Faculty Bibliography

BACKGROUND:Polyvictimisation (PV) - exposure to violence across multiple contexts - causes considerable morbidity and mortality among adolescents. Despite high levels of violence in urban disadvantaged settings, gender differences in associations between PV and mental health have not been well established. METHODS:We analysed data from a survey with 2393 adolescents aged 15-19 years, recruited using respondent-driven sampling from urban disadvantaged settings in Baltimore (USA), Delhi (India), Ibadan (Nigeria), Johannesburg (South Africa) and Shanghai (China). PV was defined as exposure to two or more types of violence in the past 12 months with family, peers, in the community, or from intimate partners and non-partner sexual violence. Weighted logistic regression models are presented by gender to evaluate whether PV is associated with posttraumatic stress, depression, suicidal thoughts and perceived health status. RESULTS:PV was extremely common overall, but ranged widely, from 74.5% of boys and 82.0% of girls in Johannesburg, to 25.8 and 23.9% respectively in Shanghai. Community violence was the predominant violence type, affecting 72.8-93.7% across the sites. More than half of girls (53.7%) and 45.9% of boys had at least one adverse mental health outcome. Compared to those that did not report violence, boys exposed to PV had 11.4 higher odds of having a negative perception of health (95%CI adjusted OR = 2.45-53.2), whilst this figure was 2.58 times in girls (95%CI = 1.62-4.12). Among girls, PV was associated with suicidal thoughts (adjusted OR = 4.68; 95%CI = 2.29-9.54), posttraumatic stress (aOR = 4.53; 95%CI = 2.44-8.41) and depression (aOR = 2.65; 95%CI = 1.25-5.63). Among boys, an association was only detected between PV and depression (aOR = 1.82; 95%CI = 1.00-3.33). CONCLUSION:The findings demonstrate that PV is common among both sexes in urban disadvantaged settings across the world, and that it is associated with poor mental health outcomes in girls, and with poor health status in both girls and boys. Clearly, prevention interventions are failing to address violence exposure across multiple contexts, but especially within community settings and in Johannesburg. Interventions are needed to identify adolescents exposed to PV and link them to care, with services targeting a range of mental health conditions among girls and perhaps focusing on depression among boys.

The Dementia with Lewy Bodies (DLB) Consortium has refined its recommendations about the clinical and pathologic diagnosis of DLB, updating the previous report, which has been in widespread use for the last decade. The revised DLB consensus criteria now distinguish clearly between clinical features and diagnostic biomarkers, and give guidance about optimal methods to establish and interpret these. Substantial new information has been incorporated about previously reported aspects of DLB, with increased diagnostic weighting given to REM sleep behavior disorder and 123iodine-metaiodobenzylguanidine (MIBG) myocardial scintigraphy. The diagnostic role of other neuroimaging, electrophysiologic, and laboratory investigations is also described. Minor modifications to pathologic methods and criteria are recommended to take account of Alzheimer disease neuropathologic change, to add previously omitted Lewy-related pathology categories, and to include assessments for substantia nigra neuronal loss. Recommendations about clinical management are largely based upon expert opinion since randomized controlled trials in DLB are few. Substantial progress has been made since the previous report in the detection and recognition of DLB as a common and important clinical disorder. During that period it has been incorporated into DSM-5, as major neurocognitive disorder with Lewy bodies. There remains a pressing need to understand the underlying neurobiology and pathophysiology of DLB, to develop and deliver clinical trials with both symptomatic and disease-modifying agents, and to help patients and carers worldwide to inform themselves about the disease, its prognosis, best available treatments, ongoing research, and how to get adequate support.

Geosocial-networking smartphone applications represent an increasingly common virtual context in which men who have sex with men (MSM) meet one another. The purpose of the current study is to describe levels of involvement with the mainstream gay community among a sample of MSM in Atlanta who use apps (n = 92) and assess their associations with condomless anal intercourse. Among the sample, 53.3% agreed that they felt distant from the gay community and 72.8% reported going to a gay bar/club once a month or less. No associations between involvement with the gay community and condomless anal intercourse were observed.

Context: Common environmental contaminants can disrupt normal thyroid function, which plays essential but varying roles at different ages. Objective: To evaluate the relationship of perchlorate, thiocyanate, and nitrate, three sodium-iodide symporter (NIS) inhibitors, and thyroid function in different age-sex-stratified populations. Design, Setting, Participants, and Intervention: This was a cross-sectional analysis of data from the 2009-2012 National Health and Nutrition Examination Surveys (NHANES) evaluating the exposure to perchlorate, thiocyanate, and nitrate in 3,151 participants aged 12-80. Main Outcome Measure: Blood serum free thyroxine (FT4) as both a continuous and categorical variable. We also assessed blood serum thyroid stimulating hormone (TSH). Results: Controlling for serum cotinine, BMI, total daily energy consumption, race/ethnicity, and poverty-to-income ratio, for each log unit increase in perchlorate, FT4 decreased by 0.03 ng/dL in both the general population (p=0.004) and in all women (p=0.005), and by 0.06 ng/dL in adolescent girls (p=0.029), corresponding to 4% and 8% decreases relative to median FT4, respectively. For each log unit increase thiocyanate, FT4 decreased by 0.07 ng/dL in adolescent boys (p=0.003), corresponding to a 9% decrease relative to median FT4, respectively. Conclusions: Our results indicate that adolescent boys and girls represent vulnerable subpopulations to the thyroid-blocking effects of NIS symporter inhibitors. These results suggest a valuable screening and intervention opportunity.

OBJECTIVE: This study compared health care access, utilization, and functional indicators among adults with and without serious psychological distress (SPD) in the years surrounding implementation of the Patient Portable and Affordable Care Act (ACA). METHODS: Adults ages 18 to 64 from the 2006-2014 National Health Interview Survey (N=207, 853) were examined on 11 access, utilization, and functional indicators: health insurance coverage (health coverage), insufficient money for medications, delay in health care (delay in care), insufficient money for health care, visiting a doctor ten or more times in the past 12 months, change in place of health care, change in place of health care due to insurance, limitations in ability to work, limitations in activities of daily living (ADLs), insufficient money for mental health care, and having seen a mental health care provider. RESULTS: Multivariate models that were adjusted for health coverage and sociodemographic characteristics indicated that compared with adults without SPD, adults with SPD had greater odds of lacking money for medications (AOR=10.0) and health care (AOR=3.1), experiencing delays in care (AOR=2.7), visiting a doctor ten or more times in the past 12 months (AOR=3.2), changing usual place of health care (AOR=1.5), changing usual place of health care because of insurance (AOR=1.5), and experiencing limitations in ADLs (AOR=3.6) and ability to work (AOR=1.8). The proportions of adults with SPD who lacked health coverage and money to buy prescriptions increased during the study period. Although this trend reversed in 2014, the proportion with SPD experiencing barriers remained above 2006 levels. CONCLUSIONS: Health care patterns among adults with SPD require greater attention.

Importance: While statin therapy for primary cardiovascular prevention has been associated with reductions in cardiovascular morbidity, the effect on all-cause mortality has been variable. There is little evidence to guide the use of statins for primary prevention in adults 75 years and older. Objectives: To examine statin treatment among adults aged 65 to 74 years and 75 years and older when used for primary prevention in the Lipid-Lowering Trial (LLT) component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT). Design, Setting, and Participants: Post hoc secondary data analyses were conducted of participants 65 years and older without evidence of atherosclerotic cardiovascular disease; 2867 ambulatory adults with hypertension and without baseline atherosclerotic cardiovascular disease were included. The ALLHAT-LLT was conducted from February 1994 to March 2002 at 513 clinical sites. Interventions: Pravastatin sodium (40 mg/d) vs usual care (UC). Main Outcomes and Measures: The primary outcome in the ALLHAT-LLT was all-cause mortality. Secondary outcomes included cause-specific mortality and nonfatal myocardial infarction or fatal coronary heart disease combined (coronary heart disease events). Results: There were 1467 participants (mean [SD] age, 71.3 [5.2] years) in the pravastatin group (48.0% [n = 704] female) and 1400 participants (mean [SD] age, 71.2 [5.2] years) in the UC group (50.8% [n = 711] female). The baseline mean (SD) low-density lipoprotein cholesterol levels were 147.7 (19.8) mg/dL in the pravastatin group and 147.6 (19.4) mg/dL in the UC group; by year 6, the mean (SD) low-density lipoprotein cholesterol levels were 109.1 (35.4) mg/dL in the pravastatin group and 128.8 (27.5) mg/dL in the UC group. At year 6, of the participants assigned to pravastatin, 42 of 253 (16.6%) were not taking any statin; 71.0% in the UC group were not taking any statin. The hazard ratios for all-cause mortality in the pravastatin group vs the UC group were 1.18 (95% CI, 0.97-1.42; P = .09) for all adults 65 years and older, 1.08 (95% CI, 0.85-1.37; P = .55) for adults aged 65 to 74 years, and 1.34 (95% CI, 0.98-1.84; P = .07) for adults 75 years and older. Coronary heart disease event rates were not significantly different among the groups. In multivariable regression, the results remained nonsignificant, and there was no significant interaction between treatment group and age. Conclusions and Relevance: No benefit was found when pravastatin was given for primary prevention to older adults with moderate hyperlipidemia and hypertension, and a nonsignificant direction toward increased all-cause mortality with pravastatin was observed among adults 75 years and older. Trial Registration: clinicaltrials.gov Identifier: NCT00000542.

OBJECTIVES: We assessed the odds of having a family dinner by parental gender, family structure and parental employment. METHODS: This study used data from the American Time Use Survey (ATUS) (2006-2008). Multivariate analyses assessed the odds of two outcomes among parents: 1) eating at all with children and 2) having a family dinner. RESULTS: Single men had lower odds of eating at all with children and eating a family dinner in comparison to partnered/married males. Partnered/married women had increased odds of eating at all with children and eating a family dinner compared to their partnered/married male counterparts. While single women had increased odds of eating at all with children compared to partnered/married males, no difference was detected in the odds of having a family dinner. Among dual-headed households, women had lower odds of eating a family dinner when both parents were employed compared a dual-headed household with employed male/non-employed female. There were no differences among men regardless of their employment status or that of their partner/spouse. CONCLUSIONS: Family structure, parental gender and employment status all influence the odds of having a family dinner. Future research on family meals should consider all of these factors to better understand trends and disparities across household compositions.

INTRODUCTION: Prenatal smoking exposure may lead to permanent changes in neonatal inflammation and immune response that have lifelong implications, including increased risks for atopy and respiratory disorders. METHODS: The effect of maternal smoking on neonatal biomarkers of inflammation and immune response was assessed among 3459 singletons and twins in the Upstate KIDS Study. The following inflammatory biomarkers were measured using newborn dried blood spots (DBSs): interleukin (IL)-1alpha, IL-1 receptor antagonist, IL-6, IL-8, C-reactive protein, and tumor necrosis factor alpha. Immunoglobulins (IgE, IgA, IgM, and IgG subclasses) were also assessed. We used generalized estimating equations to calculate mean differences (beta) in biomarker levels by timing of pregnancy smoking, cigarette load, and secondhand smoke exposure after adjusting for sociodemographic and lifestyle factors including maternal body mass index. RESULTS: Of the 344 (12%) women reporting smoking during pregnancy, about 40% continued throughout pregnancy and 13% reported smoking more than 1 pack per day. After covariate adjustment and Bonferroni correction for multiple comparisons, maternal smoking throughout pregnancy remained significantly associated with increased levels of IL-8 (beta = 0.20, 95% confidence interval: 0.07, 0.32; p < .003). No significant associations were found with cigarette load or secondhand smoke exposure. Higher IgG3 levels were also associated with maternal smoking throughout pregnancy, although the association became nominally significant after adjustment for covariates (beta = 0.09; 95% confidence interval: 0.0007, 0.17; p < .05). CONCLUSIONS: Maternal smoking throughout pregnancy was independently associated with increased IL-8 levels in newborns. Importantly, neonates of women who stopped smoking anytime in pregnancy did not have increased IL-8 levels. IMPLICATIONS: This study evaluated a range of inflammatory biomarkers and immunoglobulins in association with maternal smoking and timing/duration of smoking along with secondhand smoke exposure. By using DBSs, we present data from a large cohort of children born in Upstate New York. Our findings suggest that early differences in immunoregulation of neonates exposed to maternal smoking for full duration in utero may already be detected at birth.

OBJECTIVE: Given the prevalence of mental health (MH) conditions (MHC) in children, pediatricians should initiate treatment alone or in collaboration with a specialist for children with MHC. However, the majority of pediatricians do not manage or comanage common MHC even with an on-site MH provider. We examined which physician, practice, and training characteristics are associated with pediatricians' comanaging at least half of their patients with MHC. METHODS: We analyzed responses of general pediatricians (n = 305) from the American Academy of Pediatrics 2013 Periodic Survey. Practice characteristics include presence of an on-site MH provider and perceived access to services. Independent variables included sociodemographics, training experiences, and interest in further training. The outcome was comanagement of >/=50% of patients with MHC. Weighted univariate, bivariate, and multivariable analyses were performed. RESULTS: Of the pediatricians who reported comanaging >/=50% of their patients with MHC, logistic regression analysis showed that pediatricians who completed >/=4 weeks of developmental behavioral pediatrics training had 1.8 increased odds (95% confidence interval 1.06, 3.08, P = .03) of comanagement, those very interested in further education in managing/treating MHC had 2.75 increased odds (95% confidence interval 1.63, 3.08, P < .001), and those with more training in MH treatment with medications had 1.4 increased odds (95% confidence interval 1.12, 1.75, P = .004) of comanaging children with MHC. CONCLUSIONS: Specific educational experiences and interest in further education in managing or treating MHC were significantly associated with comanaging >/=50% of patients, suggesting that enhanced MH training among pediatricians could increase the comanagement of children with MHC.