Determinants of active surveillance uptake in a diverse population-based cohort of men with low-risk prostate cancer: The Treatment Options in Prostate Cancer Study (TOPCS)

BACKGROUND

Active surveillance (AS) is the preferred strategy for low-risk prostate cancer (LRPC); however, limited data on determinants of AS adoption exist, particularly among Black men.

METHODS

Black and White newly diagnosed (from January 2014 through June 2017) patients with LRPC ≤75 years of age were identified through metro-Detroit and Georgia population-based cancer registries and completed a survey evaluating factors influencing AS uptake.

RESULTS

Among 1688 study participants, 57% chose AS (51% of Black participants, 61% of White) over definitive treatment. In the unadjusted analysis, patient factors associated with initial AS uptake included older age, White race, and higher education. However, after adjusting for covariates, none of these factors was significant predictors of AS uptake. The strongest determinant of AS uptake was the AS recommendation by a urologist (adjusted prevalence ratio, 6.59, 95% CI, 4.84-8.97). Other factors associated with the decision to undergo AS included a shared patient-physician treatment decision, greater prostate cancer knowledge, and residence in metro-Detroit compared with Georgia. Conversely, men whose decision was strongly influenced by the desire to achieve "cure" or "live longer" with treatment and those who perceived their LRPC diagnosis as more serious were less likely to choose AS.

CONCLUSIONS

In this contemporary sample, the majority of patients with newly diagnosed LRPC chose AS. Although the input from their urologists was highly influential, several patient decisional and psychological factors were independently associated with AS uptake. These data shed new light on potentially modifiable factors that can help further increase AS uptake among patients with LRPC.

Childhood Violence Exposure Predicts High Blood Pressure in Black American Young Adults

OBJECTIVE

To test the impact of childhood adversity, including community violence exposure, on hypertension risk in Black American young adults to understand what risk factors (eg, prenatal factors, later exposures) and ages of adversity exposure increased hypertension risk.

STUDY DESIGN

The study included 396 Black American participants with data from prenatal, birth, and age 7-, 14-, and 19-year visits. At age 19 years, individuals with blood pressure (BP) measures >120 mmHg systolic and/or >80 mmHg diastolic were classified as having high blood pressure (HBP), and those with BP <120/80 mmHg were classified as normal. Associations between prenatal and birth risk factors; childhood adversity at age 7, 14, and 19 years; age 19 body mass index (BMI); and both systolic and diastolic BP at age 19 were tested using logistic regression models.

RESULTS

Age 19 BMI was positively associated with systolic and diastolic HBP status at age 19. Controlling for all covariates, community violence exposure at age 7 and 19 years was associated with 2.2-fold (95% CI, 1.242-3.859) and 2.0-fold (95% CI, 1.052-3.664) greater odds of systolic HBP, respectively, at age 19 years. Prenatal risk, birth risk, and other dimensions of childhood adversity were not associated with HBP in this cohort.

CONCLUSION

Childhood community violence exposure is a significant risk factor for HBP in young adults. As Black American children typically experience more community violence exposure than other American children, our results suggest that racial disparities in childhood community violence exposure may contribute to racial disparities in adult hypertension burden.

Postdischarge Adverse Events Among Neonates Admitted to the Neonatal Intensive Care Unit

OBJECTIVES

We aimed to determine the rate of postdischarge adverse events (AEs), classify the types of postdischarge AEs, and identify risk factors for postdischarge AEs among neonates admitted to the neonatal intensive care unit (NICU).

STUDY DESIGN

This was a prospective cohort study of neonates admitted to the NICU from February 2017 through June 2019. We enrolled 170 neonates from a level 4 NICU who were being discharged home and whose parents can speak English and could be contacted after discharge. The main outcome of the study was postdischarge AEs based on structured telephone interviews, health record review, and adjudication by 2 blinded, trained physicians using a previously established methodology.

RESULTS

Fourteen percent of 170 neonates admitted to the NICU experienced postdischarge AEs, with 48% being either preventable or ameliorable. Adverse drug events and procedural complications comprised most of the AEs (48%), but most of the preventable and ameliorable AEs were due to management, therapeutic, or diagnostic errors. Seventy-nine percent of neonates who suffered an AE experienced either a readmission to the hospital or an emergency department visit. Neonates admitted to a level 4 NICU from another NICU (level 1, 2, or 3) (adjusted odds ratio, 3.62; 95% confidence interval, 1.27-12.60; P = 0.01) and those 28 to 36 weeks (adjusted odds ratio, 11.38; 95% confidence interval, 1.67-127.98; P = 0.01) had a significantly higher risk of AEs at discharge.

CONCLUSIONS

Neonates discharged from a level 4 NICU were at high risk for experiencing postdischarge AEs. The identification of AE types and risk factors can be used to guide efforts to develop interventions to improve neonatal patient safety during the postdischarge period.

Choosing active surveillance versus curative treatment in a population-based survey of men with low-risk prostate cancer

Context: Active Surveillance (AS) is a preferred treatment option for low-risk prostate cancer (LPC) in current practice guidelines. Limited data as to factors influencing men's decision to choose AS. Objective: To identify determinants of initial treatment choice and whether race and geographical location influence the AS decision. Design: Longitudinal cohort study. Setting: Population-based sample recruited from two cancer registries. Patients: Black and white men with newly diagnosed LPC. Instrument: Mailed survey. Main Outcome Measure: Initial treatment choice (AS vs. curative treatment). Results: Of the 1688 eligible patients, 925 (54.8%) recruited from metro-Detroit and 763 (45.2%) from Georgia. Overall, 79.4% were White and 20.6% were Black, with a mean age of 62.8 years (SD=6.9, range 39-78). Regarding initial treatment choice, 56.9% of men chose AS, 23.4% surgery, 16.6% radiation, 1.1% watchful waiting, and 1.7% other treatment. In multivariable analysis, men who reported that their Urologist recommended AS were 56 times more likely to choose AS (OR=56, 95%CI 33-94) compared to men who reported that their Urologist recommended treatment. Similarly, men who reported that the decision was made jointly by doctor and patient or predominately by doctor, were about 2 times more likely to choose AS (OR=1.9, 95%CI 1.2-3.0) compared to men who made the decision alone. Men who believed their "cancer is small", had better health, higher yearly income (>=$70,000), higher prostate cancer knowledge, higher decisional conflict, and lived in metro-Detroit, were more likely to choose AS. In contrast, men who expected to "live longer" with chosen treatment, had friends "with good treatment results", and were influenced by "curing cancer", were less likely to choose AS. There was an interaction between race and "curing cancer" (p=0.005). White men were more likely (OR=3.2, 95%CI 1.2-8.9) to choose AS than Black men when "curing cancer" was not influential in their decision. When "curing cancer" was highly influential, White men were less likely than Black men to choose AS (OR 0.5, 95%CI 0.2-0.9). Conclusions: In this population-based sample, more than half of patients with LPC chose AS. Many factors influenced patient's AS decision with Urologist's AS recommendation being the strongest predictor of patient's AS decision.

Five-year follow-up study of a population-based prospective cohort of men with low-risk prostate cancer: the treatment options in prostate cancer study (TOPCS): study protocol

INTRODUCTION

Active surveillance (AS) is recommended for men with low-risk prostate cancer (LRPC) to reduce overtreatment and to maintain patients' quality of life (QOL). However, whether African American (AA) men can safely undergo AS is controversial due to concerns of more aggressive disease and lack of empirical data on the safety and effectiveness of AS in this population. Withholding of AS may lead to a lost opportunity for improving survivorship in AA men. In this study, peer-reviewed and funded by the US Department of Defense, we will assess whether AS is an equally effective and safe management option for AA as it is for White men with LRPC.

METHODS AND ANALYSIS

The project extends follow-up of a large contemporary population-based cohort of LRPC patients (n=1688) with a high proportion of AA men (~20%) and well-characterised baseline and 2-year follow-up data. The objectives are to (1) determine any racial differences in AS adherence, switch rate from AS to curative treatment and time to treatment over 5 years after diagnosis, (2) compare QOL among AS group and curative treatment group over time, overall and by race and (3) evaluate whether reasons for switching from AS to curative treatment differ by race. Validation of survey responses related to AS follow-up procedures is being conducted through medical record review. We expect to obtain 5-year survey from ~900 (~20% AA) men by the end of this study to have sufficient power. Descriptive and inferential statistical techniques will be used to examine racial differences in AS adherence, effectiveness and QOL.

ETHICS AND DISSEMINATION

The parent and current studies were approved by the Institutional Review Boards at Wayne State University and Emory University. Since it is an observational study, ethical or safety risks are low. We will disseminate our findings to relevant conferences and peer-reviewed journals.

Standardized Treatment and Assessment Pathway Improves Mortality in Adults With Methicillin-resistant Staphylococcus aureus Bacteremia: STAPH Study

Background

Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) management remains challenging for clinicians. Numerous in vitro studies report synergy when vancomycin (VAN) and daptomycin (DAP) are combined with beta-lactams (BLs), which has led to clinical implementation of these combinations. While shorter durations of bacteremia have often been reported, there has been no significant impact on mortality.

Methods

The Detroit Medical Center (DMC) developed and implemented a clinical pathway algorithm for MRSA BSI treatment in 2016 that included the early use of BL combination therapy with standard of care (VAN or DAP) and a mandatory Infectious Diseases consultation. This was a retrospective, quasi-experimental study at the DMC between 2013 and 2020. Multivariable logistic regression was used to assess the independent association between pathway implementation and 30-day mortality while adjusting for confounding variables.

Results

Overall, 813 adult patients treated for MRSA BSI were evaluated. Compared with prepathway (PRE) patients (n = 379), those treated postpathway (POST; n = 434) had a significant reduction in 30-day and 90-day mortality: 9.7% in POST vs 15.6% in PRE (P = .011) and 12.2% in POST vs 19.0% in PRE (P = .007), respectively.

The incidence of acute kidney injury (AKI) was higher in the PRE compared with the POST group: 9.6% vs 7.2% (P = .282), respectively. After adjusting for confounding variables including Infectious Diseases consult, POST was independently associated with a reduction in 30-day mortality (adjusted odds ratio [aOR], 0.608; 95% CI, 0.375–0.986).

Conclusions

Implementation of an MRSA BSI treatment pathway with early use of BL reduced mortality with no increased rate of AKI. Further prospective evaluation of this pathway approach is warranted.

Urologists' Perceptions of Active Surveillance and Their Recommendations for Low-risk Prostate Cancer Patients

OBJECTIVE

To assess practicing urologists' attitudes and perceptions of active surveillance (AS) and other treatment options for low-risk prostate cancer.

METHODS

This was a cross-sectional survey of urologists practicing in Michigan and Georgia. Urologists were asked about perceptions and practices pertaining to AS.

RESULTS

Overall, 225 urologists completed the survey; 147 (65%) were from Michigan and 78 (35%) were from Georgia. Most urologists reported they provided (99%), discussed (97%), and offered (61%) AS to all of their low-risk patients. Most believed AS is effective (97%) and underused (90%), while 80% agreed that curative therapy (surgery, radiation) is overused in the United States. Although most (79%) endorse that Black men are more likely to have aggressive low-risk disease, 89% reported feeling comfortable recommending AS to Black men. In multivariable analysis, significant provider-related predictors of AS recommendation were practice location, number of years in practice, beliefs pertaining to survival benefit of prostatectomy and effectiveness of AS, and expectation that patients are not interested in AS. The patient characteristics of race, age, life expectancy, fear of cancer progression, and fear of treatment side effects were also significant predictors of AS recommendations.

CONCLUSION

Most urologists surveyed stated that AS is effective and underused for low-risk prostate cancer . Overall, urologists are much less likely to recommend AS to younger men and slightly less to Black men. AS recommendations varied by practice location and by years in practice. These findings indicate targeted educational efforts in the US are needed to influence urologists toward greater acceptance of AS.

Efficacy of enhanced emergency department discharge for chronic hypertension management - Results of a randomized controlled trial

Introduction

AchieveBP is a randomized controlled trial (RCT) of an education intervention for patients with chronic hypertension who have uncontrolled blood pressure (BP) at discharge from an urban emergency department (ED). The study examined efficacy and moderators of an educational intervention in an RCT on BP control at 180-day post-intervention.

Methods

Participants were recruited from a single, urban ED and randomized to receive or not to receive hypertension education. To minimize potential bias, participants were all started on an evidence-based anti-hypertensive regimen and medications were dispensed directly to participants by the study team. Bivariate analysis was performed to examine differences in sociodemographic characteristics between patients achieving BP control and those who did not. Paired t-test was used to compare the difference of systolic and diastolic BP between baseline and 180 days post-discharge. Multiple logistic regression analysis examined interaction of covariates and intervention on achieving BP control.

Results

One hundred and thirty-nine participants were randomized into the study. All were African-American with a mean age of 47.6 (SD = 10.8) years; 51% were male, 63% had smoked cigarettes and 15% had diabetes. A total of 66 patients completed the study (47.4%), 44 of whom (67%) achieved BP control. However, there was no difference in BP reduction or control between the two groups. Age and smoking status showed moderation effects on intervention efficacy.

Conclusion

Despite a neutral effect of our intervention, a high level of BP control was achieved overall, suggesting that the ED may be a viable location for efforts aimed at reducing the impact of chronic hypertension in predominantly African American communities.

Physical Activity as a Predictor of Changes in Systolic Blood Pressure for African-American Adolescents Seeking Treatment for Obesity

PURPOSE

The aim of the study was to examine changes in systolic blood pressure (SBP) and whether physical activity and obesity status predicted SBP change for African-American adolescents (n = 181) participating in a behavioral weight control trial.

METHODS

Data were collected at baseline, 7 months (end-of-treatment), and 9 months (2-month follow-up).

RESULTS

Nearly half of adolescents achieved clinically significant SBP reductions at 7 and 9 months. Significantly, fewer adolescents had elevated SBP at 7 and 9 months compared with baseline (both p < .001). Changes in percent overweight and moderate-to-vigorous activity predicted changes in SBP over time.

CONCLUSIONS

Obesity reduction and increases in moderate-to-vigorous physical activity may predict short-term, clinically meaningful reductions in SBP for African American adolescents with obesity.

Feasibility and Acceptability of e-Screening and Brief Intervention and Tailored Text Messaging for Marijuana Use in Pregnancy

Background: There are at present no evidence-based interventions for marijuana use during pregnancy, despite it being by far the most commonly used illicit drug during pregnancy. Lack of treatment-seeking, combined with implementation challenges, has limited the extent to which at-risk women receive interventions of any kind. This study sought to evaluate the feasibility and acceptability of two high-reach technology-based interventions: electronic screening and brief intervention (e-SBI) and tailored text messaging, delivered either alone or in combination. Materials and Methods: In this exploratory feasibility trial, pregnant women seeking prenatal care services and scoring positive for marijuana use risk (n = 45) were randomly assigned to e-SBI, text messaging, or e-SBI plus text messaging. We examined completion rates and acceptability ratings as a function of intervention condition and participant characteristics. Results: All participants assigned to receive the e-SBI (n = 30) were able to complete it during the in-clinic baseline session. Participants assigned to text messaging (n = 30) received a median of 24 text messages before giving birth; 6 of 30 (20%) chose to end text messages before giving birth. Acceptability ratings for the e-SBI were high, with most being above 4.4 on a 5-point scale (e.g., for ease of use, respectfulness, and helpfulness). Acceptability ratings for some aspects of the texting intervention were also high (e.g., for ease of understanding and respectfulness). Participants in the combined e-SBI plus texting condition chose to stop messages at a rate of 13.3% (2 of 15), versus 26.7% (4 of 15) in the texting-only condition (p = 0.37). Conclusions: These two high-reach intervention elements showed strong feasibility and modest to high acceptability. Future efforts evaluating efficacy are warranted, and should specifically examine the possibility that combining text messaging with a brief intervention may promote retention.

Computer-delivered indirect screening and brief intervention for drug use in the perinatal period: A randomized trial

BACKGROUND

Under-reporting of drug use in the perinatal period is well-documented, and significantly limits the reach of proactive intervention approaches. The Wayne Indirect Drug Use Screener (WIDUS) focuses on correlates of drug use rather than use itself. This trial tested a computer-delivered, brief intervention designed for use with indirect screen-positive cases, seeking to motivate reductions in drug use without presuming its presence.

METHODS

Randomized clinical trial with 500 WIDUS-positive postpartum women recruited between August 14, 2012 and November 19, 2014. Participants were randomly assigned to either a time control condition or a single-session, tailored, indirect brief intervention. The primary outcome was days of drug use over the 6-month follow-up period; secondary outcomes included urine and hair analyses results at 3- and 6-month follow-up. All outcomes were measured by blinded evaluators.

RESULTS

Of the 500 participants (252 intervention and 248 control), 36.1% of participants acknowledged drug use in the 3 months prior to pregnancy, but 89% tested positive at the 6-month follow-up. Participants rated the intervention as easy to use (4.9/5) and helpful (4.4/5). Analyses revealed no between-group differences in drug use (52% in the intervention group, vs. 53% among controls; OR 1.03). Exploratory analyses also showed that intervention effects were not moderated by baseline severity, WIDUS score, or readiness to change.

CONCLUSIONS

The present trial showed no evidence of efficacy for an indirect, single-session, computer-delivered, brief intervention designed as a complement to indirect screening. More direct approaches that still do not presume active drug use may be possible and appropriate.

Clinical and metabolic correlates of cerebral calcifications in Sturge-Weber syndrome

AIM

To evaluate clinical and metabolic correlates of cerebral calcifications in children with Sturge-Weber syndrome (SWS).

METHOD

Fifteen children (11 females, four males; age range 7mo-9y, mean 4y 1mo) with unilateral SWS underwent baseline and follow-up magnetic resonance imaging (MRI) with susceptibility weighted imaging (SWI), glucose metabolism positron emission tomography (PET), and neurocognitive assessment (mean follow-up 1y 8mo). Calcified brain volumes measured on SWI were correlated with areas of abnormal glucose metabolism, seizure variables, and cognitive function (IQ).

RESULTS

Ten children had brain calcification at baseline and 11 at follow-up. Mean calcified brain volume increased from 1.69 to 2.47cm³ (p=0.003) in these children; the rate of interval calcified volume increase was associated with early onset of epilepsy (Spearman's rho [r_s ]=-0.63, p=0.036). Calcified brain regions showed a variable degree of glucose hypometabolism with the metabolic abnormalities often extending to non-calcified cerebral lobes. Larger calcified brain volumes at baseline were associated with longer duration of epilepsy (r_s =0.69, p=0.004) and lower outcome IQ (r_s =-0.53, p=0.042).

INTERPRETATION

Brain calcifications are common and progress faster in children with SWS with early epilepsy onset, and are associated with a variable degree of hypometabolism, which is typically more extensive than the calcified area. Higher calcified brain volumes may indicate a risk for poorer neurocognitive outcome.

Willingness to pay and willingness to accept in a patient-centered blood pressure control study

Background

Elevated blood pressure is a major risk factor for cardiovascular disease and stroke but patients often discount recommended behavioral changes and prescribed medications. While effective interventions to promote adherence have been developed, cost-effectiveness from the patient’s perspective, has not been well studied. The valuation of patient time and out of pocket expenses should be included while performing cost effectiveness evaluation. The AchieveBP study uses the contingent valuation method to assess willingness to accept (WTA) and willingness to pay (WTP) among patients with a history of uncontrolled blood pressure discharged from an urban emergency department and enrolled in a larger randomized controlled trial.

Methods

WTA and WTP were assessed by asking patients a series of questions about time and travel costs and time value related to their study participation. A survey was conducted during the final study visit with patients to investigate the effectiveness of a kiosk-based educational intervention on blood pressure control. All study patients, regardless of study arm, received the same clinical protocol of commonly prescribed antihypertensive medication and met with research clinicians four times as part of the study procedures.

Results

Thirty-eight patients were offered the opportunity to participate in the cost-effectiveness study and all completed the survey. Statistical comparisons revealed these 38 patients were similar in representation to the entire RCT study population. All 38 (100.0%) were African-American, with an average age of 49.1 years; 55.3% were male, 21.1% were married, 78.9% had a high school or higher education, and 44.7% were working. 55.9% did not have a primary care provider and 50.0% did not have health insurance. Time price linear regression analysis was performed to estimate predictors of WTA and WTP.

Conclusions

WTP and WTA may generate different results, and the elasticities were proportional to the estimated coefficients, with WTP about twice as responsive as WTA. An additional feature for health services research was successful piloting in a clinical setting of a brief patient-centered cost effectiveness survey.

Trial registration

https://clinicaltrials.gov. Registration Number NCT02069015. Registered February 19, 2014 (Retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2451-5) contains supplementary material, which is available to authorized users.

Patients' Survival Expectations With and Without Their Chosen Treatment for Prostate Cancer

PURPOSE

Overtreatment of screen-detected localized prostate cancer (LPC) is an important public health concern, since the survival benefit of aggressive treatment (surgery or radiation) has not been well established. We investigated the survival expectations of patients who had LPC with and without their chosen treatment.

METHODS

A population-based sample of 260 men (132 black, 128 white) 75 years old or younger with newly diagnosed LPC completed a self-administered survey. How long the patients expected to live with their chosen treatment, how long they would expect to live with no treatment, and factors associated with the difference in perceived life expectancy were assessed using multivariable analysis.

RESULTS

Without any treatment, 33% of patients expected that they would live less than 5 years, 41% 5 to 10 years, 21% 10 to 20 years, and 5% more than 20 years. With their chosen treatment, 3% of patients expected to live less than 5 years, 9% 5 to 10 years, 33% 10 to 20 years, and 55% more than 20 years. Treatment chosen, age, general health perception, and perceived cancer seriousness predicted the differences in perceived life expectancy, while race and actual tumor risk did not. After adjustment for other covariates, men who choose surgery or radiation expected greater gain in survival than men who chose watchful waiting or active surveillance.

CONCLUSIONS

Most patients with LPC underestimated their life expectancy without treatment and overestimated the gain in life expectancy with surgery or radiation. These unrealistic expectations may compromise patients' ability to make informed treatment decisions and may contribute to overtreatment of LPC. Primary care physicians, when included in the decision process, should focus on helping patients develop realistic expectations and choices that support their treatment goals.

Parental Support, Mental Health, and Alcohol and Marijuana Use in National and High-Risk African-American Adolescent Samples

African-American adolescents experience disproportionate rates of negative consequences of substance use despite using substances at average or below-average rates. Due to underrepresentation of African-American adolescents in etiological literature, risk and protective processes associated with their substance use require further study. This study examines the role of parental support in adolescents' conduct problems (CPs), depressive symptoms (DSs), and alcohol and marijuana use in a national sample and a high-risk sample of African-American adolescents. In both samples, parental support was inversely related to adolescent CPs, DSs, and alcohol and marijuana use. CPs, but not DSs, partially mediated the relation of parental support to substance use. Results were consistent across the national and high-risk samples, suggesting that the protective effect of parental support applies to African-American adolescents from a range of demographic backgrounds.

Prenatal alcohol exposure selectively enhances young adult perceived pleasantness of alcohol odors

Prenatal alcohol exposure (PAE) can lead to life-long neurobehavioral and social problems that can include a greater likelihood of early use and/or abuse of alcohol compared to older teens and young adults without PAE. Basic research in animals demonstrates that PAE influences later postnatal responses to chemosensory cues (i.e., odor & taste) associated with alcohol. We hypothesized that PAE would be related to poorer abilities to identify odors of alcohol-containing beverages, and would alter perceived alcohol odor intensity and pleasantness. To address this hypothesis we examined responses to alcohol and other odors in a small sample of young adults with detailed prenatal histories of exposure to alcohol and other drugs. The key finding from our controlled analyses is that higher levels of PAE were related to higher relative ratings of pleasantness for alcohol odors. As far as we are aware, this is the first published study to report the influence of PAE on responses to alcohol beverage odors in young adults. These findings are consistent with the hypothesis that positive associations (i.e., "pleasantness") to the chemosensory properties of alcohol (i.e., odor) are acquired prenatally and are retained for many years despite myriad interceding postnatal experiences. Alternate hypotheses may also be supported by the results. There are potential implications of altered alcohol odor responses for understanding individual differences in initiation of drinking, and alcohol seeking and high-risk alcohol-related behaviors in young adults.

Alluvial and riparian soils as major sources of lead exposure in young children in the Philippines: the role of floods

The objective of this paper was to determine the prevalence and sources of high lead (Pb) exposure among children in Bulacan, Philippines. A total of 150 children (6-7 years old) and their caregivers were studied. Lead was analyzed in children hair and deciduous teeth. Sources of lead exposure were determined by caregiver interview and Pb analysis of house soil, drinking faucet water, air, and water from seven Bulacan rivers. Lead was positive in 91.3% of children's hair (MC or median concentration = 8.9 μg/g; range = 0-38.29), in 46.2% of the teeth (MC = 0.000 μg/mg in positive samples; range = 0.00-0.020), in 100% of soil (MC = 27.06 mg/kg; range = 3.05-1155.80), in 21.1% of air (MC = 0 μg/Ncm; range = 0-0.10), in 4% of house, faucet water (MC = 0.0 ppm; range = 0-40). There was a significant correlation (Spearman's rho) between Pb in children's hair and soil (r = 0.195; p = 0.017) and between Pb in house water and outdoor air (r = 0.616; p = 0.005). There is no significant correlation between Pb in children's hair and teeth. None of the potential sources of Pb from interview were related to lead exposure in the children. Water from seven Bulacan rivers was 100% positive for lead (MC = 70.00 ppb; range = 30-90). Widespread flooding with river overflow occurred in Bulacan in 2009 which likely caused lead contamination of the soil. There was no significant difference in the lead concentration of the soil whether near or far from the river (p = 0.205, Mann-Whitney U test). High lead exposure in children in Bulacan is likely from soil contaminated by lead-polluted rivers during flooding. In areas where flooding is common, alluvial and riparian soils from polluted rivers are important sources of lead exposure in children.

Maternal endotoxin exposure results in abnormal neuronal architecture in the newborn rabbit

Maternal intrauterine inflammation/infection is a potential risk factor for the development of neurologic disorders such as cerebral palsy (CP) in preterm and term infants. CP is associated with white matter and grey matter injury. In the current study, we used a rabbit model of CP in which pregnant rabbits are administered intrauterine injections of the endotoxin lipopolysaccharide. We then investigated the extent of neuronal damage in the newborn kit brain. We observed an overall decrease in the number of MAP2-stained neurons and an increase in Fluoro-Jade C-stained cells in the anterior thalamus of 1-day-old rabbit brain. We also observed an overall decrease in the number of branching points and spine density in the retrosplenial cortex, a major output region of the anterior thalamus that is involved in cognition and memory. The loss of spines and dendritic atrophy in the retrosplenial cortex may be caused by loss of presynaptic input from the thalamus. Our study indicates that the cognitive impairments seen in patients with CP may be related to the degeneration of neurons and abnormal arborization of the thalamic and cortical neurons.

15O PET measurement of blood flow and oxygen consumption in cold-activated human brown fat

Although it has been believed that brown adipose tissue (BAT) depots disappear shortly after the perinatal period in humans, PET imaging using the glucose analog (18)F-FDG has shown unequivocally the existence of functional BAT in adult humans, suggesting that many humans retain some functional BAT past infancy. The objective of this study was to determine to what extent BAT thermogenesis is activated in adults during cold stress and to establish the relationship between BAT oxidative metabolism and (18)F-FDG tracer uptake.

METHODS

Twenty-five healthy adults (15 women and 10 men; mean age ± SD, 30 ± 7 y) underwent triple-oxygen scans (H2(15)O, C(15)O, and (15)O2) as well as measurements of daily energy expenditure (DEE; kcal/d) both at rest and after exposure to mild cold (15.5°C [60°F]) using indirect calorimetry. The subjects were divided into 2 groups (high BAT and low BAT) based on the presence or absence of (18)F-FDG tracer uptake (standardized uptake value [SUV] > 2) in cervical-supraclavicular BAT. Blood flow and oxygen extraction fraction (OEF) were calculated from dynamic PET scans at the location of BAT, muscle, and white adipose tissue. Regional blood oxygen saturation was determined by near-infrared spectroscopy. The total energy expenditure during rest and mild cold stress was measured by indirect calorimetry. Tissue-level metabolic rate of oxygen (MRO2) in BAT was determined and used to calculate the contribution of activated BAT to DEE.

RESULTS

The mass of activated BAT was 59.1 ± 17.5 g (range, 32-85 g) in the high-BAT group (8 women and 1 man; mean age, 29.6 ± 5.5 y) and 2.2 ± 3.6 g (range, 0-9.3 g) in the low-BAT group (9 men and 7 women; mean age, 31.4 ± 10 y). Corresponding maximal SUVs were significantly higher in the high-BAT group than in the low-BAT group (10.7 ± 3.9 vs. 2.1 ± 0.7, P = 0.01). Blood flow values were significantly higher in the high-BAT group than in the low-BAT group for BAT (12.9 ± 4.1 vs. 5.9 ± 2.2 mL/100 g/min, P = 0.03) and white adipose tissue (7.2 ± 3.4 vs. 5.7 ± 2.3 mL/100 g/min, P = 0.03) but were similar for muscle (4.4 ± 1.9 vs. 3.9 ± 1.7 mL/100 g/min). Moreover, OEF in BAT was similar in the 2 groups (0.51 ± 0.17 in high-BAT group vs. 0.47 ± 0.18 in low-BAT group, P = 0.39). During mild cold stress, calculated MRO2 values in BAT increased from 0.97 ± 0.53 to 1.42 ± 0.68 mL/100 g/min (P = 0.04) in the high-BAT group and were significantly higher than those determined in the low-BAT group (0.40 ± 0.28 vs. 0.51 ± 0.23, P = 0.67). The increase in DEE associated with BAT oxidative metabolism was highly variable in the high-BAT group, with an average of 3.2 ± 2.4 kcal/d (range, 1.9-4.6 kcal/d) at rest, and increased to 6.3 ± 3.5 kcal/d (range, 4.0-9.9 kcal/d) during exposure to mild cold. Although BAT accounted for only a small fraction of the cold-induced increase in DEE, such increases were not observed in subjects lacking BAT.

CONCLUSION

Mild cold-induced thermogenesis in BAT accounts for 15-25 kcal/d in subjects with relatively large BAT depots. Thus, although the presence of active BAT is correlated with cold-induced energy expenditure, direct measurement of MRO2 indicates that BAT is a minor source of thermogenesis in humans.

Dendrimer-based postnatal therapy for neuroinflammation and cerebral palsy in a rabbit model

Cerebral palsy (CP) is a chronic childhood disorder with no effective cure. Neuroinflammation, caused by activated microglia and astrocytes, plays a key role in the pathogenesis of CP and disorders such as Alzheimer's disease and multiple sclerosis. Targeting neuroinflammation can be a potent therapeutic strategy. However, delivering drugs across the blood-brain barrier to the target cells for treating diffuse brain injury is a major challenge. We show that systemically administered polyamidoamine dendrimers localize in activated microglia and astrocytes in the brain of newborn rabbits with CP, but not healthy controls. We further demonstrate that dendrimer-based N-acetyl-l-cysteine (NAC) therapy for brain injury suppresses neuroinflammation and leads to a marked improvement in motor function in the CP kits. The well-known and safe clinical profile for NAC, when combined with dendrimer-based targeting, provides opportunities for clinical translation in the treatment of neuroinflammatory disorders in humans. The effectiveness of the dendrimer-NAC treatment, administered in the postnatal period for a prenatal insult, suggests a window of opportunity for treatment of CP in humans after birth.

Where does work stress come from? A generalizability analysis of stress in police officers

Differences among workers and workplace stressors both contribute to perceiving work as stressful. However, the relative importance of these sources to work stress is not well delineated. Moreover, the extent to which work stress additionally reflects unique matches between specific workers and particular job stressors is also unclear. In this study, we use generalizability theory to specify and compare sources of variance in stress associated with police work. US police officers (N = 115) provided ratings of 60 stressors commonly associated with policing duties. Primary and secondary stress appraisal ratings reflected differences among officers in tendencies to generally perceive work stressors as stressful (14-15% officer effect), and also agreement among officers in viewing some stressors as more stressful than others (18-19% stressor effect). However, ratings especially reflected distinct pairings of officers and stressors (38-41% interaction effect). Additional analyses revealed individual differences and stressor characteristics associated with each variance component, including an officer × stressor interaction - compared to officers low in neuroticism, highly neurotic officers provided lower primary appraisal ratings of stressors generally seen as not serious, and also higher primary appraisal ratings of stressors that were seen as serious. We discuss implications of the current approach for the continued study of stress at work.

Recognized spontaneous abortion in mid-pregnancy and patterns of pregnancy alcohol use

Alcohol consumption during pregnancy is one potential risk factor for spontaneous abortion (SAb). Prior research suggested that heavy drinking during pregnancy was associated with significantly increased rates of SAb, but results for lower levels of drinking have been inconsistent. We examined the association between different levels and patterns of prenatal alcohol consumption and SAb in a high-risk inner-city sample. We hypothesized that higher levels, binge patterns, and more frequent drinking would be associated with increased rates of SAb. The quantity and frequency of self-reported peri-conceptional and repeated in-pregnancy maternal drinking volumes per beverage type were assessed with semi-structured interviews in a prospective subsample of 302 African-American mothers. Relations between various measures of prenatal alcohol exposure and SAb were assessed using logistic regression. After controlling for various potential confounders, there was a significant positive relation between average absolute alcohol use per day across pregnancy and SAb. Greater frequency of drinking episodes also predicted SAb: an average of even one day of drinking per week across pregnancy was associated with an increase in the incidence of SAb. However, contrary to our hypothesis, neither the amount of alcohol drunk per drinking day nor a measure of binge drinking was significantly related to SAb after controlling for confounders. Differences in when women who drank at risk levels initiated antenatal care may have under-estimated the impact of alcohol on SAb in this low-SES urban African-American sample. Some drinking measures averaged across pregnancy may have under-estimated consumption and overestimated risk of SAb, but other risk drinking measures that avoid this limitation show similar relations to SAb. Identifying fetal risk drinking in pregnant women is critical to increasing the effectiveness of interventions that reduce risk level alcohol consumption and protect from pregnancy loss.

Brain damage and IQ in unilateral Sturge-Weber syndrome: support for a "fresh start" hypothesis

We tested the hypothesis that extent of severe hypometabolism measured by fluorodeoxyglucose PET has a U-shaped (nonlinear) relationship to IQ in children with unilateral Sturge-Weber syndrome. Thirty-five consecutive children (age range: 30-153 months) with Sturge-Weber syndrome and unilateral brain involvement were enrolled in the study. Participants underwent cognitive assessment and interictal fluorodeoxyglucose PET scans. Regression analyses tested whether a quadratic model best accounted for the relationship between extent of severe cortical hypometabolism and IQ, controlling for seizure variables. A significant quadratic relationship was found between IQ and extent of severe (but not total) hypometabolism. Seizure variables also contributed significant variance to cognitive functions. Results suggest that intermediate size of severe hemispheric hypometabolism is associated with the worst cognitive outcomes, and small or absent lesions, with the best cognitive outcomes. Children in whom a very large extent of the hemisphere is severely affected are likely to have relatively preserved cognitive function.

Magnitude of [(11)C]PK11195 binding is related to severity of motor deficits in a rabbit model of cerebral palsy induced by intrauterine endotoxin exposure

Intrauterine inflammation is known to be a risk factor for the development of periventricular leukomalacia (PVL) and cerebral palsy. In recent years, activated microglial cells have been implicated in the pathogenesis of PVL and in the development of white matter injury. Clinical studies have shown the increased presence of activated microglial cells diffusely throughout the white matter in brains of patients with PVL. In vitro studies have reported that activated microglial cells induce oligodendrocyte damage and white matter injury by release of inflammatory cytokines, reactive nitrogen and oxygen species and the production of excitotoxic metabolites. PK11195 [1-(2-chlorophenyl)-N-methyl-N-(1-methylpropyl)-3-isoquinoline carboxamide] is a ligand that is selective for the 18-kDa translocator protein expressed on the outer mitochondrial membrane of activated microglia and macrophages. When labeled with carbon-11, [(11)C]PK11195 can effectively be used as a ligand in positron emission tomography (PET) studies for the detection of activated microglial cells in various neuroinflammatory and neurodegenerative conditions. In this study, we hypothesized that the magnitude of [(11)C]-(R)-PK11195 uptake in the newborn rabbit brain, as measured using a small-animal PET scanner, would match the severity of motor deficits resulting from intrauterine inflammation-induced perinatal brain injury. Pregnant New Zealand white rabbits were intrauterinely injected with endotoxin or saline at 28 days of gestation. Kits were born spontaneously at 31 days and underwent neurobehavioral testing and PET imaging following intravenous injection of the tracer [(11)C]-(R)-PK11195 on the day of birth. The neurobehavioral scores were compared with the change in [(11)C]PK11195 uptake over the time of scanning, for each of the kits. Upon analysis using receiver operating characteristic curves, an optimal combined sensitivity and specificity for detecting abnormal neurobehavioral scores suggestive of cerebral palsy in the neonatal rabbit was noted for a positive change in [(11)C]PK11195 uptake in the brain over time on PET imaging (sensitivity of 100% and area under the curve of >0.82 for all parameters tested). The strongest agreements were noted between a positive uptake slope - indicating increased [(11)C]PK11195 uptake over time - and worsening scores for measures of locomotion (indicated by hindlimb movement, forelimb movement, circular motion and straight- line motion; Cohen's κ >0.75 for each) and feeding (indicated by ability to suck and swallow and turn the head during feeding; Cohen's κ >0.85 for each). This was also associated with increased numbers of activated microglia (mean ratio ± SD of activated to total microglia: 0.96 ± 0.16 in the endotoxin group vs. 0.13 ± 0.08 in controls; p < 0.001) in the internal capsule and corona radiata. Our findings indicate that the magnitude of [(11)C]PK11195 binding measured in vivo by PET imaging matches the severity of motor deficits in the neonatal rabbit. Molecular imaging of ongoing neuroinflammation in the neonatal period may be helpful as a screening biomarker for detecting patients at risk of developing cerebral palsy due to a perinatal insult.

Demographic and lifestyle factors associated with perceived stress in the primary care setting: a MetroNet study

BACKGROUND

Stress and stress-related disorders are common in primary care. The stress-related needs for patients are often unmet partially due to the time and resource constraints inherent to many primary care settings. We examined the relative significance of key demographic and lifestyle factors related to stress among primary care patients. This information is unknown and needed to strategize these increasingly limited resources.

METHODS

We distributed surveys to 100 consecutive adult patients in each of four family medicine centres in metropolitan Detroit between 2006 and 2007. Hierarchical multivariable regression analyses were used to assess the relative significance of the demographic and lifestyle factors related to stress.

RESULTS

Of the 400 distributed surveys, 315 (78.7%) answered a minimum of 70% of the questions and were included in the analysis. The lifestyle factors [exercise, body mass index (BMI), sleep, social support, recovery or self-care skills (such as the ability to rest, relax and recuperate)] explained 39% (P < 0.001) of the variance in stress compared to 10% (P < 0.001) by the demographic factors (age, gender, race, employment, education and marital status). Stress was inversely related to sleep (P < 0.001), recovery (P < 0.001) and social support (P = 0.02) and positively to education (P < 0.001).

CONCLUSIONS

The modifiable lifestyle factors explained significantly more of perceived stress among primary care patients than the demographic factors. Sleep and recovery had the biggest inverse relationship with stress, which suggests that they should be the primary target for assessment and intervention in patients who report stress or stress-related disorders.

Do household smoking behaviors constitute a risk factor for hookah use?

INTRODUCTION

Much research has focused on the role played by families in cigarette smoking behavior. However, there is a lack of such research for hookah (waterpipe) smoking. This study focuses on the role of family members' hookah smoking behaviors as a possible risk factor for hookah smoking.

METHODS

Eight hundred and one adults in southeast Michigan responded to an anonymous self-administered survey regarding personal and family members' hookah smoking behavior and perceptions of health risks related to hookah smoking. Multinomial logistic regression modeling was used to examine risk factors for hookah use.

RESULTS

The prevalence of current hookah smoking in the study population was 26%. The odds ratio for an individual to smoke hookah were 9.5 (95% CI = 2.37-38.47, p < .01), 8.6 (95% CI = 3.92-19.02, p < .001), and 1.2 (95% CI = 1.14-1.41, p < .05) if the father, mother, or sibling, respectively, smoked hookah at home. Male gender and younger age were also significantly associated with hookah smoking. Household hookah smoking behaviors were also significant risk factors among former hookah smokers compared with nonsmokers, but there were no significant risk factors when comparing former hookah smokers with current hookah smokers.

CONCLUSIONS

Having a father, mother, or sibling smoking hookah at home, male gender and younger age are significant risk factors for current hookah smoking.

Validity of the T-ACE in pregnancy in predicting child outcome and risk drinking

Preventing fetal alcohol spectrum disorders (FASDs) requires detection of in-pregnancy maternal risk drinking. The widely used T-ACE screen has been applied in various ways, although the impact of those different uses on effectiveness is uncertain. We examined relations among different T-ACE scoring criteria, maternal drinking, and child outcome. Self-reported across-pregnancy maternal drinking was assessed in 75 African-American women. The different T-ACE criteria used varied the level of drinking that defined tolerance (two or three drinks) and the total T-ACE score cut-points (two or three). Receiver operator curves and regression analysis assessed the significance of relations. Increasing the total T-ACE score cut-point to 3 almost doubled specificity in detecting risk drinking whereas maintaining adequate sensitivity, equivalent to that in the original report, and identified substantially more neurobehavioral deficits in children. Redefining tolerance at three drinks did not improve T-ACE effectiveness in predicting outcomes. This study is among the first to show the ability of an in-pregnancy T-ACE assessment to predict child neurodevelopmental outcome. In addition, increasing the total T-ACE score criterion (from 2 to 3) improved identification of non-drinking mothers and unaffected children with little loss in detection of drinkers and affected children. Efficient in-pregnancy screens for risk drinking afford greater opportunities for intervention that could prevent/limit FASDs.

A 14-year retrospective maternal report of alcohol consumption in pregnancy predicts pregnancy and teen outcomes

Detecting patterns of maternal drinking that place fetuses at risk for fetal alcohol spectrum disorders (FASDs) is critical to diagnosis, treatment, and prevention but is challenging because information on antenatal drinking collected during pregnancy is often insufficient or lacking. Although retrospective assessments have been considered less favored by many researchers due to presumed poor reliability, this perception may be inaccurate because of reduced maternal denial and/or distortion. The present study hypothesized that fetal alcohol exposure, as assessed retrospectively during child adolescence, would be related significantly to prior measures of maternal drinking and would predict alcohol-related behavioral problems in teens better than antenatal measures of maternal alcohol consumption. Drinking was assessed during pregnancy, and retrospectively about the same pregnancy, at a 14-year follow-up in 288 African-American women using well-validated semistructured interviews. Regression analysis examined the predictive validity of both drinking assessments on pregnancy outcomes and on teacher-reported teen behavior outcomes. Retrospective maternal self-reported drinking assessed 14 years postpartum was significantly higher than antenatal reports of consumption. Retrospective report identified 10.8 times more women as risk drinkers (≥ one drink per day) than the antenatal report. Antenatal and retrospective reports were moderately correlated and both were correlated with the Michigan Alcoholism Screening Test. Self-reported alcohol consumption during pregnancy based on retrospective report identified significantly more teens exposed prenatally to at-risk alcohol levels than antenatal, in-pregnancy reports. Retrospective report predicted more teen behavior problems (e.g., attention problems and externalizing behaviors) than the antenatal report. Antenatal report predicted younger gestational age at birth and retrospective report predicted smaller birth size; neither predicted teen IQ. These results suggest that if only antenatal, in-pregnancy maternal report is used, then a substantial proportion of children exposed prenatally to risk levels of alcohol might be misclassified. The validity of retrospective assessment of prior drinking during pregnancy as a more effective indicator of prenatal exposure was established by predicting more behavioral problems in teens than antenatal report. Retrospective report can provide valid information about drinking during a prior pregnancy and may facilitate diagnosis and subsequent interventions by educators, social service personnel, and health-care providers, thereby reducing the life-long impact of FASDs.

Just say "I don't": lack of concordance between teen report and biological measures of drug use

BACKGROUND

Prevalence estimates of illicit drug use by teens are typically generated from confidential or anonymous self-report. While data comparing teen self-report with biological measures are limited, adult studies identify varying degrees of under-reporting.

METHODS

Hair analyses for cocaine, opiates and marijuana were compared to confidential teen self- and parent-reported teen drug use in a longitudinal cohort of >400 high-risk urban teens and parents.

RESULTS

Both teens and parents substantially underreported recent teen cocaine and opiate use. However, compared with parents, teens were more likely to deny biomarker-verified cocaine use. Teen specimens (hair) were 52 times more likely to identify cocaine use compared with self-report. Parent hair analyses for cocaine and opiate use were 6.5 times and 5.5 times, respectively, more likely to indicate drug use than were parental self-report. The lack of concordance between self-report and bioassay occurred despite participant's knowledge that a "certificate of confidentiality" protected both teen and adult participants, and that the biological specimens would be tested for drugs.

CONCLUSIONS

These findings confirm prior reports of adult under-reporting of their own drug use while extending our understanding of teen's self-admitted drug use. The lack of concordance between teen self- or parent-reported teen drug use and biomarkers confirm our concerns that both teen- and parent-reported teen drug use is limited, at least for youth in high-risk urban settings. Methods of ascertainment other than self- or parent-report must be considered when health care providers, researchers and public health agencies attempt to estimate teen drug-use prevalence.

The impact of maternal age on the effects of prenatal alcohol exposure on attention

BACKGROUND

Prenatal exposure to alcohol has a variety of morphologic and neurobehavioral consequences, yet more than 10% of women continue to drink during pregnancy, placing their offspring at risk for fetal alcohol spectrum disorders (FASD). Identification of at-risk pregnancies has been difficult, in part, because the presence and severity of FASD are influenced by factors beyond the pattern of alcohol consumption. Establishing maternal characteristics, such as maternal age, that increase the risk of FASD is critical for targeted pregnancy intervention.

METHODS

We examined the moderating effect of maternal age on measures of attention in 462 children from a longitudinal cohort born to women with known alcohol consumption levels (absolute ounces of alcohol per day at conception) who were recruited during pregnancy. Analyses examined the impact of binge drinking, as average ounces of absolute alcohol per drinking day. Smoking and use of cocaine, marijuana, and opiates were also assessed. At 7 years of age, the children completed the Continuous Performance Test, and their teachers completed the Achenbach Teacher Report Form.

RESULTS

After controlling for covariates, stepwise multiple regression analyses revealed a negative relation between levels of prenatal binge drinking and several measures of attention. The interaction between alcohol consumption and maternal age was also significant, indicating that the impact of maternal binge drinking during pregnancy on attention was greater among children born to older drinking mothers.

CONCLUSION

These findings are consistent with previous findings that children born to older alcohol-using women have more deleterious effects of prenatal alcohol exposure on other neurobehavioral outcomes.

Prenatal and postnatal cocaine exposure predict teen cocaine use

Preclinical studies have identified alterations in cocaine and alcohol self-administration and behavioral responses to pharmacological challenges in adolescent offspring following prenatal exposure. To date, no published human studies have evaluated the relation between prenatal cocaine exposure and postnatal adolescent cocaine use. Human studies of prenatal cocaine-exposed children have also noted an increase in behaviors previously associated with substance use/abuse in teens and young adults, specifically childhood and teen externalizing behaviors, impulsivity, and attention problems. Despite these findings, human research has not addressed prior prenatal exposure as a potential predictor of teen drug use behavior. The purpose of this study was to evaluate the relations between prenatal cocaine exposure and teen cocaine use in a prospective longitudinal cohort (n=316) that permitted extensive control for child, parent and community risk factors. Logistic regression analyses and Structural Equation Modeling revealed that both prenatal exposure and postnatal parent/caregiver cocaine use were uniquely related to teen use of cocaine at age 14 years. Teen cocaine use was also directly predicted by teen community violence exposure and caregiver negativity, and was indirectly related to teen community drug exposure. These data provide further evidence of the importance of prenatal exposure, family and community factors in the intergenerational transmission of teen/young adult substance abuse/use.

Teens with heavy prenatal cocaine exposure respond to experimental social provocation with escape not aggression

Preclinical data show that, compared to no exposure, prenatal cocaine exposure (PCE) has age-dependent effects on social interaction and aggression. The aim of this clinical study was to determine how heavy/persistent PCE--after controlling for other prenatal drug exposures, sex and postnatal factors--predicts behavioral sensitivity to provocation (i.e., reactive aggression) using a well-validated human laboratory model of aggression. African American teens (mean=14.2 years old) with histories of heavy/persistent PCE (maternal cocaine use ≥ 2 times/week during pregnancy, or positive maternal or infant urine/meconium test at delivery; n=86) or none/some exposure (NON: maternal cocaine use < 2 times/week during pregnancy; n=330) completed the Point Subtraction Aggression Paradigm. In this task, teens competed in a computer game against a fictitious opponent. There were three possible responses: (a) earn points, to exchange for money later; or (b) "aggress" against the fictitious opponent by subtracting their points; or (c) escape temporarily from point subtraction perpetrated by the fictitious opponent. The PCE group responded significantly more frequently on the escape option than the NON group, but did not differ in aggressive or money-earning responses. These data indicate that PCE-teens provoked with a social stressor exhibit a behavioral preference for escape (negative reinforcement) than for aggressive (retaliatory) or appetitive (point- or money-reinforced) responses. These findings are consistent with preclinical data showing that social provocation of adolescent or young adult offspring after PCE is associated with greater escape behavior, inferring greater submission, social withdrawal, or anxiety, as opposed to aggressive behavior.

Alterations in frontal lobe tracts and corpus callosum in young children with autism spectrum disorder

Major frontal lobe tracts and corpus callosum (CC) were investigated in 32 children with autism spectrum disorder (ASD, mean age: 5 years), 12 nonautistic developmentally impaired children (DI, mean age: 4.6 years), and 16 typically developing children (TD, mean age: 5.5 years) using diffusion tensor imaging tractography and tract-based spatial statistics. Various diffusion and geometric properties were calculated for uncinate fasciculus (UF), inferior fronto-occipital fasciculus (IFO), arcuate fasciculus (AF), cingulum (Cg), CC, and corticospinal tract. Fractional anisotropy was lower in the right UF, right Cg and CC in ASD and DI children; in right AF in ASD children; and in bilateral IFO in DI children, compared with TD children. Apparent diffusion coefficient was increased in right AF in both ASD and DI children. The ASD group showed shorter length of left UF and increased length, volume, and density of right UF; increased length and density of CC; and higher density of left Cg, compared with the TD group. Compared with DI group, ASD group had increased length, volume, and density of right UF; higher volume of left UF; and increased length of right AF and CC. Volume of bilateral UF and right AF and fiber density of left UF were positively associated with autistic features.

Intrauterine endotoxin administration leads to white matter diffusivity changes in newborn rabbits

Maternal intrauterine inflammation has been implicated in the development of periventricular leukomalacia and white matter injury in the neonate. We hypothesized that intrauterine endotoxin administration would lead to microstructural changes in the neonatal rabbit white matter in vivo that could be detected at birth using diffusion tensor magnetic resonance imaging (MRI). Term newborn rabbit kits (gestational age 31 days) born to dams exposed to saline or endotoxin in utero on gestational day 28 underwent diffusion tensor imaging, and brain sections were stained for microglia. Comparison between normal and endotoxin groups showed significant decreases in both fractional anisotropy and eigenvalue (e(1)) in all periventricular white matter regions that showed an increase in the number of activated microglial cells, indicating that after maternal inflammation, microglial infiltration may predominantly explain this change in diffusivity in the immediate neonatal period. Diffusion tensor imaging may be a clinically useful tool for detecting neuroinflammation induced by maternal infection in neonatal white matter.

Predictors of decision making in families at risk for inherited breast/ovarian cancer

OBJECTIVE

The purpose of this study was to identify factors associated with decision making about inherited cancer risk information within families and determine the interdependence between survivors' and relatives' decision making.

DESIGN

A descriptive, cross-sectional design using a population-based sample of 146 dyads (N = 292) was used. Analyses included multilevel modeling using the Actor-Partner-Interdependence Model.

MAIN OUTCOME MEASURES

Decision making regarding inherited cancer risk information.

RESULTS

Several individual and family factors contributed toward survivors' and female relatives' decision making about inherited cancer risk information. Individual factors included the individual's perceptions of their family communication and cancer history. Family factors included survivors' and family members' age, communication and coping style that influenced the decision making of the other member of the dyad. Cancer worries and a monitoring coping style affected both seeking and avoiding decision making for survivors and relatives.

CONCLUSIONS

In view of the importance of genetic information upon family health outcomes, it is critical to address both individual and family factors that may influence decision making about cancer risk information and surveillance options for all members within the family.

Risk perception and cancer worries in families at increased risk of familial breast/ovarian cancer

While families at increased risk for familial breast/ovarian cancer continue to overestimate their cancer risk with increased cancer worries about the future, few studies have examined factors that affect inherited cancer risk perception and cancer worries in both survivors and unaffected female relatives. The purpose of this study was to examine variables that may affect cancer worries and risk perceptions from a family-based perspective in a racially diverse, community-based, random sample of 146 dyads consisting of adult female breast and/or ovarian cancer survivors and their unaffected female relatives (N=292). Results indicated that coping style, self-efficacy, partner's income, family role relationship, and cancer risk perception were significant contributors to the survivors' and their unaffected relatives' cancer worries. Significant variables for perception of cancer risk for both survivors and relatives included income, race, family history of cancer, and cancer worries. Relatives had a higher perception of cancer risk, whereas survivors had more cancer worries. Additionally, the level of cancer worries reported by one member of the dyad was related to the amount of worries reported by the other. The results from this study underscore the importance of clinicians addressing concerns of both affected and unaffected members of families at increased risk of cancer to assist them in managing cancer worries and having realistic risk appraisals to make informed decisions about their own and their family's health surveillance options.

Intrauterine administration of endotoxin leads to motor deficits in a rabbit model: a link between prenatal infection and cerebral palsy

OBJECTIVE

This study was undertaken to determine whether maternal intrauterine endotoxin administration leads to neurobehavioral deficits in newborn rabbits.

STUDY DESIGN

Pregnant New Zealand white rabbits were injected with 1 mL saline solution (n = 8) or 20 microg/kg of lipopolysaccharide in saline solution (n = 8) into the uterine wall on day 28/31 of gestation. On postnatal day 1, kits (saline solution [n = 30] and lipolysaccharide in saline solution [n = 18] from 4 consecutive litters) underwent neurobehavioral testing. Neonatal brains were stained for microglial cells and myelin.

RESULTS

Kits in the lipopolysaccharide in saline solution group were hypertonic and demonstrated significant impairment in posture, righting reflex, locomotion, and feeding, along with neuroinflammation indicated by activated microglia and hypomyelination in the periventricular regions. A greater mortality was noted in the lipopolysaccharide in saline solution group (16 stillbirths from 3 litters vs 3 from 1 litter).

CONCLUSION

Maternal intrauterine endotoxin administration leads to white matter injury and motor deficits in the newborn rabbit, resulting in a phenotype that resembles those found in periventricular leukomalacia and cerebral palsy.

Percutaneous liver biopsy is safe in chronic hepatitis C patients with end-stage renal disease

BACKGROUND & AIMS

Liver biopsy is useful for staging fibrosis in chronic hepatitis C (CHC) patients with end-stage renal disease (ESRD) to determine renal transplant eligibility and to make CHC treatment decisions. There is concern about an increased risk associated with percutaneous liver biopsy (PCNB) in ESRD patients. We compared the safety of PCNB in CHC patients with and without ESRD.

METHODS

We reviewed PCNBs performed between 1996 and 2004 for technique, histology, and complications in 78 ESRD patients with CHC and in 241 control patients with CHC and no renal failure, randomly matched for age, sex, and race. Platelet counts, prothrombin, and partial thromboplastin times, but not bleeding times, were checked before biopsy. Deamino-8-D-arginine vasopressin was not given before the biopsy.

RESULTS

The mean age of the patients was 50 years; 72% were male, 97% were African American, and 3% were Caucasian. The control group had a significantly higher proportion of patients with advanced fibrosis (P < .04). Only 1 patient with ESRD (1.3%) developed a moderate complication. Five controls (2.1%) developed complications, 3 of which were severe.

CONCLUSIONS

Severe complications after PCNB are uncommon, and patients with ESRD and CHC are at no increased risk. Testing for bleeding time and the routine use of deamino-8-D-arginine vasopressin are not necessary before PCNB in patients with ESRD.

Characteristics of abnormal diffusivity in normal-appearing white matter investigated with diffusion tensor MR imaging in tuberous sclerosis complex

BACKGROUND AND PURPOSE

Although patients with tuberous sclerosis complex (TSC) manifest various structural abnormalities, we hypothesized that white matter (WM) structures that appear normal on conventional MR imaging may be accompanied by microstructural changes, such as gliosis and myelinization defects. Our objective was to determine in vivo whether there was evidence for WM microstructural changes by using diffusion tensor imaging (DTI).

MATERIALS AND METHODS

We used DTI to evaluate diffusivity and anisotropy in normal-appearing WM (NAWM) of 6 children with TSC and 12 age-matched control subjects. The anterior and posterior limbs of the internal capsule, the external capsule, and the genu and splenium of the corpus callosum were assessed. We hypothesized that previously reported DTI abnormalities of NAWM in patients with TSC may not be equal in all diffusion directions as measured by the major, middle, and minor eigenvalues.

RESULTS

When combining NAWM regions in patients with TSC, we observed a significant increase in mean diffusivity (P = .003) and a decrease in anisotropy (P = .03) compared with those of controls. However, the increase in diffusivity was more pronounced in directions orthogonal to the axons measured by the minor and middle eigenvalues (P = .005) than by the major eigenvalue (P = .02).

CONCLUSION

Our findings revealed a decrease in anisotropy and an increase in longitudinal and radial diffusivities in NAWM beyond the location of TSC lesions seen on conventional MR imaging. The axonal microstructural changes suggested by our study may be related to changes in myelin packing due to giant cells accompanied by gliosis and myelination defects known to occur in TSC WM.

Microglial Activation in Perinatal Rabbit Brain Induced by Intrauterine Inflammation: Detection with 11C-(R)-PK11195 and Small-Animal PET

Intrauterine infection can lead to a fetal inflammatory response syndrome that has been implicated as one of the causes of perinatal brain injury leading to periventricular leukomalacia (PVL) and cerebral palsy. The presence of activated microglial cells has been noted in autopsy specimens of patients with PVL and in models of neonatal hypoxia and ischemia. Activated microglial cells can cause oligodendrocyte damage and white matter injury by release of inflammatory cytokines and production of excitotoxic metabolites. We hypothesized that exposure to endotoxin in utero leads to microglial activation in the fetal brain that can be monitored in vivo by (11)C-(R)-PK11195 (1-[2-chlorophenyl]-N-methyl-N-[1-methylpropyl]-3-isoquinoline carboxamide)--a positron-emitting ligand that binds peripheral benzodiazepine receptor sites in activated microglia--using small-animal PET.

METHODS

Pregnant New Zealand White rabbits underwent laparotomy and were injected with 20 and 30 microg/kg of Escherichia coli lipopolysaccharide along the length of the uterus on day 28 of gestation. The pups were born spontaneously at term (31 d) and were scanned using small-animal PET after intravenous administration of (11)C-(R)-PK11195 and by MRI on postnatal day 1. The standard uptake values (SUVs) of the tracer were calculated for the whole brain at 10-min intervals for 60 min after tracer injection. The pups were euthanized after the scan, and brains were fixed, sectioned, and stained for microglial cells using biotinylated tomato lectin.

RESULTS

There was increased brain retention of (11)C-(R)-PK11195--as determined by a significant difference in the slope of the SUV over time--in the endotoxin-treated pups when compared with that of age-matched controls. Immunohistochemical staining showed dose-dependent changes in activated microglia (increased number and morphologic changes) in the periventricular region and hippocampus of the brain of newborn rabbit pups exposed to endotoxin in utero.

CONCLUSION

Intrauterine inflammation leads to activation of microglial cells that may be responsible for the development of brain injury and white matter damage in the perinatal period. PET with the tracer (11)C-(R)-PK11195 can be used as a noninvasive, sensitive tool for determining the presence and progress of neuroinflammation due to perinatal insults in newborns.

PET of human prostate cancer xenografts in mice with increased uptake of 64CuCl2

Our objective was to determine whether human prostate cancer xenografts in mice can be localized by PET using 64CuCl2 as a probe (64Cu PET).

METHODS

Athymic mice bearing human prostate cancer xenografts were subjected to 64Cu PET, followed by quantitative analysis of the tracer concentrations and immunohistochemistry study of human copper transporter 1 expression in the tumor tissues.

RESULTS

Human prostate cancer xenografts expressing high levels of human copper transporter 1 were well visualized on the PET images obtained 24 h after injection but not on the images obtained 1 h after injection. PET quantitative analysis demonstrated a high concentration of 64CuCl2 in the tumors in comparison to that in the left shoulder regions (percentage injected dose per gram of tissue: 3.6 +/- 1.3 and 0.6 +/- 0.3, respectively; P = 0.004), at 24 h after injection.

CONCLUSION

The data from this study suggested that locally recurrent prostate cancer might be localized with 64Cu PET using 64CuCl2 as a probe.

Cerebellar lesions in tuberous sclerosis complex: neurobehavioral and neuroimaging correlates

We assessed the structural and functional imaging features of cerebellar lesions and their neurobehavioral correlates in a large cohort of patients with tuberous sclerosis complex. A consecutive series of 78 patients with tuberous sclerosis complex underwent magnetic resonance imaging (MRI) and positron emission tomography (PET) studies with [(18)F]fluorodeoxyglucose (FDG) and alpha-[(11)C]methyl-l-tryptophan (AMT) as part of their evaluation for epilepsy surgery. Neurobehavioral assessment included the Gilliam Autism Rating Scales (GARS) and the Vineland Adaptive Behavior Scales (VABS). Twenty-one patients (27%) had cerebellar lesions (10 boys; mean age 9 +/- 8 years; 9 had right-sided, 10 had left-sided, and 2 had bilateral cerebellar lesions). The lesions showed decreased glucose metabolism (0.79 +/- 0.10) and increased (1.04 +/- 0.10) AMT uptake compared with the normal (nonlesional) cerebellar cortex. Comparisons between patients with (n = 20) and without (n = 57) a cerebellar lesion on neurobehavioral functioning, controlling for the number and location of cortical tubers, revealed that the cerebellar lesion group had higher overall autistic symptomatology. Within-group analyses of the cerebellar lesion group revealed that children with right-sided cerebellar lesions had higher social isolation and communicative and developmental disturbance compared with children with left-sided cerebellar lesions. The side of the cerebellar lesion was not related to adaptive behavior functioning. These findings provide additional empiric support for a role of the cerebellum in autistic symptomatology. Further investigation of the potential role of the right cerebellum in autism, particularly with regard to the dentatothalamofrontal circuit, is warranted.

Application of an objective method for localizing bilateral cortical FDG PET abnormalities to guide the resection of epileptic foci

PURPOSE

In order to improve the objective localization of bilateral cortical abnormalities in positron emission tomography (PET) image volumes, we developed a new three-dimensional image processing technique. The accuracy of this approach with respect to invasive subdural electroencephalography (EEG) data was assessed in a group of children with neocortical epilepsy.

METHODS

Glucose PET image volumes were obtained from 12 epileptic children (mean age 5.2 +/- 4.3 years). Bilateral cortical areas of abnormal glucose metabolism were objectively determined using two conditional criteria assessed against a normal database. The normal database was derived from a group of 15 adult controls (mean age 27.6 years). The spatial relationship between seizure onset electrodes and PET abnormalities was assessed using a conventional receiver operating characteristic (ROC) analysis as well as using a newly defined spatial proximity index (SPI), which characterizes the association between adjacent, but not coincident, abnormalities.

RESULTS

ROC analysis at the 2 standard deviation (SD) threshold, revealed an accuracy of 65% to detect seizure onset areas with a sensitivity of 64 +/- 17% and a specificity of 66 +/- 24%. Sensitivity decreased to 46 +/- 24% at the 3-SD threshold with a specificity of 80 +/- 21% (accuracy 75%). The average value for the SPI was determined as 3.82 +/- 1.65 which was 20% lower than the SPI value calculated using a simple in-plane two-dimensional asymmetry between homotopic cortical segments (4.52 +/- 3.82).

CONCLUSION

The presented image processing technique improves localization of cortical abnormalities and provides valuable imaging clues for placement of subdural EEG grids prior to surgical resection.