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BackgroundPre-school children spend an average of two-hours daily using screens. We examined associations between screen-time on pre-school behavior using data from the Canadian Healthy Infant Longitudinal Development (CHILD) study.MethodsCHILD participant parents completed the Child Behavior Checklist (CBCL) at five-years of age. Parents reported their child's total screen-time including gaming and mobile devices. Screen-time was categorized using the recommended threshold of two-hours/day for five-years or one-hour/day for three-years. Multiple linear regression examined associations between screen-time and externalizing behavior (e.g. inattention and aggression). Multiple logistic regression identified characteristics of children at risk for clinically significant externalizing problems (CBCL T-score≥65).ResultsScreen-time was available for over 95% of children (2,322/2,427) with CBCL data. Mean screen-time was 1·4 hours/day (95%CI 1·4, 1·5) at five-years and 1·5 hours/day (95%CI: 1·5, 1·6) at three-years. Compared to children with less than 30-minutes/day screen-time, those watching more than two-hours/day (13·7%) had a 2·2-point increase in externalizing T-score (95%CI: 0·9, 3·5, p≤0·001); a five-fold increased odd for reporting clinically significant externalizing problems (95%CI: 1·0, 25·0, p = 0·05); and were 5·9 times more likely to report clinically significant inattention problems (95%CI: 1·6, 21·5, p = 0·01). Children with a DSM-5 ADHD T-score above the 65 clinical cut-off were considered to have significant ADHD type symptoms (n = 24). Children with more than 2-hours of screen-time/day had a 7·7-fold increased risk of meeting criteria for ADHD (95%CI: 1·6, 38·1, p = 0·01). There was no significant association between screen-time and aggressive behaviors (p>0.05).ConclusionIncreased screen-time in pre-school is associated with worse inattention problems.

Established during infancy, our complex gut microbial community is shaped by medical interventions and societal preferences, such as cesarean section, formula feeding, and antibiotic use. We undertook this study to apply the significance analysis of microarrays (SAM) method to quantify changes in gut microbial composition during later infancy following the most common birth and postnatal exposures affecting infant gut microbial composition. Gut microbiota of 166 full-term infants in the Canadian Healthy Infant Longitudinal Development birth cohort were profiled using 16S high-throughput gene sequencing. Infants were placed into groups according to mutually exclusive combinations of birth mode (vaginal/cesarean birth), breastfeeding status (yes/no), and antibiotic use (yes/no) by 3 months of age. Based on repeated permutations of data and adjustment for the false discovery rate, the SAM statistic identified statistically significant changes in gut microbial abundance between 3 months and 1 year of age within each infant group. We observed well-known patterns of microbial phyla succession in later infancy (declining Proteobacteria; increasing Firmicutes and Bacteroidetes) following vaginal birth, breastfeeding, and no antibiotic exposure. Genus Lactobacillus, Roseburia, and Faecalibacterium species appeared in the top 10 increases to microbial abundance in these infants. Deviations from this pattern were evident among infants with other perinatal co-exposures; notably, the largest number of microbial species with unchanged abundance was seen in gut microbiota following early cessation of breastfeeding in infants. With and without antibiotic exposure, the absence of a breast milk diet by 3 months of age following vaginal birth yielded a higher proportion of unchanged abundance of Bacteroidaceae and Enterobacteriaceae in later infancy, and a higher ratio of unchanged Enterobacteriaceae to Alcaligenaceae microbiota. Gut microbiota of infants born vaginally and exclusively formula fed became less enriched with family Veillonellaceae and Clostridiaceae, showed unchanging levels of Ruminococcaceae, and exhibited a greater decline in the Rikenellaceae/Bacteroidaceae ratio compared to their breastfed, vaginally delivered counterparts. These changes were also evident in cesarean-delivered infants to a lesser extent. The clinical relevance of these trajectories of microbial change is that they culminate in taxon-specific abundances in the gut microbiota of later infancy, which we and others have observed to be associated with food sensitization.

Changes in maternal innate immunity during healthy human pregnancy are not well understood. Whether basal immune status in vivo is largely unaffected by pregnancy, is constitutively biased towards an inflammatory phenotype (transiently enhancing host defense) or exhibits anti-inflammatory bias (reducing potential responsiveness to the fetus) is unclear. Here, in a longitudinal study of healthy women who gave birth to healthy infants following uncomplicated pregnancies within the Canadian Healthy Infant Longitudinal Development (CHILD) cohort, we test the hypothesis that a progressively altered bias in resting innate immune status develops. Women were examined during pregnancy and again, one and/or three years postpartum. Most pro-inflammatory cytokine expression, including CCL2, CXCL10, IL-18 and TNFα, was reduced in vivo during pregnancy (20-57%, p

Introduction: In battle-injured U.S. service members, head and neck (H&N) injuries have been documented in 29% who were treated for wounds in deployed locations and 21% who were evacuated to a Role 4 MTF. The purpose of this study is to examine the H&N surgical workload at deployed U.S. military facilities in Iraq and Afghanistan in order to inform training, needed proficiency, and MTF manning., Materials and Methods: A retrospective analysis of the DoD Trauma Registry was performed for all Role 2 and Role 3 MTFs, from January 2002 to May 2016; 385 ICD-9 CM procedure codes were identified as H&N surgical procedures and were stratified into eight categories. For the purposes of this analysis, H&N procedures included dental, ophthalmologic, airway, ear, face, mandible maxilla, neck, and oral injuries. Traumatic brain injuries and vascular injuries to the neck were excluded., Results: A total of 15,620 H&N surgical procedures were identified at Role 2 and Role 3 MTFs. The majority of H&N surgical procedures (14,703, 94.14%) were reported at Role 3 facilities. Facial bone procedures were the most common subgroup across both roles of care (1,181, 75.03%). Tracheostomy accounted for 16.67% of all H&N surgical procedures followed by linear repair of laceration of eyelid or eyebrow (8.23%) and neck exploration (7.41%). H&N caseload was variable., Conclusions: H&N procedures accounted for 8.25% of all surgical procedures performed at Role 2 and Role 3 MTFs; the majority of procedures were eye (40.54%) and airway (18.50%). These data can be used as planning tools to help determine the medical footprint and also to help inform training and sustainment requirements for deployed military general surgeons especially if future contingency operations are more constrained in terms of resources and personnel., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Leptospirosis is an ever-present threat found in the freshwater areas in many tropical and sub-tropical regions throughout the world and travelers to these areas are at increased risk of infection. This study describes a case series of 47 US Marines who experienced a single point leptospirosis exposure in 2014 and were admitted to a military treatment facility., Methods: Descriptive statistics were conducted for patient demographics, symptoms, laboratory results, and outcomes. Hypothesis tests were conducted to identify significant outcomes (length of hospitalization, severity of infection, intensive care unit (ICU) admission, and cholecystectomy). Patient data was applied to five leptospirosis scoring models to assess their accuracy in the context of this population., Results: The patients were all male (n = 47, 100%), had a median age of 22 (range 19-37), a mean body mass index of 24.3 (SD 2.5), and most were taking antibiotic prophylaxis (n = 40, 85.1%). Most patients experienced thrombocytopenia (n = 37, 78.7%), proteinuria (n = 35, 74.5%), and transaminitis (n = 37, 78.7%). Correct classification of infection varied among the models from 42.6% (n = 20) to 10.6% (n = 5). Not taking pre-exposure prophylaxis was significantly correlated with severe infection (p = 0.02), undergoing a cholecystectomy (p = 0.01), and being admitted to the ICU (p < 0.01). No other results were found to be both clinically and statistically significant., Conclusions: Leptospirosis diagnostic models currently in use may be less effective in predicting disease severity in young and healthy populations who are taking antibiotic prophylaxis. The use of pre-exposure prophylaxis significantly correlates with less severe health outcomes., Competing Interests: Declaration of competing interest A conflicting interest exists when professional judgement concerning a primary interest (such as patient's welfare or the validity of research) may be influenced by a secondary interest (such as financial gain or personal rivalry). It may arise for the authors when they have financial interest that may influence their interpretation of their results or those of others. Examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding., (Copyright © 2022. Published by Elsevier Ltd.)

Blood pressure (BP) screening using an office-based measurement is recommended for adults 18 years and older without a history of hypertension. If abnormal, the BP measurement should be repeated twice with the average of those final two readings used to determine the BP category. Home BP monitoring and ambulatory BP monitoring are beneficial in patients for whom there is a concern for masked or white-coat hypertension. Guidelines differ regarding the BP cutoff used for the diagnosis of hypertension. Lifestyle modifications are the foundation of hypertension management with the Dietary Approaches to Stop Hypertension (DASH) diet being the most effective dietary modification. First-line pharmacotherapy should include one or more of the following: an angiotensin-converting enzyme inhibitor, an angiotensin receptor blocker, a dihydropyridine calcium channel blocker, and a thiazide or thiazidelike diuretic. Compared with standard BP control, intensive BP control (ie, systolic BP less than 120 mm Hg) leads to a decrease in atherosclerotic cardiovascular disease and all-cause mortality in patients with elevated risk but increases adverse effects, including hypotension, electrolyte abnormalities, acute kidney injury, and syncope., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Secondary hypertension (HTN) refers to high blood pressure (BP) caused by an identifiable and potentially correctable condition or disease. Common causes of secondary HTN include renovascular disease, renal parenchymal disease, primary hyperaldosteronism, drug and substance use, and obstructive sleep apnea; less common etiologies include pheochromocytoma/paraganglioma, Cushing syndrome, thyroid and parathyroid conditions, congenital adrenal hyperplasia, and aortic coarctation. An identifiable secondary cause of HTN is present in approximately 10% of adult patients with HTN. Early recognition of suggestive clinical findings and laboratory results enables the timely diagnosis of specific secondary causes of HTN. Correct diagnosis of a causative underlying condition can lead to more effective, even curative management and subsequent cardiovascular risk reduction. Management involves treating the underlying condition. Some patients may benefit from referral to a specialist with specific expertise in treating the causative condition., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Hypertensive disorders in pregnancy (HDP) represent a spectrum of disease that affect women through pregnancy and the immediate postpartum period. These conditions are associated with significant morbidity and mortality during and after pregnancy and have been linked to cardiovascular disease later in life. The HDP spectrum includes gestational hypertension (HTN), preeclampsia, eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, chronic HTN, and chronic HTN with superimposed preeclampsia. Low-dose aspirin is recommended as a preventive drug after 12 weeks' gestation in women who are at high risk of preeclampsia. In HDP, close blood pressure (BP) monitoring, laboratory evaluation, and fetal assessment are warranted. Labetalol and nifedipine extended release are first-line oral antihypertensives for outpatient BP management of chronic HTN; labetalol, hydralazine, and nifedipine immediate release are used for hospitalized patients. HDP may develop or progress in the postpartum period; continued vigilance is important in the puerperium.

Hypertension (HTN) in children and adolescents is a spectrum of disease, ranging from elevated blood pressure (BP) to stage 1 and 2 HTN. The prevalence of elevated BP and HTN in this age group has increased significantly over the past 20 years, particularly in girls. Screening for HTN in asymptomatic children and adolescents is controversial. Primary HTN is now the predominant cause of HTN among the pediatric population in the United States, especially among adolescents. Secondary pediatric HTN is high BP due to an underlying medical condition and is more common among children 6 years and younger. Ambulatory BP monitoring should be considered in pediatric patients with repeatedly elevated office BP measurements. All children with BP greater than the 90th percentile should be encouraged to adopt lifestyle changes, but those with persistent or severe elevations in BP may benefit from pharmacotherapy., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Introduction: Stress from negative life events may be an important risk factor for chronic cardiometabolic conditions, which are increasingly prevalent among young adults. Support from personal networks is known to buffer stress from negative life events. Yet, evidence for these relationships among both young and older adults remains unclear., Methods: Longitudinal data came from the University of California, Berkeley Social Networks Study (2015-2018), which followed young (aged 21-30 years) and late middle-aged (aged 50-70 years) adults over 4 years. Weighted hybrid fixed and random effects models (completed in 2020) were used to examine the causal relationships among 4 negative life events, distinct forms of network support (e.g., social companionship, emergency help), and self-reported chronic cardiometabolic disease outcomes (i.e., hypertension, diabetes, or a heart condition)., Results: Among young adults, both the death of a close tie (average marginal effect=0.10, p<0.001) and financial difficulties (average marginal effect=0.07, p<0.05) were associated with a higher probability of chronic cardiometabolic outcomes. Higher numbers of confidants (average marginal effect= -0.03, p<0.01) and practical helpers (average marginal effect= -0.02, p<0.01) were associated with a lower probability of chronic cardiometabolic outcomes, whereas higher numbers of social companions were associated with a higher probability of having chronic cardiometabolic outcomes among young adults (average marginal effect=0.02, p<0.01)., Conclusions: Negative life events may be important risk factors for chronic cardiometabolic disease outcomes, particularly among young adults. Although there is no evidence of network support mediating the effects of negative life events, increases in network support were directly associated with chronic cardiometabolic outcomes., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

The coronavirus disease 2019 (COVID-19) has greatly impacted health-care systems worldwide, leading to an unprecedented rise in demand for health-care resources. In anticipation of an acute strain on established medical facilities in Dallas, Texas, federal officials worked in conjunction with local medical personnel to convert a convention center into a Federal Medical Station capable of caring for patients affected by COVID-19. A 200,000 square foot event space was designated as a direct patient care area, with surrounding spaces repurposed to house ancillary services. Given the highly transmissible nature of the novel coronavirus, the donning and doffing of personal protective equipment (PPE) was of particular importance for personnel staffing the facility. Furthermore, nationwide shortages in the availability of PPE necessitated the reuse of certain protective materials. This article seeks to delineate the procedures implemented regarding PPE in the setting of a COVID-19 disaster response shelter, including workspace flow, donning and doffing procedures, PPE conservation, and exposure event protocols.

Musculoskeletal care of the adolescent patient involves unique knowledge of their rapidly changing physical and psychological health. In this article, the importance of preventing early sports specialization is elucidated, and an encouragement of the safety and necessity of resistance training in adolescents is undertaken. It also explores two common conditions, one affecting the immature skeleton (apophysitis), and one affecting the improperly developed muscular system (patellofemoral syndrome), both of which are diagnosed clinically, and require little advanced imaging. Finally, a brief overview of relative energy deficiency in sport is given., Competing Interests: Disclosure The authors have nothing to disclose. Dr K. Bernstein and Dr P. Seales are current, active duty of the United States Navy. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Despite efforts by the U.S. Department of Defense to train behavioral health (BH) providers in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), numerous barriers limit EBP implementation. A context-tailored implementation approach called TACTICS (Targeted Assessment and Context-Tailored Implementation of Change Strategies) holds promise for increasing the use of EBPs such as prolonged exposure therapy (PE) in military treatment facilities. TACTICS combines a needs assessment, a rubric for selecting implementation strategies based on local barriers, an implementation toolkit, and external facilitation to support local champions and their implementation teams in enacting changes. This paper describes the rationale for and design of a study that will evaluate whether TACTICS can increase implementation of PE for PTSD and improve patient outcomes in military BH clinics relative to provider training in PE alone., Methods: The study is a multi-site, cluster randomized, stepped-wedge trial, with the military treatment facility as the unit of analysis. Eight facilities undergo a provider-training phase, followed by 5 months of TACTICS implementation. The timing of TACTICS at each facility is randomly assigned to begin 9, 14, or 19 months after beginning the provider-training phase. Primary analyses will compare the proportion of PTSD patients receiving PE and patients' mean improvement in PTSD symptoms before and after the onset of TACTICS., Discussion: TACTICS endeavors to balance standardization of empirically-supported implementation strategies with the flexibility of application necessary for success across varied clinical settings. If successful, TACTICS may represent a systematic and scalable method of promoting and supporting EBP implementation., Trial Registration: Clinicaltrials.gov Identifier: NCT03663452., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The aim of the study was to provide new tests of the argument that aspects of personal networks affect psychological distress and moderate the effects of negative life events, leveraging new, rich data on two different cohorts., Method: The UCNets project measured psychological distress, life events, and various dimensions of personal networks for 673 50- to 70-year old adults and 485 21- to 30-year old adults. The project used stratified random address based sampling for all the older adults. Such sampling, supplemented with Facebook advertisement and referral sampling, yielded the young adult sample. Networks were measured using several name-eliciting questions and several name descriptors., Results: The findings differed for younger versus older adults. Among young adults, personal network characteristics were not directly associated with, nor did they moderate the effect of negative life events on psychological distress. Unlike younger adults, the presence of supportive network ties, including social companions and emergency helpers, were directly associated with lower distress among older adults, while difficult and demanding ties as well as advisors were directly associated with higher distress. There was limited evidence of buffering among older adults, albeit through the presence of difficult and demanding ties., Conclusions: In the current sample, network exchange roles (i.e., specific types of network support and burden) were associated with psychological distress among older adults while other characteristics of the network, including size, multiplexity, and social participation were not. Further, network support may be best positioned to have direct, as opposed to buffering, effects on psychological well-being., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: To examine associations between socioeconomic status and two forms of social capital, namely, neighborhood and network measures, and how these distinct forms of capital are associated with body mass index (BMI) among Black residents of low-income communities., Design: Respondent-driven sampling was used to engage residents in a household survey to collect data on the respondents' personal network, perceptions about their neighborhood environment, and health., Setting: Eight special emphasis neighborhoods in Greenville, South Carolina., Participants: N = 337 black/African American older adults, nearly half of whom have a household income of less than $15 000 and a high school education, were included., Measures: Neighborhood capital was assessed via three scales on social cohesion, collective efficacy, and social support from neighbors. Network capital was calculated via a position generator, common in egocentric network surveys. Body mass index was calculated with self-reported height and weight., Analysis: Multilevel linear regression models were used to examine the association between neighborhood and network capital and obesity among respondents within sampling chains., Results: Higher household income was associated with greater neighborhood capital, whereas higher educational attainment was associated with greater network capital. Social cohesion was negatively associated with BMI ( b = -1.25, 95% confidence interval [CI]: -2.39 to -0.11); network diversity was positively associated with BMI ( b = 0.31, 95% CI: 0.08 to 0.55)., Conclusion: The findings shed light on how social capital may be patterned by socioeconomic status and, further, how distinct forms of capital may be differentially associated with health among black Americans.

Introduction: Tactical Combat Casualty Care (TCCC) is the execution of prehospital trauma skills in the combat environment. TCCC was recognized by the 2018 Department of Defense Instruction on Medical Readiness Training as a critical wartime task. This study examines the training, understanding, and utilization of TCCC principles and guidelines among US Army medical providers and examines provider confidence of medics in performing TCCC skills., Materials and Methods: A cross-sectional survey, developed by members of the Committee on TCCC, was distributed to all US Army Physicians and Physician Assistants via anonymous electronic communication., Results: A total of 613 completed surveys were included in the analyses. Logistic regression analyses were conducted on: TCCC test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine in accordance with TCCC., Conclusions: <60% of respondents expressed confidence in the ability of the medics to perform all TCCC skills. Supervising providers who that believed 80 to 100% of their medics had completed TCCC training had more confidence in their medic's TCCC abilities. With TCCC, a recognized lifesaver on the battlefield, continued training and utilization of TCCC concepts are paramount for deploying personnel., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Orthopedic surgery constitutes 27% of procedures performed for combat injuries. General surgeons may deploy far forward without orthopedic surgeon support. This study examines the type and volume of orthopedic procedures during 15 years of combat operations in Iraq and Afghanistan., Materials and Methods: Retrospective analysis of the US Department of Defense Trauma Registry (DoDTR) was performed for all Role 2 and Role 3 facilities, from January 2002 to May 2016. The 342 ICD-9-CM orthopedic surgical procedure codes identified were stratified into fifteen categories, with upper and lower extremity subgroups. Data analysis used Stata Version 14 (College Station, TX)., Results: A total of 51,159 orthopedic procedures were identified. Most (43,611, 85.2%) were reported at Role 3 s. More procedures were reported on lower extremities (21,688, 57.9%). Orthopedic caseload was extremely variable throughout the 15-year study period., Conclusions: Orthopedic surgical procedures are common on the battlefield. Current dispersed military operations can occur without orthopedic surgeon support; general surgeons therefore become responsible for initial management of all injuries. Debridement of open fracture, fasciotomy, amputation and external fixation account for 2/3 of combat orthopedic volume; these procedures are no longer a significant part of general surgery training, and uncommonly performed by general/trauma surgeons at US hospitals. Given their frequency in war, expertise in orthopedic procedures by military general surgeons is imperative., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background . Associations between religious involvement and substance use are well established. However, limited research examines the effects of religious affiliation, informal participation, and network support on substance use among two distinct age cohorts. Objectives . This study aims to examine whether religious affiliation, informal participation, and network support are associated with alcohol, tobacco, and marijuana use among young and late middle-age adults. Method . The UC Berkeley Social Networks Study (Wave 1, 2015) offers novel cohort data on young (21-30 years old, n = 483) and late middle-age (50-70 years old, n = 673) adults. Poisson regression models were used to predict alcohol use, while logistic regression models were used to predict odds of smoking and marijuana use. Results . Among young adults, membership in a religious organization was associated with less alcohol, tobacco, and marijuana use. Conversely, participating in informal organizations was associated with more alcohol and marijuana use. Desiring more people to talk to and get together with were associated with more smoking and drinking, respectively. However, wishing more people to ask for help was associated with less substance use altogether. In a similar pattern, among older adults, religious involvement was associated with less alcohol and marijuana use. Desiring more people to ask for help was also related to less marijuana use. Conclusion . Younger adult participation in informal groups serves to encourage social substance use. In contrast, older people are more involved in religious groups, which support social behaviors that do not include substance use.

Objective: The purpose of this study was to explore perceptions of the benefits of and influencing factors for neighborhood-based physical activity (PA), and elicit suggestions for increasing neighborhood-based PA among primarily Black residents living in lower income neighborhoods., Design: Eight focus groups were conducted in low-income, predominantly Black neighborhoods (n = 8) in Greenville, SC during Spring 2014. Using a semi-structured focus group guide with open-ended questions, residents were asked to describe benefits of PA, neighborhood factors associated with PA, and ways to increase PA within their neighborhoods. Trained research assistants transcribed audio recordings verbatim. Using grounded theory and an ecological perspective, emergent coding was employed to generate initial categories with open and axial coding used to achieve consensus on themes., Results: Primarily Black (95%), female (72%), and older (M = 61.5 years) residents (N = 76) participated in the study. Seven themes were identified across the three main focus group topics: physical and mental health benefits of neighborhood PA, safety/hazards and social factors as influencing neighborhood PA, and improving safety, structural opportunities, and programing support to improve neighborhood PA. Most participants reported walking within their communities, despite describing several community-level barriers (e.g. drugs, safety). Residents desired structured neighborhood-based opportunities for increasing PA, including walking tracks and walking groups, and reported social benefits to being active, including increased awareness within the community and trust. Participants conveyed that walking strengthened the social environment of their community as well as the health of residents., Conclusion: Few studies of contextual factors and PA have focused on African-American, low-income neighborhoods. Despite diverse environmental constraints, residents reported walking within their communities as part of a healthy lifestyle. Social ecological interventions tailored to promote PA and reduce health disparities among residents of low-income communities should highlight neighborhood-based opportunities for PA, focusing on personal and collective social benefits of neighborhood walking.

Background: Personal (i.e. egocentric) network characteristics are associated with health outcomes, including overweight and obesity. Previous research suggests educational attainment may interact with network characteristics to buffer these relationships. Limited research has examined the personal network characteristics of Black Americans, who have increased risk of overweight and obesity. The purpose of the current study was to examine associations between network characteristics and body mass index (BMI), and whether educational attainment modified these associations among Black Americans., Methods: In 2014, using respondent-driven sampling, we recruited 430 adult residents of eight low-income neighborhoods in Greenville, SC. Self-administered questionnaires assessed structural and compositional characteristics (i.e. size, density) of respondents' personal networks, socio-demographic characteristics, and health-related behaviors and conditions. Multilevel regression models with robust sandwich estimation accounted for clustering within respondent chains., Results: Among Black adults overall, network density-the number of connections among network members-was positively associated with BMI. Higher education moderated this relationship; among Black adults with a college degree, higher network density was inversely associated with BMI., Conclusions: Our data suggest low educational attainment may reflect more homogenous and less resourceful networks. Multiple pathways are discussed for how education interacts with network density on BMI among Black Americans., (© The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Associations between social networks and loneliness or social isolation are well established among older adults. Yet, limited research examines personal networks and participation on perceived loneliness and social isolation as distinct experiences among younger adults. Accordingly, we explore relationships among objective and subjective measures of personal networks with loneliness and isolation, comparing a younger and older cohort., Methods: The UC Berkeley Social Networks Study offers unique cohort data on young (21-30 years old, n = 472) and late middle-age adults' (50-70 years old, n = 637) personal network characteristics, social participation, network satisfaction, relationship status, and days lonely and isolated via online survey or in-person interview. Negative binomial regression models were used to examine associations between social network characteristics, loneliness, and isolation by age group., Results: Young adults reported twice as many days lonely and isolated than late middle-age adults, despite, paradoxically, having larger networks. For young adults, informal social participation and weekly religious attendance were associated with fewer days isolated. Among late middle-age adults, number of close kin and relationship status were associated with loneliness. Network satisfaction was associated with fewer days lonely or isolated among both age groups., Conclusion: Distinct network characteristics were associated with either loneliness or isolation for each cohort, suggesting network factors are independently associated with each outcome, and may fluctuate over time. Network satisfaction was associated with either loneliness or isolation among both cohorts, suggesting perceptions of social networks may be equally important as objective measures, and remain salient for loneliness and isolation throughout the life course.

Purpose of Review: A large body of research has indicated social network characteristics are associated with health and mortality. Additional literature suggests the structure and function of social networks differ by race and socioeconomic status. The current paper seeks to synthesize and further contextualize these two separate bodies of work, as well as illustrate potential mechanisms by which social networks may contribute to current disparities in cardiovascular disease outcomes., Recent Findings: An increasing number of studies have examined the link between social networks and cardiovascular outcomes. Social isolation and loneliness are two network-based sources of risk for coronary heart disease and stroke. Social resource theory provides a framework for how network structure and function may differ among distinct population groups, and argues for more research regarding differential access to social drivers of health. While previous studies have often focused on lack of support or resources within networks, more recent studies have examined negative impacts of social networks on health, including network-based stress, which provide additional mechanisms for associations between present, yet, burdensome relationships. Other mechanisms linking social networks with cardiovascular disease risk, including social influence for behaviors associated with ideal cardiovascular health, are discussed., Summary: Examination of social network structure and function among diverse populations, including Black Americans and low socioeconomic status individuals, may elucidate potential sources of physiological and psychological distress, as well as sources of support, that are associated with cardiovascular disease outcomes. A richer understanding of these associations may offer solutions for alleviating systemic causes of cardiovascular disease disparities among high risk populations., Competing Interests: Conflict of Interest Stephanie Child and Michelle Albert declare that they have no conflict of interest.

A Child Psychiatry Consultation Model (CPCM) offering primary care providers (PCPs) expedited access to outpatient child psychiatric consultation regarding management in primary care would allow more children to access mental health services. Yet, little is known about outpatient CPCMs. This pilot study describes an outpatient CPCM for 22 PCPs in a large Northeast Florida county. PCPs referred 81 patients, of which 60 were appropriate for collaborative management and 49 were subsequently seen for outpatient psychiatric consultation. The most common psychiatric diagnoses following consultation were anxiety (57%), ADHD (53%), and depression (39%). Over half (57%) of the patients seen for consultation were discharged to their PCP with appropriate treatment recommendations, and only a small minority (10%) of patients required long-term care by a psychiatrist. This CPCM helped child psychiatrists collaborate with PCPs to deliver mental health services for youth. The CPCM should be considered for adaptation and dissemination.

Pulmonary hypertension (PH) is a spectrum disorder with multiple causes of the elevation of pressure in the lungs. It often is difficult to diagnose because it mimics many commonly reported symptoms (eg, dyspnea, exercise intolerance, chest pain). Diagnosis is made via right heart catheterization; however, transthoracic echocardiography may show evidence of elevated pulmonary pressure as the first clue to the diagnosis. Diagnostic tests to consider include a liver panel, complete blood count, and thyroid function test; electrocardiogram; chest x-ray; pulmonary function testing; and possibly lung imaging via computed tomography scan or ventilation-perfusion scan. PH is grouped into several broad categories: group 1 is pulmonary artery hypertension, group 2 is PH due to left heart disease, group 3 is PH due to lung disease, group 4 is chronic thromboembolic PH, and group 5 is PH due to unclear or multifactorial mechanisms. Therapy targets the underlying etiology and may include physical activity and pulmonary rehabilitation; drugs such as diuretics, vasodilators, and anticoagulants; oxygen therapy; and lung transplantation. Significant PH can result in increased mortality risk. Because of its complex and heterogeneous nature, PH is best managed by subspecialists with expertise in the condition., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Bradyarrhythmia (bradycardia) is a heart rate lower than 60 beats/min. It can be due to sinus, atrial, or junctional bradycardia or to a problem with the conduction system (eg, an atrioventricular block). Asymptomatic bradycardia is common, especially among trained athletes or during sleep. Bradycardia symptoms can include syncope, dizziness, chest pain, dyspnea, or fatigue. It is important to determine during the evaluation if bradycardia is the cause of the patient's symptoms. In the acute setting, symptomatic patients should be treated with atropine. Percutaneous pacing can be used as a bridge to definitive treatment. The only therapy for persistent bradycardia is placement of a permanent pacemaker. Symptomatic patients with sick sinus syndrome and high second- or third-degree atrioventricular blocks require placement of permanent pacemakers., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Coronary artery bypass graft (CABG) is a surgical procedure in which a vessel, normally the left internal mammary artery and/or a segment of an excised vein (typically from the leg), is grafted to the coronary arteries to bypass a blockage. CABG has been shown to be superior to percutaneous coronary intervention for patients with complex three vessel disease and left main coronary artery disease. All patients undergoing CABG should receive aspirin preoperatively; they also should receive a beta blocker preoperatively to reduce the likelihood of postsurgical atrial fibrillation. All patients should receive aspirin within 6 hours postsurgery to prevent graft thrombosis and should continue taking aspirin indefinitely, be started or continued on a high-intensity statin, be enrolled in a cardiac rehabilitation program, and be screened and treated if necessary for depression., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The prevalence increases with age, especially in the seventh and eighth decades of life. AF also is associated with multiple risk factors and conditions that are managed commonly in family medicine settings, such as hypertension and diabetes. Rhythm control and rate control are primarily equivalent for mortality rate, but patients treated for rhythm control have more hospitalizations; however, rhythm control may be a viable option for select patients. Beta blockers and nondihydropyridine calcium channel blockers can be used to achieve rate control. Pharmacotherapy or electrical cardioversion can be used to achieve rhythm control, and antiarrhythmic drugs are used to maintain sinus rhythm. Catheter ablation is an option for symptomatic patients whose AF is refractory to standard treatment. The CHA2DS2-VASc score should be used to predict the risk of stroke for patients with AF. Patients with nonvalvular AF and a history of stroke or transient ischemic attack or CHA2DS2-VASc scores of 2 or greater should be treated with warfarin or novel oral anticoagulants. Patients with valvular AF should be treated with warfarin., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Purpose: To examine the association between specific attributes of neighborhood environments and four social environment measures., Design: Data were collected as part of a baseline survey among participants enrolling in a walking intervention., Setting: Participants were recruited from a metropolitan area in a Southeastern state., Subjects: Participants (n = 294) were predominantly African-American (67%) and female (86%), with some college education (79%) and a mean age of 49., Measures: The International Physical Activity Questionnaire Environment Module assessed perceptions about neighborhood attributes. The social environment was assessed using three distinct scales: social cohesion, social interactions with neighbors, and social support for physical activity from family and friends., Analysis: Multiple regression models examined associations between neighborhood attributes and social environment measures, adjusting for demographic variables., Results: Having walkable destinations and having access to amenities and transit stops were associated with increased interactions with neighbors (b = 1.32, 1.04, and 1.68, respectively, p < .05). Attributes related to structural support for physical activity (sidewalks, street connectivity, recreation facilities) were associated with increased interactions with neighbors (b = 1.47, 1.34, and 1.13, respectively, p < .05). Bicycling facilities that were maintained (i.e., bike lanes, racks) were associated with social support for physical activity from family and friends (b = .43 and .30, respectively, p < .05)., Conclusion: The study highlights key attributes of neighborhood environments that may be associated with the social context of such settings., (© 2016 by American Journal of Health Promotion, Inc.)

Outdoor recreation areas (ORA) are important resources for physical activity (PA) and health promotion. While past research has identified correlates of ORA use, few studies have examined predictors of longitudinal changes in park- and trail-based PA in community settings. Using data from a 6-month community-based walking intervention study, we examined cross-sectional and longitudinal predictors of PA in ORAs. Data were collected from baseline and 6-month assessments from participants (n=295) in a group walking intervention in South Carolina; participants enrolled from January 2012-May 2013. A decomposition scheme was used to examine the cross-sectional and longitudinal predictors of average group ORA use for PA, including social support, self-efficacy for PA, perceptions of neighborhood environment, and accelerometer-based PA, adjusting for gender. On average, participants were 49.4+13.3years old, 66.1% were Black, and the majority were women. There was a mean increase in group ORA use of 2.1+0.4days/month from baseline to 6months. Cross-sectionally, higher levels of the percentage of time in MVPA, self-efficacy, and social support were associated with greater group-average ORA use. Longitudinally, increased social support from friends and rating of lighter motorized traffic were associated with increased group ORA use. Additionally, longitudinal increases in percentage of MVPA and more favorable rating of the neighborhood as a place to walk were both associated with decreased group ORA use. Better understanding how social and physical environmental characteristics impact ORA use for PA can lead to more effective intervention strategies and warrants greater attention in future research and public health promotion efforts., (Copyright © 2015 Elsevier Inc. All rights reserved.)

An association between sleep disorders and autistic spectrum disorders in children is considered. Characteristic variants of sleep disorders, including resistance to going to bed, frequent night awakenings, parasomnias, changes in sleep structure, primarily, the decrease in the percentage of rapid eye movement sleep, are presented. Attention is focused on the possibility of the direct relationship between sleep disturbance and the pathogenesis of autistic spectrum disorders. A role of pathological alterations in the production of neuromediators and morphological changes in the brain structures characteristic of autistic spectrum disorders in the genesis of sleep disorders in children is discussed. Possible non-pharmacological and pharmacological approaches are suggested.

Background: Exaggerated dispersion of repolarization is likely to play a role in both the initiation and the maintenance of malignant ventricular arrhythmias. It was proposed that the inter-lead QT interval differences within a 12-lead ECG termed 'QT dispersion' might reflect regional differences in myocardial refractoriness, and that this might predict cardiac dysrhythmias., Aim: The study aimed to perform a meta-analysis of the relevant available publications., Methods: A MEDLINE search from 1990 to 2012 at PubMed (NLM) was performed. An all-fields search for index terms 'QT dispersion' and 'anxiety' was done. Case-control studies and surveys were included in the analysis provided they encompassed physically healthy subjects who had been evaluated for anxiety disorders with validated inventories. Outcome measures were either crude or heart rate-corrected QT dispersions., Results: Five studies were included in the analysis, which encompassed 580 patients with calculated mean age of 36.8 years (standard error = 5.5). The values of crude and heart rate-corrected QT dispersions across the studies were statistically significantly higher in the patients with anxiety disorders. Crude values of QT dispersion were available in 164 patients with anxiety and in 273 controls. Summarized standardized difference in the means (random effect model) was equal to 1.472 (95% confidence interval: 1.034-1.911). Heart rate-corrected QT dispersion values were available in 193 patients with anxiety and in 282 controls, and the summarized standardized difference in the means was equal to 3.299 (95% confidence interval: 1.215-5.384)., Conclusion: High anxiety is associated with increased QT dispersion, which may predispose to cardiac arrhythmias., (© The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objective: Empirical studies have established that clinical anxiety and depressive disorders may arise in preschool children as young as 3.0 years. Because empirical studies validating and characterizing these disorders in preschoolers are relatively recent, less work has been done on the development and testing of age-appropriate treatments., Method: A comprehensive literature search yielded several small randomized controlled trials of psychotherapeutic treatments for preschool anxiety and depression. The literature also contained case series of behavioral and psychopharmacologic interventions for specific anxiety disorders. However, to date, no large-scale randomized controlled trials of treatment for any anxiety or depressive disorder specifically targeting preschool populations have been published., Results: Several age-adapted forms of cognitive-behavioral therapy have been developed and preliminarily tested in small randomized controlled trials and appear promising for different forms of preschool anxiety disorders. Notably, these adaptations centrally involve primary caregivers and use age-adjusted methodology such as cartoon-based materials and co-constructed drawing or narratives. Modified forms of parent child interaction therapy have been tested and appear promising for anxiety and depression. Although preventive interventions that target parenting have shown significant promise in anxiety, these methods have not been explored in early childhood depression. Studies of the impact of parental treatment on infants suggest that direct treatment of the youngest children may be necessary to affect long-term change., Conclusions: Recommendations are made for the clinical treatment of these disorders when psychotherapy is the first line of intervention., (Copyright © 2013 American Academy of Child & Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: The present study examined the course of ADHD over 24 months in a preschool population., Method: n=48 preschoolers with ADHD, aged 3.0-5.11 years, subjects included in a larger sample of preschoolers with depression and other disorders (n=306) were comprehensively assessed at 3 annual time points over 24 months in a prospective longitudinal follow-up study., Results: Baseline diagnoses of preschool MDD, ODD, and CD were risk factors for ADHD diagnosis over 24 months in this preschool population. Among older preschoolers and after controlling for key demographic variables, ADHD predicted later ADHD diagnosis, along with other significant risk factors - baseline diagnosis of ODD, and/or family history of disruptive disorders, and stressful life events., Conclusions: ADHD showed greater homotypic continuity at later rather than earlier preschool ages. Other disruptive comorbidities also emerged as key predictors of stable ADHD course. Study findings may help to inform which preschool ADHD populations to target for early intervention. Larger sample sizes are needed to confirm these findings and to further explore the stability, course, and predictors of outcome of preschool onset ADHD.

Aim: The aim of this study was to evaluate possible relationship between infant-parent(s) bed sharing during night sleep and sleep characteristics in two-month-old infants., Methods: One hundred and twelve healthy infants from the community setting (48 males, 64 females) who were singletons born in St. Petersburg, Russia in 2007, at term, with normal weight entered the study. Infants did not have signs of inborn malformations, intrauterine infections, inherited or progressive diseases. Information about major infant, maternal, and demographic characteristics was collected from available medical documents. The mothers were approached by trained interviewer. As a part of interview, the mothers were requested to answer whether the baby was a regularly solitary sleeper or regularly shared the bed with parent(s) during night sleep and to fill in the questionnaire addressing infant's behaviour during sleep., Results: Of 112 infants, 83 (74%) were solitary sleepers, 29 (26%) shared the bed with parent(s). No statistically significant difference was found for major infant, parental and demographic characteristics between two groups. Bed sharing babies had significantly higher values (more problems) on sleep duration and night wakening scores. It was more common with them to sleep too little, wake more than twice during the night, less often return to sleep without help after waking. Significantly higher values were found on sleep disordered breathing and parasomnia scores; noisy breathing during sleep was more commonly reported in them., Conclusion: Maternal reports on disturbed sleep in two-month-old babies were more common in the cases of infant-parent(s) bed sharing.

Postpartum EEG spectral and coherence characteristics were estimated in mothers with or without postpartum depressions. In mothers without affective disorders the power of oscillations in the delta, theta, and alpha 1 frequency bands was increased as compared to controls. Intrahemispheric EEG coherence between the left frontal and adjacent derivations in the delta and theta bands and interhemispheric coherence in the central areas was increased and decreased over the remaining cortical surface. These changes led to a significant decrease in EEG asymmetry. It is suggested that during normal postpartum the influence of the limbicodiencephalic and lower brainstem structures on the cortex is augmented and a certain kind of dominanta is formed. In mothers with postpartum depressions the EEG alpha-band power was lower than in the control and normal groups, coherence changes in the delta and theta bands diminished the EEG asymmetry. The insufficiency of limbicodiencephalic influence and impairment of adaptive brainstem reactions are suggested to be responsible for problems in the formation of maternal dominanta, which results in the development of postpartum depressions.

Planning health care for unknown situations is inevitably difficult. This case demonstrates how the US Navy used the WBB to provide blood replacement in a hemorrhaging patient when no other source of blood was available. Although transfusion at sea is a rare event, the availability of a well-planned blood transfusion program prevented a fatality and ultimately returned a sailor to his ship. It was an excellent test of materials, process, and personnel.