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1.  Systemic glucocorticoid use and early-onset basal cell carcinoma 
Annals of epidemiology  2014;24(8):625-627.
PMCID: PMC4119504  PMID: 24958637
basal cell carcinoma; case-control; epidemiology; glucocorticoids; immunosuppressives; keratinocyte carcinoma; non-melanoma skin cancer
2.  Use of Alcohol Before Suicide in the United States 
Annals of epidemiology  2014;24(8):588-592.e2.
Few studies have compared acute use of alcohol in suicide decedents with that in a nonsuicide group. This study provides the first national analysis of acute use of alcohol prior to suicide compared with an estimate of acute use of alcohol in a living sample.
Pooled 2003-2011 National Violent Death Reporting System data were used to estimate the prevalence of postmortem blood alcohol content positivity (BAC >0.0 g/dl) and intoxication (BAC ≥ 0.08 g/dl). Population estimates of comparable use of alcohol (within the past 48 hours) were based on the National Epidemiologic Survey on Alcohol and Related Conditions.
Compared to the living sample, male and female suicide decedents showed, respectively, a 1.83- (95% confidence interval [CI], 1.73-1.93) and 2.40-fold (95% CI, 2.24-2.57) increased risk of alcohol ingestion prior to their death after age, race/ethnicity, and chronic alcohol problems were controlled. Furthermore, male and female decedents exhibited, respectively, a 6.18- (95% CI, 5.57-6.86) and a 10.04-fold (95% CI, 8.67-11.64) increased risk of being intoxicated prior to their death after confounders were considered.
The findings underscore the crucial need to include among the essential components of suicide prevention policies programs that minimize use of alcohol, particularly drinking to intoxication.
PMCID: PMC4119510  PMID: 24953567
Suicide; Toxicology; Alcohol Drinking; and Epidemiology
3.  Declines in Coronary Heart Disease Incidence and Mortality among Middle-Aged Adults with and without Diabetes 
Annals of epidemiology  2014;24(8):581-587.
To investigate secular changes in CHD incidence and mortality among adults with and without diabetes and determine the effect of increased lipid-lowering medication use and reductions in low-density lipoprotein cholesterol (LDL-C) levels on these changes.
We analyzed data on participants aged 45–64 years from the Atherosclerosis Risk in Communities Study in 1987–1996 (early time period) and the Reasons for Geographic and Racial Differences in Stroke Study in 2003–2009 (late time period). Hazard ratios (HR) for the association of diabetes and time period with incident CHD and CHD mortality were obtained after adjustment for socio-demographics, cardiovascular risk factors, lipid-lowering medication use, and LDL-C.
After multivariable adjustment, diabetes was associated with an increased CHD risk during the early (HR=1.99,95% CI=1.59,2.49) and late (HR=2.39,95% CI=1.69,3.35) time periods. CHD incidence and mortality declined between the early and late time periods for individuals with and without diabetes. Increased use of lipid-lowering medication and lower LDL-C explained 33.6% and 27.2% of the decline in CHD incidence and CHD mortality, respectively, for those with diabetes.
Although rates have declined, diabetes remains associated with an increased risk of CHD incidence and mortality, highlighting the need for continuing diabetes prevention and cardiovascular risk factor management.
PMCID: PMC4135722  PMID: 24970491
diabetes; CHD; LDL-cholesterol; epidemiology
4.  Mortality cohort effects from mid-19th to mid-20th century Britain: did they exist? 
Annals of epidemiology  2014;24(8):570-574.
Identification is a central problem with age–period–cohort analysis. Because age + cohort = period, there is no unique solution to the linear effect using generalized linear modeling, but cohort effects have caused greater controversy than age and period effects. To illustrate the magnitude of cohort effects given the presence of collinearity, we reanalyze data from the seminal study by Kermack et al, with an update.
Relative mortality data in England and Wales between year 1845 and 1995 were analyzed using partial least squares regression. There were seven age groups ranging from 5 to 74 years old and 16 periods with 22 cohorts.
Our reanalysis seemed to support the existence of cohort effects in the mortality trends. Period and cohort effects were generally consistent with changes in the social, economic, and environmental factors taking place in the last two centuries. Our analysis also showed a declining trend in period effects up to 1950s.
Partial least squares and related methods provide intuitive pointers toward the separation of linear age, period, and cohort effects. Because statistical algorithms cannot distinguish between relative and actual mortality rates, cohort effects may be underestimated because of contamination by negative age effects.
PMCID: PMC4402224  PMID: 25084701
Age–period–cohort analysis; Mortality; Partial least squares; Cohort effects
5.  Associations of Allostatic Load with Sleep Apnea, Insomnia, Short Sleep Duration, and Other Sleep Disturbances: Findings from the National Health and Nutrition Examination Survey 2005-2008 
Annals of epidemiology  2014;24(8):612-619.
To examine whether allostatic load (AL), a measure of cumulative physiologic dysregulation across biological systems, was associated with sleep apnea, insomnia, and other sleep disturbances.
Data from the National Health and Nutrition Examination Survey 2005-2008 were used. AL was measured using nine biomarkers representing cardiovascular, inflammatory, and metabolic system functioning. A total of 7,726 US adults aged 18 years and older were included in this study.
The prevalence of high AL (AL score ≥3) was the highest among African Americans (25.2%), followed by Hispanic Americans (21.0%), Whites (18.8%), and other racial/ethnic group (16.5%). After adjustment for sociodemographic and lifestyle factors and depression status, high AL was significantly associated with sleep apnea (odds ratio (OR)=1.49, 95% confidence interval (CI): 1.14-1.95), snoring (1.65, 95% CI: 1.41-1.93), snorting/stop breathing (OR=1.62, 95% CI: 1.25-2.10), prolonged sleep latency (OR=1.33, 95% CI: 1.13-1.56), short sleep duration (<6 hours) (OR=1.29, 95% CI: 1.04-1.61), and diagnosed sleep disorder (OR=1.85, 95% CI: 1.53-2.24). There was no clear evidence that observed associations varied by sociodemographic characteristics or depression status.
This study suggests significant associations of high AL with sleep apnea, sleep apnea symptoms, insomnia component, short sleep duration, and diagnosed sleep disorder among US adults.
PMCID: PMC4188508  PMID: 24985316
adult; allostatic load; insomnia; national survey; short sleep duration; sleep apnea; sleep disorder; sleep disturbance
6.  Racial differences in prostate cancer screening by family history 
Annals of epidemiology  2008;18(7):579-583.
Prostate cancer (CaP) is disproportionately prevalent among Black, compared to White men. Additionally, men with a family history of CaP have 75% to 80% higher risk of CaP. Therefore, we examined racial variation in the association of family history of CaP and self-reported PSA testing in the nationally-representative National Health Interview Survey (NHIS)
Data was obtained from the 2005 NHIS, including the Cancer Control Module supplement. We restricted the sample to men, over the age of 40 who reported having “ever heard of a PSA test” (N=1,744). Men were considered to have a positive family history if either their biological father or at least one biological brother had been diagnosed with CaP. SUDAAN 9.0 was used to perform descriptive and multivariable logistic regression analyses.
Men with a family history of CaP were more likely to have a PSA test than those who never had a PSA test (OR=1.8 CI 1.3, 2.5). Among Blacks, men with a family history were not significantly more likely to have a PSA test.
Despite having the highest risk of cancer, Black men with a family history are not screened more than Black men without a family history.
PMCID: PMC4518720  PMID: 18486487
Prostate cancer; screening; family history; NHIS; disparity
7.  The PhenX Toolkit pregnancy and birth collections 
Annals of epidemiology  2012;22(11):753-758.
Pregnancy and childbirth are normal conditions, but complications and adverse outcomes are common. Both genetic and environmental factors influence the course of pregnancy. Genetic epidemiologic research into pregnancy outcomes could be strengthened by the use of common measures, which would allow data from different studies to be combined or compared. Here, we introduce perinatal researchers to the PhenX Toolkit and the Collections related to pregnancy and childbirth.
The Pregnancy and Birth Collections were drawn from measures in the PhenX Tooklit. The lead author selected a list of measures for each Collection, which was reviewed by the remaining authors and revised on the basis of their comments. We chose the measures we thought were most relevant for perinatal research and had been linked most strongly to perinatal outcomes.
The Pregnancy and Birth Health Conditions Collection includes 24 measures related to pregnancy and fertility history, maternal complications, and infant complications. The Pregnancy and Birth Outcome Risk Factors Collection includes 43 measures of chemical, medical, psychosocial, and personal factors associated with pregnancy outcomes.
The biological complexity of pregnancy and its sensitivity to environmental and genomic influences suggest that multidisciplinary approaches are needed to generate new insights or practical interventions. To fully exploit new research methods and resources, we encourage the biomedical research community to adopt standard measures to facilitate pooled or meta-analyses.
PMCID: PMC4508122  PMID: 22954959
Pregnancy; Birth; Risk factors; Pregnancy outcomes
8.  Variability of the Date of HIV Diagnosis: A Comparison of Self-Report, Medical Record, and HIV/AIDS Surveillance Data 
Annals of epidemiology  2010;20(10):734-742.
Describe and quantify differences among the year of first positive HIV test from patient report, the medical record, and HIV/AIDS surveillance data.
We merged two clinic-based studies with overlapping HIV-infected participant populations in North Carolina with the HIV/AIDS Reporting System (HARS) and examined the first positive HIV test year from patient report, the medical record, and HARS. Matches were considered the same year of diagnosis.
The self-reported year of diagnosis had high agreement with the medical record (67% matched exactly and 19% differed by one year, weighted kappa=0.85), although there were wide 95% limits of agreement (−4.0 earlier to 3.9 years later). On average, the dates of diagnosis from patient report and the medical record were earlier than HARS with wide 95% limits of agreement (7.5 years earlier to 6.0 years later for patient report vs. HARS, 7.7 years earlier to 6.0 years later for medical record vs. HARS).
These measures could not reliably be used interchangeably as there was wide variability in both directions. Although collection of data from patient report or existing sources is convenient, cost-effective, and efficient, there is significant variability between sources.
PMCID: PMC4489564  PMID: 20620077
HIV infections; reproducibility of results; HIV serodiagnosis; surveillance; comparative study
9.  Serum Cotinine and Whole Blood Folate Concentrations in Pregnancy 
Annals of epidemiology  2014;24(7):498-503.e1.
Prenatal tobacco smoke exposure may be associated with low maternal folate levels that increase the risk of adverse infant and child health outcomes by reducing folate availability during fetal development.
Using data from the HOME Study, we examined the relationship between secondhand or active tobacco smoke exposure and whole blood folate concentrations in pregnant women from Cincinnati, OH (n=362) at approximately 16 weeks gestation. We used multivariable linear regression to examine the association between continuous or categorical serum cotinine levels and whole blood folate levels, adjusting for sociodemographic, dietary, and perinatal variables.
After adjustment for potential confounders, an interquartile range increase in serum cotinine concentration (0.012 to 0.224 ng/mL) was suggestively associated with decreased whole blood folate levels (β:−23 nmol/L; 95% CI:−49, 3, p-value=0.08). Compared to unexposed women, reductions in mean whole blood folate were observed among active smokers (β:−94, 95% CI:−195, 6 nmol/L, p-value=0.40); smaller reductions were observed among women with secondhand exposure (β:−26; CI:−84, 32 nmol/L, p-value=0.07).
Consistent with prior studies, active smoking was associated with reduced whole blood folate levels among these pregnant women. Secondhand tobacco smoke exposures were associated with small and imprecise reductions in whole blood folate levels.
PMCID: PMC4071615  PMID: 24854185
Epidemiology; folic acid; pregnancy; tobacco smoke pollution; smoking
10.  Disability and the Built Environment: An Investigation of Community and Neighborhood Land Uses and Participation for Physically Impaired Adults 
Annals of epidemiology  2014;24(7):545-550.
There is a need for empirical support of the association between the built environment and disability-related outcomes. This study explores the associations between community and neighborhood land uses and community participation among adults with acquired physical disability.
Cross-sectional data from 508 community-living, chronically disabled adults in New Jersey were obtained from among participants in national Spinal Cord Injury Model Systems database. Participants’ residential addresses were geocoded to link individual survey data with Geographic Information Systems (GIS) data on land use and destinations. The influence of residential density, land use mix, destination counts, and open space on four domains of participation were modeled at two geographic scales—the neighborhood (i.e., half mile buffer) and community (i.e., five mile) using multivariate logistic regression. All analyses were adjusted for demographic and impairment-related differences.
Living in communities with greater land use mix and more destinations was associated with a decreased likelihood of reporting optimum social and physical activity. Conversely, living in neighborhoods with large portions of open space was positively associated with the likelihood of reporting full physical, occupational, and social participation.
These findings suggest that the overall living conditions of the built environment may be relevant to social inclusion for persons with physical disabilities.
PMCID: PMC4100068  PMID: 24935467
Disability; Neighborhood/Place; GIS; Participation
11.  Using a physician panel to estimate food allergy prevalence in a longitudinal birth cohort 
Annals of epidemiology  2014;24(7):551-553.
PMCID: PMC4104510  PMID: 24854182
food allergy; food-specific IgE; double-blind placebo-controlled food challenge; sensitization; milk; egg; peanut; physician panel; birth cohort
12.  Assessing Validity of a Depression Screening Instrument in the Absence of a Gold Standard 
Annals of epidemiology  2014;24(7):527-531.
We evaluated the extent to which use of a hypothesized imperfect gold standard, the Composite International Diagnostic Interview (CIDI), biases the estimates of diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9). We also evaluate how statistical correction can be used to address this bias.
The study was conducted among 926 adults where structured interviews were conducted to collect information about participants’ current major depressive disorder (MDD) using PHQ-9 and CIDI instruments. First, we evaluated the relative psychometric properties of PHQ-9 using CIDI as a gold standard. Next, we employed a Bayesian latent-class model to correct for the bias.
In comparison with CIDI, the relative sensitivity and specificity of the PHQ-9 for detecting MDD at a cut point of ≥10 were 53.1% (95%CI: 45.4–60.8%) and 77.5% (95%CI: 74.5–80.5%), respectively. Using a Bayesian latent-class model to correct for the bias arising from the use of an imperfect gold standard increased the sensitivity and specificity of PHQ-9 to 79.8% (95% Bayesian credible interval (BCI): 64.9–90.8%) and 79.1% (95%BCI:74.7–83.7%), respectively
Our results provided evidence that assessing diagnostic validity of mental health screening instrument, where application of a gold standard might not be available, can be accomplished by using appropriate statistical methods.
PMCID: PMC4104527  PMID: 24935465
13.  Using Sociometric Measures to Assess Non-Response Bias 
Annals of epidemiology  2014;24(7):554-557.
Much attention has been given to the potential non-response bias that occurs in epidemiologic studies that attempt to enroll a representative sample. Most analyses surrounding non-respondents focus on individual-level attributes and how they vary across respondents and non-respondents. While these attributes are of interest, analysis of the social network position of non-respondents as defined by traditional sociometric measures (i.e. centrality, bridging) has not been conducted, and could provide further insights into the validity of the sample.
We utilized data from the Secunderabadi Mens’ Study, a whole network of Indian men who have sex with men (MSM) generated using cell phone contact lists of men approached using Time Location Cluster Sampling. Multivariable logistic regression was used to determine whether demographic and behavioral attributes and in-degree (the frequency that a MSM was listed across all cell phone contact lists) were associated with being a respondent.
239 respondents were interviewed and 81 were approached but did not consent to the interview (“non-respondents”).
Respondents were more likely to have higher in-degree than non-respondents, adjusting for attribute differences (OR 1.19; 95% CI 1.07, 1.34). This analysis suggests that the network position of non-respondents may be important when considering the potential impact of non-response bias.
PMCID: PMC4128320  PMID: 24935468
Epidemiologic Biases; Social Networking; Data Collection
14.  Changes in the prevalence of mood and anxiety disorders among male and female current smokers in the United States: 1990 to 2001 
Annals of epidemiology  2014;24(7):493-497.
The present study investigated whether the prevalence of mood and anxiety disorders has increased over time among current smokers, as well as whether these trends differ by gender and in comparison to non-smokers.
Data were drawn from the National Comorbidity Survey (NCS; 1990) and the National Comorbidity Survey-Replication (NCS-R; 2001), representative samples of the US adult population. Binomial regression analyses were used to determine differences between mood and anxiety disorders among current smokers in 1990 and 2001 and whether these differed by gender and in comparison to those who were former or never current smokers.
Any anxiety disorder, panic attacks, panic disorder, social anxiety disorder and dysthymia were all significantly more common among current smokers in 2001 compared with 1990 and these increases were significantly greater than any trend found in non-smokers. Increases in each of these disorders were more pronounced in female than in male smokers. Major depressive disorder and generalized anxiety disorder were not found to increase over time among smokers.
The prevalence of several anxiety disorders and dysthymia among current smokers appears to have increased from 1990 to 2001. Future studies are needed to determine whether these trends have continued. If so, interventions aimed at moving the prevalence lower may have limited success if mental health problems such as anxiety disorders and certain mood disorders are not considered in the development and dissemination of tobacco control programs.
PMCID: PMC4393820  PMID: 24935462
tobacco; depression; anxiety; prevalence
15.  Estimation of biomarker distributions using laboratory data collected during routine delivery of medical care 
Annals of epidemiology  2014;24(10):754-761.
To examine the extent to which commonly ordered laboratory values obtained from large health care databases are representative of the distribution of laboratory values from the general population as reflected in the National Health and Nutrition Examination Survey.
Means of test values from commercial insurance laboratory data and National Health and Nutrition Examination Survey data were compared. Inverse probability of selection weighting was used to account for possible selection bias and to create comparability between the two data sources. Results: The average values of most of the laboratory results from routine care were very close to their population means as estimated from NHANES. Tests that were more selectively ordered tended to differ. The inverse probability of selection weighting approach generally had a small effect on the estimated means but did improve estimation of some of the more selected tests.
Commonly ordered laboratory tests appear to be representative of values from the underlying population. This suggests that trends and other patterns in biomarker levels in the population may be reasonably studied using data collected during the routine delivery of medical care.
PMCID: PMC4476533  PMID: 25238941
National Health and Nutrition Examination; Survey; Laboratories; Selection bias; Epidemiologic methods
16.  A Multi-State Model of Cognitive Dynamics in Relation to Resistance Training: The Contribution of Baseline Function 
Annals of epidemiology  2013;23(8):463-468.
We investigated: 1) the effect of different targeted exercise training on an individual’s overall probability for cognitive improvement, maintenance, or decline; and 2) the simultaneous effect of targeted exercise training and baseline function on the dynamics of executive functions using a multi-state transition model.
Analyses are based on a 12-month randomized clinical trial including 155 community-dwelling women 65 to 75 years old who were randomly allocated to once-weekly resistance training (1x RT; n=54), twice-weekly resistance training (2x RT; n=52), or twice-weekly balance and tone training (BAT; n=49). The primary outcome measure was performance on the Stroop Test, an executive cognitive test of selective attention and conflict resolution. Secondary outcomes of executive functions were set shifting and working memory.
Individuals in the 1x RT or 2x RT group demonstrated a significantly higher probability for improved performance on the Stroop Test (0.49; 95% CI=0.41 to 0.57) compared with those in the BAT group (0.25; 95% CI=0.25 to 0.40). Resistance training had significant effects on transitions in selective attention and conflict resolution.
Resistance training is efficacious in improving a measure of selective attention and conflict resolution in older women – probably more so among those with higher baseline cognitive function.
PMCID: PMC4476840  PMID: 23830936 CAMSID: cams4721
Resistance Training; Executive Functions; Multi-State Transition Model
17.  Economic contraction and maternal health behaviors during pregnancy in a national sample of U.S. women 
Annals of epidemiology  2014;24(6):432-440.
The purpose of this study was to examine associations between maternal exposure to unexpected economic contraction and health behaviors during pregnancy, using methods to account for impacts of economic contraction on selection into pregnancy.
Data on health behaviors among 7,074 pregnancies in the National Longitudinal Survey of Youth 1979 were linked to monthly unemployment rates in maternal state of residence. The study examined associations between exposure to unexpected economic contraction (higher than expected state-level unemployment) during each trimester of pregnancy and maternal smoking, alcohol use, and gestational weight gain using generalized linear models.
Economic contraction was not associated with maternal smoking or gestational weight gain. Associations between economic contraction and maternal alcohol use differed by maternal race/ethnicity and education. Among Black/non-Hispanic women, exposure to economic contraction during the first and second trimester of pregnancy were associated with a 42% (95% CI: 1.08, 1.85) and 33% (95% CI: 1.01, 1.74) increased risk of alcohol use, respectively.
Findings suggest that exposure to extreme economic contraction during pregnancy may be associated with increased use of alcohol with differences by maternal race/ethnicity and educational attainment. Economic contraction was not associated with other maternal pregnancy behaviors.
PMCID: PMC4029848  PMID: 24703197
economic conditions; pregnancy; smoking; alcohol consumption; weight gain
18.  Association of Long-Duration Breastfeeding and Dental Caries Estimated with Marginal Structural Models 
Annals of epidemiology  2014;24(6):448-454.
Estimate the association between breastfeeding ≥24 months and severe early childhood caries (ECC).
Within a birth cohort (n=715) from low-income families in Porto Alegre, Brazil, the age 38-month prevalence of severe-ECC (≥4 affected tooth surfaces or ≥1 affected maxillary anterior teeth) was compared over breastfeeding duration categories using marginal structural models to account for time-dependent confounding by other feeding habits and child growth. Additional analyses assessed whether daily breastfeeding frequency modified the association of breastfeeding duration and severe-ECC. Multiple imputation and censoring weights were used to address incomplete covariate information and missing outcomes, respectively. Confidence intervals (CI) were estimated using bootstrap re-sampling.
Breastfeeding ≥24 months was associated with the highest adjusted population-average severe-ECC prevalence (0.45, 95% CI: 0.36, 0.54) compared with breastfeeding <6 months (0.22, 95% CI: 0.15, 0.28), 6–11 months (0.38, 95% CI: 0.25, 0.53), or 12–23 months (0.39, 95% CI: 0.20, 0.56). High frequency breastfeeding enhanced the association between long-duration breastfeeding and caries (excess prevalence due to interaction: 0.13, 80% CI: −0.03, 0.30).
In this population, breastfeeding ≥24 months, particularly if frequent, was associated with severe-ECC. Dental health should be one consideration, among many, in evaluating health outcomes associated with breastfeeding ≥24 months.
PMCID: PMC4029874  PMID: 24636616
breastfeeding; dental caries; epidemiologic methods; feeding behavior; marginal structural models; prospective studies
19.  Racial differences in gestational weight gain and pregnancy-related hypertension 
Annals of epidemiology  2014;24(6):441-447.
To examine racial differences in gestational weight gain (GWG) and pregnancy-related hypertension.
Logistic regression models tested racial differences in adequacy of GWG and pregnancy-induced hypertension in all singleton live births from the South Carolina 2004-2006 birth certificates.
Compared to white women, black and Hispanic women had 16%-46% lower odds of gaining weight above the recommendations. However, the odds of inadequate GWG was ~50% higher in black and Hispanic women with a pregnancy body mass index (BMI) <25kg/m2. Furthermore, compared to women with adequate GWG, women with excessive GWG had higher odds of pregnancy-related hypertension (underweight: 2.35, 95% CI(1.66, 3.32); normal: 2.05, 95% CI(1.84, 2.27); overweight: 1.93, 95% CI(1.64, 2.27); obese: 1.46, 95% CI(1.30, 1.63)). Among women with a BMI <25 kg/m2, black women had higher odds of pregnancy-related hypertension than white women (underweight: 1.64, 95% CI(1.14, 2.36); normal weight: 1.28, 95% CI(1.15, 1.42)), while among women with a BMI ≥25 kg/m2, Hispanic women had 40% lower odds.
Programs are needed to curb excessive GWG in all racial groups and to help some sub-groups ensure adequate GWG. Maternal obesity and GWG are two factors that should be used in combination to reduce racial differences in pregnancy-related hypertension.
PMCID: PMC4029921  PMID: 24685832
20.  Multiple metabolic risk factors and mammographic breast density 
Annals of epidemiology  2014;24(6):479-483.
We examined whether obesity and a history of diabetes, hypertension, and elevated cholesterol, individually and in combination, are associated with breast density, a strong risk factor for breast cancer.
We measured percent density and dense area using a computer-assisted method (n=191; age range=40-61 years). We used linear regression models to examine the associations of each metabolic condition and the number of metabolic conditions (0, 1, 2, and 3 or 4 conditions) with breast density.
Among individual metabolic conditions, only high blood cholesterol was inversely associated with percent density (β=-5.4, 95% CI: -8.5, -2.2) and dense area (β= -6.7, 95% CI=-11.1, -2.4). Having multiple metabolic conditions was also associated with lower breast density, with 2 conditions and 3 or 4 conditions vs. 0 conditions associated with 6.4% (95% CI:-11.2, -1.6) and 7.4% (95% CI:-12.9, -1.9) reduction in percent density and with 6.5 cm2 (95% CI: -13.1, -0.1) and 9.5 cm2 (95% CI: -17.1, -1.9) smaller dense area.
A history of high blood cholesterol and multiple metabolic conditions were associated with lower relative and absolute measures of breast density. The positive association between metabolic abnormalities and breast cancer risk may be driven by pathways unrelated to mammographic breast density.
PMCID: PMC4076948  PMID: 24698111
21.  Heterogeneity in Periodontitis Prevalence in the Hispanic Community Health Study/Study of Latinos 
Annals of epidemiology  2014;24(6):455-462.
To examine acculturation and established risk factors in explaining variation in periodontitis prevalence among Hispanic/Latino subgroups.
Participants were 12,730 dentate adults aged 18–74 years recruited into the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) from four U.S. field centers between 2008 and 2011. A standardized periodontal assessment measured probing pocket depth and gingival recession at six sites per tooth for up to 28 teeth. Periodontitis was defined according to the CDC/AAP case classifications developed for population surveillance. Covariates included acculturation indicators and established periodontitis risk factors. Survey estimation procedures took account of the complex sampling design. Adjusted multivariate binomial regression estimated prevalence ratios (PR) and 95% confidence limits (95% CL).
Unadjusted prevalence of moderate/severe periodontitis was 38.5% and ranged from 24.7% among Dominicans to 52.1% among Cubans. Adjusted prevalence ratios for subgroups relative to Dominicans were: 1.34 (95% CL: 1.13, 1.58) among South Americans; 1.37 (95% CL: 1.17, 1.61) among Puerto Ricans; 1.43 (95% CL: 1.25, 1.64) among Mexicans; 1.53 (95% CL: 1.32, 1.76) among Cubans; and 1.55 (95% CL: 1.35, 1.78) among Central Americans.
Heterogeneity in prevalence of moderate/severe periodontitis among Hispanic/Latino subpopulations was not explained by acculturation or periodontitis risk factors.
PMCID: PMC4050972  PMID: 24731697
Acculturation; American; Hispanic; Chronic Periodontitis; Effect Modifier; Epidemiologic; Epidemiology; Population Groups; Risk Factors
22.  Exploring the association between melanoma and glioma risks 
Annals of epidemiology  2014;24(6):469-474.
Gliomas are one of the most fatal malignancies, with largely unknown etiology. This study examines a possible connection between glioma and melanoma, which might provide insight into gliomas’ etiology.
Using data provided by the Surveillance, Epidemiology, and End Results (SEER) program from 1992-2009, a cohort was constructed to determine the incidence rates of glioma among those who had a prior diagnosis of invasive melanoma. Glioma rates in those with prior melanoma were compared to those in the general population.
The incidence rate of all gliomas was greater among melanoma cases than in the general population: 10.46 vs. 6.13 cases per 100,000 person-years, SIR = 1.42 (1.22-1.62). The female excess rate was slightly greater (42%) than that among males (29%). Sensitivity analyses did not reveal evidence that radiation treatment of melanoma is responsible for the detected gap in the rates of gliomas.
Our analysis documented increased risk of glioma among melanoma patients. Since no common environmental risk factors are identified for glioma and melanoma, it is hypothesized that a common genetic predisposition may be responsible for the detected association.
PMCID: PMC4111084  PMID: 24703682
SEER; epidemiology; melanoma; glioma; glioblastoma
23.  Alcohol Intake and Non-Coronary Cardiovascular Diseases 
Annals of epidemiology  2007;17(5 0):S8-S12.
Moderate drinking has complex associations with cardiovascular diseases other than coronary heart disease. Recent cohort studies examining the relationship between alcohol use and ischemic stroke have shown a modest association, with risk ratios approximating 0.8, and the lowest risk among those who drink less than daily. In contrast, alcohol use is generally associated with a roughly dose-dependent risk for hemorrhagic stroke throughout the full range of intake.
Several prospective studies of alcohol intake and congestive heart failure have found lower risk with moderate drinking. This risk is also dose-dependent through the moderate range, but its underlying mechanism remains uncertain. Accounting for the lower risk of myocardial infarction associated with moderate intake does not eliminate the observed association. Cohort studies have found no association of chronic alcohol intake with risk of atrial fibrillation below levels of at least three standard drinks per day. Finally, two prospective studies have found lower risks of claudication or clinically more severe peripheral arterial disease among moderate drinkers, an association also supported by cross-sectional studies of alcohol intake and ankle-brachial index.
PMCID: PMC4446120  PMID: 17478332
Alcohol drinking; stroke; heart failure; peripheral arterial disease; atrial fibrillation
24.  Early childhood diarrhea and cardiometabolic risk factors in adulthood: The Institute of Nutrition of Central America and Panama (INCAP) Nutritional Supplementation Longitudinal Study 
Annals of epidemiology  2013;23(6):314-320.
Nutritional deficits in early life have been associated with a higher prevalence of metabolic syndrome (MetS) in adulthood. Early childhood diarrhea contributes to under-nutrition and may potentially increase the risk for adult non-communicable diseases. Our objective was to examine associations between early childhood diarrhea burden and later development of MetS.
We studied individuals who participated in the Institute of Nutrition of Central America and Panama Nutritional Supplementation Longitudinal Study (1969–1977) and were followed up in 2002–04. We used logistic regression to determine associations of diarrhea burden at ages 0–6 mo, 6–12 mo, and 12–24 mo with odds of MetS and elevations in its components as adults.
Among 389 adults age 25–42 years at follow-up the prevalence of MetS was 29%. Adjusting for several confounders including adult BMI, each absolute 1% increase in diarrhea burden at age 0–6 mo (but not at other time periods) was associated with increased odds of MetS (odds ratio 1.03; 95% CI 1.01–1.06). This was attributable primarily to associations with elevated BP (OR 1.03, 1.00–1.06) and waist circumference (OR 1.03, 1.00–1.06).
Childhood diarrhea burden 0–6 months is associated with MetS in adulthood after controlling for childhood growth parameters and adult BMI.
PMCID: PMC4431615  PMID: 23608305
metabolic syndrome; enteric disease; infection; malnutrition; early origins of adult disease
25.  Proteinuria in Mid-Life and 39-Year Total Mortality: The Honolulu Heart Program 
Annals of epidemiology  2014;24(5):407-409.
PMCID: PMC3992477  PMID: 24613198
proteinuria; urinalysis; mortality; cohort studies; Japanese Americans

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