Faculty Bibliography

Cardiovascular disease deaths are increasing in low- and middle-income countries and are exacerbated by health care systems that are ill-equipped to manage chronic diseases. Global health partnerships, which have stemmed the tide of infectious diseases in low- and middle-income countries, can be similarly applied to address cardiovascular diseases. In this review, we present the experiences of an academic partnership between North American and Kenyan medical centers to improve cardiovascular health in a national public referral hospital. We highlight our stepwise approach to developing sustainable cardiovascular services using the health system strengthening World Health Organization Framework for Action. The building blocks of this framework (leadership and governance, health workforce, health service delivery, health financing, access to essential medicines, and health information system) guided our comprehensive and sustainable approach to delivering subspecialty care in a resource-limited setting. Our experiences may guide the development of similar collaborations in other settings.

Cardiovascular disease (CVD) is the leading cause of death in the world, with a substantial health and economic burden confronted by low- and middle-income countries. In low-income countries such as Kenya, there exists a double burden of communicable and noncommunicable diseases, and the CVD profile includes many nonatherosclerotic entities. Socio-politico-economic realities present challenges to CVD prevention in Kenya, including poverty, low national spending on health, significant out-of-pocket health expenditures, and limited outpatient health insurance. In addition, the health infrastructure is characterized by insufficient human resources for health, medication stock-outs, and lack of facilities and equipment. Within this socio-politico-economic reality, contextually appropriate programs for CVD prevention need to be developed. We describe our experience from western Kenya, where we have engaged the entire care cascade across all levels of the health system, in order to improve access to high-quality, comprehensive, coordinated, and sustainable care for CVD and CVD risk factors. We report on several initiatives: 1) population-wide screening for hypertension and diabetes; 2) engagement of community resources and governance structures; 3) geographic decentralization of care services; 4) task redistribution to more efficiently use of available human resources for health; 5) ensuring a consistent supply of essential medicines; 6) improving physical infrastructure of rural health facilities; 7) developing an integrated health record; and 8) mobile health (mHealth) initiatives to provide clinical decision support and record-keeping functions. Although several challenges remain, there currently exists a critical window of opportunity to establish systems of care and prevention that can alter the trajectory of CVD in low-resource settings.

The effect of years of residence in the US on the weight of adolescents is unclear. We examined the association between generation (i.e. 1st, 1.5, 2nd, and 3rd) and weight indicators among Boston adolescents. Data are from a sample of 1,420 9-12th grade public school students in Boston, Massachusetts. We used self-reported information to calculate generation and weight characteristics (i.e., body mass index (BMI), BMI z-score, overweight status), and ran multivariate analyses to estimate the association between generation and weight characteristics, adjusting for race/ethnicity, gender, age and school. In pooled multivariate models, 1.5 generation, second generation, and third generation youth had significantly higher mean BMI scores and mean BMI z-scores than first generation youth. Second (RR 1.87, 95% CI 1.13-3.12) and third generation youth (RR 2.06, 95% CI 1.21-3.50) were also significantly more likely to be overweight than first generation youth. In multivariate models stratified by sex, this pattern persisted for females only. There is a positive, linear trend in BMI by generation that differs by gender. Mechanisms underlying this association should be addressed.

The goal of this study was to evaluate a novel measure of environmental risk factors for bullying among sexual minority youths. Data on lesbian, gay, bisexual, and transgender (LGBT) assault hate crimes were obtained from police records, geocoded, and then linked to individual-level data on bullying and sexual orientation from the 2008 Boston Youth Survey Geospatial Dataset (N = 1,292; 108 sexual minorities). Results indicated that sexual minority youths who reported relational and electronic bullying were more likely to reside in neighborhoods with higher LGBT assault hate crime rates. There was no asso- ciation between LGBT assault hate crimes and bullying among heterosexual youths, pro- viding evidence for specificity to sexual minority youth. Moreover, no relationships were observed between sexual minority bullying and neighborhood-level violent and property crimes, indicating that the results were specific to LGBT assault hate crimes.

Early life trauma exposure represents a potent risk factor for the development of mental illnesses such as anxiety, depression and post-traumatic stress disorder. Moreover, deleterious consequences of trauma are exacerbated in youth living in impoverished, urban environments. A priori probability maps were used to examine resting-state functional connectivity (FC) of the amygdala in 21 trauma-exposed, and 21 age- and sex-matched urban children and adolescents (youth) without histories of trauma. Intrinsic FC analyses focused on amygdala-medial prefrontal circuitry, a key emotion regulatory pathway in the brain. We discovered reduced negative amygdala-subgenual cingulate connectivity in trauma-exposed youth. Differences between groups were also identified in anterior insula and dorsal anterior cingulate to amygdala connectivity. Overall, results suggest a model in which urban-dwelling trauma-exposed youth lack negative prefrontal to amygdala connectivity that may be critical for regulation of emotional responses. Functional changes in amygdala circuitry might reflect the biological embedding of stress reactivity in early life and mediate enhanced vulnerability to stress-related psychopathology.

Childhood trauma exposure is a potent risk factor for psychopathology. Emerging research suggests that aberrant saliency processing underlies the link between early trauma exposure and later cognitive and socioemotional deficits that are hallmark of several psychiatric disorders. Here, we examine brain and behavioral responses during a face categorization conflict task, and relate these to intrinsic connectivity of the salience network (SN). The results demonstrate a unique pattern of SN dysfunction in youth exposed to trauma (n = 14) relative to comparison youth (n = 19) matched on age, sex, IQ, and sociodemographic risk. We find that trauma-exposed youth are more susceptible to conflict interference and this correlates with higher fronto-insular responses during conflict. Resting-state functional connectivity data collected in the same participants reveal increased connectivity of the insula to SN seed regions that is associated with diminished reward sensitivity, a critical risk/resilience trait following stress. In addition to altered intrinsic connectivity of the SN, we observed altered connectivity between the SN and default mode network (DMN) in trauma-exposed youth. These data uncover network-level disruptions in brain organization following one of the strongest predictors of illness, early life trauma, and demonstrate the relevance of observed neural effects for behavior and specific symptom dimensions. SN dysfunction may serve as a diathesis that contributes to illness and negative outcomes following childhood trauma.