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1.  Cancer Screening: The Journey from Epidemiology to Policy 
Annals of epidemiology  2012;22(6):439-445.
Cancer screening procedures have brought great benefit to the public’s health. However, the science of cancer screening and the evidence arising from research in this field as it is applied to policy is complex and has been difficult to communicate, especially on the national stage. We explore how epidemiologists have contributed to this evidence base and to its translation into policy. Our essay focuses on breast and lung cancer screening to identify commonalities of experience by epidemiologists across two different cancer sites and describe how epidemiologists interact with evolving scientific and policy environments. We describe the roles and challenges that epidemiologists encounter according to the maturity of the data, stakeholders, and the related political context. We also explore the unique position of cancer screening as influenced by the legislative landscape where, due to recent healthcare reform, cancer screening research plays directly into national policy. In the complex landscape for cancer screening policy, epidemiologists can increase their impact by learning from past experiences, being well prepared and communicating effectively.
PMCID: PMC4096857  PMID: 22626002
Epidemiology; Public Policy; Health Policy; Cancer Screening
2.  The impact of HIPAA authorization on willingness to participate in clinical research 
Annals of epidemiology  2007;17(11):899-905.
This study systematically examines the impact of inclusion of HIPAA authorization on the willingness of African Americans of diverse sociodemographic characteristics to participate in a clinical research study and explores reasons for non-participation.
For a purposive sample of 384 African American outpatients at 4 metropolitan primary care clinics from August 2005 through May 2006, willingness to participate in a hypothetical clinical research study of an antihypertensive medication under one of two experimental conditions was compared. Interviewees were randomly assigned to undergo informed consent alone (control group) or informed consent with HIPAA authorization (HIPAA group). They were asked whether they would participate and reasons for their decision.
A smaller proportion of interviewees in the HIPAA group were willing to enroll in the study (27% vs. 39%; p=.02), with an adjusted odds ratio = 0.56 (95% confidence interval: 0.36 – 0.91). Those in the HIPAA group were more likely to give reasons related to privacy (p<.001), poor understanding of the form (p=.01), and mistrust or fear of research (p=0.04) for non-participation.
The inclusion of HIPAA authorization within the informed consent process may adversely affect the willingness of African Americans to participate in clinical research and may raise concerns about privacy, understanding the forms, and mistrust or fear of research.
PMCID: PMC4096152  PMID: 17689261
clinical trial; consent form; HIPAA; minority groups; patient participation
3.  Physical health indicators among lesbian, gay, and bisexual U.S. Veterans 
Annals of epidemiology  2013;23(7):448-451.
To provide information about lesbian, gay and bisexual (LGB) veterans’ health status, diagnoses, and health screening behaviors compared with heterosexual veterans.
Data are from ten states’ 2010 Behavioral Risk Factor Surveillance System (BRFSS) surveys that contained sexual orientation data for veterans (n=11,665). Chi-square tests and multiple logistic regression were used to examine outcomes among LGB and heterosexual veterans.
More LGB veterans than heterosexual veterans reported current smoking, not seeking medical care due to cost, and activity limitations. Compared with heterosexual veterans, LGB veterans had greater odds of ever having an HIV test (OR=5.42; 95%CI: 3.28–8.96) but lower odds of diabetes diagnosis (0.55 (0.34–0.89).
Findings from this sample suggest patterns of health behaviors and outcomes among LGB veterans that are both unique from and similar to results from general samples of LGB persons. With the formal end of the “Don’t Ask, Don’t Tell” policy that discriminated against LGB people in the military, institutions such as the Department of Veterans Affairs (VA) are likely to see an increase in its current population of LGB veterans. The VA stands in a unique place to meet the health equity needs of this minority population.
PMCID: PMC3698572  PMID: 23688720
4.  Medically induced preterm birth and the associations between prenatal care and infant mortality 
Annals of epidemiology  2013;23(7):435-440.
Over the last thirty years, prenatal care utilization, both the proportion of women receiving the recommended number of visits and the average number of visits, has increased substantially. Although infant mortality has fallen, preterm birth has increased. We hypothesized that prenatal care may lead to lower infant mortality in part by increasing the detection of obstetrical problems for which the clinical response may be to medically induce preterm birth.
We examine whether medically induced preterm birth mediates the association between prenatal care and infant mortality using newly developed methods for mediation analysis. Data are the cohort version of the national linked birth certificate and infant death data for 2003 births. Analyses adjust for maternal sociodemographic, geographic and health characteristics.
Receiving more prenatal care visits than recommended was associated with medically induced preterm birth (OR=2.44 (95% CI: 2.40,2.49) compared with fewer visits than recommended). Medically induced preterm birth was itself associated with higher infant mortality (OR=5.08, 95% CI: 4.61,5.60)), but that association was weaker among women receiving extra prenatal care visits (OR=3.08 95% CI: 2.88,3.30)) compared to women receiving the recommended number of visits or fewer.
These analyses suggest that some of the benefit of prenatal care in terms of infant mortality may be mediated by medically induced preterm birth. If so, using preterm birth rates as a metric for tracking birth policy and outcomes could be misleading.
PMCID: PMC3711527  PMID: 23726822
5.  Adipocytokines as Features of the Metabolic Syndrome Determined Using Confirmatory Factor Analysis 
Annals of epidemiology  2013;23(7):415-421.
Confirmatory factor analysis (CFA) was used to test the hypothesis whether adipocytokines are associated with the risk factor cluster that characterizes the metabolic syndrome (MetS).
Data from 134 nondiabetic subjects were analyzed using CFA. Insulin sensitivity (SI) was quantified using intravenous glucose tolerance tests, visceral fat area by CT scan and fasting HDL, triglycerides, monocyte chemo-attractant protein-1 (MCP-1), serum amyloid A (SAA), tumor necrosis factor-α (TNF-α), adiponectin, resistin, leptin, interleukin-6 (IL-6), C-reactive protein (CRP) and plasminogen activator inhibitor-1 (PAI-1) were measured.
The basic model representing the MetS included six indicators comprising obesity, SI, lipids and hypertension, and demonstrated excellent goodness-of-fit. Using multivariate analysis, MCP-1, SAA and TNF-α were not independently associated with any of the MetS variables. Adiponectin, resistin, leptin, CRP and IL-6 were associated with at least one of the risk factors, but when added to the basic model decreased all goodness-of-fit parameters. PAI-1 was associated with all cardiometabolic factors and improved goodness-of-fit compared to the basic model.
Addition of PAI-1 increased the CFA model goodness-of-fit compared to the basic model, suggesting that this protein may represent an added feature of the MetS.
PMCID: PMC3778191  PMID: 23535025
metabolic syndrome; adipokines; cytokines; inflammatory proteins; factor analysis; obesity; insulin sensitivity
6.  Cardiovascular Health: Associations with Race-ethnicity, Nativity, and Education in a Diverse, Population-based Sample of Californians 
Annals of epidemiology  2013;23(7):388-394.
This study examined how race-ethnicity, nativity, and education interact to influence disparities in cardiovascular (CV) health, a new concept defined by the American Heart Association (AHA). We assessed whether race-ethnicity and nativity disparities in CV health vary by education, and whether the foreign-born differ in CV health from their US-born race-ethnic counterparts with comparable education.
We used data from the 2009 California Health Interview Survey to determine the prevalence of optimal CV health metrics (based on selected AHA guidelines) among adults ages 25 and over (n = 42,014). We examined the interaction between education and ethnicity-nativity, comparing predicted probabilities of each CV health measure between US-born and foreign-born Whites, Asians, and Latinos.
All groups were at high risk of suboptimal physical activity levels, fruit and vegetable and fast food consumption, and overweight/obesity. Those with higher education were generally better-off, except among Asians. Ethnicity-nativity differences were more pronounced among those with less than a college degree. The foreign-born exhibited both advantages and disadvantages in CV health compared to their US-born counterparts that varied by ethnicity-nativity.
Education influences ethnicity-nativity disparities in CV health, with most race-ethnic and nativity differences occurring among the less educated. Studies of nativity differences in CV health should stratify by education in order to adequately address SES differences.
PMCID: PMC3794704  PMID: 23726820
risk factors; lifestyle; immigrants; health behavior
7.  Relationship of Race/Ethnicity, Body Mass Index, and Economic Strain with Longitudinal Self-Report of Physical Functioning: The Study of Women’s Health Across the Nation 
Annals of epidemiology  2013;23(7):401-408.
This study examined progression and improvement of physical functioning limitations during the mid-life, and whether race/ethnicity, economic strain, or body mass index were associated with these changes.
Women from the Study of Women’s Health Across the Nation with ≥1 measure of self-reported physical functioning, categorized as no, some, or substantial limitations, between study visit 4 and 12 were included (n=2497).
When women were aged 56–66, almost 50% reported limitations in functioning. African American women were more likely to report substantial (OR=1.63; 95% CI: 1.06,2.52) and Chinese women were more likely to report some limitations (OR=2.03; 95% CI: 1.22,3.36) compared to Caucasian women. Economic strain and obesity predicted limitations. The probability of worsening ranged from 6 to 22% and of improving ranged from 11% to 30%. Caucasian and Japanese women had the highest probability of remaining fully functional (80% and 84%, respectively) compared to 71% of African American women.
Race/ethnicity, obesity, and economic strain were associated with prevalence and onset of physical functioning limitations. Functional improvement is common, even among vulnerable subgroups of women. Future studies should characterize predictors of decline and improvement so that interventions can sustain functioning even in the context of many known immutable risk factors.
PMCID: PMC3898343  PMID: 23694761
8.  Antidepressant Use and Cognitive Deficits in Older Men: Addressing Confounding by Indications Using Different Methods 
Annals of epidemiology  2011;22(1):9-16.
Antidepressant use has been associated with cognitive impairment in older persons. This study sought to examine whether this association might reflect an indication bias.
544 community-dwelling hypertensive men aged ≥65 years completed the Hopkins Verbal Learning Test (HVLT) at baseline and one year. Antidepressant medications were ascertained using medical records. Potential confounding by indications was examined by adjusting for depression-related diagnoses and severity of depression symptoms using multiple linear regression (MLR), a propensity-score (PS) and a structural equation model (SEM).
Before adjusting for the indications, a one unit cumulative exposure to antidepressants was associated with −1.00 (95% Confidence Interval (CI): −1.94, −0.06) point lower HVLT score. After adjusting for the indications using MLR or a PS, the association diminished to −0.48 (95% CI: −0.62, 1.58) and −0.58 (95% CI: −0.60, 1.58), respectively. The most clinical interpretable empirical SEM with adequate fit involves both direct and indirect paths of the two indications. Depression-related diagnoses and depression symptoms significantly predict antidepressant use (P <0.05). Their total standardized path coefficients on HVLT score were twice (0.073) or as large (0.034) as the antidepressant use (0.035).
The apparent association between antidepressant use and memory deficit in older persons may be confounded by indications. SEM offers a heuristic empirical method for examining confounding by indications, but not quantitatively superior bias reduction compared to conventional methods.
PMCID: PMC4054866  PMID: 22037381
Antidepressant use; confounding by indication; structural equation modeling; elderly; cognitive deficit; multiple linear regression
9.  Sociodemographic, Clinical and Psychological Factors Associated with Attrition in a Prospective Study of Cardiovascular Prevention: The Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) Study 
Annals of epidemiology  2013;23(6):328-333.
To identify factors associated with attrition in a longitudinal study of cardiovascular prevention.
Demographic, clinical and psychosocial variables potentially associated with attrition were investigated in 1,841 subjects enrolled in the southwestern Pennsylvania Heart Strategies Concentrating on Risk Evaluation study. Attrition was defined as study withdrawal, loss to follow-up, or missing ≥50% of study visits.
Over four years of follow up, 291 subjects (15.8%) met criteria for attrition. In multivariable regression models, factors that were independently associated with attrition were: Black race (Odds Ratio(OR):2.21, 95%Confidence Interval(CI):1.55, 3.16; P<0.001), younger age (OR per 5-year increment:0.88, 95%CI:0.79, 0.99; P<0.05), male sex (OR: 1.79, 95%CI: 1.27, 2.54; P<0.05), no health insurance (OR:2.04, 95%CI:1.20, 3.47; P<0.05), obesity (OR:1.80, 95%CI:1.07, 3.02; P<0.05), CES-D depression score≥16 (OR:2.02, 95%CI:1.29, 3.19; P<0.05), higher ongoing life events questionnaire score (OR=1.09, 95%CI= 1.04–1.13; P<0.001). Having a spouse/partner participating in the study was associated with lower odds of attrition (OR=0.60 95%CI=0.37–0.97; P<0.05). A synergistic interaction was identified between black race and depression.
Attrition over four years was influenced by sociodemographic, clinical and psychological factors that can be readily identified at study entry. Recruitment and retention strategies targeting these factors may improve participant follow-up in longitudinal cardiovascular prevention studies.
PMCID: PMC3660424  PMID: 23535026
Cardiovascular Diseases; Cohort Studies; Lost to Follow-Up
10.  Sleep duration and all-cause mortality: a critical review of measurement and associations 
Annals of epidemiology  2013;23(6):361-370.
Variation in sleep duration has been linked with mortality risk. The purpose of this review is to provide an updated evaluation of the literature on sleep duration and mortality, including a critical examination of sleep duration measurement and an examination of correlates of self-reported sleep duration.
We did a systematic search of studies reporting associations between sleep duration and all-cause mortality and extracted the sleep duration measure and the measure(s) of association.
We identified 42 prospective studies of sleep duration and mortality drawing on 35 distinct study populations across the globe. Unlike previous reviews, we find that the published literature does not support a consistent finding of an association between self-reported sleep duration and mortality. Most studies have employed survey measures of sleep duration, which are not highly correlated with estimates based on physiologic measures.
Despite a large body of literature, it is premature to conclude, as previous reviews have, that a robust, U-shaped association between sleep duration and mortality risk exists across populations. Careful attention must be paid to measurement, response bias, confounding, and reverse causation in the interpretation of associations between sleep duration and mortality.
PMCID: PMC3660511  PMID: 23622956
Sleep; Mortality; Review; Epidemiology; Adult; Polysomnography; Actigraphy
11.  The Association of Whole Grain Consumption with Incident Type 2 Diabetes: The Women's Health Initiative Observational Study 
Annals of epidemiology  2013;23(6):321-327.
Whole grains may offer protection from diabetes by decreasing energy intake, preventing weight gain, and direct effects on insulin resistance. This study examined associations of whole and refined grains with incident type 2 diabetes (T2D) ascertained by self-reported medication use in a cohort of post-menopausal women.
72,215 women free of diabetes at baseline from the Women's Health Initiative Observational Study were included. Whole grain consumption was categorized as 0, <0.5, 0.5-1.0, 1.0-<1.5, 1.5-<2.0, and ≥2.0 servings/day. Proportional hazards regression was performed to estimate hazard ratios (HR) and 95% confidence intervals adjusting for potential confounders.
There were 3,465 cases of incident T2D over median 7.9 years follow-up. Adjusted for age and energy intake/day, successively increasing categories of whole grain consumption were associated with statistically significant reduced risk of incident T2D (HRs= 1.00, 0.83, 0.73, 0.69, 0.61, 0.57, p for trend <0.0001). Results were attenuated after adjustment for confounders and other dietary components. Non-smokers and those who maintained their weight within 5 pounds had a greater reduced risk of T2D with higher consumption of whole grains than smokers and women who gained more weight.
This large, prospective study found an inverse, dose-response relationship between whole grain consumption and incident T2D in postmenopausal women.
PMCID: PMC3662533  PMID: 23608304
type 2 diabetes; whole grains; cohort studies
12.  Do the psychosocial risks associated with television viewing increase mortality? Evidence from the 2008 General Social Survey-National Death Index Dataset 
Annals of epidemiology  2013;23(6):355-360.
Television viewing is associated with an increased risk of mortality, which could be caused by a sedentary lifestyle, the content of television programming (e.g., cigarette product placement or stress-inducing content), or both.
We examined the relationship between self-reported hours of television viewing and mortality risk over 30 years in a representative sample of the American adult population using the 2008 General Social Survey-National Death Index dataset. We also explored the intervening variable effect of various emotional states (e.g., happiness) and beliefs (e.g., trust in government) of the relationship between television viewing and mortality.
We find that for each additional hour of viewing, mortality risks increased 4%. Given the mean duration of television viewing in our sample, this amounted to about 1.2 years of life expectancy in the US. This association was tempered by a number of potential psychosocial mediators, including self-reported measures of happiness, social capital, or confidence in institutions. While none of these were clinically significant, the combined mediation power was statistically significant (p < 0.001).
Television viewing among healthy adults is correlated with premature mortality in a nationally-representative sample of US adults, and this association may be partially mediated by programming content related to beliefs or affective states. However, this mediation effect is the result of many small changes in psychosocial states rather than large effects from a few factors.
PMCID: PMC3662979  PMID: 23683712
13.  Appalachian versus non-Appalachian US traffic fatalities, 2008-2010 
Annals of epidemiology  2013;23(6):377-380.
Though myriad health disparities exist in Appalachia, limited research has examined traffic fatalities in the region. This study compared traffic-fatality rates in Appalachia and the non-Appalachian US.
Fatality Analysis Reporting System and Census data from 2008-2010 were used to calculate traffic-fatality rates. Poisson models were used to estimate unadjusted (RR) and adjusted rate ratios (aRR), controlling for age, sex, and county-specific population density levels. Results: The Appalachian traffic-fatality rate was 45% (95% CI: 1.42, 1.47) higher than the non-Appalachian rate. Though only 29% of fatalities occur in rural counties in non-Appalachia versus 48% in Appalachia, rates in rural counties were similar (RR=0.97; 95% CI: 0.95, 1.00). However, the rate for urban, Appalachian counties was 42% (95% CI: 1.38, 1.45) higher than among urban, non-Appalachian counties. Appalachian rates were higher for passenger-vehicle drivers, motorcyclists, and all-terrain-vehicle riders, regardless of rurality, as well as for passenger-vehicle passengers overall and for urban counties. Conversely, Appalachia experienced lower rates among pedestrians and bicyclists, regardless of rurality.
Disparities in traffic fatality rates exist in Appalachia. Though elevated rates are partially explained by the proportion of residents living in rural settings, overall rates in urban Appalachia were consistently higher than in urban non-Appalachia.
PMCID: PMC3689544  PMID: 23619016
Accidents; Appalachia; health disparities
14.  Risk of Non-Hodgkin Lymphoma in Relation to Tricyclic Antidepressant Use 
Annals of epidemiology  2013;23(6):349-354.
We investigated the relationship between use of tricyclic antidepressants (TCA) and risk of non-Hodgkin lymphoma (NHL). Previous studies provided some evidence of an association, but did not assess risk of NHL subtypes.
Cases and controls were members of Group Health (GH), an integrated healthcare delivery system. Cases were persons diagnosed with NHL between 1980–2011 at age ≥25; 8 controls were matched to each case on age, sex, and length of enrollment. Information on prior TCA use was ascertained from automated pharmacy data. Conditional logistic regression was used to calculate ORs and 95%CIs for NHL, overall and for common subtypes, for various patterns of TCA use.
We identified 2,768 cases and 22,127 matched controls. We did not observe an appreciably increased risk of NHL among TCA ever-users compared to non-users (OR=1.1; 95%CI=1.0–1.2). Overall risk of NHL was associated to at most a small degree with longer-term use (OR=1.2; 95%CI=1.0–1.4; ≥10 prescriptions), high-dose use (OR=1.1; 95%CI=0.8–1.5; ≥50mg), or non-recent use (OR=1.0; 95%CI=0.9=1.2; >5y ago). TCA use was not associated with NHL subtypes, except chronic lymphocytic leukemia/small lymphocytic lymphoma (OR=1.5; 95%CI=1.1–2.0; longer-term use).
We found little evidence that TCA use increases risk of NHL, overall or for specific common subtypes of NHL.
PMCID: PMC3718633  PMID: 23683711
Lymphoma, non-Hodgkin; Antidepressive Agents, Tricyclic; Epidemiology; Case-Control Studies
15.  Assessing the component associations of the healthy worker survivor bias: occupational asbestos exposure and lung cancer mortality 
Annals of epidemiology  2013;23(6):334-341.
The healthy worker survivor bias is well-recognized in occupational epidemiology. Three component associations are necessary for this bias to occur: i) prior exposure and employment status; ii) employment status and subsequent exposure; and iii) employment status and mortality. Together, these associations result in time-varying confounding affected by prior exposure. We illustrate how these associations can be assessed using standard regression methods.
We use data from 2975 asbestos textile factory workers hired between January 1940 and December 1965 and followed for lung cancer mortality through December 2001.
At entry, median age was 24 years, with 42% female and 19% non-Caucasian. Over follow-up, 21% and 17% of person-years were classified as at work and exposed to any asbestos, respectively. For a 100 fiber-year/mL increase in cumulative asbestos, the covariate-adjusted hazard of leaving work decreased by 52% (95% confidence interval [CI], 46–58). The association between employment status and subsequent asbestos exposure was strong due to nonpositivity: 88.3% of person-years at work (95% CI, 87.0–89.5) were classified as exposed to any asbestos; no person-years were classified as exposed to asbestos after leaving work. Finally, leaving active employment was associated with a 48% (95% CI, 9–71) decrease in the covariate-adjusted hazard of lung cancer mortality.
We found strong associations for the components of the healthy worker survivor bias in these data. Standard methods, which fail to properly account for time-varying confounding affected by prior exposure, may provide biased estimates of the effect of asbestos on lung cancer mortality under these conditions.
PMCID: PMC3773512  PMID: 23683709
Epidemiologic methods; Occupational health; Healthy worker effect; Bias; Lung cancer; Mortality
16.  Risk of Leukemia Among Survivors of Testicular Cancer: A Population-based Study of 42,722 Patients 
Annals of epidemiology  2008;18(5):416-421.
The aim of this study is to quantify excess absolute risk (EAR) and excess relative risk (ERR) of secondary leukemia among a large population-based group of testicular cancer survivors.
We identified 42,722 1-year survivors of testicular cancer within 14 population-based cancer registries in Europe and North America (1943–2002). Poisson regression analysis was used to model EAR (per 100,000 person-years [PY]) and ERR of secondary leukemia. Cumulative risks were calculated using a competing risk model.
Secondary leukemia developed in 89 patients (EAR = 10.8 per 100,000 PY, 95% confidence interval [CI] = 7.6–14.6; ERR = 1.6, 95%CI = 1.0–2.2). Statistically significantly elevated risks were observed for acute myeloid leukemia (AML) (EAR = 7.2, 95%CI = 4.7–10.2) and acute lymphoblastic leukemia (EAR = 1.3, 95%CI = 0.4–2.8). In multivariate analyses, AML risk was higher among patients whose initial management included chemotherapy compared to those receiving radiotherapy alone (p = 0.1). Excess cumulative leukemia risk was approximately 0.23% by 30 years after testicular cancer diagnosis.
Although ERR of leukemia following testicular cancer is large, EAR and cumulative risk, which are better gauges of the population burden, are small.
PMCID: PMC4034178  PMID: 18433667
Testicular Neoplasms; Leukemia; Second Primary Neoplasms; Cohort Studies
17.  Blunt Trauma as a Risk Factor for Group A Streptococcal Necrotizing Fasciitis 
Annals of epidemiology  2007;17(11):878-881.
Anecdotal reports suggest that blunt trauma and seemingly innocuous musculoskeletal injuries (e.g. muscle strains) are risk factors for developing necrotizing fasciitis (NF) and myositis caused by group A Streptococcus and other bacteria; however, this hypothesis has not been tested in analytic epidemiologic studies of invasive group A streptococcal (GAS) disease. We conducted two case-control studies to determine whether nonpenetrating trauma is a risk factor for either NF or severe cellulitis caused by GAS.
A secondary analysis of patients that were hospitalized throughout Florida for invasive GAS disease during a four-year period was conducted. Two case series were used. The first series comprised patients who had severe GAS cellulitis. The second were patients who had GAS NF. Cases were compared to a single control series comprised of patients with invasive GAS disease not including either NF or cellulitis (e.g. primary bacteremia, septic arthritis, etc.).
After adjusting for age, race, and clindamycin, GAS NF cases were 5.97 times as likely as controls to have a recent history of blunt trauma (p=0.04). Patients with severe cellulitis were not more likely than controls to have associated blunt trauma.
Nonpenetrating trauma is significantly associated with the development of GAS NF.
PMCID: PMC4029051  PMID: 17697787
Streptococcus pyogenes; necrotizing fasciitis; wounds, nonpenetrating; cellulitis
18.  Incidence of sport-related traumatic brain injury and risk factors of severity: a population-based epidemiologic study 
Annals of epidemiology  2013;23(12):750-756.
Few studies of sport-related traumatic brain injury (TBI) are population-based or rely on directly observed data on cause, demographic characteristics, and severity. This study addresses the epidemiology of sport-related TBI in a large population.
Data on all South Carolina hospital and emergency department encounters for TBI, 1998–2011, were analyzed. Annual incidence rate of sport-related TBI was calculated, and rates were compared across demographic groups. Sport-related TBI severity was modeled as a function of demographic and TBI characteristics using logistic regression.
A total of 16,642 individuals with sport-related TBI yielded an average annual incidence rate of 31.5/100,000 population with a steady increase from 19.7 in 1998 to 45.6 in 2011. The most common mechanisms of sport-related TBI were kicked in football (38.1%), followed by fall injuries in sports (20.3%). Incidence rate was greatest in adolescents ages 12–18 (120.6/100,000/persons). Severe sport-related TBI was strongly associated with off-road vehicular sport (odds ratio [OR], 4.73; 95% confidence interval [95% CI], 2.92–7.67); repeated head trauma (OR, 4.36; 95% CI, 3.69–5.15); equestrian sport (OR, 2.73; 95% CI, 1.64–4.51); and falls during sport activities (OR, 2.72; 95% CI, 1.67–4.46).
The high incidence of sport-related TBI in youth, potential for repetitive mild TBI, and its long-term consequences on learning warrants coordinated surveillance activities and population-based outcome studies.
PMCID: PMC4021712  PMID: 24060276
Sport-related TBI; Severity; Concussion; Mechanism of injury; Repetitive TBI
20.  Individual and neighborhood correlates of membership in drug using networks with a higher prevalence of HIV in New York City (2006–2009) 
Annals of epidemiology  2013;23(5):267-274.
To identify individual-/neighborhood-level correlates of membership within high HIV prevalence drug networks.
378 New York City drug users were recruited via respondent-driven sampling (2006–2009). Individual-level characteristics and recruiter-recruit relationships were ascertained and merged with 2000 tract-level US Census data. Descriptive statistics and population average models were used to identify correlates of membership in high HIV prevalence drug networks (>10.54% HIV vs. <10.54% HIV).
Individuals in high HIV prevalence drug networks were more likely to be recruited in neighborhoods with greater inequality (Adjusted Odds Ratio [AOR]=5.85; 95%CI:1.40–24.42), higher valued owner-occupied housing (AOR=1.48;95%CI:1.14–1.92), and a higher proportion of Latinos (AOR=1.83; 95%CI:1.19–2.80). They reported more crack use (AOR=7.23; 95%CI:2.43–21.55), exchange sex (AOR=1.82; 95%CI:1.03–3.23), and recent drug treatment enrollment (AOR=1.62; 95%CI:1.05–2.50) and were less likely to report cocaine use (AOR=0.40; 95%CI:0.20–0.79) and recent homelessness (AOR=0.32; 95%CI:0.17–0.57).
The relationship between exchange sex, crack use and membership within high HIV prevalence drug networks may suggest an ideal HIV risk target population for intervention. Coupling network-based interventions with those adding risk-reduction and HIV testing/care/adherence counseling services to the standard of care in drug treatment programs should be explored in neighborhoods with increased inequality, higher valued owner-occupied housing, and a greater proportion of Latinos.
PMCID: PMC3640756  PMID: 23523090
HIV; drug use; networks; inequality; neighborhoods
21.  Frequency of private spiritual activity and cardiovascular risk in postmenopausal women: the Women’s Health Initiative 
Annals of epidemiology  2013;23(5):239-245.
Spirituality has been associated with better cardiac autonomic balance, but its association with cardiovascular risk is not well studied. We examined whether more frequent private spiritual activity was associated with reduced cardiovascular risk in postmenopausal women enrolled in the Women’s Health Initiative Observational Study.
Frequency of private spiritual activity (prayer, Bible reading, and meditation) was self-reported at year 5 of follow-up. Cardiovascular outcomes were centrally adjudicated, and cardiovascular risk was estimated from proportional hazards models.
Final models included 43,708 women (mean age, 68.9 ± 7.3 years; median follow-up, 7.0 years) free of cardiac disease through year 5 of follow-up. In age-adjusted models, private spiritual activity was associated with increased cardiovascular risk (hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.02–1.31 for weekly vs. never; HR, 1.25; 95% CI, 1.11–1.40 for daily vs. never). In multivariate models adjusted for demographics, lifestyle, risk factors, and psychosocial factors, such association remained significant only in the group with daily activity (HR, 1.16; 95% CI, 1.03–1.30). Subgroup analyses indicate this association may be driven by the presence of severe chronic diseases.
Among aging women, higher frequency of private spiritual activity was associated with increased cardiovascular risk, likely reflecting a mobilization of spiritual resources to cope with aging and illness.
PMCID: PMC3741666  PMID: 23621989
Women’s health; Cardiovascular diseases; Spirituality
22.  Associations of oxidative balance-related exposures with incident, sporadic colorectal adenoma according to antioxidant enzyme genotypes 
Annals of epidemiology  2013;23(4):223-226.
Previous research found inverse associations between oxidative balance and risk of colorectal adenoma. However, these measures were limited to extrinsic (dietary and lifestyle) exposures and did not account for intrinsic factors, specifically antioxidant enzymes responsible for cellular defense against oxidative stress. We investigated whether the association between an oxidative balance score (OBS) and colorectal adenoma may vary according to polymorphisms in genes that encode three antioxidant enzymes: manganese superoxide dismutase (SOD2), catalase (CAT), and glutathione-S-transferase P1 (GSTP1).
Using data pooled from three colonoscopy-based case-control studies of incident, sporadic colorectal adenoma, we constructed an OBS reflecting pro- and anti-oxidant exposures. We used multivariable logistic regression to assess whether the association between the OBS and colorectal adenoma differed according to polymorphisms in the genes encoding the antioxidant enzymes.
The OBS was inversely associated with colorectal adenoma, adenoma risk was not associated with the genetic polymorphisms, and there was no consistent pattern of effect modification by individual genotypes or combined gene scores.
Variations in the antioxidant enzyme genes SOD2, CAT, and GSTP1 do not appear to substantially modify associations of environmental exposures related to oxidative balance with risk for sporadic colorectal adenoma.
PMCID: PMC3605204  PMID: 23290999
23.  Differences between Hispanic and non-Hispanic White Women with Breast Cancer for Clinical Characteristics and their Correlates 
Annals of epidemiology  2013;23(4):227-232.
Body size and ethnicity may influence breast cancer tumor characteristics at diagnosis. We compared Hispanic and non-Hispanic white cases for stage of disease, estrogen receptor status, tumor size, and lymph node status, and the associations of these with body size in the 4-Corners Breast Cancer Study (4-CBCS).
1,527 Non-Hispanic white and 798 Hispanic primary incident breast cancer cases diagnosed between October 1999 and May 2004 were included. Odds ratios (OR) and 95% Confidence Intervals (CI) were calculated by multiple logistic regression.
Hispanic women were more likely to have larger (>1cm), ER- tumors, and >4 positive lymph nodes (p < 0.003). Lymph node status was not associated with body size. However, among non-Hispanic white women, obesity (BMI >30) and increased waist circumference (> 38.5 inches) were significantly, positively associated with ER- tumor status; ORs = 1.87, 95% CI 1.24–2.81 and 2.59, 95% CI 1.58–4.22, respectively. In contrast, among Hispanic women, obesity and waist circumference had inverse associations with ER- status (OR = 0.49, 95% CI 0.29–0.84) and (0.56, 95% CI 0.30–1.05), respectively.
Hispanic ethnicity may modify the association of body size and composition with ER- breast cancer. This finding could have relevance to clinical treatment and prognosis.
PMCID: PMC3605206  PMID: 23369848
Breast Neoplasms; Hispanic Americans; Obesity
24.  Socioeconomic mobility in adulthood and cardiovascular disease mortality 
Annals of epidemiology  2013;23(4):167-171.
Life course models suggest that socioeconomic mobility is associated with decreased cardiovascular disease (CVD) mortality risk. We examined adult socioeconomic mobility measured by household income in relation to CVD mortality risk among older adults.
Data from 2691 (nmen=1157, nwomen=1534) Alameda County Study respondents in 1994 were used in these analyses. Latent growth curve models were used to identify income patterns from 1965–1994.
Income patterns were categorized as consistently low, moderately low, increasing, and high. Bivariate models showed that membership in the increasing compared to high pattern was associated with decreased hazards of CVD mortality (HR=0.15, 95% CI=0.04–0.53). Controlling for age, race/ethnicity, marital status and gender, respondents in the consistently low (HR= 2.1, 95% CI=1.5–3.1) and high pattern (HR=2.2, 95% CI=1.1–4.2) had increased hazards of CVD mortality than those in the moderately low income group.
Patterns of association were consistent with social mobility models of SEP, indicating lower CVD mortality risk for those with increasing or higher incomes. Future work should continue to investigate measures that capture the variation in social mobility over the life course, and how these patterns shape chronic disease risk in later life.
PMCID: PMC3616478  PMID: 23453385
income; socioeconomic; social mobility; cardiovascular disease; mortality
25.  Potential missed detection with screening mammography: does the quality of radiologist’s interpretation vary by patient socioeconomic advantage/disadvantage 
Annals of epidemiology  2013;23(4):210-214.
We examined whether quality of mammography interpretation as performed by the original reading radiologist varied by patient sociodemographic characteristics.
For 149 patients residing in Chicago and diagnosed in 2005-2008, we obtained the original index mammogram that detected the breast cancer and at least one prior mammogram that did not detect the cancer performed within 2 years of the index mammogram. A single breast imaging specialist performed a blinded review of the prior mammogram. Potentially missed detection was defined as an actionable lesion seen during a blinded review of the prior mammogram that was in the same quadrant as the cancer on the index mammogram.
Of 149 prior mammograms originally read as non-malignant, 46% (N=68) had a potentially detectable lesion. In unadjusted analyses, potentially missed detection was greater among minority patients (54% vs. 39%, p=0.07), for patients with incomes below $30,000 (65% vs. 36%, p<0.01), with less education (58% vs. 39%, p=0.02), and lacking private health insurance (63% vs. 40%, p=0.02). Likelihood ratio tests for the inclusion of socioeconomic variables in multivariable logistic regression models were highly significant (p<=0.02).
Disadvantaged socioeconomic status appears to be associated with potentially missed detection of breast cancer at mammography screening.
PMCID: PMC3633590  PMID: 23453384
breast cancer; health care disparities; screening; mammography; socioeconomic status

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