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1.  Merging Systems: Integrating Home Visitation and the Family-Centered Medical Home 
Pediatrics  2013;132(Suppl 2):S74-S81.
To improve the health of children and bend the health care cost curve we must integrate the individual and population approaches to health and health care delivery. The 2012 Institute of Medicine (IOM) report Primary Care and Public Health: Exploring Integration to Improve Population Health laid out the continuum for integration of primary care and public health stretching from isolation to merging systems. Integration of the family-centered medical home (FCMH) and home visitation (HV) would promote overall efficiency and effectiveness and help achieve gains in population health through improving the quality of health care delivered, decreasing duplication, reinforcing similar health priorities, decreasing costs, and decreasing health disparities. This paper aims to (1) provide a brief description of the goals and scope of care of the FCMH and HV, (2) outline the need for integration of the FCMH and HV and synergies of integration, (3) apply the IOM’s continuum of integration framework to the FCMH and HV and describe barriers to integration, and (4) use child developmental surveillance and screening as an example of the potential impact of HV-FCMH integration.
PMCID: PMC4080633  PMID: 24187126
home visiting; family-centered medical home; patient-centered medical home; primary care
2.  Retaliatory attitudes and violent behaviors among assault-injured youth 
The Journal of Adolescent Health  2011;50(3):215-220.
To examine the impact of retaliatory attitudes on subsequent violent behavior and fight-related injuries among youth who presented to the emergency department with assault-injuries.
Assault-injured youth were interviewed at baseline, 6 months and 18 months to assess fighting behavior, retaliatory attitudes, weapon carrying and injury history as part of a larger randomized control trial.
Two emergency departments in urban areas.
One hundred twenty-nine adolescents aged 10 to 15.
Outcome measures
Fighting behavior, assault-injury, weapon carrying, and aggressive behavior.
Higher retaliatory attitudes at baseline were associated with more aggression and a higher frequency of fighting over time.
Retaliatory attitudes may fuel cycles of violence among youth. Medical professionals in acute care settings have an opportunity to identify youths at risk of future assault injury by assessing retaliation, providing anticipatory guidance and referring to intervention programs.
PMCID: PMC3279700  PMID: 22325125
3.  Burden of Unmet Mental Health Need in Assault-Injured Youth Presenting to the Emergency Department 
Academic Pediatrics  2011;12(2):125-130.
To determine if there is a gap between behavioral symptoms and previously recognized mental health conditions in youth victims of peer assault injuries and to describe gender differences in psychological symptoms.
A cross-sectional comparison of rates of previously diagnosed mental health conditions and clinical range behavioral symptoms as measured by the Child Behavior Checklist (CBCL) in 168 youth (10-15 years old) presenting to the emergency department (ED) after an interpersonal assault injury. Fisher’s exact test was used for comparisons.
Mental health symptoms were common among assault-injured youth. More than half of youth demonstrating clinical range symptoms on the attention problems or anxious / depressed scales of the CBCL had no prior diagnosis of these conditions. Females were more likely than males to exhibit clinical range aggressive behavior symptoms (OR 3.61, 95% CI 1.64-7.97). Aggressive behavior was associated with clinical range scores on the other problem scales of the CBCL.
After an ED visit for an assault-related injury, less than half of 10-15 year olds with significant symptoms of common mental conditions reported having a previously diagnosed disorder, reflecting a burden of unmet psychological needs. An ED visit for an assault injury provides an opportunity to screen for emotional / behavioral symptoms and to refer to appropriate follow-up mental health care.
What’s New
Assault-injured youth are likely to have unmet mental health needs. This study compares mental health symptoms after an assault injury to previously diagnosed mental health conditions and describes differences in mental health characteristics of assault-injured youth by gender.
PMCID: PMC3307901  PMID: 22112395
mental health; assault; gender; aggression; emergency department
4.  Abiraterone and Increased Survival in Metastatic Prostate Cancer 
The New England journal of medicine  2011;364(21):1995-2005.
Biosynthesis of extragonadal androgen may contribute to the progression of castration-resistant prostate cancer. We evaluated whether abiraterone acetate, an inhibitor of androgen biosynthesis, prolongs overall survival among patients with metastatic castration-resistant prostate cancer who have received chemotherapy.
We randomly assigned, in a 2:1 ratio, 1195 patients who had previously received docetaxel to receive 5 mg of prednisone twice daily with either 1000 mg of abiraterone acetate (797 patients) or placebo (398 patients). The primary end point was overall survival. The secondary end points included time to prostate-specific antigen (PSA) progression (elevation in the PSA level according to prespecified criteria), progression-free survival according to radiologic findings based on prespecified criteria, and the PSA response rate.
After a median follow-up of 12.8 months, overall survival was longer in the abiraterone acetate–prednisone group than in the placebo–prednisone group (14.8 months vs. 10.9 months; hazard ratio, 0.65; 95% confidence interval, 0.54 to 0.77; P<0.001). Data were unblinded at the interim analysis, since these results exceeded the preplanned criteria for study termination. All secondary end points, including time to PSA progression (10.2 vs. 6.6 months; P<0.001), progression-free survival (5.6 months vs. 3.6 months; P<0.001), and PSA response rate (29% vs. 6%, P<0.001), favored the treatment group. Mineralocorticoid-related adverse events, including fluid retention, hypertension, and hypokalemia, were more frequently reported in the abiraterone acetate–prednisone group than in the placebo–prednisone group.
The inhibition of androgen biosynthesis by abiraterone acetate prolonged overall survival among patients with metastatic castration-resistant prostate cancer who previously received chemotherapy. (Funded by Cougar Biotechnology; COU-AA-301 number, NCT00638690.)
PMCID: PMC3471149  PMID: 21612468
5.  Examining the Link between Neighborhood Context and Parental Messages to their Adolescent Children About Violence 
Living in violent neighborhoods has been shown to alter adolescent’s social-cognitions and increase aggressive behavior. A similar process may also occur for parents and result in parental support of aggressive behavior. This research examines the influence of perceived neighborhood violence and neighborhood collective efficacy on parents’ attitudes toward violence and the messages they give their adolescent children about how to resolve interpersonal conflict.
These data come from 143 African-American parents and their adolescent children recruited from 3 inner-city middle schools to participate in a parenting intervention. Models were fit using structural equation modeling in Mplus.
Contrary to expectations, exposure to neighborhood violence was not predictive of either aggressive attitudes or conflict solutions for parents or adolescents. Rather, a mixed effect was found for neighborhood collective efficacy, with higher perceived neighborhood collective efficacy related to less violent attitudes for adolescents but not parents. Collective efficacy also predicted the messages that parents gave their adolescents about interpersonal conflict, with higher collective efficacy related to messages that were less supportive of violence.
Parent and adolescent perception of neighborhood collective efficacy influences the messages that adolescents receive about interpersonal conflict resolution. This suggests that for parents living in violent neighborhoods their appraisal of the neighborhood is more important in shaping conflict resolution messages than parents’ own experiences with violence. Parent and family-based programs to prevent youth violence need to address neighborhood factors that influence the messages adolescents receive about how to resolve conflict.
PMCID: PMC3124663  PMID: 21700158
Adolescents; Violence; Parenting; Collective Efficacy; Parent/child communications
6.  The Importance of Early Parenting in At-Risk Families and Children’s Social-Emotional Adaptation to School 
Academic Pediatrics  2010;10(5):330-337.
To determine the specific aspects of early parenting in psychosocially at-risk families most strongly related to children’s social-emotional adaptation to school.
Cohort study of families (n=318) identified as at-risk for maltreatment of their newborns. Quality of early parenting was observed in the home when the child was one year old. Social-emotional adaptation to school was reported by teachers in first grade. Multivariable models assessed the independent influence of early parenting variables on social-emotional adaptation.
Early parenting and social-emotional adaptation to school varied greatly across families. Parental warmth was associated with lower teacher ratings of shyness, concentration problems, and peer rejection. Parental lack of hostility was associated with decreased teacher ratings of concentration problems and peer rejection. Parental encouragement of developmental advance was associated with lower ratings of aggression and peer rejection. Provision of materials to promote learning and literacy was associated with lower ratings of concentration problems.
In this sample of families with multiple psychosocial risks for child maltreatment, specific aspects of early parenting were associated with better social-emotional adaptation to school in the first grade in theoretically predicted ways. Improving parental knowledge about positive parenting via anticipatory guidance should be a focus of well child visits. Well child visit-based interventions to improve the quality of early parenting especially among at-risk families should be studied for their impact on parenting behavior and on children’s successful social-emotional adaptation to school. Primary care providers should reinforce complementary services, such as home visiting, that seek to promote positive parenting.
PMCID: PMC3383459  PMID: 20816655
Parenting; Child Rearing; Parent-Child Relations; Social Adjustment; Social Behavior (Aggression, Shyness, Rejection); Vulnerable Populations
7.  Is Chytridiomycosis an Emerging Infectious Disease in Asia? 
PLoS ONE  2011;6(8):e23179.
The disease chytridiomycosis, caused by the fungus Batrachochytrium dendrobatidis (Bd), has caused dramatic amphibian population declines and extinctions in Australia, Central and North America, and Europe. Bd is associated with >200 species extinctions of amphibians, but not all species that become infected are susceptible to the disease. Specifically, Bd has rapidly emerged in some areas of the world, such as in Australia, USA, and throughout Central and South America, causing population and species collapse. The mechanism behind the rapid global emergence of the disease is poorly understood, in part due to an incomplete picture of the global distribution of Bd. At present, there is a considerable amount of geographic bias in survey effort for Bd, with Asia being the most neglected continent. To date, Bd surveys have been published for few Asian countries, and infected amphibians have been reported only from Indonesia, South Korea, China and Japan. Thus far, there have been no substantiated reports of enigmatic or suspected disease-caused population declines of the kind that has been attributed to Bd in other areas. In order to gain a more detailed picture of the distribution of Bd in Asia, we undertook a widespread, opportunistic survey of over 3,000 amphibians for Bd throughout Asia and adjoining Papua New Guinea. Survey sites spanned 15 countries, approximately 36° latitude, 111° longitude, and over 2000 m in elevation. Bd prevalence was very low throughout our survey area (2.35% overall) and infected animals were not clumped as would be expected in epizootic events. This suggests that Bd is either newly emerging in Asia, endemic at low prevalence, or that some other ecological factor is preventing Bd from fully invading Asian amphibians. The current observed pattern in Asia differs from that in many other parts of the world.
PMCID: PMC3156717  PMID: 21887238
9.  Health Disparities Across the Lifespan 
PMCID: PMC2974843  PMID: 19531790
11.  A Glimpse into Urban Middle Schools on Probation for “Persistently Dangerous” Status: Identifying Malleable Predictors of Fighting 
Journal of school violence  2009;8(4):284-300.
The No Child Left Behind Act requires state boards of education to identify schools that are unsafe. Schools that are identified by measures such as suspension and expulsion rates are subsequently labeled “persistently dangerous.” To our knowledge there is no published research that attempts to characterize fighting behavior among youth who may attend schools designated as “persistently dangerous.” Two hundred and thirteen sixth grade African American boys and girls attending two urban middle schools on probation for “persistently dangerous” status were examined to investigate differences in demographic characteristics of gender and age and predictor factors of non-parental adult mentorship, parental acceptance of fighting behavior, and peer fighting. These analyses suggest a relationship between the number of peers who fight, youth who believed their parents endorse fighting, and youth without non parental adult mentorship were more likely to fight. This study also indicates that regardless of school status there are modifiable predictors associated with early adolescent fighting.
PMCID: PMC2840646  PMID: 20300444
Persistently Dangerous; Mentoring; Early Adolescence; Fighting; Parents
12.  A population-based study examining the effect of tyrosine kinase inhibitors on survival in metastatic renal cell carcinoma in Alberta and the role of nephrectomy prior to treatment 
We performed a retrospective population-based study to assess the impact of tyrosine kinase inhibitors (TKIs) on overall survival (OS) in patients treated for metastatic renal cell carcinoma (mRCC) in Alberta, Canada and to assess the impact of nephrectomy on OS in patients treated with TKIs.
We identified 134 patients who began taking a TKI between December 2003 and June 2007 for mRCC in Alberta. We compared survival in this group to that in an earlier cohort of 141 patients treated with interferon-α (IFN-α) between May 1995 and March 2003. We used the Kaplan–Meier method to determine OS, and we used a Cox proportional hazards model to determine hazard ratios (HRs) and confidence intervals (CIs). We performed multivariate analysis to assess the impact of neprhectomy on OS.
Of the 134 patients treated with TKIs, 81 received treatment in the first-line setting, whereas 53 received treatment after prior IFN-α therapy. All 141 patients from the IFN-α cohort received treatment in the first-line setting. Patients treated with TKIs had an improved OS compared with the IFN-α cohort (HR 0.61, 95% CI 0.45–0.83, p = 0.001). The median OS was 18 months in the TKI group and 10 months in the IFN-α group. The benefit of TKIs was confined to favourable and intermediate risk groups according to the Memorial Sloan-Kettering Cancer Center prognostic model. Prior nephrectomy was associated with improved OS in the TKI cohort, independent of other prognostic factors.
Tyrosine kinase inhibitors improve OS compared with IFN-α in mRCC. In patients treated with TKIs, prior nephrectomy is associated with improved survival independent of other prognostic variables.
PMCID: PMC2723887  PMID: 19672439
13.  Effectiveness of a Mentor-Implemented Violence Prevention Intervention for Assault-Injured Youth Presenting to the Emergency Department: Results of a Randomized Trial 
Pediatrics  2008;122(5):938-946.
The emergency department has been described as a promising setting to initiate interventions with assault-injured youth to reduce the risk of re-injury and reactive perpetration. Efforts to intervene have received little study.
To assess the impact of a mentor-implemented violence prevention intervention on reducing aggression, fighting and re-injury among assault-injured youth.
Randomized controlled trial
Two large urban hospital emergency departments
Youth age 10–15 presenting with peer assault injury were recruited and randomly assigned to intervention and comparison groups.
Intervention youth received a mentor who implemented a 6 session problem-solving curriculum while parents received 3 home visits with a health educator to discuss family needs and facilitate service use and parental monitoring. The comparison group received a list of community resources with 2 follow-up phone calls to facilitate service use.
Main Outcome Measures
Youth and parents were interviewed at baseline and 6 months to assess attitudes about violence, risk factors, fighting and repeat injury.
227 families were recruited with 23% refusing participation and 4% partial interview completion. 166 families were enrolled with 87 randomized to the intervention group and 79 in the comparison group; 118 (71%) completed both youth and parent follow-up interviews and 113 had usable data. Intervention and comparison groups were not significantly different at baseline on demographics or risk factors except for increased knife carrying and less deviant peers in the intervention group. After adjustment for baseline differences, there was a trend toward significant program effect including reducing misdemeanor activity (rate ratio 0.29, confidence interval 0.08–0.98), youth-reported aggression scores (rate ratio .63, 0.4–1.00) and increasing youth self efficacy (beta=2.28, p<.05). Program impact was associated with number of intervention sessions received.
A community-based, mentor-implemented program with assault-injured youth presenting to the ED trended in the direction of decreased violence with reduced misdemeanors and increased self efficacy. The ED may be an important contact location, and injuries an important context, for augmenting self efficacy for violence prevention.
PMCID: PMC2587407  PMID: 18977971
Adolescent health; emergency department; fighting; injury prevention and control; youth violence
14.  Differential Inhibition of Wnt-3a by Sfrp-1, Sfrp-2, and Sfrp-3 
Secreted frizzled related proteins (Sfrps) are extracellular attenuators of Wnt signaling that play important roles in both embryogenesis and oncogenesis. Although Sfrps are generally thought to bind and sequester Wnts away from active receptor complexes, very little is known about the specificity of Sfrp family members for various Wnts. In the developing chick neural tube, sfrp-1, 2 and 3 transcripts are expressed in and adjacent to the dorsal neural tube, where Wnt-1 and Wnt-3a are expressed. To better define the possible roles of Sfrp-1, 2 and 3 in the neural tube, we first tested the ability of purified Sfrps to inhibit Wnt-3a induced accumulation of β-catenin in L cells. We find that both Sfrp-1 and Sfrp-2 can inhibit Wnt-3a activity while Sfrp-3 cannot. To determine where Sfrp-1 and Sfrp-2 impinge on the Wnt signaling pathway, we tested the ability of these Sfrps to inhibit Wnt signaling induced by the addition of LiCl, an inhibitor of GSK-3. Sfrp-1 and Sfrp-2 are unable to inhibit the accumulation of β-catenin in LiCl treated cells, suggesting that the ability of Sfrps to inhibit the accumulation of β-catenin is GSK-3 dependent. We have further shown that Sfrp-2 inhibits the ability of ectopic Wnt-3a to stimulate proliferation in the developing chick neural tube. These results provide the framework for understanding how Sfrps function to regulate Wnt-3a activity in developing embryos and in cancer.
PMCID: PMC2566934  PMID: 16425220
chick embryo; neural tube; Sfrp-1; Sfrp-2; Sfrp-3; Wnt-3a
15.  Nonabusive physical punishment and child behavior among African-American children: a systematic review. 
BACKGROUND: The use of nonabusive physical punishment as a form of discipline has been greatly debated in the scientific and popular literature. Impact on child behavioral outcomes has frequently been found; however, the effects of its use are not clear, particularly for African-American children. This systematic review of the literature examined the impact of exposure to nonabusive physical punishment on the behavior of African-American children. METHODS: A search was conducted of PubMed and Psyclnfo from 1970 to 2000 using the key terms: corporal punishment, physical punishment, disciplinary practices, and discipline and parenting. Studies that described ethnicity of the population and included a majority of a well-described African-American population were included. Each study was required to include measurable data on child behavioral outcomes and at least one measure of discipline that assessed use of nonabusive physical punishment in children 0-14 years of age. RESULTS: All seven included studies used lower socioeconomic status (SES) and/or urban African-American populations. Study design and rural versus urban populations differentiated beneficial and detrimental outcomes. In all longitudinal studies, African-American children had beneficial or neutral outcomes. DISCUSSION: This review suggests that it is possible that there are benefits to nonabusive physical punishment for African-American children. However, needed are further longitudinal studies that better assess the multiple confounders that impact the use of discipline, such as SES, parental education level, and exposure to community or domestic violence.
PMCID: PMC2568462  PMID: 15481744

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