, less education, more residential instability, and more instability in adult occupants in the home, whereas time spent in center-based day care was associated with lower exposure. Conclusions/UNASSIGNED:Young children from low-income, nonurban communities appear to bear a higher burden of secondhand smoke exposure than previous studies have reported. Results contribute to understanding populations at greater risk, as well as specific, potentially malleable, environmental factors that may be examined as direct contributors to exposure. Implications/UNASSIGNED:Results suggest that infants from low-income, nonurban families have higher risk for environmental smoke exposure than data from nationally representative samples. Predictors of exposure offer insights into specific factors that may be targeted for risk reduction efforts, specifically conditions of children's physical space. In addition to considering the increases in risk when an adult smoker lives in a child's home, families should also attend to the possible risk embedded within the home itself, such as residual smoke from previous occupants. For high-risk children, day care appears to mitigate the magnitude of exposure by providing extended time in a smoke-free environment.

PURPOSE/OBJECTIVE:To examine provider perceptions of practice behaviors and barriers related to fertility counseling, fertility preservation, and family building among transgender patients. METHODS:Participants were medical and mental health professionals who treat adult and youth transgender patients. Recruitment occurred online and in person, via professional listservs for transgender professionals, conferences, and gender clinics. From August-November 2017, 110 participants representing nine countries responded to four open-ended questions included on a survey related to provider practice behaviors and perceived barriers to fertility counseling, fertility preservation, and family building with transgender patients. Thematic coding analysis was used to identify themes. RESULTS:Multiple themes were identified including the following: access and cost issues; urgency for gender-affirming treatment; patient maturity and inability to make future-oriented decisions; and provider-related challenges pertaining to knowledge, role, and general lack of information in the nascent field of transgender reproductive health. CONCLUSION(S)/CONCLUSIONS:This study yielded insights into practice behaviors, challenges, and perceived barriers to fertility counseling with transgender individuals and can serve as a basis for intervention development to optimize clinical practices with this population.

Ovarian cancer risk factors differ by histotype; however, within subtype there is substantial variability in outcomes. We hypothesized that risk factor profiles may influence tumor aggressiveness, defined by time between diagnosis and death, independent of histology. Among 1.3 million women from 21 prospective cohorts, 4,584 invasive epithelial ovarian cancers were identified and classified as highly aggressive (death in <1 year, n=864), very aggressive (death in 1-<3 years, n=1,390), moderately aggressive (death in 3-<5 years, n=639), and less aggressive (lived 5+ years, n=1,691). Using competing risks Cox proportional hazards regression, we assessed heterogeneity of associations by tumor aggressiveness for all cases and among serous and endometrioid/clear cell tumors. Associations between parity (p_het =0.01), family history of ovarian cancer (p_het =0.02), body mass index (BMI; p_het ≤0.04) and smoking (p_het <0.01) and ovarian cancer risk differed by aggressiveness. A first/single pregnancy, relative to nulliparity, was inversely associated with highly aggressive disease (HR: 0.72; 95% CI [0.58-0.88]), no association was observed for subsequent pregnancies (per pregnancy, 0.97 [0.92-1.02]). In contrast, first and subsequent pregnancies were similarly associated with less aggressive disease (0.87 for both). Family history of ovarian cancer was only associated with risk of less aggressive disease (1.94 [1.47-2.55]). High BMI (≥35 vs. 20-<25 kg/m² , 1.93 [1.46-2.56] and current smoking (vs. never, 1.30 [1.07-1.57]) were associated with increased risk of highly aggressive disease. Results were similar within histotypes. Ovarian cancer risk factors may be directly associated with subtypes defined by tumor aggressiveness, rather than through differential effects on histology. Studies to assess biological pathways are warranted.

Though prior research has examined the links between executive function (EF) – the higher order cognitive processes involved in self-regulation – and academic achievement, and between teacher–child relationships and academic achievement, few studies have examined the extent to which EF, teacher–child conflict, and academic achievement are related. The present study explores the longitudinal, bidirectional relations among direct assessments of children's EF and early reading and math achievement and teacher-reports of relationship closeness and conflict with target children. Data were collected with N = 759 children in fall and spring of kindergarten and in fall of first grade. The results confirm bidirectional associations between EF and math achievement. Moreover, the study finds that conflict with teachers predicts EF and reading achievement, but not math achievement, though the relations are not bidirectional

OBJECTIVE:The goal of this study was to determine whether newborn concentrations of perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and bisphenol A (BPA) are associated with early childhood growth. METHODS:A total of 1,954 singletons and 966 twins from the Upstate KIDS Study (born 2008-2010) were included in this study. Newborn dried blood spot concentrations of PFOS, PFOA, and BPA were quantified by liquid chromatography tandem mass spectrometry. Children's weight and height were reported from birth through 3 years of age. Repeated measures were modeled using generalized linear mixed models. RESULTS:[-0.17 to -0.051] per 1 standard deviation increase in log PFOS and PFOA, respectively) and not with early obesity among singletons. Inconsistent associations were observed for twins. BPA levels were higher among neonates with a neonatal intensive care unit stay (P < 0.001), making associations difficult to interpret. CONCLUSIONS:Perfluorinated alkyl substances did not exhibit obesogenic associations with early measures of childhood growth. Blood-based BPA measures are limited by the nonpersistent nature of the chemical, and unknown sources from hospital settings may present only transient exposures.

STUDY QUESTION/OBJECTIVE:Are early-pregnancy urinary bisphenol and phthalate metabolite concentrations associated with placental function markers, blood pressure (BP) trajectories during pregnancy and risk of gestational hypertensive disorders? SUMMARY ANSWER/UNASSIGNED:Early-pregnancy bisphenols and phthalate metabolites were not consistently associated with maternal BP changes or gestational hypertensive disorders, but subclinical, statistically significant associations with placental angiogenic markers and placental hemodynamics were identified. WHAT IS KNOWN ALREADY/UNASSIGNED:In vitro studies suggest that bisphenols and phthalate metabolites may disrupt early placental development and affect the risk of gestational hypertensive disorders. Previous studies investigating effects of bisphenols and phthalate metabolites on gestational hypertensive disorders reported inconsistent results and did not examine placental function or BP throughout pregnancy. STUDY DESIGN, SIZE, DURATION/UNASSIGNED:In a population-based prospective cohort study, bisphenol and phthalate metabolite concentrations were measured in a spot urine sample in early pregnancy among 1396 women whose children participated in postnatal follow-up measurements. PARTICIPANTS/MATERIALS, SETTING, METHODS/UNASSIGNED:After exclusion of women without any BP measurement or with pre-existing hypertension, 1233 women were included in the analysis. Urinary bisphenol and phthalate metabolite concentrations were measured in early-pregnancy [median gestational age 13.1 weeks, inter-quartile range 12.1-14.5]. Molar sums of total bisphenols and of low molecular weight phthalate, high molecular weight (HMW) phthalate, di-2-ethylhexylphthalate, and di-n-octylphthalate metabolites were calculated. Placental angiogenic markers (placental growth factor (PlGF), soluble fms-like tyrosine kinase (sFlt)-1), placental hemodynamic function measures (umbilical artery pulsatility index (PI), uterine artery resistance index (RI), notching and placental weight), and maternal BP were measured in different trimesters. Information on gestational hypertensive disorders was obtained from medical records. MAIN RESULTS AND THE ROLE OF CHANCE/UNASSIGNED:Each log unit increase in HMW phthalate metabolites was associated with a 141.72 (95% CI: 29.13, 373.21) higher early pregnancy sFlt-1/PlGF ratio (range in total sample 9-900). This association was driven by mono-[(2-carboxymethyl)hexyl]phthalate. In the repeated measurements regression models, each log unit increase in bisphenol A was associated with a 0.15 SD (95% CI: 0.03, 0.26) higher intercept and -0.01 SD (95% CI: -0.01, -0.00) decreasing slope of the umbilical artery PI Z-score and a -1.28 SD (95% CI: -2.24, -0.33) lower intercept and 0.06 SD (95% CI: 0.02, 0.11) increasing slope of the uterine artery RI Z-score. These associations remained significant after Bonferroni correction. Early-pregnancy bisphenols or phthalate metabolites showed no consistent associations with any other outcome. LIMITATIONS, REASONS FOR CAUTION/UNASSIGNED:Information on a large number of potential confounders was available but was partly self-reported. Bisphenols and phthalate metabolites, which typically have a half-life of 24-48 h, were measured via single spot urine samples in early-pregnancy. In addition, at the current sample size, the study was powered to detect an odds ratio of 1.57 for gestational hypertension and 1.78 for pre-eclampsia, but was underpowered to perform multivariable analyses for these outcomes. Further studies combining data from different cohorts may be necessary to increase power. These limitations are possible sources of non-differential misclassification leading to bias toward the null. WIDER IMPLICATIONS OF THE FINDINGS/UNASSIGNED:Bisphenols and phthalate metabolites were not associated with longitudinal changes in BP in pregnancy in our low-risk population. The observed subclinical associations of phthalates with the sFlt-1/PlGF ratio and of bisphenol A with placental hemodynamics may contribute to adverse pregnancy outcomes. Our results are therefore more supportive of an association of early pregnancy bisphenols and phthalate metabolites with risk for pre-eclampsia than with gestational hypertension. STUDY FUNDING/COMPETING INTEREST(S)/UNASSIGNED:This analysis was supported by Grant (ES022972) from the National Institutes of Health, USA. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health. The authors report no conflicts of interest.

The Triple Aim framework for advancing health care transformation elevated population health improvement as a central goal, together with improving patient experiences and reducing costs. Though population health improvement is often viewed in the context of clinical care delivery, broader-reaching approaches that bridge health care delivery, public health, and other sectors to foster area-wide health gains are gathering momentum. Academic medical centers (AMCs) across the United States are poised to play key roles in advancing population health and have begun to structure themselves accordingly. Yet few frameworks exist to guide these efforts. Here, the authors offer a generalizable approach for AMCs to promote population health across the domains of research, education, and practice. In 2012, NYU School of Medicine, a major AMC dedicated to high-quality care of individual patients, launched an academic Department of Population Health with a strongly applied approach. A rigorous research agenda prioritizes scalable initiatives to improve health and reduce inequities in populations defined by race, ethnicity, geography, and/or other factors. Education targets population-level thinking among future physicians and research leadership among graduate trainees. Four key mission-bridging approaches offer a framework for population health departments in AMCs: engaging community, turning information into insight, transforming health care, and shaping policy. Challenges include tensions between research, practice, and evaluation, navigating funding sources, and sustaining an integrated, interdisciplinary approach. This framework of discipline-bridging, partnership-engaging inquiry, as it diffuses throughout academic medicine, holds great promise for realigning medicine and public health.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

This research is a cross-sectional study of young adult gay men (YAGM), ages 18 to 29, that aims to understand their health-care access including: having a primary care provider (PCP), frequency of health-care visits, and instances of foregone health care. Surveys were conducted with a modified time-space sample of 800 YAGM in New York City (NYC). Surveys were conducted between November 2015 and June 2016. This study examined associations between sociodemographic characteristics and health-care access using multivariable logistic regression models. In multivariable logistic regression models, there were higher odds of having a PCP among participants enrolled in school (Adjusted Odds Ratio [AOR] = 1.85, 95% CI [1.18, 2.91], p < .01) and covered by insurance (AOR = 21.29, 95% CI [11.77, 38.53], p < .001). Modeling indicated higher odds of more than one health visit in the past 12 months for non-White participants (AOR = 2.27, 95% CI [1.43, 3.63], p < .001), those covered by insurance (AOR = 3.10, 95% CI [1.06, 9.04], p < .05), and those who disclosed their sexual orientation to their PCP (AOR = 2.99, 95% CI [1.58, 5.69], p < .001). Participants with insurance were less likely to report instances of foregone care (AOR = 0.21, 95% CI [0.21, 0.13], p < .001). Understanding the facilitators and barriers to health-care access among YAGM populations is of critical importance, as many YAGM between the ages of 18 and 29 are establishing their access to health care without parental guidance. Health-care access, including the decision to forego care, can represent a missed opportunity for primary prevention and early diagnosis of health issues, as well as more effective, less invasive, and less costly treatments.

Approximately 9% of adults report the symptoms of insomnia, and there are a number of adverse consequences of insomnia. This could be a public health concern. The current study seeks plausible longitudinal predictors of insomnia for prevention purposes. A community sample of 674 participants (53% African Americans and 47% Puerto Ricans; 60% were females) were recruited from the Harlem Longitudinal Development Study. We applied a growth mixture model to obtain the triple trajectories of alcohol, cigarette, and marijuana use. Logistic regression analyses were then conducted to examine the associations between the triple trajectory groups from mean age 14 to 36 and insomnia at age 36. The estimated prevalence of insomnia is 7.1%. A five-group triple trajectory model was selected: A) Increasing use of all three substances (18%); B) Moderate use of alcohol and marijuana, and high use of cigarette (11%); C) Moderate use of alcohol and cigarette, and experimental use of marijuana (3%); D) Moderate use of all three substances (5%); and E) No or low use of all three substances (63%). Among the five trajectory groups, the increasing use of all three substances group (AOR = 2.71, p-value = .011) was associated with an increased likelihood of having insomnia as compared to the no or low use of all three substances group. Treatment programs to quit or reduce the use of alcohol, cigarette, and marijuana may help decrease the prevalence of insomnia. This could lead to improvements in individualized treatments for patients who have symptoms of insomnia and who also use substances.

OBJECTIVES/OBJECTIVE:To conduct a comprehensive analysis of prospectively measured circulating high sensitivity C reactive protein (hsCRP) concentration and risk of lung cancer overall, by smoking status (never, former, and current smokers), and histological sub-type. DESIGN/METHODS:Nested case-control study. SETTING/METHODS:20 population based cohort studies in Asia, Europe, Australia, and the United States. PARTICIPANTS/METHODS:5299 patients with incident lung cancer, with individually incidence density matched controls. EXPOSURE/METHODS:Circulating hsCRP concentrations in prediagnostic serum or plasma samples. MAIN OUTCOME MEASURE/METHODS:Incident lung cancer diagnosis. RESULTS:A positive association between circulating hsCRP concentration and the risk of lung cancer for current (odds ratio associated with a doubling in hsCRP concentration 1.09, 95% confidence interval 1.05 to 1.13) and former smokers (1.09, 1.04 to 1.14) was observed, but not for never smokers (P<0.01 for interaction). This association was strong and consistent across all histological subtypes, except for adenocarcinoma, which was not strongly associated with hsCRP concentration regardless of smoking status (odds ratio for adenocarcinoma overall 0.97, 95% confidence interval 0.94 to 1.01). The association between circulating hsCRP concentration and the risk of lung cancer was strongest in the first two years of follow-up for former and current smokers. Including hsCRP concentration in a risk model, in addition to smoking based variables, did not improve risk discrimination overall, but slightly improved discrimination for cancers diagnosed in the first two years of follow-up. CONCLUSIONS:Former and current smokers with higher circulating hsCRP concentrations had a higher risk of lung cancer overall. Circulating hsCRP concentration was not associated with the risk of lung adenocarcinoma. Circulating hsCRP concentration could be a prediagnostic marker of lung cancer rather than a causal risk factor.