Faculty Bibliography

BACKGROUND:Studies have shown that children with cancer globally lack access to palliative care. Little is known regarding physicians' perceptions of palliative care, treatment access, and self-reported competence in providing palliative care. PROCEDURE/METHODS:Members of the Global Neuroblastoma Network (online tumor board) were surveyed. Eighty-three respondents met inclusion criteria; 53 (64%) completed the survey. RESULTS:Most respondents trained in high-income countries (HIC) but practice in low- and middle-income countries (LMIC), and care for more than five patients with neuroblastoma annually. WHO Essential Medicines in palliative care varied in availability, with incomplete access across LMIC centers. Nonpharmacologic therapies were inconsistently available. Contrary to international definitions, 17% of respondents inappropriately considered palliative care as that initiated only after curative therapy is stopped. Mean physician competence composite score (Likert scale 1-5, 5 = very competent) in providing symptomatic relief and palliative care across phases of care was 2.93 (95% CI 2.71-3.22). Physicians reported significantly greater competence in symptom management during cure-directed therapy than during end-of-life (P = 0.02) or when patients are actively dying (P = 0.007). Practicing in HIC, prior palliative care training, having access to radiotherapy, and not having to turn patients away due to bed shortages were significantly predictive of perceived competence in providing palliative care at end of life. CONCLUSIONS:An international sample identified gaps in treatment and palliative care service availability, in understanding the definition of palliative care, and in self-reported competence in providing palliative care. Increased perceived competence was associated with training, which supports the need for increased palliative care education and advocacy, especially in LMIC.

Suicide is a leading cause of premature mortality. Aspects of the social environment such as incidents of violence in the community may induce psychological distress and affect suicidality, but these determinants are not well understood. We conducted an ecological study using California vital statistics records, geocoded to address of the decedent, to examine whether proximity to homicide was associated with the occurrence of suicide in urban census tracts. For each urban tract (N = 7194) and each month in 2012, we assessed homicides in the tract or within buffer zones around the tract with a 1-month lag. We estimated two risk difference parameters that capture how suicide risk is related to differences in homicide exposure. Proximity to homicides was negatively associated with suicide occurrence after controlling for demographic factors, seasonality, and other confounders. Estimates suggest that the absence of homicides would be associated with a 4.2 % higher number of tract-months with one or more suicides (95 % confidence interval 2.2-6.0). This relationship was stronger in tracts that were wealthier, older, and less civically engaged. Results were robust to a wide variety of sensitivity tests. Contrary to expectations, we identified a consistent negative association of proximity to homicide with suicide occurrence. It may be that a homicide deters or distracts from suicidality or that aggression or hopelessness may be expressed as inward or outward directed violence in different settings. Further investigation is needed to identify the drivers of this association.

Propensity score methods, such as subclassification, are a common approach to control for confounding when estimating causal effects in non-randomized studies. Propensity score subclassification groups individuals into subclasses based on their propensity score values. Effect estimates are obtained within each subclass and then combined by weighting by the proportion of observations in each subclass. Combining subclass-specific estimates by weighting by the inverse variance is a promising alternative approach; a similar strategy is used in meta-analysis for its efficiency. We use simulation to compare performance of each of the two methods while varying (i) the number of subclasses, (ii) extent of propensity score overlap between the treatment and control groups (i.e., positivity), (iii) incorporation of survey weighting, and (iv) presence of heterogeneous treatment effects across subclasses. Both methods perform well in the absence of positivity violations and with a constant treatment effect with weighting by the inverse variance performing slightly better. Weighting by the proportion in subclass performs better in the presence of heterogeneous treatment effects across subclasses. We apply these methods to an illustrative example estimating the effect of living in a disadvantaged neighborhood on risk of past-year anxiety and depressive disorders among U.S. urban adolescents. This example entails practical positivity violations but no evidence of treatment effect heterogeneity. In this case, weighting by the inverse variance when combining across propensity score subclasses results in more efficient estimates that ultimately change inference. Copyright © 2016 John Wiley & Sons, Ltd.

A substitution estimator can be used to predict how shifts in population exposures might change health. We illustrated this method by estimating how an upper limit on alcohol outlet density might alter binge drinking in the New York Social Environment Study (n = 4000), and provided statistical code and sample data. The largest differences in binge drinking were for an upper limit of 70 outlets per square mile; there was a -0.7% difference in binge drinking prevalence for New York City overall (95% confidence interval [CI] = -0.2%, -1.3%) and a -2.4% difference in binge drinking prevalence for the subset of communities the intervention modified (95% CI = -0.5%, -4.0%). A substitution estimator is a flexible tool for estimating population intervention parameters and improving the translation of public health research results to practitioners.

BACKGROUND:Prospective data suggest depressive symptoms worsen insulin resistance and accelerate type 2 diabetes (T2D) onset. PURPOSE:We sought to determine whether reducing depressive symptoms in overweight/obese adolescents at risk for T2D would increase insulin sensitivity and mitigate T2D risk. METHOD:We conducted a parallel-group, randomized controlled trial comparing a 6-week cognitive-behavioral (CB) depression prevention group with a 6-week health education (HE) control group in 119 overweight/obese adolescent girls with mild-to-moderate depressive symptoms (Center for Epidemiological Studies-Depression Scale [CES-D] ≥16) and T2D family history. Primary outcomes were baseline to post-intervention changes in CES-D and whole body insulin sensitivity index (WBISI), derived from 2-h oral glucose tolerance tests. Outcome changes were compared between groups using ANCOVA, adjusting for respective baseline outcome, puberty, race, facilitator, T2D family history degree, baseline age, adiposity, and adiposity change. Multiple imputation was used for missing data. RESULTS:Depressive symptoms decreased (p < 0.001) in CB and HE from baseline to posttreatment, but did not differ between groups (ΔCESD = -12 vs. -11, 95 % CI difference = -4 to +1, p = 0.31). Insulin sensitivity was stable (p > 0.29) in CB and HE (ΔWBISI = 0.1 vs. 0.2, 95 % CI difference = -0.6 to +0.4, p = 0.63). Among all participants, reductions in depressive symptoms were associated with improvements in insulin sensitivity (p = 0.02). CONCLUSIONS:Girls at risk for T2D displayed reduced depressive symptoms following 6 weeks of CB or HE. Decreases in depressive symptoms related to improvements in insulin sensitivity. Longer-term follow-up is needed to determine whether either program causes sustained decreases in depressive symptoms and improvements in insulin sensitivity. TRIAL REGISTRATION NUMBER:The trial was registered with clinicaltrials.gov (NCT01425905).

OBJECTIVE:Interpersonal psychotherapy (IPT) is aimed at improving negative affect that is purported to contribute to the development and maintenance of loss-of-control (LOC) eating. Although youth who report LOC over eating tend to consume more snack-foods than those without LOC, it is unknown if IPT impacts objective energy intake. METHODS:To test if IPT improves mood and eating in the laboratory, we examined a sample of 88 girls with LOC eating who were randomized to either IPT (n = 46) or a standard-of-care health education (HE) group program. At baseline, and 6-month (follow-up 1) and 1-year (follow-up 2) following the initiation of the groups, girls consumed lunch from a multi-item meal with an instruction designed to model a LOC episode. Girls also reported mood state immediately before each meal. RESULTS:Girls in IPT experienced no significant changes in pre-meal state depressive affect, while girls in HE experienced a non-significant improvement by follow-up 1 and then returned to baseline by follow-up 2 (p < .04). We found no significant group difference for changes in total intake relative to girls' daily energy needs (p's ≥ .25). However, IPT reduced, while HE increased, the percentage of daily energy needs consumed from snack-foods by follow-up 2 (p = .04). Within-groups, HE increased their snack food intake from follow-up 1 to follow-up 2 (p = .01). CONCLUSIONS:In adolescent girls with LOC, IPT did not change total intake at the test meal and was associated with reduced snack-food intake. Data are required to determine if IPT effectively prevents excess weight gain in the longer-term. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:490-498).

Obesity is widespread, associated with several physical and psychosocial comorbidities, and is difficult to treat. Prevention of obesity across the lifespan is critical to improving the health of individuals and society. Screening and prevention efforts in primary care are an important step in addressing the obesity epidemic. Each period of human development is associated with unique risks, challenges, and opportunities for prevention and intervention. Screening tools for overweight/obesity, although imperfect, are quick and easy to administer. Screening should be conducted at every primary care visit and tracked longitudinally. Screening tools and cutoffs for overweight and obesity vary by age group.

PURPOSE/OBJECTIVE:Extant research indicates that some of the comorbidities associated with adult obesity may be adversely affected by the stress resulting from negative body image and weight-related stigma. This study examined the association between weight-related pressure and insulin sensitivity in adolescents, who are vulnerable to both weight-based teasing and the onset of metabolic dysregulation. METHODS:Participants were 215 adolescent healthy volunteers (55% female; 59% white; 35% overweight/obese; mean ± standard deviation age = 15.4 ± 1.4 year), who completed a self-report measure of pressure to be thin from parents, friends, and romantic partners. Fasting blood samples were obtained to assess serum insulin and glucose, which were used to calculate insulin sensitivity; fat mass (kg) and fat-free mass (%) were measured with air-displacement plethysmography. Pubertal stage was determined by physical examination. RESULTS:Pressure to be thin was positively associated with fasting insulin (p = .01) and negatively associated with insulin sensitivity (p = .02), after controlling for pubertal stage, sex, race, height, fat-free mass, and adiposity. Pressure to be thin was associated with a greater odds of having hyperinsulinemia (fasting insulin ≥ 15 μIU/mL; odds ratio (95% confidence interval): 1.65 [1.08-2.50], p = .02), adjusting for the same covariates. CONCLUSIONS:Results indicate that adolescents perceiving more pressure to be thin have greater elevations of fasting insulin and poorer insulin sensitivity above and beyond the effect of fat mass. Future research is warranted to elucidate the mechanisms responsible for this relationship.

OBJECTIVES:Short sleep duration and daytime sleepiness have been associated with an increased risk for the onset of type 2 diabetes in adults. There has been far less attention to the characterization of sleep in adolescents at-risk for diabetes or to the possible behavioral mechanisms, such as disinhibited eating, through which sleep may affect metabolic functioning. METHODS:We evaluated the associations of sleep duration and daytime sleepiness with a multi-modal assessment of disinhibited eating in 119 adolescent girls at-risk for type 2 diabetes based upon being overweight/obese and having a family history of diabetes. Girls also endorsed mild-to-moderate depressive symptoms. Adolescents reported sleep duration and daytime sleepiness with the Sleep Habits Survey and Children's Sleep Habits Questionnaire. They were administered a series of successive test meals to measure total energy intake and eating in the absence of hunger (EAH). Adolescent binge eating was assessed with the Eating Disorder Examination interview. RESULTS:Accounting for age, race, puberty, body composition, depressive symptoms, and perceived stress, reported sleep duration was positively related to test meal total energy intake (p=0.04), but not to EAH. Adjusting for the same covariates, daytime sleepiness was associated with a greater odds of objective binge eating in the previous month (p=0.009). CONCLUSIONS:In adolescent girls at-risk for type 2 diabetes, reported sleep characteristics are associated with disinhibited eating behaviors that have been linked to excessive weight and adverse metabolic outcomes. Future studies are called for to evaluate these links using objective measures of sleep.