Dayna A. Johnson

Association of depressive symptoms with inflammatory biomarkers among pregnant African-American women.

Depression and inflammation are associated with poorer birth outcomes. African-American women have higher levels of inflammatory biomarkers, more depressive symptoms, and a disparate burden of poorer birth outcomes, but the association between depressive symptoms and inflammation within this higher-risk group is unknown. We examined this association among African-American women in the second trimester of pregnancy and additionally tested whether body mass index (BMI) mediates or moderates this relationship. We recruited 187 women from the obstetrics clinics of a large urban health system. Depression symptoms were measured with the Center for Epidemiological Studies Depression (CES-D) scale and inflammatory biomarkers (high-sensitivity C-reactive protein [hs-CRP], interleukin [IL]-6, IL-10, IL-1β, and tumor necrosis factor-α [TNF-α]) with enzyme immunoassays. Multivariate regression models were fitted to determine the association between CES-D score and each inflammatory biomarker. CES-D was not associated with hs-CRP or TNF-α. CES-D was directly associated with IL-1β (P=0.03). BMI moderated the relationship between CES-D and IL-6 (P<0.01) and IL-10 (P=0.04); in leaner women, depressive symptoms were associated with higher IL-6 and IL-10 levels, whereas in heavier women, depressive symptoms were associated with lower IL-10 levels. BMI did not mediate the relationship between CES-D and inflammation. We conclude that depressive symptoms are associated with increased inflammation among pregnant African-American women. Future studies are needed to examine if depression, mediated through inflammation, increases the risk of adverse pregnancy outcomes in African-American women.

Vitamin D Nutritional Status and Antenatal Depressive Symptoms in African American Women

BACKGROUND Vitamin D deficiency is associated with depression; however, no studies have examined the relationship of vitamin D and antenatal depression. Antenatal depression increases the risk of adverse birth outcomes and poorer postpartum maternal and infant health. African American women are at increased risk for vitamin D deficiency and antenatal depression. Thus, we examined if early pregnancy vitamin D nutrition (VDN) was associated with antenatal depressive symptoms among African American women in the second trimester of pregnancy. METHODS Women (n=178) were recruited from obstetrics clinics of a large health system. VDN was assessed by serum 25-hydroxyvitamin D (25-OHD). Depression symptoms were measured with the Center for Epidemiological Studies Depression (CES-D) scale; CES-D≥16 equates with criteria for clinical depression. Logistic regression was used to examine the association of log-transformed 25-OHD and elevated depression symptoms (CES-D≥16). RESULTS Mean 25-OHD was 13.4±8.4 ng/mL; most women (82.6%, n=147) were vitamin D inadequate or deficient (25-OHD<20 ng/mL). Mean CES-D was 15.2±10.7, and 74 (41.6%) women had a CES-D≥16, suggestive of clinical depression. A significant inverse relationship was found between log (25-OHD) and CES-D≥16 (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.29-0.99, p=0.046). For every 1-unit increase in log (25-OHD) (corresponding to ~2.72 ng/mL increase in 25-OHD), the odds of CES-D≥16 decreased by 46%. CONCLUSIONS African American women with lower VDN exhibit increased depressive symptoms. Research on vitamin D supplementation for reducing antenatal depressive symptoms is needed.

Factors Associated With Nonresponse to a Computer-Tailored Asthma Management Program for Urban Adolescents With Asthma

Background. The ability to identify potentially resistant participants early in the course of an intervention could inform development of strategies for behavior change and improve program effectiveness. Objective. The objective of this analysis was to identify factors related to nonresponse (i.e., lack of behavior change) to an asthma management intervention for urban teenagers. The intervention targeted several behaviors, including medication adherence, having a rescue inhaler nearby, and smoking. Methods. A discriminate analysis was conducted using data from a randomized trial of the intervention. Included in this analysis are participants who reported a physician diagnosis of asthma, completed a baseline questionnaire, were randomized to the treatment group, completed ≥2 of 4 educational sessions, and completed ≥2 of 3 follow-up questionnaires. Ninety students met criteria for inclusion in this subgroup analysis. Results. In logistic regression models for medication adherence, nonresponse was related to low baseline asthma self-regulation, odds ratio = 3.6 (95% confidence interval = 1.3–9.5). In models for having an inhaler nearby, nonresponse was related to low baseline self-regulation and to rebelliousness, OR = 4.7 (1.6–13.2) and 5.6 (1.7–18.0), respectively. Nonresponse to smoking messages was related to rebelliousness, low emotional support, and low religiosity, ORs = 7.6 (1.8–32.3), 9.5 (1.4–63.5), and 6.6 (1.5–29.8) respectively. Conclusions. Certain variables had the ability to discriminate the likelihood of response from that of nonresponse to an asthma program for urban, African American adolescents with asthma. These variables can be used to identify resistant subgroups early in the intervention, allowing the application of specialized strategies through tailoring. These types of analyses can inform behavioral interventions.

Identification of Patients With Nonmelanoma Skin Cancer Using Health Maintenance Organization Claims Data

Cancer registries usually exclude nonmelanoma skin cancers (NMSC), despite the large population affected. Health maintenance organization (HMO) and health system administrative databases could be used as sampling frames for ascertaining NMSC. NMSC patients diagnosed between January 1, 1988, and December 31, 2007, from such defined US populations were identified by using 3 algorithms: NMSC International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, NMSC treatment Current Procedural Terminology (CPT) codes, or both codes. A subset of charts was reviewed to verify NMSC diagnosis, including all records from HMO-enrollee members in 2007. Positive predictive values for NMSC ascertainment were calculated. Analyses of data from 1988-2007 ascertained 11,742 NMSC patients. A random sample of 965 cases was selected for chart review, and NMSCs were validated in 47.0% of ICD-9-CM-identified patients, 73.4% of CPT-identified patients, and 94.9% identified with both codes. All charts from HMO-health plan enrollees in 2007 were reviewed (n = 1,116). Cases of NMSC were confirmed in 96.5% of ICD-9-CM-identified patients, 98.3% of CPT-identified patients, and 98.7% identified with both codes. HMO administrative data can be used to ascertain NMSC with high positive predictive values with either ICD-9-CM or CPT code, but both codes may be necessary among non-HMO patient populations.

The association of neighborhood characteristics with sleep duration and daytime sleepiness

BACKGROUND Neighborhood characteristics have been linked to health outcomes. Various mechanisms link neighborhoods and health outcomes; sleep patterns may be 1 contributor; however, little is known about the social determinants of disordered sleep. We examined the association of neighborhood characteristics with sleep duration and daytime sleepiness. METHODS Participants (n = 801) enrolled as pairs (55 without pair), from 10 churches in the Stroke Health and Risk Education project; 760 were included for analysis (41 withdrew). Sleep duration (hours of sleep at night) and daytime sleepiness (adaptation of Berlin questionnaire; range, 0-3 [more daytime sleepiness]) were self-reported. Neighborhood characteristics included disadvantage, per capita violent crime (census tract level), and safety (self-reported and individual level). We fit generalized linear mixed models and multinomial and binomial logistic regression models to examine the associations between neighborhood characteristics and sleep outcomes while accounting for the clustering within churches and pairs, before and after adjustment for self-reported confounders (age, gender, income, education, body mass index, depressive symptoms, hypertension, and diabetes). RESULTS The mean hours of sleep duration is 6.7 ± 1.2, and the mean daytime sleepiness is 0.8 ± 0.9. Neighborhood characteristics were not associated with sleep duration. Higher perceived neighborhood safety was associated with an 18.4% lower odds of daytime sleepiness in the unadjusted model (odds ratio, 0.82 [95% confidence interval, 0.69-0.96]). The association was attenuated in the fully adjusted model. Neighborhood disadvantage and violent crime were related to lower daytime sleepiness; however, associations were not statistically significant. CONCLUSION Self-reported neighborhood safety was associated with lower daytime sleepiness. Future exploration of the pathways linking neighborhood characteristics and sleep is warranted.

The Social Patterning of Sleep in African Americans: Associations of Socioeconomic Position and Neighborhood Characteristics with Sleep in the Jackson Heart Study.

STUDY OBJECTIVES We investigated cross-sectional associations of individual-level socioeconomic position (SEP) and neighborhood characteristics (social cohesion, violence, problems, disadvantage) with sleep duration and sleep quality in 5,301 African Americans in the Jackson Heart Study. METHODS All measures were self-reported. Sleep duration was assessed as hours of sleep; sleep quality was reported as poor (1) to excellent (5). SEP was measured by categorized years of education and income. Multinomial logistic and linear regression models were fit to examine the associations of SEP and neighborhood characteristics (modeled dichotomously and tertiles) with sleep duration (short vs. normal, long vs. normal) and continuous sleep duration and quality after adjustment for demographics and risk factors. RESULTS The mean sleep duration was 6.4 ± 1.5 hours, 54% had a short (≤ 6 h) sleep duration, 5% reported long (≥ 9 h) sleep duration, and 24% reported fair to poor sleep quality. Lower education was associated with greater odds of long sleep (odds ratio [OR] = 2.19, 95% confidence interval [CI] = 1.42, 3.38) and poorer sleep quality (β = -0.17, 95% CI = -0.27, -0.07) compared to higher education after adjustment for demographics and risk factors. Findings were similar for income. High neighborhood violence was associated with shorter sleep duration (-9.82 minutes, 95% CI = -16.98, -2.66) and poorer sleep quality (β = -0.11, 95% CI = -0.20, 0.00) after adjustment for demographics and risk factors. Results were similar for neighborhood problems. In secondary analyses adjusted for depressive symptoms in a subset of participants, most associations were attenuated and only associations of low SEP with higher odds of long sleep and higher neighborhood violence with poorer sleep quality remained statistically significant. CONCLUSIONS Social and environmental characteristics are associated with sleep duration and quality in African Americans. Depressive symptoms may explain at least part of this association.

Greater Cognitive Deficits with Sleep-disordered Breathing among Individuals with Genetic Susceptibility to Alzheimer Disease. The Multi-Ethnic Study of Atherosclerosis

Rationale: There are conflicting findings regarding the link between sleep apnea and cognitive dysfunction. Objectives: Investigate associations between indicators of sleep‐disordered breathing (SDB) and cognitive function in the Multi‐Ethnic Study of Atherosclerosis and assess effect modification by the apolipoprotein &egr;‐4 (APOE‐&egr;4) allele. Methods: A diverse population (N = 1,752) underwent type 2 in‐home polysomnography, which included measurement of percentage sleep time less than 90% oxyhemoglobin saturation (%Sat < 90%) and apnea‐hypopnea index (AHI). Epworth Sleepiness Scale score (ESS) and sleep apnea syndrome (SAS; AHI ≥ 5 and ESS > 10) were also analyzed. Cognitive outcomes included the Cognitive Abilities Screening Instrument; Digit Symbol Coding (DSC) test; and Digit Span Tests (DST) Forward and Backward. Results: Participants were 45.4% men, aged 68.1 years (SD, 9.1 yr) with a median AHI of 9.0 and mean ESS of 6.0. Approximately 9.7% had SAS, and 26.8% had at least one copy of the APOE‐&egr;4 allele. In adjusted analyses, a 1‐SD increase in %Sat < 90% and ESS score were associated with a poorer attention and memory assessed by the DST Forward score (&bgr; = ‐0.12 [SE, 0.06] and &bgr; = ‐0.13 [SE, 0.06], respectively; P ≤ 0.05). SAS and higher ESS scores were also associated with poorer attention and processing speed as measured by the DSC (&bgr; = ‐0.69 [SE, 0.35] and &bgr; = ‐1.42 [SE, 0.35], respectively; P < 0.05). The presence of APOE‐&egr;4 allele modified the associations of %Sat < 90% with DST forward and of ESS with DSC (Pinteraction ≤ 0.05). Conclusions: Overnight hypoxemia and sleepiness were associated with cognition. The average effect estimates were small, similar to effect estimates for several other individual dementia risk factors. Associations were strongest in APOE‐&egr;4 risk allele carriers. Our results (1) suggest that SDB be considered among a group of modifiable dementia risk factors, and (2) highlight the potential vulnerability of APOE‐&egr;4 risk allele carriers with SDB.

Comparison of early-, late-, and non-participants in a school-based asthma management program for urban high school students

BackgroundTo assess bias and generalizability of results in randomized controlled trials (RCT), investigators compare participants to non-participants or early- to late-participants. Comparisons can also inform the recruitment approach, especially when working with challenging populations, such as urban adolescents. In this paper, we describe characteristics by participant status of urban teens eligible to participate in a RCT of a school-based, web-based asthma management program.MethodsThe denominator for this analysis was all students found to be eligible to participate in the RCT. Data were analyzed for participants and non-participants of the RCT, as well as for students that enrolled during the initially scheduled recruitment period (early-participants) and persons that delayed enrollment until the following fall when recruitment was re-opened to increase sample size (late-participants). Full Time Equivalents (FTEs) of staff associated with recruitment were estimated.ResultsOf 1668 teens eligible for the RCT, 386 enrolled early, and 36 enrolled late, leaving 1246 non-participants. Participants were younger (p < 0.01), more likely to be diagnosed, use asthma medication, and have moderate-to-severe disease than non-participants, odds ratios (95% Confidence Intervals) = 2.1(1.7-2.8), 1.7(1.3-2.1), 1.4(1.0-1.8), respectively. ORs were elevated for the association of late-participation with Medicaid enrollment, 1.9(0.7-5.1) and extrinsic motivation to enroll, 1.7(0.6-5.0). Late-participation was inversely related to study compliance for teens and caregivers, ORs ranging from 0.1 to 0.3 (all p-values < 0.01). Early- and late-participants required 0.45 FTEs/100 and 3.3 FTEs/100, respectively.ConclusionsRecruitment messages attracted youth with moderate-to-severe asthma, but extending enrollment was costly, resulting in potentially less motivated, and certainly less compliant, participants. Investigators must balance internal versus external validity in the decision to extend recruitment. Gains in sample size and external validity may be offset by the cost of additional staff time and the threat to internal validity caused by lower participant follow-up.Trial RegistrationClinicalTrials.gov: NCT00201058

Influence of neighbourhood-level crowding on sleep-disordered breathing severity: mediation by body size

Neighbourhood‐level crowding, a measure of the percentage of households with more than one person per room, may impact the severity of sleep‐disordered breathing. This study examined the association of neighbourhood‐level crowding with apnoea–hypopnoea index in a large clinical sample of diverse adults with sleep‐disordered breathing. Sleep‐disordered breathing severity was quantified as the apnoea–hypopnoea index calculated from overnight polysomnogram; analyses were restricted to those with apnoea–hypopnoea index ≥5. Neighbourhood‐level crowding was defined using 2000 US Census tract data as percentage of households in a census tract with >1 person per room. Multivariable linear mixed models were fit to examine the associations between the percentage of neighbourhood‐level crowding and apnoea–hypopnoea index, and a causal mediation analysis was conducted to determine if body mass index acted as a mediator between neighbourhood‐level crowding and apnoea–hypopnoea index. Among 1789 patients (43% African American; 68% male; 80% obese), the mean apnoea–hypopnoea index was 29.0 ± 25.3. After adjusting for race, age, marital status and gender, neighbourhood‐level crowding was associated with apnoea–hypopnoea index; for every one‐unit increase in percentage of neighbourhood‐level crowding mean, the apnoea–hypopnoea index increased by 0.40 ± 0.20 (P = 0.04). There was a statistically significant indirect effect of neighbourhood‐level crowding through body mass index on the apnoea–hypopnoea index (P < 0.001). Neighbourhood‐level crowding is associated with severity of sleep‐disordered breathing. Body mass index partially mediated the association between neighbourhood‐level crowding and sleep‐disordered breathing. Investigating prevalent neighbourhood conditions impacting breathing in urban settings may be promising.

Improving efficiency and reducing costs: Design of an adaptive, seamless, and enriched pragmatic efficacy trial of an online asthma management program

Clinical trials are critical for medical decision-making, however, under the current paradigm, clinical trials are fraught with problems including low enrollment and high cost. Promising alternatives to increase trial efficiency and reduce costs include the use of (1) electronic initiatives that permit electronic remote data capture (EDC) for direct data collection at a site (2), electronic medical records (EMR) for patient identification and data collection, and (3) adaptive, enrichment designs with pragmatic approaches. We describe the design of a seamless, multi-site randomized Phase II/III trial to evaluate an asthma management intervention in urban adolescents with asthma. Patients are randomized, asked to access four online sessions of the intervention or control asthma management program, and are then followed for one year. The primary efficacy endpoint is self-reported asthma control as measured by the Asthma Control Test (ACT). Comparative effectiveness parametric approaches are utilized to conduct the trial in a real world setting with reduced costs. Escalated electronic initiatives are implemented for patient identification, assent, enrollment and tracking. Patient enrollment takes place during primary care visits. A centralized database with EDC is used for CRF data collection with integration of EMR data. This Phase II/III trial plans to have a total sample size of 500 patients with an interim look at the completion of Phase II (n=250), The interim analyses include an assessment of the intervention effect, marker(s) identification and the feasibility study of EMR data as the trial CRF data collection. Patient enrollment has begun and is ongoing.