Last data update: Sep 23, 2024. (Total: 47723 publications since 2009)
Records 1-29 (of 29 Records) |
Query Trace: Greenspan A [original query] |
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Severity of COVID-19 Hospitalization Outcomes and Patient Disposition Differ by Disability Status and Disability Type.
Clarke KEN , Hong K , Schoonveld M , Greenspan AI , Montgomery M , Thierry JM . Clin Infect Dis 2022 76 (5) 871-880 BACKGROUND: Systemic inequities may place people with disabilities at higher risk of severe COVID-19 illness or lower likelihood to be discharged home after hospitalization. We examined whether severity of COVID-19 hospitalization outcomes and disposition differ by disability status and disability type. METHODS: In a retrospective analysis of April 2020-November 2021 hospital-based administrative data among 745,375 people hospitalized with COVID-19 from 866 US hospitals, people with disabilities (n = 120,360) were identified via ICD-10-CM codes. Outcomes compared by disability status included intensive care admission, invasive mechanical ventilation (IMV), in-hospital mortality, 30-day readmission, length of stay, and disposition (discharge to home, long-term care facility (LTCF), or skilled nursing facility (SNF). RESULTS: People with disabilities had increased risks of IMV (aRR: 1.05; 95%CI: 1.03-1.08) and in-hospital mortality (1.04; 1.02-1.06) compared to those with no disability; risks were higher among people with intellectual and developmental disabilities (IDD) (IMV [1.34; 1.28-1.40], mortality [1.31; 1.26-1.37]) or mobility disabilities (IMV [1.13; 1.09-1.16], mortality [1.04; 1.01-1.07]). Risk of readmission was increased among people with any disability (1.23; 1.20-1.27) and each disability type. Risks of discharge to a LTCF (1.45, 1.39-1.49) or SNF (1.78, 1.74-1.81) were increased among community-dwelling people with each disability type. CONCLUSIONS: Severity of COVID-19 hospitalization outcomes vary by disability status and type; IDD and mobility disabilities were associated with higher risks of severe outcomes. Disparities such as differences in discharge disposition by disability status require further study which would be facilitated by standardized data on disability. Increased readmission across disability types indicates a need to improve discharge planning and support services. |
Urinary polycyclic aromatic hydrocarbons in relation to anthropometric measures and pubertal development in a cohort of Northern California girls
Dobraca D , Laurent CA , Greenspan LC , Hiatt RA , Sjodin A , Kushi LH , Windham GC . Environ Epidemiol 2020 4 (4) e0102 BACKGROUND: Polycyclic aromatic hydrocarbons (PAHs) are a class of ubiquitous, environmental chemicals that may have endocrine disrupting capabilities. We investigated whether childhood exposure to PAHs was associated with adiposity and pubertal timing in a longitudinal study of 404 girls enrolled in the Northern California site of the Breast Cancer and the Environment Research Program cohort. METHODS: Baseline urinary samples from girls aged 6-8-years-old were assayed for 2-naphthol, fluorene metabolites, phenanthrene metabolites, 1-hydroxypyrene, and sum of PAH metabolites. Mixed-effects linear models were used to estimate how concentrations of PAH metabolites were related to changes in girl's body mass index (BMI) and waist-to-height ratio from age 7 through 16 years old. Accelerated failure time models were used to estimate age of pubertal onset (Tanner stages 2 or higher for breast and pubic hair development). RESULTS: Higher adiposity measurements among high tertiles of baseline PAH metabolites were evident at age 7 years old and increased thereafter (i.e., BMI for all PAH metabolites, waist-to-height ratio for fluorene and phenanthrene metabolites) or leveled off (i.e., waist-to-height ratio for 2-naphthol, 1-hydroxypyrene, sum of PAHs). Among girls overweight/obese at baseline, median age of breast development onset for high tertiles was 9.1-9.4 years old compared with 10-10.2 years old for low tertiles for all PAH metabolites; in contrast, found no association or slightly later onset of breast development for girls with normal weight at baseline. DISCUSSION: These results suggest that exposure to specific PAHs during childhood may influence adiposity throughout adolescence and effect pubertal timing. |
Characteristics of concussion in elementary school-aged children: Implications for clinical management
Master CL , Curry AE , Pfeiffer MR , Metzger KB , Kessler RS , Haarbauer-Krupa J , DePadilla L , Greenspan A , Breiding MJ , Arbogast KB . J Pediatr 2020 223 128-135 OBJECTIVE: To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes. STUDY DESIGN: A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients. RESULTS: Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations. CONCLUSIONS: Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion. |
Indication-specific opioid prescribing for US patients with Medicaid or private insurance, 2017
Mikosz CA , Zhang K , Haegerich T , Xu L , Losby JL , Greenspan A , Baldwin G , Dowell D . JAMA Netw Open 2020 3 (5) e204514 Importance: Although opioids can be effective medications in certain situations, they are associated with harms, including opioid use disorder and overdose. Studies have revealed unexplained prescribing variation and prescribing mismatched with patient-reported pain for many indications. Objective: To summarize opioid prescribing frequency, dosages, and durations, stratified across numerous painful medical indications. Design, Setting, and Participants: Retrospective cross-sectional analysis of 2017 US administrative claims data among outpatient clinical settings, including postsurgical discharge. Participants had any of 41 different indications associated with nonsurgical acute or chronic pain or postsurgical pain or pain associated with sickle cell disease or active cancer and were enrolled in either private insurance (including Medicare Advantage) in the OptumLabs Data Warehouse data set (n = 18016259) or Medicaid in the IBM MarketScan Multi-State Medicaid Database (n = 11453392). OptumLabs data were analyzed from October 2018 to March 2019; MarketScan data were analyzed from January to April 2019. Exposures: Nonsurgical acute or chronic pain or postsurgical pain; pain related to sickle cell disease or active cancer. Main Outcomes and Measures: Indication-specific opioid prescribing rates; days' supply per prescription; daily opioid dosage in morphine milligram equivalents; and for chronic pain indications, the number of opioid prescriptions. Results: During the study period, of 18016259 eligible patients with private insurance, the mean (95% CI) age was 42.7 (42.7-42.7) years, and 50.3% were female; of 11453392 eligible Medicaid enrollees, the mean (95% CI) age was 20.4 (20.4-20.4) years, and 56.1% were female. A pain-related indication under study occurred in at least 1 visit among 6380694 patients with private insurance (35.4%) and 3169831 Medicaid enrollees (27.7%); 2270596 (35.6% of 6380694) privately insured patients and 1126508 (35.5% of 3169831) Medicaid enrollees had 1 or more opioid prescriptions. Nonsurgical acute pain opioid prescribing rates were lowest for acute migraines (privately insured, 4.6% of visits; Medicaid, 6.6%) and highest for rib fractures (privately insured, 44.8% of visits; Medicaid, 56.3%), with variable days' supply but similar daily dosage across most indications. Opioid prescribing for a given chronic pain indication varied depending on a patient's opioid use history. Days' supply for postoperative prescriptions was longest for combined spinal decompression and fusion (privately insured, 9.5 days [95% CI, 9.4-9.7 days]) or spinal fusion (Medicaid, 9.1 days [95% CI, 8.9-9.2 days]) and was shortest for vaginal delivery (privately insured, 4.1 days [95% CI, 4.1-4.1 days] vs Medicaid, 4.2 days [95% CI, 4.2-4.2 days]). Conclusions and Relevance: Indication-specific opioid prescribing rates were not always aligned with existing guidelines. Potential inconsistencies between prescribing practice and clinical recommendations, such as for acute and chronic back pain, highlight opportunities to enhance pain management and patient safety. |
Utility of using cancer registry data to identify patients for tobacco treatment trials
Krebs P , Rogers E , Greenspan A , Goldfeld K , Lei L , Ostroff JS , Garrett BE , Momin B , Henley SJ . J Registry Manag 2019 46 (2) 30-36 Background: Many tobacco dependent cancer survivors continue to smoke after diagnosis and treatment. This study investigated the extent to which hospital-based cancer registries could be used to identify smokers in order to offer them assistance in quitting. The concordance of tobacco use coded in the registry was compared with tobacco use as coded in the accompanying Electronic Health Records (EHRs). Methods: We gathered data from three hospital-based cancer registries in New York City during June 2014 to December 2016. For each patient identified as a current combustible tobacco user in the cancer registries, we abstracted tobacco use data from their EHR to independently code and corroborate smoking status. We calculated the proportion of current smokers, former smokers, and never smokers as indicated in the EHR for the hospitals, cancer site, cancer stage, and sex. We used a logistic regression model to estimate the log odds of the registry-based smoking status correctly predicting the EHR-based smoking status. Results: Agreement in current smoking status between the registry-based smoking status and the EHR-based smoking status was 65%, 71%, and 90% at the three participating hospitals. Logistic regression results indicated that agreement in smoking status between the registry and the EHRs varied by hospital, cancer type, and stage, but not by age and sex. Conclusions: The utility of using tobacco use data in cancer registries for population-based tobacco treatment interventions is dependent on multiple factors including accurate entry into EHR systems, updated data, and consistent smoking status definitions and registry coding protocols. Our study found that accuracy varied across the three hospitals and may not be able to inform interventions at these hospitals at this time. Several changes may be needed to improve the coding of tobacco use status in EHRs and registries. |
Longitudinal study of age of menarche in association with childhood concentrations of persistent organic pollutants
Attfield KR , Pinney SM , Sjodin A , Voss RW , Greenspan LC , Biro FM , Hiatt RA , Kushi LH , Windham GC . Environ Res 2019 176 108551 BACKGROUND: Age at female puberty is associated with adult morbidities, including breast cancer and diabetes. Hormonally active chemicals are suspected of altering pubertal timing. We examined whether persistent organic pollutants (POPs) are associated with age at menarche in a longitudinal study. METHODS: We analyzed data for females enrolled at age 6-8 years in the Breast Cancer and Environment Research Program from California and Ohio. Participants were followed annually 2004-2013 and provided serum (mean age 7.8 years) for measurement of polychlorinated biphenyl (PCB), organochlorine pesticide (OCP), and polybrominated diphenyl ether (PBDE) concentrations. Age of menarche was assigned based on parental and participant reported dates and ages of menarche. Adjusted hazard ratios (aHRs) for menarchal onset were calculated with Cox proportional regression. Body mass index (BMI), potentially on the causal pathway, was added to parallel analyses. RESULTS: Age of menarche was later with higher summed PCB levels (median 11.9 years in quartile 1 [Q1] versus 12.7 in quartile 4 [Q4]) and OCP levels (12.1 years versus 12.4, respectively). When adjusting for all covariates except BMI, higher POP concentrations were associated with later age at menarche (Q4 versus Q1 aHRs: PBDEs 0.75 [95% CI 0.58, 0.97], PCBs 0.67 [95% CI 0.5, 0.89], and OCPs 0.66 [95% CI 0.50, 0.89]). Additional adjustment for BMI attenuated aHRs; PCB aHR approached the null. CONCLUSION: Findings revealed later onset of menarche with higher concentrations of certain POPs, possibly through an association with BMI. Altered pubertal timing may have long lasting effects on reproductive health and disease risk, so continued attention is important for understanding the biological processes affected by hormonally active chemicals. |
The CDC Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children: What physical therapists need to know
Mucha A , DeWitt J , Greenspan AI . Phys Ther 2019 99 (10) 1278-1280 Mild traumatic brain injury (mTBI) or concussion, once thought to be a fairly benign injury with little or no long-term consequences, has been recognized as an important public health concern among children and adolescents. From 2005 to 2009, an estimated 3 million children were seen in emergency departments, and an additional 2 million were seen as outpatients for treatment of mTBI.1 Children with mTBI may experience symptoms that affect cognitive, physical, and psychological function.2 For most children with mTBI, symptoms resolve within 2 to 4 weeks; however, a subset of children will continue to experience symptoms for 3 or more months.3 |
Risk of repeat concussion among patients diagnosed at a pediatric care network
Curry AE , Arbogast KB , Metzger KB , Kessler RS , Breiding MJ , Haarbauer-Krupa J , DePadilla L , Greenspan A , Master CL . J Pediatr 2019 210 13-19 e2 OBJECTIVE: To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury. STUDY DESIGN: For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion. RESULTS: Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]). CONCLUSIONS: We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts. |
Association of phthalates, parabens and phenols found in personal care products with pubertal timing in girls and boys
Harley KG , Berger KP , Kogut K , Parra K , Lustig RH , Greenspan LC , Calafat AM , Ye X , Eskenazi B . Hum Reprod 2018 34 (1) 109-117 STUDY QUESTION: Are in-utero or peripubertal exposures to phthalates, parabens and other phenols found in personal care products associated with timing of pubertal onset in boys and girls? SUMMARY ANSWER: We found some associations of altered pubertal timing in girls, but little evidence in boys. WHAT IS KNOWN ALREADY: Certain chemicals in personal care and consumer products, including low molecular weight phthalates, parabens and phenols, or their precursors, are associated with altered pubertal timing in animal studies. STUDY DESIGN, SIZE, DURATION: Data were from the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) longitudinal cohort study which followed 338 children in the Salinas Valley, California, from before birth to adolescence. PARTICIPANTS/MATERIALS, SETTING, METHODS: Pregnant women were enrolled in 1999-2000. Mothers were mostly Latina, living below the federal poverty threshold and without a high school diploma. We measured concentrations of three phthalate metabolites (monoethyl phthalate [MEP], mono-n-butyl phthalate and mono-isobutyl phthalate), methyl and propyl paraben and four other phenols (triclosan, benzophenone-3 and 2,4- and 2,5-dichlorophenol) in urine collected from mothers during pregnancy and from children at age 9. Pubertal timing was assessed among 179 girls and 159 boys every 9 months between ages 9 and 13 using clinical Tanner staging. Accelerated failure time models were used to obtain mean shifts of pubertal timing associated with concentrations of prenatal and peripubertal biomarkers. MAIN RESULTS AND THE ROLE OF CHANCE: In girls, we observed earlier onset of pubic hair development with prenatal urinary MEP concentrations and earlier menarche with prenatal triclosan and 2,4-dichlorophenol concentrations. Regarding peripubertal biomarkers, we observed: earlier breast development, pubic hair development and menarche with methyl paraben; earlier menarche with propyl paraben; and later pubic hair development with 2,5-dichlorophenol. In boys, we observed no associations with prenatal urinary biomarker concentrations and only one association with peripubertal concentrations: earlier genital development with propyl paraben. LIMITATIONS, REASONS FOR CAUTION: These chemicals are quickly metabolized and one to two urinary measurements per developmental point may not accurately reflect usual exposure. Associations of peripubertal measurements with parabens may reflect reverse causality: children going through puberty early may be more likely to use personal care products. The study population was limited to Latino children of low socioeconomic status living in a farmworker community and may not be widely generalizable. WIDER IMPLICATIONS OF THE FINDINGS: This study contributes to a growing literature that suggests that exposure to certain endocrine disrupting chemicals may impact timing of puberty in children. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by the National Institute of Environmental Health Sciences and the US Environmental Protection Agency. The authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A. |
Association of prenatal urinary concentrations of phthalates and bisphenol A and pubertal timing in boys and girls
Berger K , Eskenazi B , Kogut K , Parra K , Lustig RH , Greenspan LC , Holland N , Calafat AM , Ye X , Harley KG . Environ Health Perspect 2018 126 (9) 97004 BACKGROUND: Animal studies suggest that phthalates and bisphenol A (BPA), endocrine-disrupting chemicals found in many consumer products, may impact the timing of puberty. OBJECTIVES: We aimed to determine the association of prenatal exposure to high-molecular-weight phthalates and BPA with pubertal timing in boys and girls participating in the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) longitudinal cohort study. METHODS: We quantified urinary concentrations of eight phthalate metabolites and BPA at two time points during pregnancy among participating mothers ([Formula: see text]) and conducted clinical Tanner staging of puberty on their children every 9 months between 9 and 13 y of age. We conducted accelerated failure time models and examined the role of child overweight/obese status in this association. RESULTS: The sum of urinary metabolites of di(2-ethylhexyl) phthalate [Formula: see text], monobenzyl phthalate (MBzP), and BPA were associated with later onset of at least one of the three outcomes assessed in girls (thelarche, pubarche, or menarche) and with earlier onset of at least one of the two outcomes assessed in boys (gondarche and pubarche). We found that monocarboxynonyl phthalate, monocarboxyoctyl phthalate, mono(3-carboxypropyl) phthalate, and BPA were associated with later pubarche and menarche mostly among normal-weight girls but not overweight/obese girls. MBzP was associated with later thelarche in all girls, and [Formula: see text] was associated with later thelarche and menarche in all girls. BPA and all phthalate biomarkers were associated with earlier gonadarche and pubarche in all boys as well as in overweight/obese boys when stratified by weight. Among normal-weight boys, associations with BPA were also inverse, whereas associations with phthalate metabolites were close to the null or positive. CONCLUSIONS: Several high-molecular-weight phthalates and BPA were associated with later puberty in girls and earlier puberty in boys included in the CHAMACOS cohort study. Childhood overweight/obesity may modify these associations. https://doi.org/10.1289/EHP3424. |
Nonpharmacological management of pain: Convergence in priorities fuels the drive for more evidence
George SZ , Greenspan AI . Phys Ther 2018 98 (5) 287-289 Chronic pain is recognized by the National Academy of Medicine (formerly Institute of Medicine) as a highly prevalent disease occurring much more frequently than other chronic diseases that are widely accepted as public health priorities.1 In fact, the overall prevalence of chronic pain is estimated to be higher than that of diabetes, cardiovascular disease, and cancer combined.1 As the largest subset of chronic pain conditions, musculoskeletal pain is a common reason to seek health care1 and is a leading cause of disability globally due to back, neck, and/or joint pain.2 |
Variations in mechanisms of injury for children with concussion
Haarbauer-Krupa J , Arbogast KB , Metzger KB , Greenspan AI , Kessler R , Curry AE , Bell JM , DePadilla L , Pfeiffer MR , Zonfrillo MR , Master CL . J Pediatr 2018 197 241-248 e1 Objectives: To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system. Study design: All patients, age 0-17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Children's Hospital of Philadelphia's electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion-related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities. Results: Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0-4 were sports related, compared with greater proportions for older children (67% for age 5-11, 77% for age 12-14, and 73% for age 15-17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%). Conclusions: Sports-related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one-third of concussions were from non–sports-related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed. |
Age at pubertal onset in girls and tobacco smoke exposure during pre- and postnatal susceptibility windows
Windham GC , Lum R , Voss R , Wolff M , Pinney SM , Teteilbaum SL , Sosnoff CS , Dobraca D , Biro F , Hiatt RA , Greenspan LC , Galvez M , Kushi LH . Epidemiology 2017 28 (5) 719-727 BACKGROUND: Tobacco smoke contains known hormonally active chemicals and reproductive toxicants. Several studies have examined prenatal maternal smoking and offspring age at menarche, but few examined earlier pubertal markers, nor accounted for exposure during childhood. Our objective was to examine pre- and postnatal smoke exposure in relation to timing of early pubertal events. METHODS: An ethnically diverse cohort of 1239 girls was enrolled at age 6-8 years old for a longitudinal study of puberty at three US sites. Girls participated in annual or semi-annual exams to measure anthropometry and Tanner breast and pubic hair stages. Prenatal and current tobacco smoke exposures, as well as covariates, were obtained from parent questionnaire. Cotinine was measured in urine collected at enrollment. Using accelerated failure time models, we calculated adjusted time ratios for age at pubertal onset (maturation stages 2 or higher) and smoke exposure. RESULTS: Girls with higher prenatal (≥5 cigarettes per day) or secondhand smoke exposure had earlier pubic hair development than unexposed (adjusted time ratio: 0.92 [95% CI = 0.87, 0.97] and 0.94 [95% CI = 0.90, 0.97], respectively). Including both exposures in the same model yielded similar associations. Higher urinary cotinine quartiles were associated with younger age at breast and pubic hair onset in unadjusted models, but not after adjustment. CONCLUSIONS: Greater prenatal and childhood secondhand smoke exposure were associated with earlier onset of pubic hair, but not breast, development. These exposures represent modifiable risk factors for early pubertal development that should be considered for addition to the extensive list of adverse effects from tobacco smoke. |
Pregnancy and linkage to care among women diagnosed with HIV infection in 61 CDC-funded health departments in the United States, 2013
FitzHarris LF , Hollis ND , Nesheim SR , Greenspan JL , Dunbar EK . AIDS Care 2017 29 (7) 1-8 Timely linkage to HIV care (LTC) following an HIV diagnosis is especially important for pregnant women with HIV to prevent perinatal transmission and improve maternal health. However, limited data are available on LTC among U.S. pregnant women. Our analysis aimed to identify HIV diagnoses among childbearing age (CBA) women (15-44 years old) by pregnancy status and to compare LTC of HIV-infected pregnant women to HIV-infected non-pregnant women. We analyzed 2013 CDC-funded HIV testing data from 61 health departments and 151 directly funded community-based organizations among CBA women. LTC includes linkage at any time after an HIV diagnosis and within 90 days after HIV diagnosis. Pearson's chi-square was used to compare LTC of pregnant and non-pregnant women. Data were analyzed using SAS v9.3. Among the 1,379,860 HIV testing events among CBA women in 2013, 0.3% (n = 3690) were HIV-positive. Among all HIV-positive diagnoses with an available pregnancy status (n = 1987), 7%, (n = 138) were pregnant. Among women with pregnancy status data, LTC any time after an HIV-positive diagnosis was 73.2% for pregnant women and 60.7% for non-pregnant women. LTC within 90 days was 71.7% for pregnant women and 56.2% for non-pregnant women. Pregnancy was associated with LTC any time (p < 0.01) and within 90 days of diagnosis (p < 0.01). Compared with non-pregnant women, a higher proportion of pregnant women with HIV were linked to care overall, and linked within 90 days. Pregnancy appears to facilitate better LTC, but improvements are needed for women overall and pregnant women specifically. |
Association of prenatal and childhood PBDE exposure with timing of puberty in boys and girls
Harley KG , Rauch SA , Chevrier J , Kogut K , Parra KL , Trujillo C , Lustig RH , Greenspan LC , Sjodin A , Bradman A , Eskenazi B . Environ Int 2017 100 132-138 BACKGROUND: Polybrominated diphenyl ether (PBDE) flame retardants are endocrine-disrupting chemicals that exhibit estrogenic and androgenic properties and may affect pubertal timing. METHODS: Study subjects were participants between 1999 and 2013 in the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS), a longitudinal cohort study of predominantly Mexican origin families in Northern California. We measured serum concentrations of four PBDEs (BDE-47, -99, -100, -153) in blood collected from mothers during pregnancy (N=263) and their children at age 9years (N=522). We determined timing of pubertal onset in 309 boys and 314 girls using clinical Tanner staging every 9months between 9 and 13years of age, and timing of menarche by self-report. We used Poisson regression for relative risk (RR) of earlier puberty and parametric survival analysis for time ratios (TR) of pubertal milestones. RESULTS: Prenatal concentrations of all 4 congeners and PBDEs were associated with later menarche in girls (RRearlier menarche=0.5, 95% confidence interval (CI): 0.3, 0.9 for PBDEs) but earlier pubic hair development in boys (RRearlier pubarche=2.0, 95% CI: 1.3, 3.3 for PBDEs). No associations were seen between prenatal exposure and girls' breast or pubic hair development or boys' genital development. Childhood PBDE exposure was not associated with any measure of pubertal timing, except for an association of BDE-153 with later menarche. CONCLUSIONS: We found that prenatal PBDE exposure was associated with later menarche in girls but earlier pubarche in boys, suggesting opposite pubertal effects in girls and boys. |
Thyroid hormones and timing of pubertal onset in a longitudinal cohort of females, Northern California, 2006-11
Wilken JA , Greenspan LC , Kushi LH , Voss RW , Windham GC . Paediatr Perinat Epidemiol 2016 30 (3) 285-93 BACKGROUND: Pubertal timing is regulated by a complex interplay of hormones. Few studies have evaluated the role of thyroid hormones in pubertal onset. We investigated the associations between blood concentrations of free and total thyroxine (FT4, TT4), free triiodothyronine, and thyroid stimulating hormone and pubertal onset among females. METHODS: Participants included 323 Kaiser Permanente Northern California members followed at annual intervals during 2004-11, who provided a blood sample during the first 3 years of the study. Thyroid hormone concentrations were measured in serum in the first blood specimen available for each participant. Pubertal onset was defined as Tanner stage ≥2 for breast (thelarche) and pubic hair (pubarche) development. Associations between thyroid hormones and pubertal onset were assessed by multivariable logistic regression and Cox proportional hazards modelling. RESULTS: At blood draw, participants were age 6.5-10.1 (median 7.7) years, 10% had reached thelarche, and 12% had reached pubarche. Participants were followed 0-5 years after blood draw (median 4). At most recent clinical visit, participants were age 6.7-14.7 (median 12.3) years, 92% had reached thelarche, and 89% had reached pubarche. No associations were identified between having reached thelarche or pubarche at time of blood draw and thyroid hormones. Examined longitudinally, higher concentrations of pre-pubertal FT4 and TT4 were associated with earlier pubarche (adjusted hazard ratio (HR) 1.41, 95% confidence interval (CI) 1.06, 1.86; per ng/dL and aHR 1.07, 95% CI 1.02, 1.12; per mug/dL respectively). CONCLUSIONS: Higher pre-pubertal concentrations of FT4 and TT4 are associated with earlier pubarche. |
Brominated flame retardants and other persistent organohalogenated compounds in relation to timing of puberty in a longitudinal study of girls
Windham GC , Pinney SM , Voss RW , Sjodin A , Biro FM , Greenspan LC , Stewart S , Hiatt RA , Kushi LH . Environ Health Perspect 2015 123 (10) 1046-52 BACKGROUND: Exposure to hormonally active chemicals could plausibly affect pubertal timing, so we are investigating this in the Breast Cancer and the Environment Research Program. OBJECTIVES: Our goal was to examine persistent organic pollutants (POPs) in relation to pubertal onset. METHODS: Ethnically diverse cohorts of 6- to 8-year-old girls (n = 645) provided serum for measure of polybrominated diphenyl ethers (PBDEs), polychlorinated biphenyls (PCBs), organochlorine pesticides (OCPs), and lipids. Tanner stages [breast (B) and pubic hair (PH)], and body mass index (BMI) were measured at up to seven annual clinic visits. Using accelerated failure time models, we calculated time ratios (TRs) for age at Tanner stages 2 or higher (2+) and POPs quartiles (Q1-4), adjusting for confounders (race/ethnicity, site, caregiver education, and income). We also calculated prevalence ratios (PRs) of Tanner stages 2+ at time of blood sampling. RESULTS: Cross-sectionally, the prevalence of B2+ and PH2+ was inversely related to chemical serum concentrations; but after adjustment for confounders, only the associations with B2+, not PH2+, were statistically significant. Longitudinally, the age at pubertal transition was consistently older with greater chemical concentrations; for example: adjusted TR for B2+ and Q4 for SigmaPBDE = 1.05; 95% CI: 1.02, 1.08, for SigmaPCB = 1.05; 95% CI: 1.01, 1.08, and for SigmaOCP = 1.10; 95% CI: 1.06, 1.14, indicating median ages of about 6 and 11 months older than least exposed, and with similar effect estimates for PH2+. Adjusting for BMI attenuated associations for PCBs and OCPs but not for PBDEs. CONCLUSIONS: This first longitudinal study of puberty in girls with serum POPs measurements (to our knowledge) reveals a delay in onset with higher concentrations. |
Comparability of national estimates for traumatic brain injury-related medical encounters
Taylor CA , Greenspan AI , Xu L , Kresnow MJ . J Head Trauma Rehabil 2015 30 (3) 150-9 OBJECTIVE: To describe similarities and differences in the number of civilian traumatic brain injury (TBI)-related hospitalizations and emergency department visits between national databases that capture US hospital data. PARTICIPANTS: TBI-related hospitalizations included in the National Hospital Discharge Survey (NHDS) and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) and emergency department visits in the National Hospital Ambulatory Medical Care Survey (NHAMCS) and HCUP Nationwide Emergency Department Sample (HCUP-NEDS) for 2006-2010. DESIGN: Cross-sectional design. MAIN MEASURES: Nationwide counts of TBI-related medical encounters. RESULTS: Overall, the frequency of TBI is comparable when comparing NHDS with HCUP-NIS and NHAMCS with HCUP-NEDS. However, annual counts in both NHDS and NHAMCS are consistently unstable when examined in smaller subgroups, such as by age group and injury mechanism. Injury mechanism is consistently missing from many more records in NHDS compared with HCUP-NIS. CONCLUSION: Given the large sample size of HCUP-NIS and HCUP-NEDS, these data can offer a valuable resource for examining TBI-related hospitalization and emergency department visits, especially by subgroup. These data hold promise for future examinations of annual TBI counts, but ongoing comparisons with national probability samples will be necessary to ensure that HCUP continues to track with estimates from these data. |
The role of applied epidemiology methods in the disaster management cycle
Malilay J , Heumann M , Perrotta D , Wolkin AF , Schnall AH , Podgornik MN , Cruz MA , Horney JA , Zane D , Roisman R , Greenspan JR , Thoroughman D , Anderson HA , Wells EV , Simms EF . Am J Public Health 2014 104 (11) e1-e11 Disaster epidemiology (i.e., applied epidemiology in disaster settings) presents a source of reliable and actionable information for decision-makers and stakeholders in the disaster management cycle. However, epidemiological methods have yet to be routinely integrated into disaster response and fully communicated to response leaders. We present a framework consisting of rapid needs assessments, health surveillance, tracking and registries, and epidemiological investigations, including risk factor and health outcome studies and evaluation of interventions, which can be practiced throughout the cycle. Applying each method can result in actionable information for planners and decision-makers responsible for preparedness, response, and recovery. Disaster epidemiology, once integrated into the disaster management cycle, can provide the evidence base to inform and enhance response capability within the public health infrastructure. |
Prevention of injury and violence in the USA
Haegerich TM , Dahlberg LL , Simon TR , Baldwin GT , Sleet DA , Greenspan AI , Degutis LC . Lancet 2014 384 (9937) 64-74 In the first three decades of life, more individuals in the USA die from injuries and violence than from any other cause. Millions more people survive and are left with physical, emotional, and financial problems. Injuries and violence are not accidents; they are preventable. Prevention has a strong scientific foundation, yet efforts are not fully implemented or integrated into clinical and community settings. In this Series paper, we review the burden of injuries and violence in the USA, note effective interventions, and discuss methods to bring interventions into practice. Alliances between the public health community and medical care organisations, health-care providers, states, and communities can reduce injuries and violence. We encourage partnerships between medical and public health communities to consistently frame injuries and violence as preventable, identify evidence-based interventions, provide scientific information to decision makers, and strengthen the capacity of an integrated health system to prevent injuries and violence. |
Corrigendum to “Trends in Traumatic Brain Injury in the U.S. and the public health response: 1995–2009"
Greenspan A I , Coronado VG , McGuire LC , Sarmiento K , Bell J , Lionbarger MR , Jones CD , Geller AI , Khoury N , Xu L . J Safety Res 2014 48 117 In the article Trends in Traumatic Brain Injury in the U.S. and the public health response: 1995–2009, by Victor G. Coronado et al., (Journal of Safety Research, Vol 43/Issue 4, pp 299–307, September, 2012) an error was made in the calculation of total traumatic brain injury (TBI) burden. The authors incorrectly included the number of outpatient visits and office-based visits to an estimate of the total number of patients with a primary or secondary diagnosis of TBI in 2009. While an average of 1.2 million visits (annualized average between 2007 and 2009) are made each year to outpatient departments or to office-based physicians for treatment related to a TBI, either alone or in combination with other injuries, it is impossible to identify how many of these were incident visits versus repeat or follow-up visits. By including outpatient department and office-based visits we likely overestimated their contribution to the total TBI burden. While we recognize that excluding these visits from the overall estimate eliminates some incident cases and results in an underestimate of total TBI burden, the estimate of ED visits, hospitalizations, and deaths is more precise and should be presented separately from outpatient and office-based visits. Thus, the correct estimates should read: “In 2009, there were approximately 2.4 million hospital emergency department (ED) visits, hospitalizations, or deaths related to a TBI, either alone or in combination with other injuries. Further, between 2007 and 2009 there was an annualized average of 1.1 million office-based visits and 84,000 outpatient department visits with a TBI-related diagnosis either alone or in combination with other injuries.” Our incorrect calculation which combined outpatient and office-based visits with ED visits, hospitalizations, and deaths can be found in the first line of the Abstract, (page 299 of the printed version); in the second paragraph of section 5 (page 302); and in the third line of the Conclusions and recommendations section (page 305); these numbers (3.5 million, 3.6 million, and 3.6 million, respectively) were incorrect. The Centers for Disease Control and Prevention will be using the corrected estimate of 2.4 million to describe the national burden of TBI (ED visits, hospitalizations, and deaths) in future descriptions for 2009. We continue to pursue methods to identify incident cases of TBI that do not present to EDs to more comprehensively capture the full TBI burden. |
Effectiveness of a brief parent-directed teen driver safety intervention (checkpoints) delivered by driver education instructors
Zakrajsek JS , Shope JT , Greenspan AI , Wang J , Bingham CR , Simons-Morton BG . J Adolesc Health 2013 53 (1) 27-33 BACKGROUND: The Checkpoints program (Checkpoints) uses a Parent-Teen Driving Agreement (PTDA) to help parents monitor teens' driving, and has shown efficacy in increasing parental restrictions on teens' driving and decreasing teens' risky driving. In previous trials, research staff administered Checkpoints. This study examined the effectiveness of Checkpoints when delivered by driver educators. It was hypothesized that Checkpoints would result in more PTDA use, greater PTDA limits on higher risk driving situations, and less high-risk driving. METHODS: Eight trained driving instructors were randomly assigned to intervention or control groups in a group randomized trial. Instructors enrolled 148 parent-teen dyads (intervention = 99, control = 49); 35% of those eligible. Intervention parents joined teens for a 30-minute Checkpoints session during driver education. The session included a video, persuasive messages, discussion, and PTDA initiation. Teens completed four surveys: baseline, licensure, and 3- and 6-months post-licensure. RESULTS: Intervention teens were more likely to report that they used a PTDA (OR= 15.92, p = .004) and had restrictions on driving with teen passengers (OR = 8.52, p = .009), on weekend nights (OR = 8.71, p = .021), on high-speed roads (OR = 3.56, p = .02), and in bad weather (b = .51, p = .05) during the first six months of licensure. There were no differences in offenses or crashes at six months, but intervention teens reported less high-risk driving (p = .04). CONCLUSIONS: Although challenges remain to encourage greater parent participation, Checkpoints conducted by driver education instructors resulted in more use of PTDAs, greater restrictions on high-risk driving, and less high-risk driving. Including Checkpoints in driver education parent meetings/classes has potential to enhance teen driver safety. |
Twenty years of scientific progress in injury and violence research and the next public health frontier
Greenspan AI , Noonan RK . J Safety Res 2012 43 (4) 249-55 The establishment of the National Center for Injury Prevention and Control (NCIPC or Injury Center) in 1992 as part of the Centers for Disease Control and Prevention (CDC) firmly established the Injury Center as the lead federal agency for non-occupational injury prevention and control (Sleet et al., 2012). Since then, it has provided leadership and a strong scientific base for intramural and extramural-investigator funded injury research. The Injury Center's scientific mission encompasses efforts from primary prevention to treatment and rehabilitation. Early CDC efforts were primarily focused on describing the extent of the problem, identifying risk and protective factors that affect the extent of violence and injury in our society, and gaining visibility for violence and injury as a major public health problem. Efforts such as the development of injury-based surveillance systems provided population-based surveillance data regarding the extent and distribution of fatal and non-fatal injuries, helped to identify demographic characteristics for those who were most at risk, and identified risk and protective factors that influence that risk. Celebrating the Injury Center's 20th anniversary presents an opportunity not only to reflect on past accomplishments but also to look ahead at what still needs to be done. |
Person-to-person interventions targeted to parents and other caregivers to improve adolescent health: a Community Guide systematic review
Burrus B , Leeks KD , Sipe TA , Dolina S , Soler R , Elder R , Barrios L , Greenspan A , Fishbein D , Lindegren ML , Achrekar A , Dittus P , Community Preventive Services Task Force . Am J Prev Med 2012 42 (3) 316-26 CONTEXT: Adolescence marks a time when many young people engage in risky behaviors with potential implications for long-term health. Interventions focused on adolescents' parents and other caregivers have the potential to affect adolescents across a variety of risk and health-outcome areas. EVIDENCE ACQUISITION: Community Guide methods were used to evaluate the effectiveness of caregiver-targeted interventions in addressing adolescent risk and protective behaviors and health outcomes. Sixteen studies published during the search period (1966-2007) met review requirements and were included in this review. EVIDENCE SYNTHESIS: Effectiveness was assessed based on changes in whether or not adolescents engaged in specified risk and protective behaviors; frequency of risk and protective behaviors, and health outcomes, also informed the results. Results from qualifying studies provided sufficient evidence that interventions delivered person-to-person (i.e., through some form of direct contact rather than through other forms of contact such as Internet or paper) and designed to modify parenting skills by targeting parents and other caregivers are effective in improving adolescent health. CONCLUSIONS: Interventions delivered to parents and other caregivers affect a cross-cutting array of adolescent risk and protective behaviors to yield improvements in adolescent health. Analysis from this review forms the basis of the recommendation by the Community Preventive Services Task Force presented elsewhere in this issue. |
Southeastern Center for Emerging Biologic Threats tabletop exercise: foodborne toxoplasmosis outbreak on college campuses
Morris JG , Greenspan A , Howell K , Gargano LM , Mitchell J , Jones JL , Potter M , Isakov A , Woods C , Hughes JM . Biosecur Bioterror 2012 10 (1) 89-97 The use of tabletop exercises as a tool in emergency preparedness and response has proven to be an effective means of assessing readiness for unexpected events. Whereas most exercise developers target a population in a defined space (eg, state, county, metropolitan area, hospital), the Southeastern Center for Emerging Biologic Threats (SECEBT) conducted an innovative tabletop exercise involving an unusual foodborne outbreak pathogen, targeting public health agencies and academic institutions in 7 southeastern states. The exercise tested the ability of participants to respond to a simulated foodborne disease outbreak affecting the region. The attendees represented 4 federal agencies, 9 state agencies, 6 universities, 1 nonprofit organization, and 1 private corporation. The goals were to promote collaborative relationships among the players, identify gaps in plans and policies, and identify the unique contributions of each organization-and notably academic institutions-to outbreak recognition, investigation, and control. Participants discussed issues and roles related to outbreak detection and management, risk communication, and coordination of policies and responsibilities before, during, and after an emergency, with emphasis on assets of universities that could be mobilized during an outbreak response. The exercise generated several lessons and recommendations identified by participants and evaluators. Key recommendations included a need to establish trigger points and protocols for information sharing and alerts among public health, academic, and law enforcement; to establish relationships with local, state, and federal stakeholders to facilitate communications during an emergency; and to catalogue and leverage strengths, assets, and priorities of academic institutions to add value to outbreak responses. |
Injury prevention, violence prevention, and trauma care: building the scientific base
Sleet DA , Dahlberg LL , Basavaraju SV , Mercy JA , McGuire LC , Greenspan A . MMWR Suppl 2011 60 (4) 78-85 Injuries and violence are widespread in society. Unintentional injuries and injuries caused by acts of violence are among the top 10 killers of U.S. residents of all ages. Injuries are the leading cause of death of persons aged 1--44 years and a leading cause of disability among persons of all ages, regardless of sex, race/ethnicity, or socioeconomic status. Nearly 180,000 persons die each year from unintentional injuries or from acts of violence, and one in 10 sustains a nonfatal injury serious enough to require treatment in a hospital emergency department (1). In addition, injuries and violence have a major effect on the well-being of Americans by contributing to premature death, disability, poor mental and physical health, chronic disease, and other health conditions, as well as high medical costs and lost productivity. | | The science of injury prevention and control encompasses activities from primary prevention through treatment and rehabilitation. Since 1961, when MMWR was first published by CDC, progress has been made in developing the science of injury prevention and control, creating surveillance systems to capture injury mechanisms and intent, and establishing a scientific framework to address injury prevention and treatment. |
Restraint use and seating position among children less than 13 years of age: Is it still a problem?
Greenspan AI , Dellinger AM , Chen J . J Safety Res 2010 41 (2) 183-5 INTRODUCTION: The purpose of this study was to calculate national estimates and examine the extent to which children prematurely use adult seat belts and ride in the front seat of a vehicle during a 30 day period. METHODS: Data were obtained from a nationally representative cross-sectional random-digit-dial telephone survey that included child-specific questions on motor vehicle restraint use and seating position. RESULTS: Among children less than 13 years, parents reported an estimated 618,337 who rode unrestrained and more than one million who rode in the front seat of a vehicle at least some of the time in the past 30 days. During the same time period, close to 11 million children 8 years and younger reportedly used only adult seat belts. DISCUSSION: Our results highlight the need for continued outreach to parents regarding optimal restraint use and rear seating position for children every trip, every time. |
Unintentional fall injuries associated with walkers and canes in older adults treated in U.S. emergency departments
Stevens JA , Thomas K , Teh L , Greenspan AI . J Am Geriatr Soc 2009 57 (8) 1464-9 OBJECTIVES: To characterize nonfatal, unintentional, fall-related injuries associated with walkers and canes in older adults. DESIGN: Surveillance data of injuries treated in hospital emergency departments (EDs), January 1, 2001, to December 31, 2006. SETTING: The National Electronic Injury Surveillance System All Injury Program, which collects data from a nationally representative stratified probability sample of 66 U.S. hospital EDs. PARTICIPANTS: People aged 65 and older treated in EDs for 3,932 nonfatal unintentional fall injuries and whose records indicated that a cane or a walker was involved in the fall. MEASUREMENTS: Sex, age, whether the fall involved a cane or walker, primary diagnosis, part of the body injured, disposition, and location and circumstances of the fall. RESULTS: An estimated 47,312 older adult fall injuries associated with walking aids were treated annually in U.S. EDs: 87.3% with walkers, 12.3% with canes, and 0.4% with both. Walkers were associated with seven times as many injuries as canes. Women's injury rates exceeded those for men (rate ratios=2.6 for walkers, 1.4 for canes.) The most prevalent injuries were fractures and contusions or abrasions. Approximately one-third of subjects were hospitalized for their injuries. CONCLUSION: Injuries and hospital admissions for falls associated with walking aids were frequent in this highly vulnerable population. The results suggest that more research is needed to improve the design of walking aids. More information also is needed about the circumstances preceding falls, both to better understand the contributing fall risk factors and to develop specific and effective fall prevention strategies. |
The effect of counting principal and secondary injuries on national estimates of motor vehicle-related trauma: a NEISS-AIP special study
Halpin J , Greenspan AI , Haileyesus T , Annest JL . Inj Prev 2009 15 (5) 328-33 OBJECTIVE: To demonstrate the effect of including both principal and secondary injuries in the calculation of national estimates of non-fatal motor vehicle-related injury, using the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP). METHODS: The setting was a stratified sample of 15 US hospital emergency departments selected among 50 NEISS-AIP hospitals which agreed to participate in the study. Non-fatal injury data from a special study of the 2004 NEISS-AIP were analysed which allowed up to five injuries to be coded per case. National estimates of number and rate of injuries for 2004 were calculated, first using principal injuries alone, then by including principal and secondary injuries. RESULTS: An estimated 4,833,626 principal and secondary injuries were sustained by the estimated 2,893,782 motor vehicle occupants involved in a crash and treated in US hospital emergency departments (EDs) in 2004. This represents a 67% increase in the total number of injuries compared with an estimate of principal injury alone. Incidence of contusions/abrasions and lower trunk injuries rose most steeply among broad injury types, and whiplash injury rose 18% in number and rate. A significantly lower percentage of cases with a single listed injury were hospitalised (5%) compared with those who sustained multiple injuries (8%). CONCLUSIONS: Based on an analysis of NEISS-AIP special study data, the inclusion of both principal and secondary injuries in national estimates of motor vehicle-related occupant injury would provide a more comprehensive report of non-fatal injuries treated in US hospital EDs. Other countries with ED-based surveillance systems could consider reporting multiple injuries when assessing injury count associated with motor vehicle trauma requiring ED care. |
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