Faculty Bibliography

BACKGROUND: The global economic crisis has been associated with increased unemployment, reduced health-care spending and adverse health outcomes. Insights into the impact of economic variations on cancer mortality, however, remain limited. METHODS: We used multivariate regression analysis to assess how changes in unemployment and public-sector expenditure on health care (PSEH) varied with female breast cancer mortality in the 27 European Union member states from 1990 to 2009. We then determined how the association with unemployment was modified by PSEH. Country-specific differences in infrastructure and demographic structure were controlled for, and 1-, 3-, 5- and 10-year lag analyses were conducted. Several robustness checks were also implemented. RESULTS: Unemployment was associated with an increase in breast cancer mortality [P < 0.0001, coefficient (R) = 0.1829, 95% confidence interval (CI) 0.0978-0.2680]. Lag analysis showed a continued increase in breast cancer mortality at 1, 3, 5 and 10 years after unemployment rises (P < 0.05). Controlling for PSEH removed this association (P = 0.063, R = 0.080, 95% CI -0.004 to 0.163). PSEH increases were associated with significant decreases in breast cancer mortality (P < 0.0001, R = -1.28, 95% CI -1.67 to -0.877). The association between unemployment and breast cancer mortality remained in all robustness checks. CONCLUSION: Rises in unemployment are associated with significant short- and long-term increases in breast cancer mortality, while increases in PSEH are associated with reductions in breast cancer mortality. Initiatives that bolster employment and maintain total health-care expenditure may help minimize increases in breast cancer mortality during economic crises.

The relation of self-regulation measured prior to school entry to developing math and reading ability in prekindergarten through the second grade was examined in a prospective longitudinal sample of 1,292 children and families in predominantly rural and low-income communities in 2 regions of high poverty in the United States. Direct assessments of executive function, effortful control, and stress response physiology (indexed by resting levels of cortisol and alpha amylase obtained from saliva) were measured at child age 48 months and parents and teachers reported on children's effortful control using temperament rating scales at child age approximately 60 months. Math and reading ability, as measured by the Woodcock-Johnson III applied problems and letter-word subtests, respectively, were measured at prekindergarten through the second grade. Effects for self-regulation measures were seen primarily for initial level and to some extent growth in both mathematics and reading, even when controlling for family demographic characteristics that represent relevant selection factors into higher levels of both self-regulation and academic achievement. These effects persisted for mathematics but not for reading with the inclusion of child cognitive abilities, vocabulary, and speed of processing measured in prekindergarten, concurrent with the first time point for the academic measures. Results are interpreted as indicating a role for self-regulation in learning ability generally, likely through support for attention and reasoning abilities that are most specific to the assessment of mathematics in this analysis. Implications for instruction and for assessment and the best ways to support the development of early math and reading ability for children at risk for school failure are discussed.

PURPOSE: Sports-related concussion has received increasing attention as a result of neurologic sequelae seen among athletes, highlighting the need for a validated, rapid screening tool. The King-Devick (K-D) test requires vision, eye movements, language function and attention in order to perform and has been proposed as a promising tool for assessment of concussion. We investigated the K-D test as a sideline screening tool in a collegiate cohort to determine the effect of concussion. METHODS: Athletes (n=127, mean age 19.6+/-1.2 years) from the Wheaton College football and men's and women's basketball teams underwent baseline K-D testing at pre-season physicals for the 2012-2013 season. K-D testing was administered immediately on the sidelines for football players with suspected head injury during regular games and changes compared to baseline were determined. Post-season testing was also performed to compare non-concussed athletes' test performance. RESULTS: Concussed athletes (n=11) displayed sideline K-D scores that were significantly higher (worse) than baseline (36.5+/-5.6s vs. 31.3+/-4.5s, p<0.005, Wilcoxon signed-rank test). Post-season testing demonstrated improvement of scores and was consistent with known learning effects (35.1+/-5.2s vs. 34.4+/-5.0s, p<0.05, Wilcoxon signed-rank test). Test-retest reliability was analyzed between baseline and post-season administrations of the K-D test resulting in high levels of test-retest reliability (intraclass correlation coefficient (ICC)=0.95 [95% Confidence Interval 0.85-1.05]). CONCLUSIONS: The data show worsening of K-D test scores following concussion further supporting utility of the K-D test as an objective, reliable and effective sideline visual screening tool to help identify athletes with concussion.

Background: Despite evidence of CV benefit of modest BP control in older patients, it is unclear when overly-aggressive treatment results in risk of fall injury that exceeds the CV benefits. Methods: Design: Longitudinal observation Sample: 5518 participants in the biennial Health and Retirement Study, age >65, with self-reported hypertension and taking BP medications, and who had BP measured by an enhanced HRS exam in 2008 or 2010 (randomly-assigned, mutually-exclusive cohorts). Measures: 2-year self-reported fall injury requiring medical care or acute CV event (stroke, infarction, heart failure), as a multinomial outcome: CV or fall injury, CV only, fall only, neither event. Increasing SBP control was tested in categories: (1) untreated or (2) inadequately- treated SBP >160 mmHg; (3) adequate treatment 121-159 mmHg, (3) overly-aggressive treatment to <120 mmHg. Analysis: Multinomial logistic regression to calculate net changes in risk across categories of BP control, controlling for age and sex. Results: Fall injury (12%) increased with age and was more prevalent than CV event (5%). Net harm of overly-controlling BP to <120 mmHg (compared to adequate control) was significant after age 73 (fig). Conclusions: Aggressiveness of BP care should be individualized by patient to steer clear of net harm, especially for older adults at advanced ages. (Figure Presented)

BACKGROUND: Treating systolic blood pressure (BP) of 150 mmHg with multiple medications prevents cardiovascular events and death. However, modest antihypertensive medication use is associated with an increase in fall injury risk. It is unclear whether the harms outweigh the benefits, and whether the net effects vary by degree of BP control. We aimed to quantify the net effect of increasingly aggressive hypertension control (AHC) on cardiovascular benefit versus fall-related harm in a nationally-representative sample. METHODS: Longitudinal study of 5518 participants of the Health and Retirement Study (HRS) aged 65 or older with self-reported hypertension and taking BP medications, and who had BP measured at baseline by an enhanced HRS exam in 2008 or 2010 (two randomly-assigned, mutually exclusive cohorts). The sample was categorized by increasing AHC: (1) untreated SBP >160 mmHg, (2) poorly controlled and treated SBP >160 mmHg, (3) adequate control, defined as treated SBP 121-159 mmHg or untreated SBP 140-159 mmHg, and (4) overly aggressive SBP treated to <120 mmHg. The 120 and 160mmHg cutoffs ensured that the over-and under-control groups were truly different from 140 mmHg. We determined the effect of AHC over a 2-year follow-up (2008-10 or 2010-12) on incidence of self-reported fall injury requiring medical care, acute stroke, myocardial infarction, and acute heart failure. We used multinomial logistic regression to consider fall injury only, any cardiovascular (CV) outcome, and both fall and CV outcome (compared to neither outcome), controlling for age at baseline and sex, to calculate net absolute changes in risk across increasing levels of AHC. We considered AHC classes first as a numeric predictor (where greater=more aggressive) and second as a categorical predictor. We calculated net effect of increasing AHC from one category to the next higher category, in units of absolute percentage points, with bootstrapped confidence intervals (95 %) around the net effect to determine statistical difference from zero. RESULTS: Two-year incidence of fall injury (11 % overall) increased with age and was more prevalent than any CV event (5% overall). Most of the sample (n=3676, 66 %) was classified in group 3 (BP 120-160 mmHg). Group 4, the over controlled group with BP< 120 mmHg, included n=1037 (19 %). The poorly controlled groups 1 and 2 were small (n=223 [4 %] and n=582 [11 %], respectively). When we considered AHC as a continuous predictor (greater=more aggressive), per level of AHC increased risk of fall injury (RR 1.15 [95 % CI 1.0-1.3]), but not cardiovascular events (RR=1.08 [.81- 1.44]) or both (RR=1.33 [.94-.1.9). When net harm was considered across advancing age, net harm was associated with group 4 (<120 mmHg) compared to group 3 (BP 120-160mmHg). The net harm associated with overly-treated BP ranged from2 absolute %-points at age 65, increasing to 10 absolute %-points at age 85, with net harm statistically different from zero above the age of 73 (Figure), mostly due to fall injury. There were no differences in net benefit or harm between group 3 (120-160 mmHg) compared to the poorly-controlled groups (1 and 2). CONCLUSIONS: Aggressiveness of BP control should be individualized by patient to steer clear of net harm, especially for older adults at advanced ages. Those with overly-controlled BP and at risk of net harm should be considered for de-escalation. (Figure Presented)

Emerging data indicate that adults with binge eating may exhibit an attentional bias toward highly palatable foods, which may promote obesogenic eating patterns and excess weight gain. However, it is unknown to what extent youth with loss of control (LOC) eating display a similar bias. We therefore studied 76 youth (14.5 ± 2.3 years; 86.8% female; BMI-z 1.7 ± .73) with (n = 47) and without (n = 29) reported LOC eating. Following a breakfast to reduce hunger, youth participated in a computerized visual probe task of sustained attention that assessed reaction time to pairs of pictures consisting of high palatable foods, low palatable foods, and neutral household objects. Although sustained attentional bias did not differ by LOC eating presence and was unrelated to body weight, a two-way interaction between BMI-z and LOC eating was observed (p = .01), such that only among youth with LOC eating, attentional bias toward high palatable foods versus neutral objects was positively associated with BMI-z. These findings suggest that LOC eating and body weight interact in their association with attentional bias to highly palatable foods cues, and may partially explain the mixed literature linking attentional bias to food cues with excess body weight.