Laura F. White

Effect of parents' wartime deployment on the behavior of young children in military families.

OBJECTIVE To describe the effect of wartime military deployments on the behavior of young children in military families. DESIGN Cross-sectional study. SETTING Childcare centers on a large Marine base. PARTICIPANTS Parents and childcare providers of children aged 1(1/2) to 5 years enrolled in on-base childcare centers. Main Exposure Parental deployment. OUTCOME MEASURES Mean externalizing, internalizing, and total symptom scores on the Child Behavior Checklist (CBCL) (1(1/2)-5 years) and the CBCL-Teacher Report Form (TRF) (1(1/2)-5 years). RESULTS One hundred sixty-nine of 233 consenting families (73%) participated. Nonresponders did not differ from responders in their childs age or TRF scores. Fifty-five children (33%) had a deployed parent. Parents with children aged 3 years or older and a deployed spouse had significantly higher depression scores than those without a deployed spouse. There were no differences in the demographic characteristics between groups. After controlling for respondents age, stress and depressive symptoms, deployed service members rank, and total number of children in the home, we found an age by deployment interaction: children aged 3 years or older with a deployed parent had significantly higher CBCL externalizing and total scores (externalizing, 48.50 vs 43.31, P < .05; total, 47.71 vs 42.68, P < .05) and externalizing and total TRF scores (externalizing, 50.21 vs 45.62, P < .05; total, 48.54 vs 43.73, P < .05) compared with same-aged peers without a deployed parent. CONCLUSIONS This study is the first to show that children aged 3 years or older with a deployed parent exhibit increased behavioral symptoms compared with peers without a deployed parent after controlling for caregivers stress and depressive symptoms.

Estimation of the reproductive number and the serial interval in early phase of the 2009 influenza A/H1N1 pandemic in the USA

Background  The United States was the second country to have a major outbreak of novel influenza A/H1N1 in what has become a new pandemic. Appropriate public health responses to this pandemic depend in part on early estimates of key epidemiological parameters of the virus in defined populations.

Risk factors and viruses associated with hospitalization due to lower respiratory tract infections in Canadian Inuit children: a case-control study.

Objectives: To examine risk factors for lower respiratory tract infections (LRTI) hospital admission in the Canadian Arctic. Methods: This was a case-control study during a 14-month period among children less than 2 years of age. Cases were admitted to the Baffin Regional Hospital in Iqaluit, Nunavut with LRTI. Controls were age matched and came from Iqaluit and 2 communities. Odds ratios (ORs) of hospital admission for LRTI were estimated through multivariate conditional logistic regression modeling for following risk factors: smoking in pregnancy, Inuit race, prematurity, adoption status, breast-feeding, overcrowding, and residing outside of Iqaluit. Viruses in nasophayngeal aspirates were sought at the time of each hospital admission. Results: There were 101 age-matched cases and controls. The following risk factors were significantly associated with an increased risk of admission for LRTI (adjusted OR): smoking in pregnancy (OR = 4.0; 95% CI: 1.1–14.6), residence outside of Iqaluit (OR = 2.7; 95% CI: 1.0–7.2), full Inuit race (OR = 3.8; 95% CI: 1.1–12.8), and overcrowding (OR = 2.5, 95% CI: 1.1–6.1). Non–breast-fed children had a 3.6-fold risk of being admitted for LRTI (95% CI: 1.2–11.5) and non–breast-fed adopted children had a 4.4-fold increased risk (95% CI: 1.1–17.6) when compared with breast-fed, nonadopted children. Prematurity was not associated with an increased risk of admission. Viruses were identified in 88 (72.7%) of admissions, with respiratory syncytial virus being identified in the majority of admissions, 62 (51.2%). Multiple viruses were isolated in 19 (15.7%) admissions. Conclusions: Smoking during pregnancy, place of residence, Inuit race, lack of breast-feeding, and overcrowding were all independently associated with increased risk of hospital admission for LRTI among Inuit children less than 2 years of age. Future research on the role of adoption and genetics on the health of Inuit children are required.

Prospective Study of Urban Form and Physical Activity in the Black Women's Health Study

The authors used data from the Black Womens Health Study to assess the association between neighborhood urban form and physical activity. Women reported hours/week of utilitarian and exercise walking and of vigorous activity in 1995 and on biennial follow-up questionnaires through 2001. Housing density, road networks, availability of public transit, sidewalks, and parks were characterized for the residential neighborhoods of 20,354 Black Womens Health Study participants living in New York, New York; Chicago, Illinois; and Los Angeles, California. The authors quantified the associations between features of the environment and physical activity using odds ratios for >or=5 relative to <5 hours/week of physical activity. For all women, housing density had the strongest association with utilitarian walking (odds ratio for the most- compared with the least-dense quintile = 2.72, 95% confidence interval: 2.22, 3.31), followed by availability of public transit. Women who moved during follow-up to neighborhoods of lower density were 36% more likely to decrease their levels of utilitarian walking, and those who moved to neighborhoods of higher density were 23% more likely to increase their levels of utilitarian walking, relative to women who moved to neighborhoods of similar density. These data suggest that increases in housing density may lead to increases in utilitarian walking among African-American women.

Transmissibility of the Influenza Virus in the 1918 Pandemic

BACKGROUND With a heightened increase in concern for an influenza pandemic we sought to better understand the 1918 Influenza pandemic, the most devastating epidemic of the previous century. METHODOLOGY/PRINCIPAL FINDINGS We use data from several communities in Maryland, USA as well as two ships that experienced well-documented outbreaks of influenza in 1918. Using a likelihood-based method and a nonparametric method, we estimate the serial interval and reproductive number throughout the course of each outbreak. This analysis shows the basic reproductive number to be slightly lower in the Maryland communities (between 1.34 and 3.21) than for the enclosed populations on the ships (R(0) = 4.97, SE = 3.31). Additionally the effective reproductive number declined to sub epidemic levels more quickly on the ships (within around 10 days) than in the communities (within 30-40 days). The mean serial interval for the ships was consistent (3.33, SE = 5.96 and 3.81, SE = 3.69), while the serial intervals in the communities varied substantially (between 2.83, SE = 0.53 and 8.28, SE = 951.95). CONCLUSIONS/SIGNIFICANCE These results illustrate the importance of considering the population dynamics when making statements about the epidemiological parameters of Influenza. The methods that we employ for estimation of the reproductive numbers and the serial interval can be easily replicated in other populations and with other diseases.

Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism

STUDY OBJECTIVE The objective of this study was to determine the diagnostic performance of right ventricular dilatation identified by emergency physicians on bedside echocardiography in patients with a suspected or confirmed pulmonary embolism. The secondary objective included an exploratory analysis of the predictive value of a subgroup of findings associated with advanced right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, McConnells sign). METHODS This was a prospective observational study using a convenience sample of patients with suspected (moderate to high pretest probability) or confirmed pulmonary embolism. Participants had bedside echocardiography evaluating for right ventricular dilatation (defined as right ventricular to left ventricular ratio greater than 1:1) and right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, or McConnells sign). The patients medical records were reviewed for the final reading on all imaging, disposition, hospital length of stay, 30-day inhospital mortality, and discharge diagnosis. RESULTS Thirty of 146 patients had a pulmonary embolism. Right ventricular dilatation on echocardiography had a sensitivity of 50% (95% confidence interval [CI] 32% to 68%), a specificity of 98% (95% CI 95% to 100%), a positive predictive value of 88% (95% CI 66% to 100%), and a negative predictive value of 88% (95% CI 83% to 94%). Positive and negative likelihood ratios were determined to be 29 (95% CI 6.1% to 64%) and 0.51 (95% CI 0.4% to 0.7%), respectively. Ten of 11 patients with right ventricular hypokinesis had a pulmonary embolism. All 6 patients with McConnells sign and all 8 patients with paradoxical septal motion had a diagnosis of pulmonary embolism. There was a 96% observed agreement between coinvestigators and principal investigator interpretation of images obtained and recorded. CONCLUSION Right ventricular dilatation and right ventricular dysfunction identified on emergency physician performed echocardiography were found to be highly specific for pulmonary embolism but had poor sensitivity. Bedside echocardiography is a useful tool that can be incorporated into the algorithm of patients with a moderate to high pretest probability of pulmonary embolism.

Hepatitis C Core Antigen Testing for Diagnosis of Hepatitis C Virus Infection: A Systematic Review and Meta-analysis

Background Diagnosis of chronic Hepatitis C Virus (HCV) infection requires both a positive HCV antibody screen and confirmatory nucleic acid test (NAT). HCV core antigen (HCVcAg) is a potential alternative to NAT.Approximately 130 to 150 million persons are infected with chronic hepatitis C virus (HCV), and approximately 75% of all cases occur in low- and middle-income countries (LMICs) (1, 2). Direct-acting antivirals allow safe and effective curative treatment, but treatment is the final step in a long cascade that requires screening, confirmation, notification of results, and linkage to care (3, 4). Diagnosis of HCV is a 2-step process that starts with screening for exposure with an assay that detects antibodies to HCV (anti-HCV), followed by nucleic acid testing (NAT) for persons with reactive anti-HCV to confirm active viremia. Among those who acquire a primary infection, 15% to 50% will spontaneously clear the virus within the first 2 to 6 months and remain positive for anti-HCV, although they are not actively infected and do not require treatment (5). The diagnostic process is designed to be cost-effective, with a low-cost screening test followed by targeted testing with the more expensive NAT. In LMICs, implementation of a complex algorithm is often not feasible and diagnostic capacity is low; as a result, fewer than 1% of patients are aware of their infection (6). In addition, a significant proportion of patients who test positive for anti-HCV do not receive diagnostic NAT and are lost to follow-up (7). The 2-step diagnostic process is a major bottleneck to the HCV cascade of care that needs to be addressed to achieve the ambitious elimination strategy proposed by the World Health Organization (WHO) (8). Testing for hepatitis C virus core antigen (HCVcAg) is a potential replacement for NAT. The HCVcAg forms the internal capsid, which is highly conserved and antigenic (9, 10). During viral assembly, nucleocapsid peptide 22 is released into the plasma (11) and can be detected earlier than antibodies and throughout the course of infection (12). The following 5 tests for HCVcAg detection are commercially available: Abbott ARCHITECT HCV Ag, which is an automated chemiluminescent microparticle immunoassay; Fujirebio Lumipulse Ortho HCV Ag and Eiken Lumispot HCV Ag, which are similar automated chemiluminescent enzyme immunoassays available in Japan and China; Hunan Jynda Bioengineering Group HCV Ag enzyme-linked immunosorbent assay (ELISA); and Ortho HCV Ag ELISA. Although all current HCVcAg tests require laboratory capacity, the development of a highly sensitive point-of-care (POC) platform is feasible and probably possible at a lower cost than NAT POC. Such a test has been defined as the highest-priority target product profile in a global stakeholder consultation process (13). As such, tests targeting HCVcAg could be attractive as a single-step diagnosis for chronic HCV infection in high-prevalence settings, which would streamline the HCV cascade of care and reduce loss to follow-up. This WHO-commissioned systematic review to inform forthcoming WHO guidelines on hepatitis testing evaluated the accuracy of diagnosis of active HCV infection among adults and children for 5 commercially available HCVcAg tests compared with NAT. Methods We performed a systematic review of HCV diagnostics literature, extracted data from selected studies, and conducted a bivariate meta-analysis of the test characteristics of HCVcAg as a diagnostic test for HCV infection. We used standard methods for systematic reviews and meta-analyses of diagnostic tests (1418), including preparation of an a priori protocol for the literature search, article selection, data extraction, quality assessment, and analysis (see Supplement). Supplement. Data Supplement Data Sources and Searches We searched EMBASE, PubMed, Scopus, Web of Science, and Cochrane Database of Systematic Reviews for citations related to HCVcAg screening and diagnosis published until 31 March 2016. We did not restrict the search by language, and terms were selected under the guidance of medical librarians. The search strategies included terms related to HCV, antigen, and nucleic acid amplification. See the Supplement for specific search strategies and the number of studies retrieved from each database. Two authors (J.M.F. and T.M.T.) independently assessed titles and abstracts identified by the literature search to select eligible studies. Citations identified by either reviewer were selected for full-text review. These same 2 authors then independently assessed the full-text articles using predefined inclusion and exclusion criteria. Discrepancies were resolved by discussion between the authors and, when needed, by the decision of a third author (C.M.D.). Study Selection Inclusion criteria were as follows: casecontrol, cross-sectional, cohort, or randomized trials; commercially available HCVcAg tests; commercially available NAT as the reference standard; whole blood, plasma, or serum specimens; and at least 10 independent clinically collected samples. Studies done using commercially prepared reference panel specimens, published in abstract form only, or presented as slides or posters were excluded. We included articles that reported results from populations with any distribution of patient age, from any country, and in any screening setting (for example, hospital- or community-based). Although we were primarily interested in test performance among persons at risk for HCV and with known infection, we also included studies using specimens from healthy blood donors. Because the performance characteristics of NAT are very similar when HCV RNA levels are greater than 50 IU/mL, we accepted any of the following NAT techniques as the reference standard: polymerase chain reaction, branched-chain DNA, or transcription-mediated amplification. Tests were classified as either qualitative or quantitative. Data Extraction and Quality Assessment Two authors (J.M.F. and T.M.T.) independently assessed all studies for inclusion and extracted data on study methods, characteristics, and test accuracy using a standardized extraction form (Supplement). Foreign-language studies were translated and extracted by native speakers using the same form. We crosschecked data points for 25% of the included studies. Disagreements between reviewers were resolved by discussion or by a third reviewer (C.M.D.). When elements for extraction were missing, we contacted the authors to request further data. We also requested individual specimen data to allow for a quantitative assessment of HCVcAg against HCV RNA. Studies without extractable sensitivity and specificity data were excluded if no further information was acquired after 3 attempts to contact the study authors. Methodological quality of the included studies was assessed using a validated QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool (19). Details of the QUADAS-2 questions and interpretation are reported in the Supplement. Data Synthesis and Analysis We defined HCVcAg sensitivity as the proportion of samples with a positive NAT result that was also positive for HCVcAg. We defined HCVcAg specificity as the proportion of samples with a negative NAT result that was also negative for HCVcAg. Sensitivity and specificity were the primary outcome measures. Positive and negative likelihood ratios were calculated when pooled sensitivity and specificity data were available from meta-analysis. Indeterminate test results accounted for fewer than 1% for all index tests and were excluded from further analyses. We constructed forest plots for each HCVcAg index test to visually assess heterogeneity by examining the CIs of individual studies. We then used summary plots to examine the width of the prediction region, with a wider prediction region suggesting more heterogeneity. When at least 4 studies with limited heterogeneity were available, we used a bivariate random-effects model and carried out meta-analyses using the metandi command in STATA, version 14 (StataCorp) (20, 21). When at least 4 studies provided sensitivity data only, we did a univariate random-effects meta-analysis on the sensitivities to use all available data. Results from the univariate analyses (including all studies) were compared with the pooled estimates from the bivariate analyses where possible. Descriptive analyses were done for index tests with fewer than 4 studies and when substantial heterogeneity was evident from inspection of the forest and summary plots. When quantitative data were available, a locally weighted regression smoother was used to visually assess the linearity of quantitative HCVcAg (measured in fmol/L) to HCV RNA (measured in IU/mL) (22). We identified outliers and recorded descriptive statistics of these points. Quantitative data were insufficient to assess any test other than Abbott ARCHITECT. We assessed for publication bias when more than 10 studies were available for an index test. We generated funnel plots displaying the log diagnostic odds ratio versus the SE for each study (18). We also did the trim-and-fill statistical assessment in STATA using the metatrim command (23). Unpublished data were not included. All statistical analyses were done using STATA and R, version 3.2.5 (R Foundation for Statistical Computing). Role of the Funding Source This systematic review was supported by the National Institutes of Health, which had no direct involvement in the study design, collection, analysis, or interpretation of the data or in the decision to submit the manuscript for publication. Results Study Selection and Characteristics The systematic review identified 8508 citations, from which we reviewed 299 full-text articles and identified 44 that met the a prioridefined inclusion criteria (Appendix Figure 1). Of the included studies, 44 used the 5 HCVcAg assays; 1 of these studies directly compared 3 antigen tests. Four studies were translated from Mandarin (2427), 1 from German (28), and 2 from Japanese (29, 30). Characteristics for each study are presented in Table 1. Table 1. Characteristics of Included Studies Grouped Alphabetically, by Index Test Type Appendix Fig

PM2.5 and Diabetes and Hypertension Incidence in the Black Women's Health Study.

Background: Clinical studies have shown that exposure to fine particulate matter (PM2.5) can increase insulin resistance and blood pressure. The epidemiologic evidence for an association of PM2.5 exposure with the incidence of type 2 diabetes or hypertension is inconsistent. Even a modest association would have great public health importance given the ubiquity of exposure and high prevalence of the conditions. Methods: We used Cox proportional hazards models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for incident type 2 diabetes and hypertension associated with exposure to PM2.5 in a large cohort of African American women living in 56 metropolitan areas across the US, using data from the Black Women’s Health Study. Pollutant levels were estimated at all residential locations over follow-up with a hybrid model incorporating land use regression and Bayesian Maximum Entropy techniques. Results: During 1995 to 2011, 4,387 cases of diabetes and 9,570 cases of hypertension occurred. In models controlling for age, questionnaire cycle, and metro area, there were positive associations with diabetes (HR = 1.13, 95% CI = 1.04, 1.24) and hypertension (HR = 1.06, 95% CI = 1.00, 1.12) per interquartile range of PM2.5 (2.9 &mgr;g/m3). Multivariable HRs, however, were 0.99 (95% CI = 0.90, 1.09) for diabetes and 0.99 (95% CI = 0.93, 1.06) for hypertension. Conclusions: Our results provide little support for an association of PM2.5 with diabetes or hypertension incidence.

The Impact of Footwear and Packweight on Injury and Illness Among Long-Distance Hikers

Abstract Objective.—To determine the prevalence and predictors of injury and illness among long-distance hikers. Methods.—This was a cross-sectional study of long-distance hikers (>500 miles [805 km]) along the Appalachian Trail and Pacific Crest Trails between August and October of 2006. An 8-page survey instrument was made available to hikers at a designated station near the northern terminus of the respective trails. The survey questions were yes/no or multiple choice. Independent variables included packweight, footwear, and type and frequency of water purification. χ2 tests to compare categorical data and the Cochran-Armitage test for trend were used (P < .05 significant). We used logistic regression to compare the variables concurrently, and significance was determined using likelihood ratio tests. Profile likelihood confidence intervals for the odds ratios are reported. Results.—Of the 128 hikers completing surveys that met inclusion criteria, the mean age was 33 years (range  =  18–65 years), 94% walked >1500 miles (2400 km), and 70% were male. Using univariate analysis, trends were noted in the proportion of hikers reporting paresthesias and increasing packweight (35% with 10–20 pound [4.5–9 kg] packs, 50% with 21–30 pound [9.5–13.5 kg] packs, and 69% with >31 pound [14 kg] packs [P < .002]), as well as in the proportion of hikers reporting paresthesias and increasing footwear rigidity (29% sandals, 36% running shoes, 42% hiking shoes, and 68% hiking boots [P < .001]). In multivariate analysis compared to sandals, the odds ratio of suffering from paresthesias with running shoes was 1.57 (95% CI 0.3, 12.2), hiking shoes 1.73 (95% CI 0.3, 13.9), and hiking boots 3.9 (95% CI 0.7, 32.1) (P  =  .16). Compared to 10 to 20 pound (4.5–9 kg) packs, the odds ratios of suffering from paresthesias with 21 to 30 pound (9.5–13.5 kg) packs was 1.5 (95% CI 0.6, 3.9), and for >31 pounds (14 kg) was 2.2 (CI 0.7, 7.1) (P  =  .03). Adjusting for footwear and pack weight, only pack weight was significantly associated with paresthesias. Packweight and footwear were not significantly associated with other musculoskeletal injuries, such as joint sprains or chronic pain, and muscle injuries. Conclusions.—There is an association between packweight and the prevalence of paresthesias among long-distance hikers. The association between type of footwear and the prevalence of paresthesias is significant when analyzed independently, but loses its significance when the variables are examined together. This suggests that there is confounding between footwear and packweight.

The relationship between rural status, individual characteristics, and self-rated health in the Behavioral Risk Factor Surveillance System.

PURPOSE To examine rural status and social factors as predictors of self-rated health in community-dwelling adults in the United States. METHODS This study uses multinomial logistic and cumulative logistic models to evaluate the associations of interest in the 2006 U.S. Behavioral Risk Factor Surveillance System, a cross-sectional survey of 347,709 noninstitutionalized adults. FINDINGS Self-rated health was poorer among rural residents, compared to urban residents (OR = 1.77, 95% CI: 1.54, 1.90). However, underlying risk factors such as obesity, low income, and low educational attainment were found to vary by rural status and account for the observed increased risk (OR = 1.03, 95% CI: 0.94, 1.12). There was little evidence of effect modification by rural status, though the association between obesity and self-rated health was stronger among urban residents (OR = 2.50, 95% CI: 2.38, 2.64) than among rural residents (OR = 2.18, 95% CI: 2.03, 2.34). CONCLUSIONS Our findings suggest that differences in self-rated health by rural status were attributable to differential distributions of participant characteristics and not due to differential effects of those characteristics.