Publications by authors named "Matthew S Pantell"

32 Publications

Salivary cytokine cluster moderates the association between caregivers perceived stress and emotional functioning in youth.

Brain Behav Immun 2021 Mar 2. Epub 2021 Mar 2.

Douglas Mental Health University Institute, Douglas Research Center, McGill University, Montreal, QC, Canada; Ludmer Centre for Neuroinformatics and Mental Health and Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, QC, Canada. Electronic address:

Some individuals exposed to early life stress show evidence of enhanced systemic inflammation and are at greater risk for psychopathology. In the current study, caregivers and their offspring (0-17 years) were recruited at a pediatric clinic visit at the University of California, San Francisco (UCSF). Mothers and seven-year-old children from the Growing Up inSingaporeTowards healthy Outcomes (GUSTO) prospective birth cohort were used as a replication cohort. Caregivers perceived stress was measured to determine potential intergenerational effects on the children's functioning and inflammation levels. Children's emotional functioning in the UCSF cohort was evaluated using the Pediatric Quality of Life (PedsQL) inventory. Child emotional and behavioral functioning was measured using the Child Behavior Checklist (CBCL) in GUSTO. Saliva was collected from the children and salivary levels of IL-6, IL-1β, IL-8 and TNF-α were measured using an electrochemiluminescent cytokine multiplex panel. Child IL-6, IL-1β, IL-8 cytokine levels were clustered into low, average, and high cytokine cluster groups using hierarchical cluster analysis. We did not find that salivary cytokine clusters were significantly associated with children's emotional or behavioral function. However, cytokine clusters did significantly moderate the association between increased caregiver perceived stress and reduced child emotional functioning (UCSF cohort) and increased Attention-Deficit-Hyperactivity (ADH) problems (GUSTO cohort, uncorrected Cohen's F2 = 0.02). Using a cytokine clustering technique may be useful in identifying those children exposed to increased caregiver perceived stress that are at risk of emotional and attention deficit hyperactivity problems.
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http://dx.doi.org/10.1016/j.bbi.2021.02.025DOI Listing
March 2021

A reply to Shachak.

J Am Med Inform Assoc 2021 Feb 28. Epub 2021 Feb 28.

Center for Health and Community, University of California, San Francisco, California, USA.

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http://dx.doi.org/10.1093/jamia/ocab022DOI Listing
February 2021

Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status.

Acad Pediatr 2021 Feb 17. Epub 2021 Feb 17.

Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser); Philip R. Lee Institute for Health Policy Studies (MS Pantell and SV Kaiser), San Francisco, Calif; Department of Epidemiology and Biostatistics, University of California, San Francisco (SV Kaiser).

Objective: To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities.

Methods: Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA.

Results: We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P = .01), have longer inpatient length of stay (31 vs 29 hours, P = .01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P = .02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures.

Conclusion: At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.
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http://dx.doi.org/10.1016/j.acap.2021.02.009DOI Listing
February 2021

High-risk Behavior Screening and Interventions in Hospitalized Adolescents.

Hosp Pediatr 2021 Mar 10;11(3):293-297. Epub 2021 Feb 10.

Benioff Children's Hospital and University of California San Francisco, San Francisco, California.

Background And Objectives: Risky behaviors are the main threats to adolescents' health. Consequently, guidelines recommend adolescents be screened annually for high-risk behaviors. Our objectives were to (1) determine rates of physician-documented risk behavior screening of hospitalized adolescents, (2) determine rates of positive screening results, and (3) evaluate associations between risk behavior screening and provision of risk behavior-related health care interventions.

Methods: We conducted a cross-sectional study of patients aged 12 to 24 years admitted to the pediatric hospital medicine service at an urban tertiary children's hospital from January to December 2018. Exclusion criteria were transfer to a different service, nonverbal status, or altered mental status. We reviewed 20 charts per month. Outcomes included (1) documentation of risk behavior screening (mood, sexual activity, substance use, abuse and/or violence, and suicidal ideation), and (2) risk behavior-related health care interventions (eg, testing for sexually transmitted infections). We determined associations between screening and risk behavior-related interventions using χ tests.

Results: We found that 38% (90 of 240) of adolescents had any documented risk behavior screening, 15% (37 of 240) had screening in 4 of 5 risk behavior domains, and 2% (5 of 240) had screening in all 5 domains. The majority of screened adolescents had a positive screening result (66%), and most with positive results received a risk behavior-related health care intervention (64%-100% across domains). Adolescents with documented screening were significantly more likely to receive a risk behavior-related health care intervention.

Conclusions: We found low rates of risk behavior screening documentation among hospitalized adolescents. There was a high rate of positive screen results, and those who were documented as screened were more likely to receive risk behavior-related interventions.
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http://dx.doi.org/10.1542/hpeds.2020-001792DOI Listing
March 2021

Patient Experiences with Screening and Assistance for Social Isolation in Primary Care Settings.

J Gen Intern Med 2021 Feb 2. Epub 2021 Feb 2.

Department of Pediatrics, Center for Health and Community, University of California San Francisco, San Francisco, CA, USA.

Background: Social isolation is a known predictor of mortality that disproportionately affects vulnerable populations in the USA. Although experts began to recognize it as a public health crisis prior to 2020, the novel coronavirus pandemic has accelerated recognition of social isolation as a serious threat to health and well-being.

Objective: Examine patient experiences with screening and assistance for social isolation in primary care settings, and whether patient experiences with these activities are associated with the severity of reported social isolation.

Design: Cross-sectional survey conducted in 2018.

Participants: Adults (N = 251) were recruited from 3 primary care clinics in Boston, Chicago, and San Francisco.

Main Measures: A modified version of the Berkman-Syme Social Network Index (SNI), endorsed by the National Academies of Sciences, Engineering, and Medicine; items to assess for prior experiences with screening and assistance for social isolation.

Key Results: In the sample population, 12.4% reported the highest levels of social isolation (SNI = 0/1), compared to 36.7%, 34.7%, and 16.3% (SNI = 2-4, respectively). Most patients had not been asked about social isolation in a healthcare setting (87.3%), despite reporting no discomfort with social isolation screening (93.9%). Neither discomfort with nor participation in prior screening for social isolation was associated with social isolation levels. Desire for assistance with social isolation (3.2%) was associated with a higher level of social isolation (AOR = 6.0, 95% CI, 1.3-28.8), as well as poor or fair health status (AOR = 9.1; 95% CI, 1.3-64.1).

Conclusions: In this study, few patients reported being screened previously for social isolation in a primary care setting, despite low levels of discomfort with screening. Providers should consider broadening social isolation screening and referral practices in healthcare settings, especially among sicker and more isolated patients who express higher levels of interest in assistance with social isolation.
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http://dx.doi.org/10.1007/s11606-020-06484-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853707PMC
February 2021

Racial and ethnic disparities in outcomes through 1 year of life in infants born prematurely: a population based study in California.

J Perinatol 2021 Feb 30;41(2):220-231. Epub 2021 Jan 30.

Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.

Objectives: To investigate racial/ethnic differences in rehospitalization and mortality rates among premature infants over the first year of life.

Study Design: A retrospective cohort study of infants born in California from 2011 to 2017 (n = 3,448,707) abstracted from a California Office of Statewide Health Planning and Development database. Unadjusted Kaplan-Meier tables and logistic regression controlling for health and sociodemographic characteristics were used to predict outcomes by race/ethnicity.

Results: Compared to White infants, Hispanic and Black early preterm infants were more likely to be readmitted; Black late/moderate preterm (LMPT) infants were more likely to be readmitted and to die after discharge; Hispanic and Black early preterm infants with BPD were more likely to be readmitted; Black LMPT infants with RDS were more likely to be readmitted and die after discharge.

Conclusions: Racial/ethnic disparities in readmission and mortality rates exist for premature infants across several co-morbidities. Future studies are needed to improve equitability of outcomes.
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http://dx.doi.org/10.1038/s41372-021-00919-9DOI Listing
February 2021

The National Academy of Medicine Social Care Framework and COVID-19 Care Innovations.

J Gen Intern Med 2021 Jan 19. Epub 2021 Jan 19.

Kaiser Permanente School of Medicine, Pasadena, CA, USA.

Despite social care interventions gaining traction in the US healthcare sector in recent years, the scaling of healthcare practices to address social adversity and coordinate care across sectors has been modest. Against this backdrop, the coronavirus pandemic arrived, which re-emphasized the interdependence of the health and social care sectors and motivated health systems to scale tools for identifying and addressing social needs. A framework on integrating social care into health care delivery developed by the National Academies of Science, Engineering, and Medicine provides a useful organizing tool to understand the social care integration innovations spurred by COVID-19, including novel approaches to social risk screening and social care interventions. As the effects of the pandemic are likely to exacerbate socioeconomic barriers to health, it is an appropriate time to apply lessons learned during the recent months to re-evaluate efforts to strengthen, scale, and sustain the health care sector's social care activities.
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http://dx.doi.org/10.1007/s11606-020-06433-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815281PMC
January 2021

Associations between unstable housing, obstetric outcomes, and perinatal health care utilization.

Am J Obstet Gynecol MFM 2019 11 16;1(4):100053. Epub 2019 Oct 16.

Department of Epidemiology and Biostatistics, University of California, San Francisco; California Preterm Birth Initiative, University of California, San Francisco.

Background: While there is a growing interest in addressing social determinants of health in clinical settings, there are limited data on the relationship between unstable housing and both obstetric outcomes and health care utilization.

Objective: The objective of the study was to investigate the relationship between unstable housing, obstetric outcomes, and health care utilization after birth.

Study Design: This was a retrospective cohort study. Data were drawn from a database of liveborn neonates linked to their mothers' hospital discharge records (2007-2012) maintained by the California Office of Statewide Health Planning and Development. The analytic sample included singleton pregnancies with both maternal and infant data available, restricted to births between the gestational age of 20 and 44 weeks, who presented at a hospital that documented at least 1 woman as having unstable housing using the International Classification of Diseases, ninth edition, codes (n = 2,898,035). Infants with chromosomal abnormalities and major birth defects were excluded. Women with unstable housing (lack of housing or inadequate housing) were identified using International Classification of Diseases, ninth edition, codes from clinical records. Outcomes of interest included preterm birth (<37 weeks' gestational age), early term birth (37-38 weeks gestational age), preterm labor, preeclampsia, chorioamnionitis, small for gestational age, long birth hospitalization length of stay after delivery (vaginal birth, >2 days; cesarean delivery, >4 days), emergency department visit within 3 months and 1 year after delivery, and readmission within 3 months and 1 year after delivery. We used exact propensity score matching without replacement to select a reference population to compare with the sample of women with unstable housing using a one-to-one ratio, matching for maternal age, race/ethnicity, parity, prior preterm birth, body mass index, tobacco use during pregnancy, drug/alcohol abuse during pregnancy, hypertension, diabetes, mental health condition during pregnancy, adequacy of prenatal care, education, and type of hospital. Odds of an adverse obstetric outcome were estimated using logistic regression.

Results: Of 2794 women with unstable housing identified, 83.0% (n = 2318) had an exact propensity score-matched control. Women with an unstable housing code had higher odds of preterm birth (odds ratio, 1.2, 95% confidence interval, 1.0-1.4, P < .05), preterm labor (odds ratio, 1.4, 95% confidence interval, 1.2-1.6, P < .001), long length of stay (odds ratio, 1.6, 95% confidence interval, 1.4-1.8, P < .001), emergency department visits within 3 months (odds ratio, 2.4, 95% confidence interval, 2.1-2.8, P < .001) and 1 year after birth (odds ratio, 2.7, 95% confidence interval, 2.4-3.0, P < .001), and readmission within 3 months (odds ratio, 2.7, 95% confidence interval, 2.2-3.4, P < .0014) and 1 year after birth (odds ratio, 2.6, 95% confidence interval, 2.2-3.0, P < .001).

Conclusion: Unstable housing documentation is associated with adverse obstetric outcomes and high health care utilization. Housing and supplemental income for pregnant women should be explored as a potential intervention to prevent preterm birth and prevent increased health care utilization.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100053DOI Listing
November 2019

Differences in the prevalence of childhood adversity by geography in the 2017-18 National Survey of Children's Health.

Child Abuse Negl 2021 Jan 18;111:104804. Epub 2020 Nov 18.

University of California, San Francisco, Department of Pediatrics, Division of Pediatric Hospital Medicine, 3333 California St, San Francisco, CA, 94118, United States; University of California, San Francisco, Center for Health and Community, 3333 California St, San Francisco, CA, 94118, United States. Electronic address:

Background: Previous efforts to examine differences in adverse childhood experiences (ACEs) exposure by geography have yielded mixed results, and have not distinguished between urban, suburban, and rural areas. Additionally, few studies to date have considered the potentially moderating role of geography on the relationship between ACEs and health outcomes.

Objective: To examine differences in exposure to ACEs by geography, and determine whether geography moderates the relationship between ACE exposure and health outcomes (overall health, asthma, attention deficit hyperactivity disorder (ADHD), and special health care needs).

Participants And Setting: The cross-sectional 2017-18 National Survey of Children's Health (NSCH).

Methods: Distributions of individual and cumulative ACEs by geography (urban, suburban, rural) were compared using chi-squared tests. Logistic regression was used to determine the association between geography and exposure to 4 + ACEs, and to explore whether the relationship between ACEs and health outcomes varied by geography, adjusting for sociodemographic covariates.

Results: Adjusting for covariates, rural residency was associated with 1.29 times increased odds of exposure to 4 + ACEs (95 % CI: 1.00, 1.66) compared to suburban residency. Statistically significant evidence for an interaction between geography and ACE exposure on overall health was not observed, but urban status was observed to increase the association between ACEs and asthma.

Conclusions: This analysis demonstrates a higher ACE burden in rural compared to suburban children. These findings underscore the importance of ACE screening and suggest investment of healthcare resources in the historically underserved rural population.
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http://dx.doi.org/10.1016/j.chiabu.2020.104804DOI Listing
January 2021

A call for social informatics.

J Am Med Inform Assoc 2020 11;27(11):1798-1801

Center for Health and Community, University of California, San Francisco, California, USA.

As evidence of the associations between social factors and health outcomes continues to mount, capturing and acting on social determinants of health (SDOH) in clinical settings has never been more relevant. Many professional medical organizations have endorsed screening for SDOH, and the U.S. Office of the National Coordinator for Health Information Technology has recommended increased capacity of health information technology to integrate and support use of SDOH data in clinical settings. As these efforts begin their translation to practice, a new subfield of health informatics is emerging, focused on the application of information technologies to capture and apply social data in conjunction with health data to advance individual and population health. Developing this dedicated subfield of informatics-which we term social informatics-is important to drive research that informs how to approach the unique data, interoperability, execution, and ethical challenges involved in integrating social and medical care.
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http://dx.doi.org/10.1093/jamia/ocaa175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671633PMC
November 2020

Newborn metabolic vulnerability profile identifies preterm infants at risk for mortality and morbidity.

Pediatr Res 2020 Oct 1. Epub 2020 Oct 1.

California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA.

Background: Identifying preterm infants at risk for mortality or major morbidity traditionally relies on gestational age, birth weight, and other clinical characteristics that offer underwhelming utility. We sought to determine whether a newborn metabolic vulnerability profile at birth can be used to evaluate risk for neonatal mortality and major morbidity in preterm infants.

Methods: This was a population-based retrospective cohort study of preterm infants born between 2005 and 2011 in California. We created a newborn metabolic vulnerability profile wherein maternal/infant characteristics along with routine newborn screening metabolites were evaluated for their association with neonatal mortality or major morbidity.

Results: Nine thousand six hundred and thirty-nine (9.2%) preterm infants experienced mortality or at least one complication. Six characteristics and 19 metabolites were included in the final metabolic vulnerability model. The model demonstrated exceptional performance for the composite outcome of mortality or any major morbidity (AUC 0.923 (95% CI: 0.917-0.929). Performance was maintained across mortality and morbidity subgroups (AUCs 0.893-0.979).

Conclusions: Metabolites measured as part of routine newborn screening can be used to create a metabolic vulnerability profile. These findings lay the foundation for targeted clinical monitoring and further investigation of biological pathways that may increase the risk of neonatal death or major complications in infants born preterm.

Impact: We built a newborn metabolic vulnerability profile that could identify preterm infants at risk for major morbidity and mortality. Identifying high-risk infants by this method is novel to the field and outperforms models currently in use that rely primarily on infant characteristics. Utilizing the newborn metabolic vulnerability profile for precision clinical monitoring and targeted investigation of etiologic pathways could lead to reductions in the incidence and severity of major morbidities associated with preterm birth.
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http://dx.doi.org/10.1038/s41390-020-01148-0DOI Listing
October 2020

Maintaining Social Connections in the Setting of COVID-19 Social Distancing: A Call to Action.

Am J Public Health 2020 09;110(9):1367-1368

Matthew S. Pantell is with the Department of Pediatrics and the Center for Health and Community, University of California, San Francisco. Laura Shields-Zeeman is with the Department of Mental Health & Prevention, Netherlands Institute for Mental Health and Addiction, Utrecht, Netherlands, and the Center for Health and Community, University of California, San Francisco.

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http://dx.doi.org/10.2105/AJPH.2020.305844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427209PMC
September 2020

Effects of In-Person Navigation to Address Family Social Needs on Child Health Care Utilization: A Randomized Clinical Trial.

JAMA Netw Open 2020 06 1;3(6):e206445. Epub 2020 Jun 1.

Center for Health and Community, University of California, San Francisco.

Importance: While many organizations endorse screening for social risk factors in clinical settings, few studies have examined the health and utilization effects of interventions to address social needs.

Objective: To compare the acute care utilization effects of a written resources handout vs an in-person navigation service intervention to address social needs.

Design, Settings, And Participants: In this secondary analysis of a randomized clinical trial, 1809 adult caregivers of pediatric patients seen in primary and urgent care clinics of 2 safety-net hospitals in northern California were recruited between October 13, 2013, and August 27, 2015. Each participating family was randomly assigned to an in-person navigator intervention vs active control to address the family's social needs. Analyses were conducted between February 28, 2018, and September 25, 2019.

Interventions: Caregivers either received written information about relevant local resources related to social needs (active control) or met with a patient navigator focused on helping them resolve social needs (navigator intervention). After an initial in-person visit, navigation services included telephone, email, and/or in-person follow-up for up to 3 months.

Main Outcome And Measures: Child emergency department visit or hospitalization within 12 months of study enrollment.

Results: Among the 1300 caregivers enrolled in the study without missing follow-up data, most spoke English (878 [67.5%]) and were women (1127 [86.7%]), with a mean (SD) age of 33.0 (9.33) years. Most children were aged 0 to 5 years (779 of 1300 [59.9%]), 723 children (55.6%) had Hispanic ethnicity, and 462 children (35.5%) were in excellent health; 840 families (64.6%) were recruited from urgent care. In total, 637 families (49.0%) were randomized to the in-person navigator group and 663 (51.0%) to the active control group. There was no difference in risk of an emergency department visit between the 2 groups. Children enrolled in the in-person navigator group had a decreased risk of hospitalization within 12 months (hazard ratio, 0.59; 05% CI, 0.38-0.94; P = .03), making them 69% less likely to be hospitalized.

Conclusions And Relevance: In this randomized clinical trial evaluating heath care utilization effects of programs designed to address social needs among families, children enrolled in the navigation group were significantly less likely to be hospitalized after the intervention but equally likely to have an emergency department visit. These findings strengthen our understanding of the effects of addressing social needs in clinical settings as part of a comprehensive strategy to improve health and reduce health care utilization.

Trial Registration: ClinicalTrials.gov Identifier: NCT01939704.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.6445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265099PMC
June 2020

Cohort study of respiratory hospital admissions, air quality and sociodemographic factors in preterm infants born in California.

Paediatr Perinat Epidemiol 2020 03 6;34(2):130-138. Epub 2020 Feb 6.

Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California.

Background: Preterm infants suffer from respiratory morbidity especially during the first year of life.

Objective: To investigate the association of air quality and sociodemographic indicators on hospital admission rates for respiratory causes.

Methods: This is a retrospective cohort study. We identified all live-born preterm infants in California from 2007 to 2012 in a population-based administrative data set and linked them to a data set measuring several air quality and sociodemographic indicators at the census tract level. All sociodemographic and air quality predictors were divided into quartiles (first quartile most favourable to the fourth quartile least favourable). Mixed effect logistic models to account for clustering at the census tract level were used to investigate associations between chronic air quality and sociodemographic indicators respiratory hospital admission during the first year of life.

Results: Of 205 178 preterm infants, 5.9% (n = 12 033) were admitted to the hospital for respiratory causes during the first year. In the univariate analysis, comparing the first to the fourth quartile of chronic ozone (risk ratio [RR] 1.29, 95% confidence interval [CI] 1.21, 1.37), diesel (RR 1.10, 95% CI 1.02, 1.17) and particulate matter 2.5 (RR 1.07, 95% CI 1.01, 1.14) exposure were associated with hospital admission during the first year. Following adjustment for confounders, the risk ratios for hospital admission during the first year were 1.53 (95% CI 1.37, 1.72) in relation to educational attainment (per cent of the population over age 25 with less than a high school education) and 1.23 (95% CI 1.09, 1.38) for poverty (per cent of the population living below two times the federal poverty level).

Conclusions: Among preterm infants, respiratory hospital admissions in the first year in California are associated with socioeconomic characteristics of the neighbourhood an individual is living in.
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http://dx.doi.org/10.1111/ppe.12652DOI Listing
March 2020

Associations Between Social Factor Documentation and Hospital Length of Stay and Readmission Among Children.

Hosp Pediatr 2020 01;10(1):12-19

Psychiatry, and.

Background And Objectives: Social risk factors are linked to children's health, but little is known about how frequently these factors are documented using the (ICD) or whether documentation is associated with health care use outcomes. Using a large administrative database of pediatric hospitalizations, we examined the prevalence of ICD social risk code documentation and hypothesized that social code documentation would be associated with longer length of stay (LOS) and readmission.

Methods: We analyzed hospitalizations of children ages ≤18 using the 2012 Nationwide Readmissions Database. The following ICD social codes were used as predictors: family member with alcohol and/or drug problem, history of abuse, parental separation, foster care, educational circumstance, housing instability, other economic strain, and legal circumstance. Outcomes included long LOS (top quintile) and readmission within 30 days after discharge. Covariates included individual, hospital, and season variables.

Results: Of 926 073 index hospitalizations, 7432 (0.8%) had social codes. Social code documentation was significantly associated with long LOS. Adjusting for covariates, family alcohol and/or drug problem (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.16-2.35), foster care (OR 2.37, 95% CI 1.53-3.65), other economic strain (OR 2.12, 95% CI 1.38-3.26), and legal circumstances (OR 1.66; 95% CI 1.02-2.71) remained significant predictors of long LOS. Social code documentation was not associated with readmission after adjusting for covariates.

Conclusions: Social ICD codes are associated with prolonged LOS and readmission in pediatric hospitalizations, but they are infrequently documented. Future work exploring these associations could help to determine if addressing social risk factors in inpatient settings might improve child health outcomes.
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http://dx.doi.org/10.1542/hpeds.2019-0123DOI Listing
January 2020

Depression Predicts Prolonged Length of Hospital Stay in Pediatric Inflammatory Bowel Disease.

J Pediatr Gastroenterol Nutr 2019 11;69(5):570-574

Department of Pediatrics, University of California San Francisco Benioff Children's Hospital San Francisco, CA.

Objective: Few studies report the impact of depression on inflammatory bowel disease (IBD)-related hospitalizations. We evaluated the association between depression and pediatric IBD-related hospitalizations. Our primary aim was to test the hypothesis that depression is associated with hospital length of stay (LOS); our secondary goal was to evaluate if patients with depression are at higher risk for undergoing additional imaging and procedures.

Methods: Data were extracted from the 2012 Kids Inpatient Database (KID), the largest nationally representative publicly available all-payer pediatric inpatient cross-sectional database in the United States. Hospitalizations for patients less than 21 years with a primary diagnosis Crohn disease (CD) or ulcerative colitis (UC) by ICD-9 code were included. Multivariable logistic regression was used to predict long LOS controlling for patient- and hospital-level variables and for potential disease confounders.

Results: For primary IBD-related hospitalizations (N = 8222), depression was associated with prolonged LOS (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.19-1.90) and total parenteral nutrition use (OR 1.54; 95% CI 1.04-2.27). Depression was not associated with increased likelihood of surgery (OR 0.97; 95% CI 0.72-1.30), endoscopy (OR 0.91; 95% CI 0.74-1.14), blood transfusion (OR 0.85; 95% CI 0.58-1.23), or abdominal imaging (OR 1.15; 95% CI 0.53-2.53).

Conclusions: Depression is associated with prolonged LOS in pediatric patients with IBD, even when controlling for gastrointestinal disease severity. Future research evaluating the efficacy of standardized depression screening and early intervention may be beneficial to improving inpatient outcomes in this population.
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http://dx.doi.org/10.1097/MPG.0000000000002426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183311PMC
November 2019

Autoimmune Cytopenias in Pediatric Hematopoietic Cell Transplant Patients.

Front Pediatr 2019 3;7:171. Epub 2019 May 3.

Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.

Autoimmune cytopenias (AICs) are potentially life-threatening complications following hematopoietic cell transplantation (HCT), yet little is understood about the mechanism by which they develop. We hypothesized that discordant B cell and T cell recovery is associated with AICs in transplant patients, and that this might differ based on transplant indication. In this case control study of children who underwent HCT at our institution, we evaluated the clinical and transplant characteristics of subjects who developed AICs compared to a control group matched by transplant indication and donor type. In cases, we analyzed the state of immune reconstitution, including B cell recovery, T cell recovery, and chimerism, immediately prior to AIC onset. Subjects were stratified by primary indication for transplant as malignancy ( = 7), primary immune deficiency (PID, = 9) or other non-malignant disease ( = 4). We then described the treatment and outcomes for 20 subjects who developed AICs. In our cohort, cases were older than controls, were more likely to receive a myeloablative conditioning regimen and had a significantly lower prevalence of chronic GVHD. There were distinct differences in the state of immune recovery based on transplant indication. None of the patients (0/7) transplanted for primary malignancy had T cell recovery at AIC onset compared to 71% (5/7) of patients with PID and 33% (1/3) of patients with non-malignant disease. The subset of patients with PID and non-malignant disease who achieved T cell reconstitution (6/6) prior to AIC onset, all demonstrated mixed or split chimerism. Subjects with AIHA or multi-lineage cytopenias had particularly refractory courses with poor treatment response to IVIG, steroids, and rituximab. These results highlight the heterogeneity of AICs in this population and suggest that multiple mechanisms may contribute to the development of post-transplant AICs. Patients with full donor chimerism may have early B cell recovery without proper T cell regulation, while patients with mixed or split donor chimerism may have residual host B or plasma cells making antibodies against donor blood cells. A prospective, multi-center trial is needed to develop personalized treatment approaches that target the immune dysregulation present and improve outcomes in patients with post-transplant AICs.
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http://dx.doi.org/10.3389/fped.2019.00171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509944PMC
May 2019

Association of Social and Behavioral Risk Factors With Earlier Onset of Adult Hypertension and Diabetes.

JAMA Netw Open 2019 05 3;2(5):e193933. Epub 2019 May 3.

Department of Pediatrics, University of California, San Francisco.

Importance: The National Academy of Medicine has recommended incorporating information on social and behavioral factors associated with health, such as educational level and exercise, into electronic health records, but questions remain about the clinical value of doing so.

Objective: To examine whether National Academy of Medicine-recommended social and behavioral risk factor domains are associated with earlier onset of hypertension and/or diabetes in a clinical population.

Design, Setting, And Participants: This prospective cohort study used data collected from April 1, 2005, to December 31, 2016, from a population-based sample of 41 745 patients from 4 cycles of Kaiser Permanente Northern California's Adult Member Health Survey, administered to members at 19 Kaiser Permanente Northern California medical center service populations. The study used Kaplan-Meier survival tables and Cox proportional hazards regression analysis to estimate the onset of hypertension and diabetes among patients with no indication of disease at baseline. Data analysis was performed from June 2, 2017, to March 26, 2019.

Exposures: Race/ethnicity, educational level, financial worry, partnership status, stress, intimate partner violence, concentrated neighborhood poverty, depressive symptoms, infrequent exercise, smoking, heavy alcohol consumption, and cumulative social and behavioral risk.

Main Outcomes And Measures: Onset of hypertension and diabetes during the 3.5 years after survey administration.

Results: The study included 18 133 people without baseline hypertension (mean [SD] age, 48.1 [15.3] years; 10 997 [60.7%] female; and 11 503 [63.4%] white) and 35 788 people without baseline diabetes (mean [SD] age, 56.2 [16.9] years; 20 191 [56.4%] female; and 24 351 [68.0%] white). There was a dose-response association between the number of social and behavioral risk factors and likelihood of onset of each condition. Controlling for age, sex, race/ethnicity, body mass index, and survey year, hazard ratios (HRs) comparing those with 3 or more risk factors with those with 0 risk factor were 1.41 (95% CI, 1.17-1.71) for developing hypertension and 1.53 (95% CI, 1.29-1.82) for developing diabetes. When the same covariates were adjusted for, having less than a high school educational level (hazard ratio [HR], 1.84; 95% CI, 1.40-2.43), being widowed (HR, 1.38; 95% CI, 1.11-1.71), concentrated neighborhood poverty (HR, 1.26; 95% CI, 1.00-1.59), infrequent exercise (HR, 1.22; 95% CI, 1.08-1.38), and smoking (HR, 1.35; 95% CI, 1.10-1.67) were significantly associated with hypertension onset. Having less than a high school educational level (HR, 1.58; 95% CI, 1.26-1.97), financial worry (HR, 1.29; 95% CI, 1.13-1.46), being single or separated (HR, 1.24; 95% CI, 1.08-1.42), high stress (HR, 1.28; 95% CI, 1.09-1.51), intimate partner violence (HR, 1.68; 95% CI, 1.14-2.48), concentrated neighborhood poverty (HR, 1.31; 95% CI, 1.07-1.60), depressive symptoms (HR, 1.28; 95% CI, 1.10-1.50), and smoking (HR, 1.53; 95% CI, 1.27-1.86) were significantly associated with diabetes onset, although heavy alcohol consumption was associated with protection (HR, 0.75; 95% CI, 0.66-0.85) rather than risk.

Conclusions And Relevance: Independent of traditional risk factors, individual and cumulative social and behavioral risk factor exposures were associated with onset of hypertension and diabetes within 3.5 years in a clinical setting. The findings support the value of assessing social and behavioral risk factors to help identify high-risk patients and of providing targets for intervention.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.3933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537925PMC
May 2019

Practice Capacity to Address Patients' Social Needs and Physician Satisfaction and Perceived Quality of Care.

Ann Fam Med 2019 01;17(1):42-45

Department of Family & Community Medicine, University of California, San Francisco, California.

Recent studies have explored clinician impacts of health care-based interventions that respond to patients' social and economic needs. These studies were limited by available clinician data. We used the Commonwealth International Health Policy Survey of 890 primary care physicians to examine associations between clinic capacity to respond to patients' social needs and physician satisfaction, stress, and perceived medical care quality. Results suggest that perceived capacity to address social needs is strongly associated with both clinician satisfaction and perceived medical care quality. Our findings add to a growing literature on the potential return on investment of clinical interventions to address social needs.
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http://dx.doi.org/10.1370/afm.2334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6342584PMC
January 2019

Pre-pregnancy or first-trimester risk scoring to identify women at high risk of preterm birth.

Eur J Obstet Gynecol Reprod Biol 2018 Dec 5;231:235-240. Epub 2018 Nov 5.

California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, United States; Department of Epidemiology & Biostatistics, University of California San Francisco School of Medicine, San Francisco, CA, United States.

Objective To develop a pre-pregnancy or first-trimester risk score to identify women at high risk of preterm birth. Study design In this retrospective cohort analysis, the sample was drawn from California singleton livebirths from 2007 to 2012 with linked birth certificate and hospital discharge records. The dataset was divided into a training (2/3 of sample) and a testing (1/3 of sample) set for discovery and validation. Predictive models for preterm birth using pre-pregnancy or first-trimester maternal factors were developed using backward stepwise logistic regression on a training dataset. A risk score for preterm birth was created for each pregnancy using beta-coefficients for each maternal factor remaining in the final multivariable model. Risk score utility was replicated in a testing dataset and by race/ethnicity and payer for prenatal care. Results The sample included 2,339,696 pregnancies divided into training and testing datasets. Twenty-three maternal risk factors were identified including several that were associated with a two or more increased odds of preterm birth (preexisting diabetes, preexisting hypertension, sickle cell anemia, and previous preterm birth). Approximately 40% of women with a risk score ≥ 3.0 in the training and testing samples delivered preterm (40.6% and 40.8%, respectively) compared to 3.1-3.3% of women with a risk score of 0.0 [odds ratio (OR) 13.0, 95% confidence interval (CI) 10.7-15.8, training; OR 12.2, 95% CI 9.4-15.9, testing). Additionally, over 18% of women with a risk score ≥ 3.0 had an adverse outcome other than preterm birth. Conclusion Maternal factors that are identifiable prior to pregnancy or during the first-trimester can be used create a cumulative risk score to identify women at the lowest and highest risk for preterm birth regardless of race/ethnicity or socioeconomic status. Further, we found that this cumulative risk score could also identify women at risk for other adverse outcomes who did not have a preterm birth. The risk score is not an effective screening test, but does identify women at very high risk of a preterm birth.
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http://dx.doi.org/10.1016/j.ejogrb.2018.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697157PMC
December 2018

Advances in the Diagnosis and Management of Febrile Infants: Challenging Tradition.

Adv Pediatr 2018 08;65(1):173-208

University of California San Francisco, Suite 465, 3333 California Street, San Francisco, CA 94118, USA.

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http://dx.doi.org/10.1016/j.yapd.2018.04.012DOI Listing
August 2018

Perspectives from the Society for Pediatric Research: interventions targeting social needs in pediatric clinical care.

Pediatr Res 2018 07 23;84(1):10-21. Epub 2018 May 23.

Department of Pediatrics, University of Cincinnati College of Medicine; Division of General & Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.

The social determinants of health (SDoH) are defined by the World Health Organization as the "conditions in which people are born, grow, live, work, and age." Within pediatrics, studies have highlighted links between these underlying social, economic, and environmental conditions, and a range of health outcomes related to both acute and chronic disease. Additionally, within the adult literature, multiple studies have shown significant links between social problems experienced during childhood and "adult diseases" such as diabetes mellitus and hypertension. A variety of potential mechanisms for such links have been explored including differential access to care, exposure to carcinogens and pathogens, health-affecting behaviors, and physiologic responses to allostatic load (i.e., toxic stress). This robust literature supports the importance of the SDoH and the development and evaluation of social needs interventions. These interventions are also driven by evolving economic realities, most importantly, the shift from fee-for-service to value-based payment models. This article reviews existing evidence regarding pediatric-focused clinical interventions that address the SDoH, those that target basic needs such as food insecurity, housing insecurity, and diminished access to care. The paper summarizes common challenges encountered in the evaluation of such interventions. Finally, the paper concludes by introducing key opportunities for future inquiry.
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http://dx.doi.org/10.1038/s41390-018-0012-1DOI Listing
July 2018

Initial Metabolic Profiles Are Associated with 7-Day Survival among Infants Born at 22-25 Weeks of Gestation.

J Pediatr 2018 07 13;198:194-200.e3. Epub 2018 Apr 13.

Department of Epidemiology and Biostatistics and the Preterm Birth Initiative, University of California San Francisco, San Francisco, CA.

Objective: To evaluate the association between early metabolic profiles combined with infant characteristics and survival past 7 days of age in infants born at 22-25 weeks of gestation.

Study Design: This nested case-control consisted of 465 singleton live births in California from 2005 to 2011 at 22-25 weeks of gestation. All infants had newborn metabolic screening data available. Data included linked birth certificate and mother and infant hospital discharge records. Mortality was derived from linked death certificates and death discharge information. Each death within 7 days was matched to 4 surviving controls by gestational age and birth weight z score category, leaving 93 cases and 372 controls. The association between explanatory variables and 7-day survival was modeled via stepwise logistic regression. Infant characteristics, 42 metabolites, and 12 metabolite ratios were considered for model inclusion. Model performance was assessed via area under the curve.

Results: The final model included 1 characteristic and 11 metabolites. The model demonstrated a strong association between metabolic patterns and infant survival (area under the curve [AUC] 0.885, 95% CI 0.851-0.920). Furthermore, a model with just the selected metabolites performed better (AUC 0.879, 95% CI 0.841-0.916) than a model with multiple clinical characteristics (AUC 0.685, 95% CI 0.627-0.742).

Conclusions: Use of metabolomics significantly strengthens the association with 7-day survival in infants born extremely premature. Physicians may be able to use metabolic profiles at birth to refine mortality risks and inform postnatal counseling for infants born at <26 weeks of gestation.
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http://dx.doi.org/10.1016/j.jpeds.2018.03.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016556PMC
July 2018

Two Sides of the Same Coin: Pediatric-Onset and Adult-Onset Common Variable Immune Deficiency.

J Clin Immunol 2017 Aug 28;37(6):592-602. Epub 2017 Jul 28.

Division of Allergy and Immunology, Children's Hospital of Philadelphia, ARC 1216, 3615 Civic Center Blvd., Philadelphia, PA, 19104, USA.

Purpose: Common variable immunodeficiency (CVID) is a complex, heterogeneous immunodeficiency characterized by hypogammaglobulinemia, recurrent infections, and poor antibody response to vaccination. While antibiotics and immunoglobulin prophylaxis have significantly reduced infectious complications, non-infectious complications of autoimmunity, inflammatory lung disease, enteropathy, and malignancy remain of great concern. Previous studies have suggested that CVID patients diagnosed in childhood are more severely affected by these complications than adults diagnosed later in life. We sought to discern whether the rates of various infectious and non-infectious conditions differed between pediatric-diagnosed (ages 17 or younger) versus adult-diagnosed CVID (ages 18 or older).

Methods: Using the United States Immunodeficiency Network (USIDNET) database, we performed a retrospective analysis of 457 children and adults with CVID, stratified by age at diagnosis. Chi-squared testing was used to compare pediatric versus adult groups.

Results: After correcting for multiple comparisons, we identified few statistically significant differences (p ≤ 0.0004) between pediatric and adult groups. Pediatric-onset CVID patients had more frequent diagnoses of otitis media, developmental delay, and failure to thrive compared with adult-onset CVID patients. Adult CVID patients were more frequently diagnosed with bronchitis, arthritis, depression, and fatigue. Diagnoses of autoimmunity, lymphoma, and other malignancies were higher in adults but not to a significant degree. Serum immunoglobulins (IgG, IgA, and IgM) and lymphocyte subsets did not differ significantly between the two groups. When complications of infections and co-morbid conditions were viewed categorically, there were few differences between pediatric-onset and adult-onset CVID patients.

Conclusions: These results suggest that pediatric CVID is not a distinct phenotype. Major features were comparable across the groups. This study underscores the need for continued longitudinal study of pediatric and early-onset CVID patients to further characterize accrual of features over time.
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http://dx.doi.org/10.1007/s10875-017-0415-5DOI Listing
August 2017

Auditory analysis of xeroderma pigmentosum 1971-2012: hearing function, sun sensitivity and DNA repair predict neurological degeneration.

Brain 2013 Jan;136(Pt 1):194-208

Dermatology Branch, National Cancer Institute, Bethesda, MD 20892, USA.

To assess the role of DNA repair in maintenance of hearing function and neurological integrity, we examined hearing status, neurological function, DNA repair complementation group and history of acute burning on minimal sun exposure in all patients with xeroderma pigmentosum, who had at least one complete audiogram, examined at the National Institutes of Health from 1971 to 2012. Seventy-nine patients, aged 1-61 years, were diagnosed with xeroderma pigmentosum (n = 77) or xeroderma pigmentosum/Cockayne syndrome (n = 2). A total of 178 audiograms were included. Clinically significant hearing loss (>20 dB) was present in 23 (29%) of 79 patients. Of the 17 patients with xeroderma pigmentosum-type neurological degeneration, 13 (76%) developed hearing loss, and all 17 were in complementation groups xeroderma pigmentosum type A or type D and reported acute burning on minimal sun exposure. Acute burning on minimal sun exposure without xeroderma pigmentosum-type neurological degeneration was present in 18% of the patients (10/55). Temporal bone histology in a patient with severe xeroderma pigmentosum-type neurological degeneration revealed marked atrophy of the cochlear sensory epithelium and neurons. The 19-year mean age of detection of clinically significant hearing loss in the patients with xeroderma pigmentosum with xeroderma pigmentosum-type neurological degeneration was 54 years younger than that predicted by international norms. The four frequency (0.5/1/2/4 kHz) pure-tone average correlated with degree of neurodegeneration (P < 0.001). In patients with xeroderma pigmentosum, aged 4-30 years, a four-frequency pure-tone average ≥10 dB hearing loss was associated with a 39-fold increased risk (P = 0.002) of having xeroderma pigmentosum-type neurological degeneration. Severity of hearing loss parallels neurological decline in patients with xeroderma pigmentosum-type neurological degeneration. Audiometric findings, complementation group, acute burning on minimal sun exposure and age were important predictors of xeroderma pigmentosum-type neurological degeneration. These results provide evidence that DNA repair is critical in maintaining neurological integrity of the auditory system.
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http://dx.doi.org/10.1093/brain/aws317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3562077PMC
January 2013

Rigor, vigor, and the study of health disparities.

Proc Natl Acad Sci U S A 2012 Oct 8;109 Suppl 2:17154-9. Epub 2012 Oct 8.

Department of Psychiatry, University of California, San Francisco, CA 94143-0848, USA.

Health disparities research spans multiple fields and methods and documents strong links between social disadvantage and poor health. Associations between socioeconomic status (SES) and health are often taken as evidence for the causal impact of SES on health, but alternative explanations, including the impact of health on SES, are plausible. Studies showing the influence of parents' SES on their children's health provide evidence for a causal pathway from SES to health, but have limitations. Health disparities researchers face tradeoffs between "rigor" and "vigor" in designing studies that demonstrate how social disadvantage becomes biologically embedded and results in poorer health. Rigorous designs aim to maximize precision in the measurement of SES and health outcomes through methods that provide the greatest control over temporal ordering and causal direction. To achieve precision, many studies use a single SES predictor and single disease. However, doing so oversimplifies the multifaceted, entwined nature of social disadvantage and may overestimate the impact of that one variable and underestimate the true impact of social disadvantage on health. In addition, SES effects on overall health and functioning are likely to be greater than effects on any one disease. Vigorous designs aim to capture this complexity and maximize ecological validity through more complete assessment of social disadvantage and health status, but may provide less-compelling evidence of causality. Newer approaches to both measurement and analysis may enable enhanced vigor as well as rigor. Incorporating both rigor and vigor into studies will provide a fuller understanding of the causes of health disparities.
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http://dx.doi.org/10.1073/pnas.1121399109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477386PMC
October 2012

Educational attainment and late life telomere length in the Health, Aging and Body Composition Study.

Brain Behav Immun 2013 Jan 5;27(1):15-21. Epub 2012 Sep 5.

University of California, San Francisco, USA.

Morbidity and mortality are greater among socially disadvantaged racial/ethnic groups and those of lower socioeconomic status (SES). Greater chronic stress exposure in disadvantaged groups may contribute to this by accelerating cellular aging, indexed by shorter age-adjusted telomere length. While studies consistently relate shorter leukocyte telomere length (LTL) to stress, the few studies, mostly from the UK, examining associations of LTL with SES have been mixed. The current study examined associations between educational attainment and LTL among 2599 high-functioning black and white adults age 70-79 from the Health, Aging and Body Composition Study. Multiple regression analyses tested associations of race/ethnicity, educational attainment and income with LTL, adjusting for potential confounders. Those with only a high school education had significantly shorter mean LTL (4806 basepairs) than those with post-high school education (4926 basepairs; B=125, SE=47.6, p=.009). A significant interaction of race and education (B=207.8, SE=98.7, p=.035) revealed more beneficial effects of post-high school education for blacks than for whites. Smokers had shorter LTL than non-smokers, but the association of education and LTL remained significant when smoking was covaried (B=119.7, SE=47.6, p=.012). While higher income was associated with longer LTL, the effect was not significant (p>.10). This study provides the first demonstration of an association between educational attainment and LTL in a US population where higher education appears to have a protective effect against telomere shortening, particularly in blacks.
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http://dx.doi.org/10.1016/j.bbi.2012.08.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543785PMC
January 2013

Cumulative inflammatory load is associated with short leukocyte telomere length in the Health, Aging and Body Composition Study.

PLoS One 2011 13;6(5):e19687. Epub 2011 May 13.

Department of Psychiatry, University of California San Francisco, San Francisco, California, United States of America.

Background: Leukocyte telomere length (LTL) is an emerging marker of biological age. Chronic inflammatory activity is commonly proposed as a promoter of biological aging in general, and of leukocyte telomere shortening in particular. In addition, senescent cells with critically short telomeres produce pro-inflammatory factors. However, in spite of the proposed causal links between inflammatory activity and LTL, there is little clinical evidence in support of their covariation and interaction.

Methodology/principal Findings: To address this issue, we examined if individuals with high levels of the systemic inflammatory markers interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and C-reactive protein (CRP) had increased odds for short LTL. Our sample included 1,962 high-functioning adults who participated in the Health, Aging and Body Composition Study (age range: 70-79 years). Logistic regression analyses indicated that individuals with high levels of either IL-6 or TNF-α had significantly higher odds for short LTL. Furthermore, individuals with high levels of both IL-6 and TNF-α had significantly higher odds for short LTL compared with those who had neither high (OR = 0.52, CI = 0.37-0.72), only IL-6 high (OR = 0.57, CI = 0.39-0.83) or only TNF-α high (OR = 0.67, CI = 0.46-0.99), adjusting for a wide variety of established risk factors and potential confounds. In contrast, CRP was not associated with LTL.

Conclusions/significance: Results suggest that cumulative inflammatory load, as indexed by the combination of high levels of IL-6 and TNF-α, is associated with increased odds for short LTL. In contrast, high levels of CRP were not accompanied by short LTL in this cohort of older adults. These data provide the first large-scale demonstration of links between inflammatory markers and LTL in an older population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0019687PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094351PMC
October 2011