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INTRODUCTION: Traffic-related air pollution can trigger myocardial infarction (MI). However, the hourly hazard period of exposure to nitrogen dioxide (NO2), a common traffic tracer, for incident MI has not been fully evaluated. Thus, the current hourly US national air quality standard (100 ppb) is based on limited hourly-level effect estimates, which may not adequately protect cardiovascular health. OBJECTIVES: We characterized the hourly hazard period of NO2 exposure for MI in New York state (NYS), USA, from 2000 to 2015. METHODS: For nine cities in NYS, we obtained data on MI hospitalizations from the NYS Department of Health Statewide Planning and Research Cooperative System and hourly NO2 concentrations from the US Environmental Protection Agencys Air Quality System database. We used city-wide exposures and a case-crossover study design with distributed lag non-linear terms to assess the relationship between hourly NO2 concentrations over 24 h and MI, adjusting for hourly temperature and relative humidity. RESULTS: The mean NO2 concentration was 23.2 ppb (standard deviation: 12.6 ppb). In the six hours preceding MI, we found linearly increased risk with increasing NO2 concentrations. At lag hour 0, a 10 ppb increase in NO2 was associated with 0.2 % increased risk of MI (Rate Ratio [RR]: 1.002; 95 % Confidence Interval [CI]: 1.000, 1.004). We estimated a cumulative RR of 1.015 (95 % CI: 1.008, 1.021) for all 24 lag hours per 10 ppb increase in NO2. Lag hours 2-3 had consistently elevated risk ratios in sensitivity analyses. CONCLUSIONS: We found robust associations between hourly NO2 exposure and MI risk at concentrations far lower than current hourly NO2 national standards. Risk of MI was most elevated in the six hours after exposure, consistent with prior studies and experimental work evaluating physiologic responses after acute traffic exposure. Our findings suggest that current hourly standards may be insufficient to protect cardiovascular health.

BackgroundPosttraumatic stress disorder (PTSD) symptoms can develop following acute, life-threatening medical events. This study explores a potential biomarker of PTSD risk that is novel to a medical trauma population: a noninvasive, mobile skin conductance (SC) measurement.MethodsParticipants (N=64) were enrolled in-hospital following a stroke or transient ischemic attack (TIA). Mobile measurement of SC reactivity to recalling the stroke/TIA traumatic event was conducted at hospital bedside in the days following the stroke/TIA. PTSD symptoms that developed in response to the stroke/TIA were measured at 1-month follow-up. We tested the association between SC reactivity and total 1-month PTSD symptoms, as well as PTSD symptom dimensions of fear and dysphoria.ResultsIn unadjusted analyses, there were significant positive associations between in-hospital SC reactivity to recalling the stroke/TIA traumatic event and higher-order fear-related symptoms (r=.30, p=.016), as well as lower-order fear-related symptoms of anxious arousal (r=.27, p=.035) and avoidance (r=.25, p=.043) at 1 month. Associations between SC reactivity and the fear, anxious arousal, and avoidance symptom dimensions remained significant in multivariable regression models that adjusted for relevant covariates including age, gender, stroke severity, medical comorbidity, and psychosocial factors. Although there was a positive association observed between SC reactivity to recalling the stroke/TIA event and total PTSD symptom severity at 1-month follow-up, it did not reach the level of statistical significance (r=.23, p=.070). Further, no significant association was detected for dysphoria-related symptoms (r=.11, p=.393).ConclusionsThis is the first study to test the prospective association of SC reactivity with PTSD symptom development following a medical trauma. The findings indicate that mobile measures of SC reactivity may be useful for in-hospital identification of individuals at risk for fear-related PTSD symptom development following a medical event and highlight the potential mechanisms involved in the development of these symptoms following a medical event.

Climate change is the greatest threat to global health in human history. It has been declared a public health emergency by the World Health Organization and leading researchers from academic institutions around the globe. Structural racism disproportionately exposes communities targeted for marginalization to the harmful consequences of climate change through greater risk of exposure and sensitivity to climate hazards and less adaptive capacity to the health threats of climate change. Given its interdisciplinary approach to integrating behavioral, psychosocial, and biomedical knowledge, the discipline of behavioral medicine is uniquely qualified to address the systemic causes of climate change-related health inequities and can offer a perspective that is currently missing from many climate and health equity efforts. In this article, we summarize relevant concepts, describe how climate change and structural racism intersect to exacerbate health inequities, and recommend six strategies with the greatest potential for addressing climate-related health inequities.

Background: Health care workers (HCWs) during the COVID-19 pandemic report high levels of psychological distress. We examined whether concerns regarding transmission of COVID-19 to loved ones and social distancing from loved ones were associated with HCWs' distress. We tested whether living with others modified these associations. Method: HCWs at a New York City academic medical center (N = 767; 80.7% female, 58.5% White) enrolled in the COVID-19 Health Care Provider Study and completed a web-based survey between April 9, 2020 and May 11, 2020. Results: Controlling for demographics, distress regarding potential transmission to loved ones and social distancing from loved ones were each significantly associated with higher odds of a positive screen for acute stress, depression, and anxiety (ORs = 1.29-1.59, all ps < .01). Living with others was associated with lower odds of a positive screen for depression and anxiety, though the protective effect for anxiety was evident only for HCWs with no distress regarding transmission concerns. Conclusions: Transmission concerns and social distancing from loved ones were associated with greater odds of psychological distress, whereas living with others was associated with lower odds of distress. Interventions should consider ways to facilitate the ability of HCWs to receive social support from loved ones, while simultaneously protecting their family's health. Keywords: COVID-19, coronavirus, health care workers, psychological distress, social support, Health care workers (HCWs) working during the COVID-19 pandemic exhibit high levels of psychological distress (Lai et al., 2020; Li et al., 2020; Montemurro, 2020; Shechter et al., 2020; Simione [...]

ObjectiveElevated inflammation has been repeatedly observed in posttraumatic stress disorder (PTSD), and it may drive the development of both psychiatric symptoms and physical comorbidities. However, it is not clear if elevated inflammation is a feature of both remitted and current PTSD, and little is known about relationships between specific clusters of PTSD symptoms and inflammation. Exaggerated threat sensitivity, as indexed by threat reactivity and avoidance of perceived threats, may be particularly closely associated with inflammation.MethodsWe assessed PTSD symptoms and threat sensitivity using the Clinician Administered PTSD Scale in 735 Veterans Affairs patients (35% current PTSD; 16% remitted PTSD) who participated in the Mind Your Heart Study (mean age=59±11; 94% male). High sensitivity C-reactive protein (hsCRP), white blood cell count (WBC), and fibrinogen were used as indices of inflammation. Analysis of covariance models with planned contrasts were used to examine differences in inflammation by PTSD status, adjusting for age, sex, race, kidney function and socioeconomic status.ResultsIndividuals with current PTSD had significantly higher hsCRP and WBC than patients with no history of PTSD, but there were no significant differences in inflammatory markers between those with remitted versus no history of PTSD. Within patients with current PTSD, higher threat reactivity was independently associated with higher hsCRP (β=0.16, p=0.01) and WBC count (β=0.24,

The cross-stressor adaptation hypothesis of exercise training has not been investigated under real-life conditions. Using ecological momentary assessment, we tested whether usual exercise level moderates the relationship of self-reported anxiety to concurrent ambulatory heart rate (HR) and systolic/diastolic blood pressure (SBP/DBP). Participants (N = 832) completed 24-h ambulatory monitoring of HR/BP, using a brachial BP cuff that took readings at 28-min intervals. Anxiety levels were concurrently reported on a visual analog scale (VAS) using a Palm Pilot. Usual exercise behavior was assessed by a self-report questionnaire. Random coefficients linear regression models predicting momentary HR/BP readings from time-matched anxiety scores were estimated, yielding the average within-person effect (slope) of anxiety. The interaction of exercise level (i.e., no weekly exercise, 1-149, and [greater than or equal to] 150 min/week; a between-person factor) with anxiety was added to the model in order to estimate the average anxiety slope for participants in each exercise category. The relationship of HR/BP to anxiety did not differ significantly among exercise categories, hence not providing evidence for the cross-stressor hypothesis. In an exploratory analysis of the difference in HR/BP between occasions when anxiety was in the top versus bottom person-specific quintiles of responses, the difference in HR (but not SBP or DBP) varied significantly by exercise level (F(2,625) = 4.92, p = 0.008). Though our pre-specified analysis did not support the hypothesis, we provide some post hoc evidence supporting the cross-stressor hypothesis of exercise training for the HR response to anxiety., Author(s): Ipek Ensari [sup.1] , Joseph E. Schwartz [sup.2] [sup.3] , Donald Edmondson [sup.2] , Andrea T. Duran [sup.2] , Daichi Shimbo [sup.2] , Keith M. Diaz [sup.2] Author Affiliations: [...]

The purpose of this study was to assess gender identity differences in CVD risk and CVD conditions among adults in the U.S. Using data from the 2014-2017 BRFSS we compared CVD risk and CVD conditions in gender minorities (transgender men, transgender women and gender nonconforming persons) to both cisgender men and women. The sample consisted of 662,903 participants. Transgender women (AOR 1.34, 95% CI 1.05-1.72) and transgender men (AOR 1.54, 95% CI 1.07-2.24) were more likely to be overweight than cisgender women. Compared to cisgender women, transgender women reported higher rates of diabetes (AOR 1.45, 95% CI 1.05-1.99), angina/coronary heart disease (AOR 1.90, 95% CI 1.34-2.68), stroke (AOR 1.88, 95% CI 1.16-3.03), and myocardial infarction (AOR 2.98, 95% CI 2.14-4.17). Gender nonconforming participants (AOR 2.68, 95% CI 1.14-6.30) reported higher odds of myocardial infarction than cisgender women. Transgender women also had higher rates of reporting any CVD than cisgender men (AOR 1.38, 95% CI 1.01-1.88). There is a need to elucidate the cardiovascular effects of minority stressors and gender affirming therapy in this population. More research focused on CVD prevention and management in gender minorities is recommended., Author(s): Billy A. Caceres [sup.1] , Kasey B. Jackman [sup.1] , Donald Edmondson [sup.2] , Walter O. Bockting [sup.1] Author Affiliations: (1) grid.21729.3f, 0000000419368729, Program for the Study of LGBT [...]

The notion that psychological states can influence physical health is hardly new, and perhaps nowhere has the mind-body connection been better studied than in cardiovascular disease (CVD). Recently, large prospective epidemiologic studies and smaller basic science studies have firmly established a connection between CVD and several psychological conditions, including depression, chronic psychological stress, posttraumatic stress disorder (PTSD), and anxiety. In addition, numerous clinical trials have been conducted to attempt to prevent or lessen the impact of these conditions on cardiovascular health. In this article, we review studies connecting depression, stress/PTSD, and anxiety to CVD, focusing on findings from the last 5 years. For each mental health condition, we first examine the epidemiologic evidence establishing a link with CVD. We then describe studies of potential underlying mechanisms and finally discuss treatment trials and directions for future research.

Purpose We tested the hypothesis that, during a life-threatening medical emergency, patient perception of healthcare provider (HCP) compassion is associated with the subsequent development of post-traumatic stress disorder (PTSD) symptoms. Methods Prospective cohort study in the emergency department (ED) of an urban academic medical center. We included adult patients presenting with a life-threatening medical emergency, defined as respiratory or cardiovascular instability requiring a potentially life-sustaining intervention in the ED. We measured patient perception of HCP compassion in the ED using the Consultation and Relational Empathy (CARE) measure, a validated 40-point scale. Blinded to clinical outcomes (including the CARE measure), we assessed PTSD symptoms 1 month post-discharge using the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5. Results Of the 99/113 (88%) patients who completed follow-up, 25% (95% CI 17-35%) had PTSD symptoms at 1 month. In a multivariable model adjusting for potential confounders (e.g. severity of illness score in ED, need for intensive care unit admission, ED overcrowding, and family member emotional support in the ED), patient perception of greater HCP compassion in the ED was independently associated with lower PTSD symptoms at 1 month [odds ratio 0.93 (95% CI 0.89-0.98)]. A one-point increase in the CARE measure was associated with a 7% decrease in the odds of developing PTSD symptoms. Conclusions PTSD symptoms are common among ED patients with life-threatening medical emergencies. Patient perception of greater HCP compassion during the emergency is independently associated with lower risk of developing PTSD symptoms., Author(s): Jeena Moss [sup.1], Michael B. Roberts [sup.2], Lisa Shea [sup.1], Christopher W. Jones [sup.1], Hope Kilgannon [sup.1], Donald E. Edmondson [sup.3], Stephen Trzeciak [sup.4] [sup.5], Brian W. Roberts [sup.1] [...]

Posttraumatic stress disorder (PTSD) is an anxiety disorder initiated by exposure to a traumatic event and characterized by intrusive thoughts about the event, attempts to avoid reminders of the event, and physiological hyperarousal. In a number of large prospective observational studies, PTSD has been associated with incident cardiovascular disease (CVD) and mortality. Also, in recent years, a number of studies have shown that cardiovascular events can themselves cause PTSD in more than 1 in 8 patients with acute coronary syndrome. Further, a few small studies suggest that PTSD secondary to an acute CVD event then places patients at increased risk for subsequent CVD events and mortality. In this article, we review the evidence for a link between PTSD and CVD, and discuss potential mechanisms for that association as well as future directions for research.

BackgroundPatients with post-traumatic stress disorder (PTSD) are at increased risk for adverse outcomes from comorbid medical conditions. Medication non-adherence is a potential mechanism explaining this increased risk.MethodsWe examined the association between PTSD and medication adherence in a cross-sectional study of 724 patients recruited from two Department of Veterans Affairs Medical Centers between 2008 and 2010. PTSD was assessed using the Clinician Administered PTSD Scale. Medication adherence was assessed using a standardized questionnaire. Ordinal logistic regression models were used to calculate the odds ratios (ORs) for medication non-adherence in patients with versus without PTSD, adjusting for potential confounders.ResultsA total of 252 patients (35%) had PTSD. Twelve percent of patients with PTSD reported not taking their medications as prescribed compared to 9% of patients without PTSD (unadjusted OR 1.85, 95% CI 1.37-2.50, P

Evaluation for acute coronary syndrome (ACS) can trigger posttraumatic stress symptoms (PSS). Research suggests that younger, versus older, individuals may be at elevated risk for PSS after ACS evaluation. It has been proposed that younger individuals may be at greater risk because they perceive the suspected ACS event as more threatening than their older counterparts; however, this has yet to be tested. We examined whether perceived threat during ACS evaluation mediated the association between age and PSS after ACS evaluation in an observational cohort study of patients presenting to the emergency department (ED) with suspected ACS. Demographics and perceived threat were assessed in the ED. PSS were measured upon inpatient transfer or by phone 3 days later. The analytic sample comprised 871 adult participants. Multiple linear regression was used to examine (1) associations of age and perceived threat with PSS and (2) whether perceived threat mediated the association. Bootstrapping with percentile-based confidence intervals (CIs) was used to test the indirect effect. Each year of age was associated with lower PSS (b = - 0.12, p < .001), independent of covariates. Older age was associated with lower perceived threat during ACS evaluation (b = - 0.05, p < .001). Greater threat perceptions predicted greater PSS (b = 0.94, p < .0001). The indirect effect (- 0.04) was statistically significant (95% CI - 0.07, - 0.02). Younger, versus older, individuals are at risk for greater PSS after ACS evaluation, and elevated perceived threat partially mediated this association. Understanding age differences in PSS development risk and the potential impact of age on threat perceptions may help inform ED treatment., Author(s): Laura Meli [sup.1] , Marin Kautz [sup.2] , Jacob Julian [sup.3] , Donald Edmondson [sup.1] , Jennifer A. Sumner [sup.4] Author Affiliations: (Aff1) 0000 0001 2285 2675, grid.239585.0, Center [...]

Posttraumatic stress disorder (PTSD) after acute medical events is associated with medication nonadherence. The mechanisms of PTSD-related nonadherence are poorly understood. We tested whether patients with elevated PTSD symptoms induced by suspected acute coronary syndrome (ACS) were more likely to have aversive cognitions towards cardiovascular medications. We enrolled a consecutive cohort of patients who presented to the emergency department with suspected ACS. One month after discharge, ACS-induced PTSD symptoms were assessed using the PTSD Checklist (PCL-S), and patients were asked 'how often did' (1) 'you miss your heart medication because you did not want to be reminded about your heart problem'; (2) 'thinking about your heart medication make you feel nervous or anxious'; and (3) 'thinking about your heart medication make you think about your risk for future heart problems.' Logistic regression was used to determine the association between elevated PTSD symptoms and each aversive cognition, adjusting for age, sex, race, ethnicity, education, depression, and ACS status. Of 424 patients included, 15.8% had elevated PTSD symptoms (PCL-S [greater than or equal to] 34). In adjusted analyses, higher PCL-S scores were associated with missing medications to avoid reminders of heart disease (OR 1.22 per 5-point PCL-S increase, 95%CI 1.07-1.40), as well as anxiety (OR 1.34, 95%CI 1.19-1.51) and thoughts of future risk (OR 1.19, 95%CI 1.08-1.32) when thinking about cardiovascular medications. We concluded that patients with elevated PTSD symptoms following suspected ACS were more likely to report aversive cognitions about their cardiovascular medications, suggesting that medications can act as traumatic reminders of the cardiac event and ongoing risk in this group., Author(s): S. Ali Husain [sup.1] [sup.2] , Donald Edmondson [sup.1] , Marin Kautz [sup.1] , Redeana Umland [sup.1] , Ian M. Kronish [sup.1] Author Affiliations: (Aff1) 0000 0001 2285 2675, [...]