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1.  Significant differences in global genomic DNA methylation by gender and race/ethnicity in peripheral blood 
Epigenetics  2011;6(5):623-629.
Reduced levels of global DNA methylation are associated with genomic instability and are independent predictors of cancer risk. Little is known about the environmental determinants of global DNA methylation in peripheral blood. We examined the association between demographic and lifestyle factors and levels of global leukocyte DNA methylation in 161 cancer-free subjects enrolled in the North Texas Healthy Heart Study aged 45–75 years in 2008. We used in-person interviews for demographics and lifestyle factors, a self-administrated Block food frequency questionnaire for diet, and bioelectrical impedance analysis and CT-scan for body composition. We measured genomic DNA methylation using bisulfite conversion of DNA and pyrosequencing for LINE-1. Body composition measures including body mass index, waist circumference, areas of subcutaneous fat and visceral fat, percent of fat mass and fat-free mass were not associated with global genomic DNA methylation after controlling the effect of age, gender and race/ethnicity. Instead, female gender was significantly associated with a reduced level of global methylation (β = −2.77, 95% CI: −4.33, −1.22). Compared to non-Hispanic whites, non-Hispanic blacks (β = −2.02, 95% CI: −3.55, −0.50) had significantly lower levels of global methylation. No association was found with age, cigarette smoking, alcohol drinking and dietary intake of nutrients in one-carbon metabolism. Global leukocyte DNA methylation differs by gender and race/ethnicity, suggesting these variables need to be taken into consideration in studies of global DNA methylation as an epigenetic marker for cancer.
PMCID: PMC3230547  PMID: 21739720
gender; race/ethnicity; DNA methylation
2.  Physical activity and global genomic DNA methylation in a cancer-free population 
Epigenetics  2011;6(3):293-299.
Changes in DNA methylation may represent an intermediate step between the environment and human diseases. Little is known on whether behavioral risk factors may modify gene expression through DNA methylation. To assess whether DNA methylation is associated with different levels of physical activity, we measured global genomic DNA methylation using bisulfite-converted DNA and real-time PCR (MethyLight) for LINE-1 in peripheral blood of 161 participants aged 45–75 years enrolled in the North Texas Healthy Heart Study and levels of physical activity using an accelerometer (Actigraph GT1M Monitor). We found that individuals with physical activity 26–30 min/day had a significantly higher level of global genomic DNA methylation compared to those with physical activity ≤10 min/day (β = 2.52, 95% CI: 0.70, 4.35). However, the association was attenuated and became statistically insignificant after multivariate adjustment (β = 1.24, 95% CI: −0.93, 3.40). There were some suggestions of a positive association between physical activity and global genomic DNA methylation in non-Hispanics (β = 1.50, 95% CI: −0.08, 3.08) that warrants further investigation.
PMCID: PMC3092677  PMID: 21178401
DNA methylation; physical activity; peripheral blood
3.  Improving accuracy of medication identification in an older population using a medication bottle color symbol label system 
BMC Family Practice  2011;12:142.
The purpose of this pilot study was to evaluate and refine an adjuvant system of color-specific symbols that are added to medication bottles and to assess whether this system would increase the ability of patients 65 years of age or older in matching their medication to the indication for which it was prescribed.
This study was conducted in two phases, consisting of three focus groups of patients from a family medicine clinic (n = 25) and a pre-post medication identification test in a second group of patient participants (n = 100). Results of focus group discussions were used to refine the medication label symbols according to themes and messages identified through qualitative triangulation mechanisms and data analysis techniques. A pre-post medication identification test was conducted in the second phase of the study to assess differences between standard labeling alone and the addition of the refined color-specific symbols. The pre-post test examined the impact of the added labels on participants' ability to accurately match their medication to the indication for which it was prescribed when placed in front of participants and then at a distance of two feet.
Participants appreciated the addition of a visual aid on existing medication labels because it would not be necessary to learn a completely new system of labeling, and generally found the colors and symbols used in the proposed labeling system easy to understand and relevant. Concerns were raised about space constraints on medication bottles, having too much information on the bottle, and having to remember what the colors meant. Symbols and colors were modified if they were found unclear or inappropriate by focus group participants. Pre-post medication identification test results in a second set of participants demonstrated that the addition of the symbol label significantly improved the ability of participants to match their medication to the appropriate medical indication at a distance of two feet (p < 0.001) and approached significant improvement when placed directly in front of participants (p = 0.07).
The proposed medication symbol label system provides a promising adjunct to national efforts in addressing the issue of medication misuse in the home through the improvement of medication labeling. Further research is necessary to determine the effectiveness of the labeling system in real-world settings.
PMCID: PMC3282670  PMID: 22206490
Medication labeling; medication errors; medication adherence
4.  The relationship between perceived sense of control and visceral adipose tissue - the North Texas Healthy Heart Study 
The purpose of this study was to assess the relationship between one's sense of control and visceral adipose tissue.
This cross-sectional study recruited 571 subjects (45 years and older) who were asymptomatic of CHD from Fort Worth, Texas from 2006 to 2008. Subjects completed a questionnaire, body measurements, a multi-slice computed tomography scan to assess for visceral adipose tissue (VAT) centered at the L4L5 spinal interspace, and serum chemistries. The natural log of L4L5 VAT (lnVAT) was used in all analyses to achieve normality of the data with final analyses including 506 participants. Linear regression was used to estimate unadjusted and adjusted beta-coefficients and standard errors for the association between sense of control and lnVAT.
A total of 506 participants were used in the data after adjusting for normality of the data. An increase in sense of control was associated with a decrease in lnVAT in the unadjusted (p < 0.001) and adjusted (p = 0.03) models. Other factors significantly associated with lnVAT in the adjusted model include age, BMI, male gender, non-Hispanic African American, and diet.
Sense of control remained as an independent factor associated with visceral adiposity despite adjusting for traditional cardiovascular risk factors, including BMI. Future studies should focus on establishing a causal relationship between sense of control and visceral adiposity.
PMCID: PMC3180246  PMID: 21914181
Sense of control; visceral adipose tissue; cardiovascular; psychosocial
5.  Self-reported racial discrimination, response to unfair treatment, and coronary calcification in asymptomatic adults - the North Texas Healthy Heart study 
BMC Public Health  2010;10:285.
Accruing evidence supports the hypothesis that psychosocial factors are related to cardiovascular disease. However, a limited number of studies have investigated the pathophysiologic pathways through which these associations occur. The purpose of this study was to assess whether experiences of self-reported racial discrimination and reactions to unfair treatment were associated with coronary artery calcification (CAC), an indicator of subclinical coronary heart disease (CHD).
This cross-sectional study recruited 571 subjects (45 years and older) who were asymptomatic of CHD from Fort Worth, Texas from 2006 to 2008. Subjects completed a questionnaire, a multi-slice computed tomography scan to assess for CAC presence (measured as Agatston score >0), and serum chemistries. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between self-reported discrimination and CAC. Results were stratified by response to unfair treatment as it was found to significantly modify the relationship between discrimination and CAC.
Among those who passively responded to unfair treatment, the odds of having CAC present were approximately 3 times higher for those experiencing discrimination (OR, 2.95; 95% CI, 1.19-7.32) after adjusting for age, gender, race/ethnicity, education, body mass index, hyperlipidemia, smoking status, hypertension, diabetes, and first degree relative with heart disease.
This is the first multi-racial/ethnic study to find racial discrimination associated with CAC, which differs based on how one responds to unfair treatment.
PMCID: PMC2887822  PMID: 20507602
6.  Acculturation and self-reported health among Hispanics using a socio-behavioral model: the North Texas Healthy Heart Study 
BMC Public Health  2010;10:53.
Acculturation is a continuous, firsthand contact with other cultures functioning at both group and individual levels and is reflected in our culturally diverse society, calling for a greater understanding of the environmental and cultural impact on health. Self-reported health (SRH), a robust and well validated predictor of future mortality for all racial/ethnic groups, has been differentially reported by Hispanics compared to whites, especially based on their acculturation status. This study investigated the relationship between acculturation and SRH among Hispanics. An adapted Andersen framework was used to develop logistic regression models to assess for an association between acculturation and general health status.
Hispanic participants (n = 135), as part of the North Texas Healthy Heart Study, were administered standardized questionnaires on acculturation, psychosocial measures which included sense of control, stress, depression and social support and a single item SRH measure. In addition, physiological measurements and demographic characteristics including age, gender, body mass index, medical history, and socioeconomic status were also obtained.
Bivariate analyses found Mexican-oriented participants 3.16 times more likely to report fair/poor SRH compared to Anglo-oriented Hispanics. Acculturation was also associated with SRH in multiple regression models controlling for enabling, need, and predisposing factors together (OR: 3.53, 95% CI: 1.04, 11.97).
Acculturation status was associated with SRH after accounting for other underlying factors. Medical and public health professionals should promote the use of acculturation measures in order to better understand its role in Hispanic behaviors, health outcomes and health care use. Such research findings will contribute to the design of culturally sensitive prevention and treatment strategies for diverse and immigrant populations.
PMCID: PMC2843663  PMID: 20122263
7.  Differences in risk factors for children with special health care needs (CSHCN) receiving needed specialty care by socioeconomic status 
BMC Pediatrics  2009;9:48.
The purpose of this study is to identify factors affecting CSHCN's receiving needed specialty care among different socioeconomic levels. Previous literature has shown that Socioeconomic Status (SES) is a significant factor in CHSHCN receiving access to healthcare. Other literature has shown that factors of insurance, family size, race/ethnicity and sex also have effects on these children's receipt of care. However, this literature does not address whether other factors such as maternal education, geographic location, age, insurance type, severity of condition, or race/ethnicity have different effects on receiving needed specialty care for children in each SES level.
Data were obtained from the National Survey of Children with Special Health Care Needs, 2000–2002. The study analyzed the survey which studies whether CHSCN who needed specialty care received it. The analysis included demographic characteristics, geographical location of household, severity of condition, and social factors. Multiple logistic regression models were constructed for SES levels defined by federal poverty level: < 199%; 200–299%; ≥ 300%.
For the poorest children (,199% FPL) being uninsured had a strong negative effect on receiving all needed specialty care. Being Hispanic was a protective factor. Having more than one adult in the household had a positive impact on receipt of needed specialty care but a larger number of children in the family had a negative impact. For the middle income group of children (200–299% of FPL severity of condition had a strong negative association with receipt of needed specialty care.
Children in highest income group (> 300% FPL) were positively impacted by living in the Midwest and were negatively impacted by the mother having only some college compared to a four-year degree.
Factors affecting CSHCN receiving all needed specialty care differed among socioeconomic groups. These differences should be addressed in policy and practice. Future research should explore the CSHCN population by income groups to better serve this population
PMCID: PMC2729735  PMID: 19646227
8.  Impact of predisposing, enabling, and need factors in accessing preventive medical care among U.S. children: results of the national survey of children's health 
Preventive care in the United States has been a priority, especially for children under 18 years of age. The objective of this analysis was to determine which predisposing, enabling, and need factors affect access to preventive health care for children.
Data were obtained from the National Survey of Children's Health (NSCH), a cross-sectional study of children in the United States. The current analysis examined whether predisposing, enabling, and need factors included in Andersen's Socio-Behavioral Model significantly affect having received preventive medical care among children 3–17 years of age. Logistic regression was used to compute odds ratios and 95% confidence intervals.
63,924 out of 85,151 subjects were reported as having received preventive medical care. After stratifying by geographical region, the following factors were significant for predicting having received preventive care. Age was negatively associated with having received care in all four regions. Household education of less than a college degree and being white (compared to black) were negatively associated with having received care in the Northeast, Midwest, and South. Having fewer than 4 children was negatively associated in Northeast but positively associated in the West with having received care. Being male, having less than 3 children in the household, having less than 3 adults in the household, and being Hispanic were positively associated with having received care in the West only. Not having insurance and having a lower socioeconomic status were negatively associated with having received care; while, having a personal doctor or nurse was positively associated in all four regions. Primary language other than English was negatively associated with having received care in the Northeast only. Currently needing medicine was also positively associated with having received care in all four regions; while, having limited abilities to do things was positively associated in the West only.
Older children whose family resides in Northeast, Midwest, and South regions with low household education and poverty levels experience insufficient preventive health care. Medicaid or SCHIP coverage should be expanded for children who are still uninsured. For children in the West, gender, family size, ethnicity, and their ability to do things should also be considered when providing assistance for receiving preventive care.
PMCID: PMC2615756  PMID: 19061524
9.  A case-control study of osteopathic palpatory findings in type 2 diabetes mellitus 
Although type 2 diabetes mellitus is often managed by osteopathic physicians, osteopathic palpatory findings in this disease have not been adequately studied.
A case-control study was used to measure the association between type 2 diabetes mellitus and a series of 30 osteopathic palpatory findings. The latter included skin changes, trophic changes, tissue changes, tenderness, and immobility at spinal segmental levels T5–T7, T8–T10, and T11-L2 bilaterally. Logistic regression models that adjusted for age, sex, and comorbid conditions were used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between type 2 diabetes mellitus and each of these findings.
Results and discussion
A total of 92 subjects were included in the study. After controlling for age, sex, hypertension, and clinical depression, the only significant finding was an association between type 2 diabetes mellitus and tissue changes at T11-L2 on the right side (OR, 5.54; 95% CI, 1.76–17.47; P = .003). Subgroup analyses of subjects with type 2 diabetes mellitus and hypertension demonstrated significant associations with tissue changes at T11-L2 bilaterally (OR, 27.38; 95% CI, 1.75–428; P = .02 for the left side and OR, 24.00; 95% CI, 1.51–382; P = .02 for the right side). Among subjects with type 2 diabetes mellitus and hypertension, there was also a strong diabetes mellitus duration effect for tissue changes at T11-L2 bilaterally (OR, 12.00; 95% CI, 1.02–141; P = .05 for short duration vs. OR, 32.00; 95% CI, 2.29–448; P = .01 for long duration on the left side; and OR, 17.33; 95% CI, 1.39–217; P = .03 for short duration vs. OR, 32.00; 95% CI, 2.29–448; P = .01 for long duration on the right side).
The only consistent finding in this study was an association between type 2 diabetes mellitus and tissue changes at T11-L2 on the right side. Potential explanations for this finding include reflex viscerosomatic changes directly related to the progression of type 2 diabetes mellitus, a spurious association attributable to confounding visceral diseases, or a chance observation unrelated to type 2 diabetes mellitus. Larger prospective studies are needed to better study osteopathic palpatory findings in type 2 diabetes mellitus.
PMCID: PMC1808472  PMID: 17371582
10.  Patient expectations for placebo treatments commonly used in osteopathic manipulative treatment (OMT) clinical trials: a pilot study 
Placebo treatments should be believable to ensure expectation of benefit, yet not provide a true treatment effect. One obstacle to conducting clinical trials with osteopathic manipulative treatment (OMT) is choosing an appropriate placebo. Various placebo treatments have been used in OMT clinical trials. The purpose of this study was to determine expectations of 3 treatments (HVLA, placebo light touch, placebo sub-therapeutic ultrasound) commonly used in OMT clinical research trials.
A randomized, cross-over design was utilized. Subjects were recruited from the Family Medicine Clinic, Texas College of Osteopathic Medicine. Participants watched a video with 2 minute demonstrations of a High Velocity Low Amplitude (HVLA), placebo light touch (LT), and placebo sub-therapeutic ultrasound (ULTRA) treatment for low back pain. The order of presentations was randomized to control for order effect bias. Subjects indicated the extent of their agreement (using a 4 point Likert scale) with 4 statements that were presented after each treatment was viewed: 1)I believe this treatment would allow me to get better quicker; 2)I believe this treatment would decrease my low back pain; 3)I believe this treatment would make me more able to do the things I want to do; 4)This seems like a logical way to treat low back pain. Repeated measures analysis of variance was performed, and a partial Eta squared was calculated for each statement. Effect sizes (Cohen's d) were calculated where appropriate.
Thirty of 40 eligible subjects participated. Twenty-two (73%) were female, 16 (53%) were Caucasian, and 11 (37%) had completed college. The mean age was 43 (SD = 15.). Repeated measures ANOVA revealed no significant differences for statements 2 and 4. For both statements 1 (p = 0.025) and 3 (p = 0.039), post hoc analysis revealed a difference between HVLA and LT. The partial Eta squared (ηp2) was 0.105, 0.072, 0.107, and 0.024 for each statement, respectively.
There is a difference in treatment expectation between HVLA and LT for statements 1 and 3. Participants responded more positively after viewing the HVLA treatment than the LT treatment. This suggests that sub-therapeutic ultrasound is the better placebo because the expectations were similar to those for HVLA.
PMCID: PMC1805771  PMID: 17371579

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