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Unlabelled: Catastrophizing is associated with negative outcomes in chronic pain and illness. The communal coping model (CCM) and cognitive behavioral (CB) formulations provide differing accounts of the function of catastrophizing in these contexts. In the present study we examined predictions from CCM and CB theoretical models in a sample of 116 patients with chronic fatigue to test (1) whether patient-reported solicitous responses from significant others mediate the relationship of catastrophizing with patient-reported pain and fatigue behaviors, as predicted by the CCM; and (2) whether pain and fatigue behaviors mediate the relationship of catastrophizing with solicitous responses, consistent with a CB model. This work is a secondary data analysis in which the strength of the indirect (i.e., mediating) effects among study variables was examined. Consistent with CB models, pain and fatigue behaviors were associated with catastrophizing and solicitous responses, and there was a significant indirect effect of catastrophizing on solicitous responses through pain and fatigue behaviors. Results were inconsistent with the CCM; catastrophizing was not significantly associated with solicitous responses, nor did solicitous responses mediate the relationship between catastrophizing and pain or fatigue behaviors. These findings highlight the importance of behavioral expressions of pain and fatigue in understanding the relationship of catastrophizing to solicitous responses in chronic fatigue.Perspective: This study of chronic fatigue patients tested CB and CCMs of catastrophizing, pain, and fatigue behaviors, and solicitous responses by significant others. Results were more consistent with CB formulations, which highlighted the importance of behavioral expressions of pain and fatigue in understanding the relationship of catastrophizing to solicitous responses. [ABSTRACT FROM AUTHOR]

Background: Neural responses to highly energetic food cues are robust and are suppressed by eating. It is not known if neural responsiveness to food cues is an inherited trait and possibly even one that mediates the genetic influences on body weight that have been previously observed. Objective: We investigated the inherited influence on brain responses to high-calorie visual food cues before and after a meal. Design: With the use of a monozygotic twin study design, 21 healthy monozygotic twin pairs consumed a standardized breakfast and, 3.5 h later, underwent the first of 2 functional MRI (fMRI) scans with the use of visual food cues. After the first fMRI session, twins consumed a standardized meal, which was followed by the second fMRI. Serial ratings of appetite and food appeal were obtained. An ad libitum buffet was used to measure total caloric and macronutrient intakes. Intraclass correlations (ICCs) were used to test for inherited influences by comparing whether intrapair similarity was greater than interpair similarity. Results: Body mass index was highly correlated within twin pairs (ICC: 0.96; P < 0.0001). ICCs also showed a strong intrapair similarity for the meal-induced change in hunger (ICC: 0.41; P = 0.03), fullness (ICC: 0.39; P = 0.04), and the appeal of fattening food (ICC: 0.57; P < 0.001). Twins ate a similar number of kilocalories at the buffet (ICC: 0.43; P = 0.02). Before the meal, the global brain activation across regions involved in satiety processing was not more similar in twins than in unrelated individuals. However, significant ICCs were present after the meal (ICC: 0.39; P = 0.04) and for the meal-induced change in activation by high-calorie visual food cues (ICC: 0.52; P < 0.01). Conclusion: Inherited factors influence both satiety perception and the effect of a meal to alter regional brain responses to images of highly energetic food. This trial was registered at clinicaltrials.gov as NCT02483663. [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: American Indians experience high rates of cervical cancer, which is preventable by vaccination against human papillomavirus (HPV). We sought information on funding, barriers, education, and policies regarding HPV vaccination from clinics that serve tribal members in the Pacific Northwest. Design: We surveyed staff either by telephone or by using a mailed survey at 31 tribal and Indian Health Service clinics serving the 29 federally recognized American Indian tribes in Washington State. The survey included 11 items on policies and use of the HPV vaccine. Main Outcome Measures: Primary outcomes were funding options for HPV vaccine administration, barriers to vaccine delivery, potential gaps in education, and determination of tribal or clinic-specific policies. Results: Thirty-one clinics provided information; 28 administered the vaccine. Vaccination was supported by federal, private, and tribal sources. Barriers were reported by 89% of clinics, most commonly patients'' lack of knowledge, distrust of the medical system, and lack of funding. Patient and provider information was widely available. Thirteen clinics had either tribal or internal clinic vaccination policies, or both. Conclusion: HPV vaccine is available, but complex policies on administration could result in tribal differences in vaccination rates. [Copyright &y& Elsevier]

Abstract: Substantial literature suggests that diverse biological, psychological, and sociocultural mechanisms account for differences by race and ethnicity in the experience, epidemiology, and management of pain. Many studies have examined differences between Whites and minority populations, but American Indians (AIs), Alaska Natives (ANs), and Aboriginal peoples of Canada have been neglected both in studies of pain and in efforts to understand its biopsychosocial and cultural determinants. This article reviews the epidemiology of pain and identifies factors that may affect clinical assessment and treatment in these populations. We searched for peer-reviewed articles focused on pain in these populations, using PubMed, CINAHL, Cochrane, and the University of New Mexico Native Health Database. We identified 28 articles published 1990 to 2009 in 3 topic areas: epidemiology of pain, pain assessment and treatment, and healthcare utilization. A key finding is that AI/ANs have a higher prevalence of pain symptoms and painful conditions than the U.S. general population. We also found evidence for problems in provider-patient interactions that affect clinical assessment of pain, as well as indications that AI/AN patients frequently use alternative modalities to manage pain. Future research should focus on pain and comorbid conditions and develop conceptual frameworks for understanding and treating pain in these populations. Perspective: We reviewed the literature on pain in AI/ANs and found a high prevalence of pain and painful conditions, along with evidence of poor patient-provider communication. We recommend further investigation of pain and comorbid conditions and development of conceptual frameworks for understanding and treating pain in this population. [Copyright &y& Elsevier]

Abstract: Chronic pain and obesity, and their associated impairments, are major health concerns. We estimated the association of overweight and obesity with 5 distinct pain conditions and 3 pain symptoms, and examined whether familial influences explained these relationships. We used data collected from 3,471 twins in the community-based University of Washington Twin Registry. Twins reported sociodemographic data, current height and weight, chronic pain diagnoses and symptoms, and lifetime depression. Overweight and obese were defined as body mass index of 25.0 to 29.9 kg/m2 and ≥ 30.0 kg/m2, respectively. Generalized estimating equation regression models, adjusted for age, gender, depression, and familial/genetic factors, were used to examine the relationship between chronic pain, and overweight and obesity. Overall, overweight and obese twins were more likely to report low back pain, tension-type or migraine headache, fibromyalgia, abdominal pain, and chronic widespread pain than normal-weight twins after adjustment for age, gender, and depression. After further adjusting for familial influences, these associations were diminished. The mechanisms underlying these relationships are likely diverse and multifactorial, yet this study demonstrates that the associations can be partially explained by familial and sociodemographic factors, and depression. Future longitudinal research can help to determine causality and underlying mechanisms. Perspective: This article reports on the familial contribution and the role of psychological factors in the relationship between chronic pain, and overweight and obesity. These findings can increase our understanding of the mechanisms underlying these 2 commonly comorbid sets of conditions. [Copyright &y& Elsevier]

Abstract: Purpose: The goal of this study was to determine whether adolescent offspring of mothers with chronic fatigue syndrome (CFS) have higher prevalence of CFS and report more fatigue, greater pain sensitivity, more sleep problems, and poorer cardiopulmonary fitness in comparison with offspring with no exposure to maternal CFS. Methods: A total of 26 adolescent offspring of 20 mothers diagnosed with CFS were compared with 45 adolescent offspring of 30 age-matched healthy control mothers. Study measures included structured interviews and medical and laboratory examinations for CFS; tender point examination; maximum oxygen uptake and perceived exertion; dolorimetry pain ratings; and questionnaires on fatigue severity and sleepiness. Results: In comparison with offspring of healthy mothers, those exposed to mothers with CFS reported higher prevalence of fatigue of at least 1-month duration (23% vs. 4%), fatigue of 6 months or longer (15% vs. 2%), and met criteria for CFS (12% vs. 2%), although these differences only approached statistical significance. CFS and healthy mothers differed on almost all study outcomes, but offspring groups did not differ on measures of current fatigue severity, pain sensitivity, sleep, mean number of tender points, and cardiopulmonary fitness. Conclusions: The higher prevalence of fatiguing states in offspring of CFS mothers, despite the lack of statistical significance, suggests that familial factors may potentially play a role in developing chronically fatiguing states. Alternately, perturbations in pain sensitivity and cardiopulmonary fitness may be consequences of CFS. Future studies should focus on examining the impact of maternal CFS and associated disability on psychosocial functioning of offspring. [Copyright &y& Elsevier]

Background: Asthma and obesity are common conditions that are strongly associated. This association might be due to shared genetic or environmental causes. Objective: We sought to determine whether a shared genetic cause is responsible for the association between asthma and obesity and to estimate the magnitude of shared genetic cause. Methods: The analyses were performed with 1001 monozygotic and 383 dizygotic same-sex twin pairs within the University of Washington Twin Registry. The presence of asthma was determined by self-report of a physician diagnosis of asthma, and body mass index (BMI) was calculated by using self-reported height and weight. Obesity was defined as a BMI of 30 or greater. The association between asthma and BMI was assessed by means of mixed-effects ordinal regression. Twin correlations examined the association of asthma and obesity. Univariate and bivariate structural equation models estimated the components of variance attributable to genetic and environmental effects. Results: A strong association between asthma and BMI was identified in the sample population (P < .001). Substantial heritability was detected for asthma (53%) and obesity (77%), which is indicative of additive genetic influences on each disorder. The best-fitting model of shared components of variance indicated that 8% of the genetic component of obesity is shared with asthma. Conclusion: The covariation between obesity and asthma is predominantly caused by shared genetic risk factors for both conditions. [Copyright &y& Elsevier]

: PurposeChronic fatigue syndrome (CFS) is characterized by profound fatigue accompanied by disturbances of sleep, cognition, mood, and other symptoms. Our objective was to describe sleep architecture in CFS-discordant twin pairs.: MethodsWe conducted a co-twin control study of 22 pairs of monozygotic twins where one twin met criteria for CFS and the co-twin was healthy. Twins underwent two nights of polysomnography.: ResultsThe percentage of Stage 3 and REM sleep was greater among the CFS twins than their healthy co-twins (P≤.05 for both), but no other differences in sleep architecture including sleep latency, REM latency, and total sleep time were observed. Compared to their co-twins, CFS twins had higher values for the apnea–hypopnea index and apnea–hypopnea arousal index (P≤.05 for both).: ConclusionThese results do not provide strong evidence for a major role for abnormalities in sleep architecture in CFS. Respiration appears impaired in CFS, but these clinical abnormalities cannot alone account for the prominence of sleep complaints in this illness. The co-twin control methodology highlights the importance of selecting well-matched control subjects. [Copyright &y& Elsevier]

Complementary and alternative medicine (CAM) has gained increasing popularity, particularly among individuals with fibromyalgia syndrome (FMS) for which traditional medicine has generally been ineffective. A systematic review of randomized controlled trials (RCTs) and non-RCTs on CAM studies for FMS was conducted to evaluate the empirical evidence for their effectiveness. Few RCTs achieved high scores on the CONSORT, a standardized evaluation of the quality of methodology reporting. Acupuncture, some herbal and nutritional supplements (magnesium, SAMe) and massage therapy have the best evidence for effectiveness with FMS. Other CAM therapies have either been evaluated in only one RCT with positive results (Chlorella, biofeedback, relaxation), in multiple RCTs with mixed results (magnet therapies), or have positive results from studies with methodological flaws (homeopathy, botanical oils, balneotherapy, anthocyanidins, dietary modifications). Lastly, other CAM therapies have neither well-designed studies nor positive results and are not currently recommended for FMS treatment (chiropractic care). [ABSTRACT FROM AUTHOR]

This chapter reviews our current knowledge on the presence of overlapping syndromes in one form of chronic diffuse pain, fibromyalgia. Patients with fibromyalgia often present with signs and symptoms of other unexplained clinical conditions, including chronic fatigue syndrome, irritable bowel syndrome, temporomandibular disorders, and multiple chemical sensitivities. The high prevalence, impact on function and opportunities for treatment underscore the need for clinicians and researchers to screen routinely for co-morbid unexplained clinical conditions among persons with fibromyalgia. We, therefore, describe a simple approach to screening for such conditions in accordance with published criteria. Interventions should directly address both fibromyalgia symptoms and co-morbid unexplained clinical conditions, as well as the multiple factors that propagate pain, fatigue and limitations in function. [ABSTRACT FROM AUTHOR]

Screening for food insecurity in clinical settings is recommended, but implementation varies widely. This study evaluated the prevalence of screening for food insecurity and other social risks in telehealth versus in-person encounters during the COVID-19 pandemic and changes in screening before versus after widespread COVID-19 vaccine availability. These cross-sectional analyses used electronic health record and ancillary clinic data from a national network of 400+ community health centers with a shared electronic health record. Food insecurity screening was characterized in 2022 in a sample of 275,465 first encounters for routine primary care at any network clinic during March 11, 2020–December 31, 2021. An adjusted multivariate multilevel probit model estimated screening prevalence on the basis of encounter mode (in-person versus telehealth) and time period (initial pandemic versus after vaccine availability) in a random subsample of 11,000 encounters. Encounter mode was related to food insecurity screening (p <0.0001), with an estimated 9.2% screening rate during in-person encounters, compared with 5.1% at telehealth encounters. There was an interaction between time period and encounter mode (p <0.0001), with higher screening prevalence at in-person versus telehealth encounters after COVID-19 vaccines were available (11.7% vs 4.9%) than before vaccines were available (7.8% vs 5.2%). Food insecurity screening in first primary care encounters is low overall, with lower rates during telehealth visits and the earlier phase of the COVID-19 pandemic. Future research should explore the methods for enhancing social risk screening in telehealth encounters. [ABSTRACT FROM AUTHOR]

Objectives: Striking disparities in access to radiation therapy (RT) exist, especially among racial and ethnic-minority patients. We analyzed census block group data to evaluate differences in travel distance to RT as a function of race and ethnicity, socioeconomic status, and rurality.Methods: The Directory of Radiotherapy Centers provided the addresses of facilities containing linear accelerators for RT. We classified block groups as majority (≥ 50%) American Indian/Alaska Native (AI/AN), black, white, Asian, no single racial majority, or Hispanic regardless of race. We used the Area Deprivation Index to classify deprivation and Rural-Urban Commuting Area codes to classify rurality. Generalized linear mixed models tested associations between these factors and distance to nearest RT facility.Results: Median distance to nearest RT facility was 72 miles in AI/AN-majority block groups, but 4 to 7 miles in block groups with non-AI/AN majorities. Multivariable models estimated that travel distances in AI/AN-majority block groups were 39 to 41 miles longer than in areas with non-AI/AN majorities. Travel distance was 1.3 miles longer in the more deprived areas versus less deprived areas and 16 to 32 miles longer in micropolitan, small town, and rural areas versus metropolitan areas.Conclusions: Cancer patients in block groups with AI/AN-majority populations, nonmetropolitan location, and low socioeconomic status experience substantial travel disparities in access to RT. Future research with more granular community- and individual-level data should explore the many other known barriers to access to cancer care and their relationship to the barriers posed by distance to RT care. [ABSTRACT FROM AUTHOR]

Introduction: Obesity rates for American Indian and Alaska Native (AI/AN) adolescents are among the highest in the US. However, little is known about the influence of maternal correlates on adolescent body mass index (BMI), and the extent to which the size and significance of these correlates vary by adolescent sex and race.Methods: We conducted a cross-sectional analysis with a sample of 531 AI/AN and 8896 White mother/adolescent pairs from Wave 1 of the National Longitudinal Study of Adolescent to Adult Health. We used generalized estimating equations to measure the association of maternal educational attainment, marital status, employment status, obesity status, and adolescent BMI of AI/AN and White adolescents, while controlling for adolescents' demographic and behavioral covariates. We sought to determine whether the size and statistical significance of maternal correlates differed by race, and between mother/son and mother/daughter pairs.Results: The strength and statistical significance of maternal correlates varied between mother/son and mother/daughter pairs in both races. However, we did not find effect modification by race. Maternal obesity showed the strongest effect on adolescent BMI in all mother/adolescent pairs.Conclusion: Our findings suggest that maternal factors are critical in the transmission of obesogenic behaviors from one generation to the next, and their effects vary between mother/son and mother/daughter pairs, and are similar for AI/ANs and Whites. We encourage future work aimed at preventing adolescent obesity to investigate causal pathways between maternal correlates and adolescent BMI. [ABSTRACT FROM AUTHOR]

Purpose: Racial and ethnic minorities in the state of Washington experience higher cancer mortality relative to whites. We sought to characterize differences in travel distance to radiation therapy (RT) facilities in Washington by race and ethnicity with a special focus on non-Hispanic American Indians and Alaska Natives as a contributor to limited access and cancer disparities.Methods and Materials: Geocoded mortality data from Washington Department of Health (2011-2018) were used to identify decedents with mortality related to all-causes, all cancers, and cancers likely requiring access to RT. This was determined from optimal RT usage estimates by diagnosis. RT facility locations were ascertained from the Directory of Radiation Therapy Centers and confirmed. Distance from decedents' address listed on death certificates to nearest RT facility was calculated. Generalized mixed models were used for statistical analysis.Results: We identified 418,754 deaths; 109,134 were cancer-related, 60,973 likely required RT. Among decedents with cancers likely requiring RT, non-Hispanic American Indians and Alaska Natives decedents would have had to travel 1.16 times (95% confidence interval [CI], 1.09-1.24) farther from their residences to reach the nearest treatment facility compared with non-Hispanic whites. This association existed in metro counties but was more pronounced in nonmetro counties (1.39 times farther; 95% CI, 1.22-1.58). In addition, Hispanics would have had to travel 1.11 times farther (95% CI, 1.06-1.16) to reach the nearest facility compared with non-Hispanic whites, primarily due to differences in urban counties. Decedents in nonmetro counties lived on average 35 miles (SD = 29) from RT centers and non-Hispanic American Indians and Alaska Natives in nonmetro counties 53 miles (SD = 38). Compared with non-Hispanic white decedents, those who were non-Hispanic black, non-Hispanic Asian, and non-Hispanic Native Hawaiian decedents lived closer to RT facilities.Conclusions: We observed significant disparities in access to RT facilities in Washington, specifically for non-Hispanic American Indians and Alaska Natives and rural decedents. The findings call for initiatives to improve access to critical cancer treatment services for these underserved populations with known disparities in cancer deaths. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To investigate the relationship of coping style and self-efficacy to functional impairment in a group of patients with both chronic widespread pain (CWP) and chronic fatigue, as well as the possible mediating role of psychiatric diagnosis. Methods: We identified 138 consecutive clinic patients who met criteria for CWP and chronic fatigue. We collected demographic and clinical characteristics, as well as measures of emotion-focused and problem-focused coping styles, fatigue-related self-efficacy and self-reported general health. Psychiatric diagnoses were determined with a structured interview. Short Form-36 subscales of pain-related and fatigue-related functioning were the dependent variables in ordinal multiple regression analyses to identify the best-fit model for each. Results: In the final model for pain, increased functional impairment was associated with increased emotion-focused coping as well as less education, lower general health scores and higher body mass index. Conversely, in the final model for fatigue, increased functional impairment was significantly associated with less emotion-focused coping, lower general health scores and lower self-efficacy. Conclusions: The unexpected finding that emotion-focused coping was associated differently with chronic pain and fatigue among patients who experience both symptoms is discussed in the context of the research on the effects of self-efficacy and possible treatment approaches. [Copyright &y& Elsevier]

Objectives: To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States.Methods: Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis.Results: Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns.Conclusions: The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the genetic and environmental relationship among prostatitis and other urological conditions, including benign prostatic hyperplasia (BPH) and prostate cancer (CaP), a classical twin design and biometric modeling was used. While prostatitis-characterized by pain and voiding symptoms, no clear etiology, and functional and quality of life impairments-co-occurs with other urinary conditions, the degree of shared overlapping etiologic processes among them remains unclear. We examined the contribution of genetic and environmental factors to these conditions and the etiology of their associations at the level of genetic and environmental influences.Methods: 4380 monozygotic and dizygotic male twin pairs from the Vietnam Era Twin Registry reported lifetime physician-diagnosed prostatitis (combined acute and chronic), bladder problems, enlarged prostate/BPH, and CaP. Multivariate biometrical modeling estimated the magnitude of genetic and environmental influences for each condition, as well as their genetic and environmental covariance. The common pathway model tested the assumption that covariation among these urinary conditions is determined by a single latent factor.Results: Overall prevalence of prostatitis was 2.7%. Heritability estimates ranged from 19% for bladder problems to 42% for CaP. Significant shared environmental influences were present for CaP (12%), enlarged prostate/BPH (10%) but were smaller than genetic influences. A reduced one factor common pathway model provided the best fit, suggesting that covariation among the conditions is determined by a shared latent factor.Conclusion: We identified a common, genetically-influenced factor that accounts for much of the comorbidity among these 4 disease conditions. Nonshared environmental factors also make a significant contribution. [ABSTRACT FROM AUTHOR]

Objective: To evaluate if patients with urologic chronic pelvic pain syndromes (UCPPS) with longer duration of symptoms experience more severe pain and urologic symptoms, higher rates of chronic overlapping pain conditions (COPC) and psychosocial comorbidities than those with a more recent onset of the condition. We evaluated cross-sectional associations between UCPPS symptom duration and (1) symptom severity, (2) presence of COPC, and (3) mental health comorbidities.Methods: We analyzed baseline data from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain. Symptom severity, COPC, and mental health comorbidities were compared between patients with symptom duration of < 2 vs ≥ 2 years. Symptom severity was assessed by the Genitourinary Pain Index, the Interstitial Cystitis Symptom and Problem Index, and Likert scales for pelvic pain, urgency, and frequency. Depression and anxiety were evaluated with the Hospital Anxiety and Depression Scale and stress with the Perceived Stress Scale.Results: Males (but not females) with UCPPS symptom duration ≥2 years had more severe symptoms than those with <2 years. Participants with short (<2 years) and longer (≥2 years) symptom duration were as likely to experience COPC.Conclusion: Longer UCPPS symptom duration was associated with more severe symptoms only in limited patient subpopulations. Symptom duration was not associated with risk for COPC or mental health comorbidities. Females with longer UCPPS duration had decreased distress, but the association was largely attributable to age. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has disproportionately affected American Indian and Alaska Native (AI/AN) people, who experience a 3.2 times higher age-adjusted rate of hospitalization and nearly double the attributed deaths compared to non-Hispanic Whites. We examined pandemic effects on emotional health and substance use in urban AI/AN people. From January–May 2021 we collected cross-sectional data from 642 patients seen at five health organizations serving primarily AI/AN people in urban settings. The outcomes are self-reported, cross-sectional changes in emotional health and substance use since pandemic onset. Exposures of interest include infection history, COVID-19 risk perception, pandemic-related life disruption, and feared effects on AI/AN culture. Poisson regression was used to model adjusted multivariate associations. Since pandemic onset, 46% of participants reported worsened emotional health; 20% reported increased substance use. Very or extremely disruptive pandemic experiences and increasing reported feared pandemic effects on culture were associated with worse pandemic emotional health [adjusted Prevalence Ratio 1.84; 95% CI 1.44, 2.35 and 1.11; 95% CI 1.03, 1.19], respectively. COVID-19 infection and risk perception were not associated with emotional health after adjustment for other factors. The primary exposures were not associated with change in substance use. The COVID-19 pandemic has impacted the emotional health of urban AI/AN people. The finding that poor emotional health is associated with pandemic-related threats to AI/AN culture may signal a protective role for community and cultural resources. This warrants further study as exploratory analysis did not find hypothesized effect modification according to strength of affiliation with AI/AN culture. • Impacts of the COVID-19 pandemic have been widespread and severe. • Emotional health worsened in many urban American Indian/Alaska Native people. • Disruptive experiences, cultural concerns were associated with poor emotional health. • American Indian/Alaska Native cultural strengths may offer a protective role. • There were no significant associations of exposure with change in substance use. [ABSTRACT FROM AUTHOR]

Introduction: Many American Indian and Alaska Native (AI/AN) people seek evidence-based, cost-effective, and culturally acceptable solutions for treating alcohol use disorders. Contingency management (CM) is a feasible, low-cost approach to treating alcohol use disorders that uses "reinforcers" to promote and support alcohol abstinence. CM has not been evaluated among AI/AN communities. This study explored the cultural acceptability of CM and adapted it for use in diverse AI/AN communities.Methods: We conducted a total of nine focus groups in three AI/AN communities: a rural reservation, an urban health clinic, and a large Alaska Native healthcare system. Respondents included adults in recovery, adults with current drinking problems, service providers, and other interested community members (n = 61). Focus group questions centered on the cultural appropriateness of "reinforcers" used to incentivize abstinence and the cultural acceptability of the intervention. Focus groups were audio-recorded, transcribed, and coded independently by two study team members using both a priori and emergent codes. We then analyzed coded data.Results: Across all three locations, focus group participants described the importance of providing both culturally specific (e.g., bead work and cultural art work supplies), as well as practical (e.g., gas cards and bus passes) reinforcers. Focus group participants underscored the importance of providing reinforcers for the children and family of intervention participants to assist with reengaging with family and rebuilding trust that may have been damaged during alcohol use. Respondents indicated that they believed CM was in alignment with AI/AN cultural values. There was consensus that Elders or a well-respected community member implementing this intervention would enhance participation. Focus group participants emphasized use of the local AI/AN language, in addition to the inclusion of appropriate cultural symbols and imagery in the delivery of the intervention.Conclusions: A CM intervention for alcohol use disorders should be in alignment with existing cultural and community practices such as alcohol abstinence, is more likely to be successful when Elders and community leaders are champions of the intervention, the intervention is compatible with counseling or treatment methodologies, and the intervention provides rewards that are both culturally specific and practical. [ABSTRACT FROM AUTHOR]

Objectives: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by pain and voiding symptoms in the absence of an obvious infection or other cause. CP/CPPS frequently occurs with non-urological chronic overlapping pain conditions (COPCs) of unknown etiology. We conducted a co-twin control study in men discordant for chronic prostatitis (CP), an overarching diagnosis of which approximately 90% is CP/CPPS. The primary aim was to investigate the contribution of familial factors, including shared genetic and common environmental factors, to the comorbidity of CP and COPCs.Methods: Data from 6824 male twins in the Vietnam Era Twin Registry were examined to evaluate the association between self-reported lifetime physician diagnosis of CP with COPCs including fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, temporomandibular disorder, tension headaches, and migraine headaches. Random effects logistic regression models were used and within-pair analyses evaluated confounding effects of familial factors on the associations.Results: There were significant associations between CP and all 6 examined COPCs. After adjusting for shared familial influences in within twin pair analyses, the associations for all COPCs diminished but remained significant. Familial confounding was strongest for the association of CP with fibromyalgia and temporomandibular disorder and smallest for irritable bowel syndrome.Conclusions: CP and COPCs are highly comorbid. These associations can be partially explained by familial factors. The mechanisms underlying these relationships are likely diverse and multifactorial. Future longitudinal research can help to further elucidate specific genetic and environmental mechanisms and determine potentially causal relationships between CP and its comorbidities. [ABSTRACT FROM AUTHOR]

Background American Indians and Alaska Natives have the highest obesity prevalence in the United States, but the influence of early childhood variables on body mass index (BMI; calculated as kg/m 2 ) is not well understood. Previous studies have investigated the association between breastfeeding in infancy and offspring BMI, but rarely included American Indians and Alaska Natives. Objective This study investigated the association between breastfeeding in infancy and BMI in American Indians and Alaska Native and non-Hispanic white adolescents and young adults. Design Longitudinal analysis based on data from the National Longitudinal Study of Adolescent to Adult Health (1994 to 2008). Participants Adolescent respondents who self-identified as American Indians and Alaska Native or non-Hispanic white, and whose parents completed the parental questionnaire, reported their height and weight. The final sample included 655 American Indians and Alaska Native and 10,305 non-Hispanic white respondents. Statistical analyses performed Generalized estimating equations were used to measure the mean differences, 95% CIs, and P values of the association between breastfeeding in infancy and offspring BMI in adolescence, stratifying by race, and adjusting for demographic and socioeconomic variables. Results The length of breastfeeding was inversely associated with BMI in both populations. American Indians and Alaska Natives that were breastfed for 6 to 12 months or for more than 12 months had a mean BMI of 2.69 (95% CI −3.46 to −1.92; P <0.01) and 1.54 (95% CI −2.75 to −0.33; P <0.05) units lower than those that were never breastfed. Non-Hispanic whites that were breastfed for 3 to 6 months, 6 to 12 months, or more than 12 months had a mean BMI of 0.71 (95% CI −0.93 to −0.50; P <0.01), 0.68 (95% CI −0.87 to −0.50; P <0.01), and 0.85 (95% CI −1.09 to −0.62; P <0.01) units lower than those that were never breastfed. The association between the length of breastfeeding and offspring BMI varied by race ( P <0.01). Conclusions Breastfeeding in infancy is associated with lower mean BMI. Future research should investigate causal pathways and whether interventions promoting breastfeeding in American Indians and Alaska Natives can prevent increasing BMI. [ABSTRACT FROM AUTHOR]

Panic disorder is a common mental health condition, but little is known about panic disorder in non-Caucasian populations. The purpose of this study is to describe the epidemiology, clinical features, and comorbidities of panic attacks and panic disorder in two large American Indian (AI) tribes (N = 3084). A culturally-adapted version of the Composite International Diagnostic Interview assessed panic attacks, panic disorder, and various psychiatric comorbidities. After adjusting for age, gender, and tribe, linear and logistic regression analyses were conducted to compare AIs with panic disorder to those with panic attacks only on clinical characteristics and panic symptoms. Approximately 8.5% (N = 234) of American Indians reported a lifetime history of panic attacks. Among individuals with panic attacks, comorbid posttraumatic stress disorder was higher in females ( p = 0.03) and comorbid alcohol-related disorders were higher in males ( p ≤ 0.001). The prevalence and clinical features of panic attacks and panic disorder in American Indians were similar to epidemiologic studies with majority populations. However, in contrast to earlier research, panic symptoms were similar in both males and females, and different patterns of comorbidity emerged. Future research should examine the availability and accessibility of evidence-based panic treatments for this traditionally underserved population. [ABSTRACT FROM AUTHOR]

Background Disproportionately high rates of alcohol use disorders are present in many American Indian/Alaska Native (AI/AN) communities, yet little information exists regarding the effectiveness of alcohol treatments in AI/AN populations. Contingency management is an intervention for illicit drug use in which tangible reinforcers (rewards) are provided when patients demonstrate abstinence as assessed by urine drug tests. Contingency management has not been widely studied as an intervention for alcohol problems because until recently, no alcohol biomarker has been available to adequately verify abstinence. Aims The HONOR Study is designed to determine whether a culturally-tailored contingency management intervention is an effective intervention for AI/AN adults who suffer from alcohol use disorders. Methods Participants include 400 AI/AN alcohol-dependent adults residing in one rural reservation, one urban community, as well as a third site to be decided, in the Western U.S. Participants complete a 4-week lead-in phase prior to randomization, then 12 weeks of either a contingency management intervention for alcohol abstinence, or a control condition where participants receive reinforcers for attending study visits regardless of alcohol use. Participants are then followed for 3-more months post-intervention. The primary study outcome is urinary ethyl glucuronide-confirmed alcohol abstinence; secondary outcomes include self-reported alcohol and drug use, HIV risk behaviors, and self-reported cigarette smoking. Discussion This will be the largest randomized, controlled trial of any alcohol for AI/ANs and the largest contingency management study targeting alcohol use disorders, thus providing important information to AI/AN communities and the alcohol treatment field in general. [ABSTRACT FROM AUTHOR]

Introduction: This study examined disparities in years of potential life lost (YPLL) related to opioid use among racial and ethnic groups adjusting for individual- and neighborhood-level characteristics.Methods: The study obtained data on 5265 geocoded death records associated with opioid use from the Washington State Department of Health. Death certificates included information on race and ethnicity, sex, marital status, and educational attainment. We linked these records to neighborhood-level indicators of rurality, area deprivation, and access to opioid treatment programs. Generalized linear mixed models tested associations between racial and ethnic identity and YPLL controlling for other individual and neighborhood characteristics.Results: Among all decedents from opioid-related causes, the study found that racial and ethnic minorities-including Black, American Indian/Alaska Native, Asian, Native Hawaiian or other Pacific Islander-multiracial, or Hispanic adults died at younger ages than did White adults (33 to 44 vs 45). In the fully adjusted models, the estimated mean for YPLL was higher for Asian or Native Hawaiian or other Pacific Islander, multiracial, and Hispanic adults compared to White adults. Accounting for educational attainment and marital status substantially reduced YPLL differences between groups, by as much as 40% in some cases.Conclusions: The study observed striking differences in YPLL related to opioid causes among racial and ethnic minorities. Accounting for social determinants of health greatly reduced YPLL across all groups but racial and ethnic disparities in YPLL remained significant. Understanding and alleviating additional causes of disparities in YPLL is warranted to abate the epidemic of opioid related deaths in the United States. [ABSTRACT FROM AUTHOR]

Objective: Determine whether a culturally tailored contingency management (CM) intervention targeting alcohol abstinence resulted in secondary effects on cannabis use among American Indian and Alaska Native (AI/AN) adults.Methods: The research team conducted this secondary data analysis to examine cannabis abstinence using data from a randomized control trial of CM for alcohol use among three AI/AN-serving organizations. One hundred and fifty-eight adults met the randomization criteria (i.e., submission of 50% or more urine samples and one alcohol-positive urine test during a 4-week, pre-randomization, observation period). For 12 weeks after randomization, participants received incentives for submitting a urine test negative for ethyl glucuronide (EtG < 150 ng/mL, CM group) or incentives for submitting a urine sample regardless of abstinence (Non-contingent [NC] Control group). Generalized linear mixed effects models assessed group differences in cannabis abstinence during the intervention, verified by urine tetrahydrocannabinol negative tests (11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid <50 ng/mL).Results: At baseline, 42.2% (n = 35) of participants in the NC group and 40.0% (n = 30) of those in the CM group had a cannabis positive urine test. An overall intervention by time interaction was detected for a cannabis negative urine test (χ2 = 13.40, p = 0.001). Compared to the NC group, the CM group had 3.92 (95% CI:1.23-12.46) times higher odds of having a cannabis negative urine test during the intervention period and 5.13 (95% CI:1.57-16.76) times higher odds of having a negative cannabis test at the end of intervention period.Conclusion: CM addressing alcohol misuse may be an effective strategy for decreasing cannabis use among AI/AN adults.Trial Registration: ClinicalTrials.gov number, Identifier: NCT02174315. [ABSTRACT FROM AUTHOR]

Background: Genetic, physiological, and psychological factors can affect food intake, but twin studies can distinguish inherited from environmental contributors. We examined the influence of attempted cognitive control of eating (“restrained eating”) on levels of appetite-regulating hormones. Methods: Sixteen female, monozygotic twin pairs, discordant for Restraint Scale score (i.e., one twin a restrained eater with score>15 whereas the co-twin was unrestrained), were selected from the University of Washington Twin Registry. Serial plasma ghrelin concentrations were monitored during meals and a preload study paradigm involving intake of a milkshake followed by an ad libitum ice cream “taste test.” Results: Body weight, body mass index, resting energy expenditure, and fasting leptin levels were very similar between restrained and unrestrained twins. In a preload study, twins ate similar amounts of ice cream shortly after drinking identical milkshakes (mean±SD; restrained 239±158 vs. unrestrained 228±132kcal; P =0.83). However, ghrelin concentrations during the preload study were significantly higher (P =0.03) in restrained twins than in their unrestrained co-twins. Regardless of restraint status, ghrelin levels prior to the preload study were prospectively and positively associated with ice cream intake (P =0.001). Conclusions: Compared to their unrestrained co-twins, restrained twins had higher endogenous ghrelin levels during a preload study, but ate similar amounts. This finding is consistent with exertion of cognitive control relative to the state of physiologic appetite stimulation. Moreover, these findings in twins suggest that higher ghrelin levels result from restrained eating behavior and not from genetic predisposition. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study examined if associations between body mass index (BMI) and mental and physical health were independent of genetic and familial factors. Method: Data from 2831 twins (66% female) were used in an epidemiological co-twin control design with measures of BMI and mental and physical health outcomes. Generalized estimating equation regressions assessed relationships between BMI and health outcomes controlling for interdependency among twins and demographics. Within-pair regression analyses examined the association of BMI with health outcomes controlling for genetic and familial influences. Results: Adjusted analyses with individual twins found associations in women between BMI and perceived stress (P=.01) and depression (P=.002), and the link between BMI and depression (P=.03) was significant in men. All physical health outcomes were significantly related to BMI. Once genetic and familial factors were taken into account, mental health outcomes were no longer significantly associated with BMI. BMI in women remained related to ratings of physical health (P=.01) and body pain (P=.004), independent of genetic and familial influences. Conclusion: These findings suggest that genetic and familial factors may account for the relationship between increased weight and poor mental health. [Copyright &y& Elsevier]

Abstract: We used a classical twin design and measures of neighborhood walkability and social deprivation, using each twin''s street address, to examine genetic and environmental influences on the residential location of 1389 same-sex pairs from a US community-based twin registry. Within-pair correlations and structural equation models estimated these influences on walkability among younger (ages 18–24.9) and older (ages 25+) twins. Adjusting for social deprivation, walkability of residential location was primarily influenced by common environment with lesser contributions of unique environment and genetic factors among younger twins, while unique environment most strongly influenced walkability, with small genetic and common environment effects, among older twins. Thus, minimal variance in walkability was explained by shared genetic effects in younger and older twins, and confirms the importance of environmental factors in walkability of residential locations. [Copyright &y& Elsevier]

Abstract: We studied whether self-reported intent to exert cognitive control over eating was associated with differences in brain response to food cues, independent of genetic background. Subjects were ten pairs of identical twins in which one twin was a restrained eater and the co-twin was unrestrained, as classified by the Herman and Polivy Restraint Scale. Before and after ingestion of a milkshake, we used functional magnetic resonance imaging to measure brain response to photographs of objects, “fattening” food, and “non-fattening” food. At baseline, restrained eaters had greater activation in the left amygdala and the right thalamus in response to fattening food cues than did their unrestrained co-twins. When restrained eaters drank a milkshake, activation in response to fattening food photographs decreased across multiple brain areas, whereas activation induced by non-fattening food photographs increased. As compared to their unrestrained co-twins, restrained eaters who drank a milkshake had greater decreases in activation by fattening food images in the left amygdala and occipital lobe, and greater increases in activation by non-fattening food images in the medial orbitofrontal cortex. Because of the discordant monozygotic twin study design, the findings provide a rigorous level of support for the hypothesis that adopting an intention to restrain eating alters brain response to food cues. [Copyright &y& Elsevier]

Abstract: A recent report suggested an association between xenotropic murine leukemia virus-related virus (XMRV) and chronic fatigue syndrome (CFS). If confirmed, this would suggest that antiretroviral therapy might benefit patients suffering from CFS. We validated a set of assays for XMRV and evaluated the prevalence of XMRV in a cohort of monozygotic twins discordant for CFS. Stored peripheral blood mononuclear cell (PBMC) samples were tested with 3 separate polymerase chain reaction (PCR) assays (one of which was nested) for XMRV DNA, and serum/plasma was tested for XMRV RNA by reverse transcription (RT)-PCR. None of the PBMC samples from the twins with CFS or their unaffected co-twins was positive for XMRV, by any of the assays. One plasma sample, from an unaffected co-twin, was reproducibly positive by RT-PCR. However, serum from the same day was negative, as was a follow-up plasma sample obtained 2 days after the positive specimen. These data do not support an association of XMRV with CFS. [Copyright &y& Elsevier]

Abstract: Objective: Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic pain condition with unclear underlying etiology. Our objectives were to determine whether psychological distress was higher in twins with urological symptoms commonly found in IC/PBS than in twins without, and if so, did familial influences contribute to this association. Method: Data from 1165 female twins in a community-based sample were used. Urological symptoms, symptoms of posttraumatic stress disorder (PTSD), depression, anxiety and perceived stress were assessed with standardized questionnaires. Generalized estimating equation (GEE) regression models were used to examine the relationship between psychological distress and urological symptoms. Results: Compared to unaffected twins, twins with urological symptoms were more likely to report PTSD symptoms (OR=3.9; 95% CI=2.6–5.8), depression (OR=3.1; 95% CI=2.0–5.0), anxiety (OR=3.4; 95% CI=2.3–5.2) and perceived stress (OR=3.2; 95% CI=2.1–4.9). After adjusting for familial influences, the within-pair effects remained significant for PTSD symptoms (OR=2.2; 95% CI=1.2–3.8) and perceived stress (OR=2.2; 95% CI=1.2–3.8). Conclusion: Familial influences partially explained the relationship between indicators of psychological distress and urological symptoms. Future research should examine shared environmental and genetic mechanisms that may further explain this relationship and improve diagnosis and treatment of this unexplained clinical condition. [Copyright &y& Elsevier]

Background: The health benefits of an active lifestyle are well established. However, Americans in general and American Indians specifically are not sufficiently active to achieve these health benefits.Purpose: This study presents the descriptive epidemiology of physical activity in a community-based sample of American-Indian adults.Methods: Data came from Education and Research Towards Health (EARTH), a cross-sectional study conducted between December 2003 and April 2006 of 5207 American-Indian adults in South Dakota and Arizona. Physical activity was assessed using a culturally tailored, computer-assisted instrument. Both type and intensity of activities were measured; minutes per week averaged over the past year was the primary outcome. Individuals were categorized as being sufficiently active, not sufficiently active, or inactive using a cut point of more or less than 150 minutes/week. Information on age, gender, and BMI was also collected.Results: More than one third of participants were not sufficiently active (<150 minutes/week) and 18% reported no leisure-time activity. Sufficient activity was less often reported by women than men (41% vs 56%) and by participants from the Southwest than those from the Northern Plains (44% vs 50%). Of all activity categories, the most time was spent on household activities among all participants. There were clear trends in physical (in)activity across BMI strata; time spent in sedentary activities increased while leisure-time activity decreased with BMI.Conclusions: American-Indian adults in this cohort exhibited levels of physical (in)activity similar to those of other racial/ethnic groups in the U.S., suggesting a need for specific interventions to increase activity levels across the population. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The purpose of the study was to evaluate quantitative sleep electroencephalogram (EEG) frequencies in monozygotic twins discordant for chronic fatigue syndrome. Methods: Thirteen pairs of female twins underwent polysomnography. During the first night, they adapted to the sleep laboratory, and during the second night, their baseline sleep was assessed. Visual stage scoring was conducted on sleep electroencephalographic records according to standard criteria, and power spectral analysis was used to quantify delta through beta frequency bands, processed in 6-s blocks. Data were averaged across sleep stage within each twin and coded for sleep stage and the presence or absence of chronic fatigue syndrome (CFS). A completely within-subjects repeated measure multivariate analysis of variance evaluated twin pairs by frequency band by sleep stage interactions and simple effects. The relationship between alpha and delta EEG was also assessed across twin pairs. Results: No significant differences in spectral power in any frequency band were found between those with CFS and their nonfatigued cotwins. Phasic alpha activity, coupled with delta was noted in five subjects with CFS but was also present in 4/5 healthy twins, indicating this finding likely reflects genetic influences on the sleep electroencephalogram rather than disease-specific sleep pathology. Conclusions: The genetic influences on sleep polysomnography and microarchitecture appear to be stronger than the disease influence of chronic fatigue syndrome, despite greater subjective sleep complaint among the CFS twins. EEG techniques that focus on short duration events or paradigms that probe sleep regulation may provide a better description of sleep abnormalities in CFS. [Copyright &y& Elsevier]

Cultural competence models assume that culture affects medical encounters, yet little research uses objective measures to examine how this may be true. Do providers and racial/ethnic minority patients interpret the same interactions similarly or differently? How might patterns of provider–patient concordance and discordance vary for patients with different cultural characteristics? We collected survey data from 115 medical visits with American Indian older adults at a clinic operated by the Cherokee Nation (in Northeastern Oklahoma, USA), asking providers and patients to evaluate nine affective and instrumental interactions. Examining data from the full sample, we found that provider and patient ratings were significantly discordant for all interactions (Wilcoxon signed-rank test p ≤0.02). However, discordance typically reflected a trend in which providers were more critical of their own behaviors than were patients. These findings suggest that providers serving American Indian patients often create greater satisfaction than they believe. We then distinguished cultural subgroups of patients, comparing magnitude of provider–patient discordance on specific interactions for patients at different levels of American Indian and White American cultural identity. Patients who affiliated strongly with American Indian cultural identity more closely shared providers' reduced evaluation for several variables related to information exchange, as compared to patients who identified weakly. These results flag interactions that providers and their most culturally distinctive patients both experience as challenging. [Copyright &y& Elsevier]

Abstract: Objectives: To examine the relationship of childhood physical and sexual abuse with reported parenting satisfaction and parenting role impairment later in life among American Indians (AIs). Methods: AIs from Southwest and Northern Plains tribes who participated in a large-scale community-based study (n =3,084) were asked about traumatic events and family history; those with children were asked questions about their parenting experiences. Regression models estimated the relationships between childhood abuse and parenting satisfaction or parenting role impairment, and tested for mediation by depression or substance use disorders. Results: Lifetime substance use disorder fully mediated the relationship between childhood physical abuse and both parenting satisfaction and parenting role impairment in the Northern Plains tribe. There was only partial mediation between childhood sexual abuse and parenting role impairment in the Southwest. In both tribes, lifetime depression did not meet the criteria for mediation of the relationship between childhood abuse and the two parenting outcomes. Instrumental and perceived social support significantly enhanced parenting satisfaction; negative social support reduced satisfaction and increased the likelihood of parenting role impairment. Exposure to parental violence while growing up had deleterious effects on parenting outcomes. Mothers and fathers did not differ significantly in the relation of childhood abuse experience and later parenting outcomes. Conclusions: Strong effects of social support and mediation of substance abuse disorders in the Northern Plains offer direct ways in which childhood victims of abuse could be helped to avoid negative attributes of parenting that could put their own children at risk. Practice implications: Mothers were not significantly different from fathers in the relation of abusive childhood experiences and later parenting outcomes, indicating both are candidates for interventions. Strong effects of social support offer avenues for interventions to parents. The prevalence of substance use disorders and their role as a mediator of two parenting outcomes in the Northern Plains should focus special attention on substance use treatment, especially among those who experienced childhood victimization. These factors offer direct ways in which childhood victims of abuse can be helped to avoid negative attributes of parenting that could put their own children at risk of violence. [Copyright &y& Elsevier]

Abstract: Objective: The objective of this study was to identify genetic, familial and environmental contributions to the association between posttraumatic stress disorder (PTSD) symptoms and poor health. Methods: A community sample of 1852 twin pairs was assessed for symptoms of PTSD [with the Impact of Events Scale (IES)] and self-reported global health status using a single five-level question. An ordinal logistic regression model estimated odds ratio/s (OR) for the association between PTSD and health status. Within-pair analysis assessed confounding by familial and genetic factors and adjusted for the possible confounding influence of age, sex, race, education and self-reported physician diagnosis of depression. Results: The IES was strongly and significantly associated with self-reported health [OR=1.8; 95% confidence interval (95% CI)=1.5–2.2; highest quartile vs. lowest quartile]. This association remained significant in within-pair analysis (OR=1.3; 95% CI=1.0–1.7), but after further adjustment for sociodemographics and depression, it was no longer significant (P trend=.17). Separate analysis by zygosity did not show differential effect in monozygotic or dizygotic pairs. Conclusion: These findings suggest that the association between PTSD symptoms and poor health is, in part, due to familial confounding and sociodemographic factors. Little evidence of confounding by genetic factors was found. These findings suggest that early prevention efforts would have the greatest potential for improving poor health in PTSD-prone patients, whereas later intervention efforts directed at treating PTSD may have a more limited impact on improving poor health. [Copyright &y& Elsevier]