Kristen E. Gray

Development at Age 36 Months in Children With Deformational Plagiocephaly

OBJECTIVES: Infants and toddlers with deformational plagiocephaly (DP) have been shown to score lower on developmental measures than unaffected children. To determine whether these differences persist, we examined development in 36-month-old children with and without a history of DP. METHODS: Participants included 224 children with DP and 231 children without diagnosed DP, all of who had been followed in a longitudinal study since infancy. To confirm the presence or absence of DP, pediatricians blinded to children’s case status rated 3-dimensional cranial images taken when children were 7 months old on average. The Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) was administered as a measure of child development. RESULTS: Children with DP scored lower on all scales of the BSID-III than children without DP. Differences were largest in cognition, language, and parent-reported adaptive behavior (adjusted differences = –2.9 to –4.4 standard score points) and smallest in motor development (adjusted difference = –2.7). Children in the control group who did not have previously diagnosed DP but who were later rated by pediatricians to have at least mild cranial deformation also scored lower on the BSID-III than unaffected controls. CONCLUSIONS: Preschool-aged children with a history of DP continue to receive lower developmental scores than unaffected controls. These findings do not imply that DP causes developmental problems, but DP may nonetheless serve as a marker of developmental risk. We encourage clinicians to screen children with DP for developmental concerns to facilitate early identification and intervention.

Population-based study of risk factors for severe maternal morbidity.

BACKGROUND Severe maternal morbidity (SMM) is a serious health condition potentially resulting in death without immediate medical attention, including organ failure, obstetric shock and eclampsia. SMM affects 20000 US women every year; however, few population-based studies have examined SMM risk factors. METHODS We conducted a population-based case-control study linking birth certificate and hospital discharge data from Washington State (1987-2008), identifying 9485 women with an antepartum, intrapartum or postpartum SMM with ≥3-day hospitalisation or transfer from another facility and 41 112 random controls. Maternal age, race, smoking during pregnancy, parity, pre-existing medical condition, multiple birth, prior caesarean delivery, and body mass index were assessed as risk factors with logistic regression to estimate odds ratios (OR) and 95% confidence intervals [CI], adjusted for education and delivery payer source. RESULTS Older women (35-39: OR 1.65 [CI 1.52, 1.79]; 40+: OR 2.48 [CI 2.16, 2.81]), non-White women (Black: OR 1.82 [CI 1.64, 2.01]; American Indian: OR 1.52 [CI 1.32, 1.73]; Asian/Pacific Islander: OR 1.30 [CI 1.19, 1.41]; Hispanic: OR 1.17 [CI 1.07, 1.27]) and women at parity extremes (nulliparous: OR 1.83 [CI 1.72, 1.95]; parity 3+: OR 1.34 [CI 1.23, 1.45]) were at greater risk of SMM. Women with a pre-existing medical condition (OR 2.10 [CI 1.88, 2.33]), a multiple birth (OR 2.54 [CI 2.26, 2.82]) and a prior caesarean delivery (OR 2.08 [CI 1.93, 2.23]) were also at increased risk. CONCLUSION The risk factors identified are not modifiable at the individual level; therefore, provider and system-level factors may be the most appropriate target for preventing SMM.

Leukocyte telomere length and age at menopause.

Background: Telomere length is a marker of cellular aging that varies with the individual, is inherited, and is highly correlated across somatic cell types within persons. Interindividual variability of telomere length may partly explain differences in reproductive aging rates. We examined whether leukocyte telomere length was associated with menopausal age. Methods: We evaluated the relationship between leukocyte telomere length and age at natural menopause in 486 white women ≥65 years of age. We fit linear regression models adjusted for age, income, education, body mass index, physical activity, smoking, and alcohol intake. We repeated the analysis in women with surgical menopause. We also performed sensitivity analyses excluding women (1) with unilateral oophorectomy, (2) who were nulliparous, or (3) reporting menopausal age <40 years, among other exclusions. Results: For every 1-kb increase in leukocyte telomere length, average age at natural menopause increased by 10.2 months (95% confidence interval = 1.3 to 19.0). There was no association among 179 women reporting surgical menopause. In all but one sensitivity analysis, the association between leukocyte telomere length and age at menopause became stronger. However, when excluding women with menopausal age <40 years, the association decreased to 7.5 months (−0.4 to 15.5). Conclusions: Women with the longest leukocyte telomere length underwent menopause 3 years later than those with the shortest leukocyte telomere length. If an artifact, an association would likely also have been observed in women with surgical menopause. If these results are replicated, leukocyte telomere length may prove to be a useful predictor of age at menopause.

Adverse Childhood Experiences, Military Service, and Adult Health

INTRODUCTION Prevalence of adverse childhood experiences (ACE) and associations with adult health may vary by gender and military service. This study compares the gender-specific prevalence of ACE by military service and determines the associations of ACE with adult health risk factors and health-related quality of life (HRQOL). METHODS This 2014 analysis used data from the 2011 and 2012 CDC Behavioral Risk Factor Surveillance System. Total ACE was operationalized as the number of reported ACE. Associations of total ACE with adult health risk factors were estimated using general linear models; associations with HRQOL were estimated using negative binomial regression. All analyses adjusted for age and race/ethnicity. RESULTS Those with military service had more total ACE than civilians. Higher ACE was associated with poorer HRQOL among women (physical health, military service, relative risk [RR]=1.20, 95% CI=1.09, 1.33; civilians, RR=1.18, 95% CI=1.17, 1.20; mental health, military service, RR=1.21, 95% CI=1.12, 1.32; civilians, RR=1.25, 95% CI=1.23, 1.26). Among men, these associations were somewhat attenuated in those with military service relative to civilians (physical health, military service, RR=1.13, 95% CI=1.09, 1.18; civilians, RR=1.20, 95% CI=1.17, 1.24; mental health, military service, RR=1.21, 95% CI=1.16, 1.27; civilians, RR=1.30, 95% CI=1.27, 1.34). CONCLUSIONS Relative to civilians, men and women with military service report more ACE, but associations of ACE with adult HRQOL are weaker among men with military service relative to civilians. There is a need to implement and disseminate evidence-based programs to prevent ACE and for research on the long-term health consequences of ACE in military populations.

Individual and contextual correlates of physical activity among a clinical sample of United States Veterans

RATIONALE Veterans, especially those using U.S. Department of Veterans Affairs (VA) healthcare, have poorer health than the general population. In addition, Veterans using VA services are more likely than non-VA users to be physically inactive. Little is known about physical activity correlates among Veterans. To identify targets for health promotion interventions, understanding barriers to and facilitators of physical activity in this population is critical. METHODS This study examined individual-, social-, and perceived neighborhood-level associations of meeting weekly physical activity recommendations (150 min/week of combined leisure and transportation activity) based on the International Physical Activity Questionnaire (IPAQ) among N = 717 patients from VA Puget Sound, Seattle Division using a mailed survey sent 2012-2013 (response rate = 40%). Independent associations were identified with direct estimation of relative risks using generalized linear models (dichotomous outcome), and linear regression (continuous outcome), including variables associated in bivariate tests (p < .05). RESULTS Most participants were male, Caucasian, and unemployed, and had an annual income ≤

Sexual Assault, Sexual Harassment, and Physical Victimization during Military Service across Age Cohorts of Women Veterans

40,000. Over two-thirds (69.9%) reported meeting physical activity recommendations. Fewer days of limitations due to physical or mental health (Relative Risk (RR) = 0.99 per day; 95% Confidence Interval (CI) = 0.98, 0.99; p = .01), others doing physical activity with the Veteran (RR = 1.18; 95% CI = 1.04, 1.33; p = .01), receiving ideas from others regarding physical activity (RR = 1.14; 95% CI = 1.01, 1.29; p = .03) and better perceived neighborhood aesthetics (RR = 1.14; 95% CI = 1.06, 1.24; p = .001) were associated with meeting physical activity recommendations. Findings were comparable for total weekly physical activity, but lower depression symptom severity was also associated with increased physical activity. CONCLUSION This study identified individual and contextual correlates of physical activity among VA-using Veterans. Targeting these factors will be important in promoting physical activity in order to address the disproportionate disease burden facing U.S. Veterans. Existing VA interventions targeting physical activity may need to be adapted to account for the influence of contextual factors.

Differences in Active and Passive Smoking Exposures and Lung Cancer Incidence Between Veterans and Non-Veterans in the Women’s Health Initiative

OBJECTIVES Exposure to sexual and physical trauma during military service is associated with adverse mental and physical health outcomes. Little is known about their prevalence and impact in women veterans across age cohorts. METHODS Data from a 2013 national online survey of women veterans was used to examine associations between age and trauma during military service, including sexual assault, sexual harassment, and physical victimization. Analyses were conducted using logistic regression, adjusting for service duration and demographic factors. In secondary analyses, the moderating role of age in the relationship between trauma and self-reported health was examined. RESULTS The sample included 781 women veterans. Compared with the oldest age group (≥ 65), all except the youngest age group had consistently higher odds of reporting trauma during military service. These differences were most pronounced in women aged 45 to 54 years (sexual assault odds ratio [OR], 3.81 [95% CI, 2.77-6.71]; sexual harassment, OR, 3.99 [95% CI, 2.25-7.08]; and physical victimization, OR, 5.72 [95% CI, 3.32-9.85]). The association between trauma during military service and self-reported health status also varied by age group, with the strongest negative impact observed among women aged 45 to 54 and 55 to 64. CONCLUSIONS Compared with other age groups, women in midlife were the most likely to report trauma during military service, and these experiences were associated with greater negative impact on their self-reported health. Providers should be aware that trauma during military service may be particularly problematic for the cohort of women currently in midlife, who represent the largest proportion of women who use Department of Veterans Affairs health care.

Hysterectomy and Bilateral Salpingo-Oophorectomy: Variations by History of Military Service and Birth Cohort.

INTRODUCTION Women Veterans may have higher rates of both active and passive tobacco exposure than their civilian counterparts, thereby increasing their risk for lung cancer. PURPOSE OF THE STUDY To compare differences in active and passive smoking exposure and lung cancer incidence among women Veterans and non-Veterans using prospective data from the Womens Health Initiative (WHI). DESIGN AND METHODS We used data from the WHI, which collected longitudinal demographic, clinical, and laboratory data on 161,808 postmenopausal women. We employed linear and multinomial regression and generalized linear models to compare active and passive smoking exposure between Veterans and non-Veterans and Cox proportional hazards models to estimate differences in lung cancer incidence rates. RESULTS After adjustment, Veterans had 2.54 additional pack years of smoking compared with non-Veterans (95% confidence interval [CI] 1.68, 3.40). Veterans also had a 1% increase in risk of any passive smoking exposure (95% CI 1.00, 1.02) and a 9% increase in risk of any workplace exposure (95% CI 1.07, 1.11) compared with non-Veterans. After adjustment for age and smoking exposures, Veterans did not have a higher risk of lung cancer compared with non-Veterans (relative risk = 1.06 95% CI 0.86, 1.30). IMPLICATIONS Women Veterans had higher rates of tobacco use and exposure to passive smoking, which were associated with a higher risk for lung cancer compared with non-Veterans. Clinicians who care for Veterans need to be aware that older women Veterans have more exposures to risk factors for lung cancer.

Vasomotor Symptoms and Quality of Life Among Veteran and Non-Veteran Postmenopausal Women

INTRODUCTION Little is known about hysterectomy and bilateral salpingo-oophorectomy (BSO), which are associated with both health risks and benefits, among women Veterans. PURPOSE OF THE STUDY To compare the prevalence of hysterectomy with or without BSO, and early hysterectomy, between postmenopausal Veterans and non-Veterans. DESIGN AND METHODS We used baseline data from the Womens Health Initiative Clinical Trial and Observational Study. Multinomial logistic regression models examined differences in the prevalence of hysterectomy (neither hysterectomy nor BSO, hysterectomy without BSO, and hysterectomy with BSO) between Veterans and non-Veterans. Generalized linear models were used to determine whether early hysterectomy (before age 40) differed between Veterans and non-Veterans. Analyses were stratified by birth cohort (<65, ≥65 years at enrollment). RESULTS The unadjusted prevalence of hysterectomy without BSO was similar among Veterans and non-Veterans in both birth cohorts (<65: 22% vs 21%; ≥65: 22% vs 21%). The unadjusted prevalence of hysterectomy with BSO was equivalent among Veterans and non-Veterans in the >65 cohort (21%), but higher among Veterans in the <65 cohort (22% vs 19%). In adjusted analyses, although no differences were observed in the >65 cohort, Veterans in the <65 cohort had higher odds of hysterectomy without BSO (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03, 1.36) and with BSO (OR 1.26, 95% CI 1.10, 1.45), as well as elevated risk of early hysterectomy (relative risk 1.32, 95% CI 1.19, 1.47), compared with non-Veterans. IMPLICATIONS Aging women Veterans may have higher prevalence of hysterectomy and BSO than non-Veterans. This information contributes to understanding the health needs and risks of women Veterans and can inform clinical practice and policy for this population.

Predicting developmental delay in a longitudinal cohort of preschool children with single-suture craniosynostosis: is neurobehavioral assessment important?

INTRODUCTION Vasomotor symptoms (VMS), including hot flashes and night sweats, are common among postmenopausal women and are associated with reduced health related quality of life (HRQOL). PURPOSE OF THE STUDY To determine whether Veterans are more likely to report VMS than non-Veterans, and whether the association of VMS with HRQOL varies by Veteran status. DESIGN AND METHODS We used data from the Womens Health Initiative Observational Study, including self-reported baseline VMS presence and severity, and HRQOL at follow-up Year 3 (RAND Short Form 36-Item Health Survey). Employing generalized linear models we estimated whether Veteran status was associated with any VMS. We estimated the association between any VMS and HRQOL using linear regression, stratified by Veteran status. Interaction terms were added separately to determine whether the association varied by baseline depression, obesity, or smoking status. RESULTS The final analyses included 77,153 postmenopausal women (2,004 Veterans). After adjustment, Veterans were no more likely than non-Veterans to report any VMS at baseline (relative risk [RR] 0.97, 95% confidence interval [CI] 0.90-1.04) or moderate to severe VMS (RR 1.03, 95% CI 0.89-1.18). Any VMS was associated with decreased HRQOL at Year 3, particularly among Veterans (mean difference range: Veterans -2.7 to -4.6, p-values < .001; non-Veterans -2.2 to -2.6, 95% CI -0.13 to -0.09, p values < .001). Baseline depression and obesity, but not smoking, amplified the negative association between VMS and HRQOL. IMPLICATIONS Multicondition care models for postmenopausal Veteran and non-Veteran women are needed that incorporate management strategies for VMS, weight, and depression.