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BackgroundSome patterns of cannabis use may presage risk for long-term negative effects. We examined associations between a novel adolescent cannabis misuse scale and early-adult life course outcomes.MethodsWe performed a secondary data analysis of a cohort of Los Angeles, CA high school students from grade 9 through age 21. Participants reported baseline individual demographic and family characteristics at grade 9, adolescent cannabis misuse (8-items) and alcohol misuse (12-items) at grade 10, and outcomes at age 21. We used multivariable regression to model the associations of cannabis misuse scale score with problem substance use (defined as any of: 30-day illegal drug use, 30-day use of another's prescription to get high, hazardous drinking) and several secondary outcomes (behavioral, mental health, academic, social determinants of health), adjusting for covariates. Parallel analyses were conducted for alcohol misuse.ResultsThe 1,148 participants (86% retention) were 47% male, 90% Latinx, 87% US born, and 40% native English speakers. Approximately 11.4% and 15.9% of participants reported at least one item on the cannabis and alcohol misuse scales, respectively. At age 21, approximately 6.7% of participants reported problem substance use, which was associated with both Cannabis and Alcohol Misuse Scales (OR 1.31, 95%CI[1.16, 1.49] and OR 1.33, 95%CI[1.18, 1.49], respectively). Both scales were similarly associated with outcomes in all four categories.ConclusionsThe Adolescent Cannabis Misuse Scale is a promising tool for identifying early patterns of substance use that predict future negative outcomes and enabling early intervention at a critical period in youth development.

BackgroundAdolescent behaviors and academic outcomes are thought to be shaped by school climate. We sought to identify longitudinal associations between school climate measures and downstream health and academic outcomes.MethodsData from a longitudinal survey of public high school students in Los Angeles were analyzed. Eleventh-grade health and academic outcomes (dependent variables, eg, substance use, delinquency, risky sex, bullying, standardized exams, college matriculation), were modeled as a function of 10th-grade school climate measures (independent variables: institutional environment, student-teacher relationships, disciplinary style), controlling for baseline outcome measures and student/parental covariates.ResultsThe 1114 student respondents (87.8% retention), were 46% male, 90% Latinx, 87% born in the United States, and 40% native English speakers. Greater school order and teacher respect for students were associated with lower odds of multiple high risk behaviors including 30-day alcohol use (odds ratio [OR] 0.81; 95% confidence interval [CI] [0.72, 0.92] and OR 0.73; [0.62, 0.85]) and 30-day cannabis use (OR 0.74; [0.59, 0.91] and OR 0.76; [0.63, 0.92]). Neglectful disciplinary style was associated with multiple poor health and academic outcomes while permissive disciplinary style was associated with favorable academic outcomes.Implications for school health policy, practice, and equitySchool health practitioners may prospectively leverage school environment, teacher-student relationships, and disciplinary style to promote health and learning.ConclusionsOur findings identify specific modifiable aspects of the school environment with critical implications for life course health.

Background: Adolescent behaviors and academic outcomes are thought to be shaped by school climate. We sought to identify longitudinal associations between school climate measures and downstream health and academic outcomes. Methods: Data from a longitudinal survey of public high school students in Los Angeles were analyzed. Eleventh-grade health and academic outcomes (dependent variables, eg, substance use, delinquency, risky sex, bullying, standardized exams, college matriculation), were modeled as a function of 10th-grade school climate measures (independent variables: institutional environment, student-teacher relationships, disciplinary style), controlling for baseline outcome measures and student/parental covariates. Results: The 1114 student respondents (87.8% retention), were 46% male, 90% Latinx, 87% born in the United States, and 40% native English speakers. Greater school order and teacher respect for students were associated with lower odds of multiple high risk behaviors including 30-day alcohol use (odds ratio [OR] 0.81; 95% confidence interval [CI] [0.72, 0.92] and OR 0.73; [0.62, 0.85]) and 30-day cannabis use (OR 0.74; [0.59, 0.91] and OR 0.76; [0.63, 0.92]). Neglectful disciplinary style was associated with multiple poor health and academic outcomes while permissive disciplinary style was associated with favorable academic outcomes. Implications for School Health Policy, Practice, and Equity: School health practitioners may prospectively leverage school environment, teacher-student relationships, and disciplinary style to promote health and learning. Conclusions: Our findings identify specific modifiable aspects of the school environment with critical implications for life course health.

ImportanceInterventions directly targeting social factors, such as education, may have the potential to greatly improve health.ObjectiveTo examine the association of attending a high-performing public charter high school with rates of substance use disorder and physical and mental health.Design, setting, and participantsThis cohort study used the random school admissions lottery system of high-performing public charter high schools in low-income neighborhoods of Los Angeles, California, to examine the health outcomes of students who applied to at least 1 of 5 of these high schools. Participants attended 147 different high schools and were randomly selected from those who won the admissions lottery (intervention group) and those who were placed on a waiting list (control group). Participants were surveyed at the end of grade 8 through transition into grade 9 and then from grade 10 through 3 years after high school completion (at age 21 years). Surveys were conducted from March 2013 through November 2021.InterventionAttendance at a high-performing public charter high school.Main outcomes and measuresSelf-reported alcohol use disorder and cannabis misuse, delinquent behaviors, physical and mental health, and body mass index.ResultsOf the 1270 participants at baseline (mean [SD] age, 14.2 [0.47] years; 668 female individuals [52.6%]). The control group included 576 individuals (45.4%), and 694 individuals (54.6%) were in the intervention group. Both groups were similar in almost all characteristics at baseline, and the median (IQR) follow-up was 6.4 (6.0-6.7) years. Participants attending a high-performing public charter high school had a 53.33% lower rate of hazardous or dependent alcohol use disorder compared with those in the control group (5.43% vs 11.64%; difference, -6.21% [95% CI, -11.87% to -0.55%]; P = .03). Among male participants, the intervention group had a 42.05% lower rate of self-reported fair or poor physical health (13.33% vs 23.01%; difference, -9.67% [95% CI, -18.30% to -1.05%]; P = .03) and a 32.94% lower rate of obesity or overweight (29.28% vs 43.67%; difference, -14.38% [95% CI, -25.74% to -3.02%]; P = .02) compared with the control group. Among female participants, attending a high-performing public charter high school was associated with worse physical health outcomes (30.29% vs 13.47% reporting fair or poor health; difference, 16.82% [95% CI, 0.36% to 33.28%]; P = .045) and higher rates of overweight or obesity (52.20% vs 32.91%; difference, 19.30% [95% CI, 3.37% to 35.22%]; P = .02) at age 21 years. Few differences in mental health outcomes were observed. Adjusting for educational outcomes did not significantly change these findings.Conclusions and relevanceResults of this study suggest that attending a high-performing public charter high school was associated with lower rates of substance use disorder independent of academic achievement. Physical health and obesity outcomes were also better but only for young men; the intervention group had worse physical health outcomes among young women for unclear reasons. Schools are a potent social determinant of health and an important target for future health interventions.

Adolescence is a critical transition period that sets the stage for adulthood and future health outcomes. Marked by key developmental milestones in brain maturation, increasing independence from parents, and greater connections to peers, adolescence is also a time of heightened risk for behavioral health problems, including substance use, violence, delinquency, and mental health issues. High school completion is a significant life course event and a powerful social determinant of health and health disparities. Jessor's Theory of Problem Behavior suggests that adolescent health behaviors and mental health problems are closely tied to poor educational outcomes and peer network formation in a reinforcing feedback loop, or vicious cycle, often leading to school failure, school disengagement, and drop-out. Schools are a novel platform through which vicious cycles can be disrupted and replaced with virtuous ones, simultaneously improving education and health. This article describes the potential for schools to transform health trajectories through interventions creating positive and supportive school climates. In addition, new models such as the Whole School Whole Community Whole Child Model promote whole child well-being, including cognitive, social, emotional, psychological, and physical development. Full-service community schools can serve as a hub coordinating and integrating all available resources to better respond to the needs of children and families. Present in every neighborhood, schools are a way to reach every school-age child and improve their health trajectories, providing an important platform for life course intervention research.

BackgroundSchools and school climate are thought to influence academic outcomes as well as child and adolescent development, health and well-being. We sought to examine the relationship between several aspects of the school climate with adolescent social-emotional health outcomes.MethodsWe analysed data from the Reducing Inequities through Social and Educational change Follow-up (RISE UP) Study, a longitudinal natural experimental study of Los Angeles high school students collected from 2013 to 2018. We analysed data on the portion of the sample that completed the baseline, 10th grade and 11th grade surveys (n=1114). Students reported their perceptions of school climate at 10th grade and social-emotional outcomes including grit, self-efficacy, depression, hopelessness, and stress at baseline (9th grade) and at 11th grade. Multivariable regressions adjusted for student and parental demographics and baseline social-emotional states tested associations between school climate and each outcome.ResultsStudents who reported being in authoritative school environments in 10th grade, one that is highly supportive and highly structured, had subsequently higher levels of self-efficacy (p

ObjectiveChaos in the home is associated with worse childhood behaviors. We hypothesize chaos in the school environment might also be associated with teen risk behaviors.MethodsWe analyzed data from the Reducing Inequities through Social and Educational change Follow-Up study, a natural experiment designed to examine the impact of high-performing schools on adolescent outcomes. Students reported the amount of noise, order, and control in their school environment and whether they engaged in substance use, fighting, school absenteeism, and delinquent behaviors. We conducted cross-lagged panel structural equation modeling to examine the relationship between school chaos at 10th grade with risk behaviors at 11th grade while simultaneously examining the relationship between behaviors at 10th grade with chaos at 11th grade.ResultsAmong a sample of 1114 teens, 90% were Latinx and 40% were native English speakers. Students reporting more school chaos in 10th grade were more likely in 11th grade to report recent alcohol and cannabis use, physical fighting, school absenteeism, and delinquent behaviors in the last year. Cross-lagged structural equation model analyses indicate school chaos at 10th grade is linked to alcohol use and absenteeism at 11th grade, while fighting, absenteeism, and any delinquent behaviors at 10th grade are associated with more chaos at 11th grade. School engagement was not a mediating factor.ConclusionsAlthough causal relationships cannot be assumed, school chaos may be an important predictor of adolescent risk behaviors. Future studies should examine whether reducing school chaos leads to lower rates of adolescent risk behaviors.

ObjectiveTo determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution.DesignRetrospective cohort study.SettingTwo affiliated academic medical centers in Los Angeles, California.PatientsHospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards.MethodsWe described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation.ResultsOf the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91-4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28-3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34-0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22-0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria.ConclusionsInpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.

BackgroundSepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis.ObjectiveTo compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis.DesignRetrospective cohort study using multivariable analysis of clinical data.ParticipantsA total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection.SettingFour university hospitals in California between 2014 and 2016.Main outcomes and measuresThe primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen.Key resultsCompared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p

ObjectivesSchools are thought to have an important impact on adolescent behaviors, but the mechanisms are not well understood. We hypothesize that there are measurable constructs of peer- and teacher-related extrinsic motivations for adolescent behaviors and sought to develop measures of school culture that would capture these constructs.MethodsWe developed several survey items to assess school behavioral culture and collected self-reported data from a sample of adolescents age 14-17 attending high school in low income neighborhoods of Los Angeles. We conducted exploratory and confirmatory factor analysis to inform the creation of simple-summated multi-item scales. We also conducted a cultural consensus analysis to identify the existence of shared pattern of responses to the items among respondents within the same school.ResultsFrom 1159 adolescents, six factors were identified: social culture regarding popular (Cronbach's alpha=0.84) and respected (alpha=0.83) behaviors, teacher support (alpha=0.86) and monitoring of school rules (alpha=0.85), valued student traits (alpha=0.67) and school order (alpha=0.68). Cultural consensus analysis identified a shared pattern of responses to the items among respondents at 8 of the 13 schools. School academic performance, which is based on standardized test results, is strongly correlated with social culture regarding popular behaviors (Pearson's correlation coefficient r=0.64), monitoring of school rules (r= 0.71), and school order (r= 0.83).ConclusionsThe exploratory and confirmatory factor analyses did not support a single, overall factor that measures school culture. However, the six identified sub-scales might be used individually to examine school influence on academic performance and health behaviors.

ImportanceAlthough school environments are thought to influence health behaviors, experimental data assessing causality are lacking, and which aspects of school environments may be most important for adolescent health are unknown.ObjectiveTo test whether exposure to high-performing schools is associated with risky adolescent health behaviors.Design, setting, and participantsThis natural experiment used admission lotteries, which mimic random assignment, to estimate the association of school environments and adolescent health. A survey of 1270 students who applied to at least 1 of 5 high-performing public charter schools in low-income minority communities in Los Angeles, California. Schools had an academic performance ranked in the top tertile of Los Angeles County public high schools, applicants outnumbered available seats by at least 50, and an admissions lottery was used. Participants included lottery winners (intervention group [n = 694]) and lottery losers (control group [n = 576]) from the end of 8th grade and beginning of 9th grade through the end of 11th grade. Intention-to-treat (ITT) and instrumental variable techniques estimated the association of winning the lottery and attending high-performing schools with health behaviors and whether the association varied by sex. Data were collected from March 11, 2013, through February 22, 2017, and analyzed from October 1, 2017, through July 1, 2018.ExposuresSchools were considered high performing if they placed in the top tercile of public high schools in LA County on 2012 state standardized tests. Most students attended that same school for 3 years (9th-11th grades).Main outcomes and measuresPrimary self-reported outcomes were 30-day and high-risk self-reported marijuana use. Additional health outcomes included 30-day alcohol use, alcohol misuse, ever being in a fight, ever having sex, and past-year delinquency. Potential intermediate factors (time studying, truancy, school mobility, school culture, school order, teacher support for college, and proportion of substance-using peers in students' social networks) were also examined.ResultsAmong the 1270 participating students (52.6% female; mean [SD] age at enrollment, 14.3 [0.5] years), ITT analysis showed that the intervention group reported less marijuana misuse than the control group (mean marijuana misuse score, 0.46 vs 0.71), as well as fewer substance-using peers (9.6% vs 12.7%), more time studying (mean, 2.63 vs 2.49 hours), less truancy (84.3% vs 77.3% with no truancy), greater teacher support for college (mean scores, 7.20 vs 7.02), more orderly schools (mean order score, 7.06 vs 6.83), and less school mobility (21.4% vs 28.4%) (all P

Competing priorities between subsistence needs and health care may interfere with HIV health. Longitudinal data from the Los Angeles-based HIV Outreach Initiative were analyzed to examine the association between competing subsistence needs and indicators of poor retention-in-care among hard-to-reach people with HIV. Sacrificing basic needs for health care in the previous six months was associated with a 1.55 times greater incidence of missed appointments (95% CI 1.17, 2.05), 2.32 times greater incidence of emergency department visits (95% CI 1.39, 3.87), 3.66 times greater incidence of not receiving ART if CD4 < 350 (95% CI 1.60, 8.37), and 1.35 times greater incidence of detectable viral load (95% CI 1.07, 1.70) (all p < 0.01). Among hard-to-reach PLHIV, sacrificing basic needs for health care delineates a population with exceptional vulnerability to poor outcomes along the HIV treatment cascade. Efforts to identify and reduce competing needs for this population are crucial to HIV health outcomes.

BackgroundWe examined whether standardized test scores and grades are related to risky behaviors among low-income minority adolescents and whether social networks and social-emotional factors explained those relationships.MethodsWe analyzed data from 929 high school students exposed by natural experiment to high- or low-performing academic environments in Los Angeles. We collected information on grade point average (GPA), substance use, sexual behaviors, participation in fights, and carrying a weapon from face-to-face interviews and obtained California math and English standardized test results. Logistic regression and mediation analyses were used to examine the relationship between achievement and risky behaviors.ResultsBetter GPA and California standardized test scores were strongly associated with lower rates of substance use, high-risk sexual behaviors, and fighting. The unadjusted relative odds of monthly binge drinking was 0.72 (95% confidence interval, 0.56-0.93) for 1 SD increase in standardized test scores and 0.46 (95% confidence interval, 0.29-0.74) for GPA of B- or higher compared with C+ or lower. Most associations disappeared after controlling for social-emotional and social network factors. Averaged across the risky behaviors, mediation analysis revealed social-emotional factors accounted for 33% of the relationship between test scores and risky behaviors and 43% of the relationship between GPA with risky behaviors. Social network characteristics accounted for 31% and 38% of the relationship between behaviors with test scores and GPA, respectively. Demographic factors, parenting, and school characteristics were less important explanatory factors.ConclusionsSocial-emotional factors and social network characteristics were the strongest explanatory factors of the achievement-risky behavior relationship and might be important to understanding the relationship between academic achievement and risky behaviors.

ObjectivesTo determine whether a treating oncologist's characteristics are associated with variation in use of chemotherapy for patients with advanced non-small cell lung cancer (aNSCLC) at the end of life.Study designRetrospective cohort.MethodsUsing the 2009 Surveillance, Epidemiology, and End Results-Medicare database, we studied chemotherapy receipt within 30 days of death among Medicare enrollees who were diagnosed with aNSCLC between 1999 and 2006, received chemotherapy, and died within 3 years of diagnosis. A multilevel model was constructed to assess the contribution of patient and physician characteristics and geography to receiving chemotherapy within 30 days of death.ResultsAmong 21,894 patients meeting eligibility criteria, 43.1% received chemotherapy within 30 days of death. In unadjusted bivariate analyses, female sex, Asian or black race, older age, and a greater number of comorbid diagnoses predicted lower likelihood of receiving chemotherapy at the end of life (P ≤.038 for all comparisons). Adjusting for patient and physician characteristics, physicians in small independent practices were substantially more likely than those employed in other practice models, particularly academic practices or nongovernment hospitals, to order chemotherapy for a patient in the last 30 days of life (P

ObjectiveStudies suggest adolescent substance use aligns with academic and behavioral self-concept (whether teens think of themselves as good or bad students and as rule followers or rule breakers) as well as peer and adult social networks. Schools are an important context in which self-concept and social networks develop, but it remains unclear how school environments might be leveraged to promote healthy development and prevent substance use. We sought to describe how youth perceive the relationships among school environments, adolescent self-concept, social networks, and substance use.MethodsSemistructured interviews with 32 low-income minority youth (aged 17-22 years) who participated in a prior study, explored self-concept development, school environments, social networks, and substance use decisions. Recruitment was stratified by whether, during high school, they had healthy or unhealthy self-concept profiles and had engaged in or abstained from substance use.ResultsYouth described feeling labeled by peers and teachers and how these labels became incorporated into their self-concept. Teachers who made students feel noticed (eg, by learning students' names) and had high academic expectations reinforced healthy self-concepts. Academic tracking, extracurricular activities, and school norms determined potential friendship networks, grouping students either with well-behaving or misbehaving peers. Youth described peer groups, combined with their self-concept, shaping their substance use decisions. Affirming healthy aspects of their self-concept at key risk behavior decision points helped youth avoid substance use in the face of peer pressure.ConclusionsYouth narratives suggest school environments shape adolescent self-concept and adult and peer social networks, all of which impact substance use.

Objective"What do you want to be when you grow up?" is a simple, commonly asked question that might provide insight into adolescent well-being. Career aspirations might reflect an adolescent's sense of identity, hope for the future, and self-efficacy, all of which are critical to identifying at-risk youth and intervening on risky behaviors. However, there are no studies on whether career aspirations are associated with adolescent emotional and health behavior outcomes.MethodsWe analyzed cross-sectional surveys of 929 ninth to 12th grade low-income minority adolescents in Los Angeles assessing career aspirations and its association with hopelessness, self-efficacy, substance use, violence, and risky sexual activity. We used Department of Labor statistics to categorize career aspirations according to amount of education required, income, and prestige. Generalized estimating equations accounted for sociodemographic characteristics, school type, academic performance, and clustering at the school level.ResultsGrades, standardized test scores, and health behaviors varied according to career type. Adolescents with higher career aspirations, measured according to career-related education, income, and prestige reported less hopelessness and more self-efficacy. After adjusting for confounders, aspirations requiring high levels of education were associated with decreased odds of alcohol use, at-school substance use, and risky sexual activity, and higher prestige scores were associated with decreased odds of other drug use.ConclusionsCareer aspirations might be a marker for adolescent health and well-being. Adults might consider asking a teen what they want to be when they grow up to gain insight into their levels of hopelessness and self-efficacy and provide context for counseling on healthy behavior change.

BackgroundPoor academic (eg, "I am a bad student") and behavioral (eg, "I am a troublemaker") self-concepts are strongly linked to adolescent substance use. Social networks likely influence self-concept. However, little is understood about the role teachers and athletic coaches play in shaping both academic and behavioral self-concepts.MethodsWe analyzed cross-sectional surveys of 929 9th-12th grade low-income minority adolescents in Los Angeles assessing self-concept, social networks, and 30-day use of alcohol, marijuana and other drugs. We performed generalized estimating equations, accounting for clustering at the school level and controlling for family and peer influences and contextual factors. We also tested whether self-concept-mediated associations between relationships with teachers or coaches and 30-day substance use.ResultsMore perceived teacher support was associated with lower odds of marijuana and other drug use and better academic and behavioral self-concepts. Behavioral self-concept mediated the associations between teacher support and substance use.ConclusionsBy facilitating relationships with adults and improving teachers' capacity to build supportive environments, schools may positively shape how adolescents see themselves, which might help reduce adolescent substance use.

ObjectiveGrit, defined as "working strenuously toward challenges, maintaining effort and interest over years despite failure, adversity, and plateaus in progress," is strongly associated with academic achievement and life success and may also be associated with health outcomes and behaviors. We examined predictors of grit, and the association between grit and health behaviors among at-risk Latino adolescents.MethodsWe analyzed baseline survey data collected in 2013-2014 from a sample of 1270 9th graders in low-income neighborhoods of Los Angeles. We examined factors associated with grit and whether grit is associated with substance use and delinquent behaviors, controlling for adolescent and parent sociodemographic factors.ResultsIn a sample of mostly Latino adolescents (89.5%), compared to those with low grit, those with high grit had significantly lower odds of alcohol use in the last 30 days (odds ratio 0.30, P < .001), marijuana use (odds ratio 0.21, P < .05), and fighting (odds ratio 0.58, P < .05). Involvement in delinquent behavior was also lower (β = -0.71, P < .001). Factors associated with more grit included authoritative parenting style, parental employment, and high self-efficacy scores.ConclusionsGrit may be an important candidate protective factor against substance use and other risk behaviors among Latino adolescents.

BackgroundAlthough physician-scientists generally contribute to the scientific enterprise by providing a breadth of knowledge complementary to that of other scientists, it is a challenge to recruit, train, and retain physicians in a research career pathway.ObjectiveTo assess the outcomes of a novel program that combines graduate coursework and research training with subspecialty fellowship.MethodsA retrospective analysis was conducted of career outcomes for 123 physicians who graduated from the program during its first 20 years (1993-2013). Using curricula vitae, direct contact, and online confirmation, data were compiled on physicians' subsequent activities and careers as of 2013. Study outcomes included employment in academic and nonacademic research, academic clinical or private practice positions, and research grant funding.ResultsMore than 80% of graduates were actively conducting research in academic, institutional, or industrial careers. The majority of graduates (71%) had academic appointments; a few (20%) were in private practice. Fifty percent had received career development awards, and 19% had received investigator-initiated National Institutes of Health (NIH) R01 or equivalent grants. Individuals who obtained a PhD during subspecialty training were significantly more likely to have major grant funding (NIH R series or equivalent) than those who obtained a Master of Science in Clinical Research. Trainees who obtained a PhD in a health services or health policy field were significantly more likely to have research appointments than those in basic science.ConclusionsIncorporation of graduate degree research, at the level of specialty or subspecialty clinical training, is a promising approach to training and retaining physician-scientists.

ObjectiveTo determine the relationship between household chaos and substance use, sexual activity, and violence-related risk behaviors in adolescents.Study designWe analyzed cross-sectional data among 929 high-school students in Los Angeles who completed a 90-minute interview that assessed health behaviors and household chaos with the 14-question Chaos, Hubbub, and Order Scale (CHAOS). Using the generalized estimating equation and adjusting for personal, parental, and family covariates, we examined associations of CHAOS score with substance use, sexual activity, and violent behavior outcome variables. We also examined the role of depression and school engagement as mediators.ResultsMean (SD) age of the 929 students was 16.4 (1.3) years, 516 (55%) were female, and 780 (84%) were Latino. After adjustment, compared with students with CHAOS score 0, those students with the greatest scores (5-14) had ORs of 3.1 (95% CI 1.1-8.7) for smoking, 2.6 (95% CI 1.6-4.4) for drinking, 6.1 (95% CI 1.8-21) for substance use at school, and 1.9 (95% CI 1.1-3.3) for fighting in the past 12 months. Associations between CHAOS score and sexual risk and other violent behaviors were not significant. Depression and school engagement attenuated the associations.ConclusionsIn this group of adolescents, greatest CHAOS score was associated with increased odds of risky health behaviors, with depression and school engagement as potential mediators. In the future, CHAOS score could be measured to assess risk for such behaviors or be a target for intervention to reduce chances of engaging in these behaviors.

South Asians are disproportionately impacted by cardiovascular disease (CVD). Our objective was to examine the association between duration of residence in the US and CVD risk factors among South Asian adult immigrants. Multivariate logistic regression analyses using pooled data from the 2005, 2007, 2009 California Health Interview Surveys. Duration of residence in the US < 15 years was significantly associated with overweight/obese BMI (OR 0.59; 95% CI 0.35, 0.98 for 5 to < 10 years), daily consumption of 5+ servings of fruits/vegetables (OR 0.37; 95% CI 0.15, 0.94 for 10 to < 15 years), and sedentary lifestyle (OR 2.11; 95% CI 1.17, 3.81 for 10 to < 15 years) compared with duration of residence ≥ 15 years after adjusting for illness burden, healthcare access, and socio-demographic characteristics. Duration of residence was not significantly associated with other CVD risk factors. Duration of residence is an important correlate of overweight/obesity and other risk factors among South Asian immigrants.

ObjectivesWe examined multiple variables influencing school truancy to identify potential leverage points to improve school attendance.MethodsA cross-sectional observational design was used to analyze inner-city data collected in Los Angeles County, California, during 2010 to 2011. We constructed an ordinal logistic regression model with cluster robust standard errors to examine the association between truancy and various covariates.ResultsThe sample was predominantly Hispanic (84.3%). Multivariable analysis revealed greater truancy among students (1) with mild (adjusted odds ratio [AOR] = 1.57; 95% confidence interval [CI] = 1.22, 2.01) and severe (AOR = 1.80; 95% CI = 1.04, 3.13) depression (referent: no depression), (2) whose parents were neglectful (AOR = 2.21; 95% CI = 1.21, 4.03) or indulgent (AOR = 1.71; 95% CI = 1.04, 2.82; referent: authoritative parents), (3) who perceived less support from classes, teachers, and other students regarding college preparation (AOR = 0.87; 95% CI = 0.81, 0.95), (4) who had low grade point averages (AOR = 2.34; 95% CI = 1.49, 4.38), and (5) who reported using alcohol (AOR = 3.47; 95% CI = 2.34, 5.14) or marijuana (AOR = 1.59; 95% CI = 1.06, 2.38) during the past month.ConclusionsStudy findings suggest depression, substance use, and parental engagement as potential leverage points for public health to intervene to improve school attendance.

ObjectivesWe examined whether exposure to high-performing schools reduces the rates of risky health behaviors among low-income minority adolescents and whether this is due to better academic performance, peer influence, or other factors.MethodsBy using a natural experimental study design, we used the random admissions lottery into high-performing public charter high schools in low-income Los Angeles neighborhoods to determine whether exposure to successful school environments leads to fewer risky (eg, alcohol, tobacco, drug use, unprotected sex) and very risky health behaviors (e.g., binge drinking, substance use at school, risky sex, gang participation). We surveyed 521 ninth- through twelfth-grade students who were offered admission through a random lottery (intervention group) and 409 students who were not offered admission (control group) about their health behaviors and obtained their state-standardized test scores.ResultsThe intervention and control groups had similar demographic characteristics and eighth-grade test scores. Being offered admission to a high-performing school (intervention effect) led to improved math (P < .001) and English (P = .04) standard test scores, greater school retention (91% vs. 76%; P < .001), and lower rates of engaging in ≥1 very risky behaviors (odds ratio = 0.73, P < .05) but no difference in risky behaviors, such as any recent use of alcohol, tobacco, or drugs. School retention and test scores explained 58.0% and 16.2% of the intervention effect on engagement in very risky behaviors, respectively.ConclusionsIncreasing performance of public schools in low-income communities may be a powerful mechanism to decrease very risky health behaviors among low-income adolescents and to decrease health disparities across the life span.

BackgroundFall-related injuries are a well-described cause of morbidity and mortality in the community-dwelling elderly population, but have not been well described in patients with cancer. Cancer treatment with chemotherapy can result in many unwanted side effects, including peripheral neuropathy if the drugs are potentially neurotoxic. Peripheral neuropathy and other side effects of chemotherapy may lead to an increased risk of fall-related injuries.MethodsWe conducted a retrospective cohort analysis using the records of 65,311 patients with breast, colon, lung, or prostate cancer treated with chemotherapy in the SEER-Medicare database from 1994 to 2007. The primary outcome was any fall-related injury defined as a traumatic fracture, dislocation, or head injury within 12 months of the first dose of chemotherapy. The sample population was divided into 3 cohorts based on whether they most frequently received a neurotoxic doublet, single agent, or a non-neurotoxic chemotherapy. Cox proportional-hazards analyses were adjusted for baseline characteristics to determine the risk of fall-related injuries among the 3 cohorts.ResultsThe rate of fall-related injuries for patients receiving a doublet of neurotoxic chemotherapy (9.15 per 1000 person-months) was significantly higher than for those receiving a single neurotoxic agent (7.76 per 1000 person-months) or a non-neurotoxic agent (5.19 per 1000 person-months). Based on the Cox proportional-hazards model risk of fall-related injuries was highest for the cohort receiving a neurotoxic doublet after the model was adjusted for baseline characteristics.ConclusionsAmong elderly patients with cancer, use of neurotoxic chemotherapy is associated with an increased risk of fall-related injuries.

ObjectiveThe aim of this study was to examine the association between religiosity and overweight or obese body mass index among a multi-religious group of Asian Indian immigrants residing in California.MethodsWe examined cross-sectional survey data obtained from in-language telephone interviews with 3228 mostly immigrant Asian Indians in the 2004 California Asian Indian Tobacco Survey using multivariate logistic regression.ResultsHigh self-identified religiosity was significantly associated with higher BMI after adjusting for socio-demographic and acculturation measures. Highly religious Asian Indians had 1.53 greater odds (95% CI: 1.18, 2.00) of being overweight or obese than low religiosity immigrants, though this varied by religious affiliation. Religiosity was associated with greater odds of being overweight/obese for Hindus (OR 1.54; 95% CI: 1.08, 2.22) and Sikhs (OR 1.88; 95% CI: 1.07, 3.30), but not for Muslims (OR 0.69; 95% CI: 0.28, 1.70).ConclusionsReligiosity in Hindus and Sikhs, but not immigrant Muslims, appears to be independently associated with greater body mass index among Asian Indians. If this finding is confirmed, future research should identify potentially mutable mechanisms by which religion-specific religiosity affects overweight/obesity risk.

Background: Poor academic (eg, "I am a bad student") and behavioral (eg, "I am a troublemaker") self-concepts are strongly linked to adolescent substance use. Social networks likely influence self-concept. However, little is understood about the role teachers and athletic coaches play in shaping both academic and behavioral self-concepts. Methods: We analyzed cross-sectional surveys of 929 9th-12th grade low-income minority adolescents in Los Angeles assessing self-concept, social networks, and 30-day use of alcohol, marijuana and other drugs. We performed generalized estimating equations, accounting for clustering at the school level and controlling for family and peer influences and contextual factors. We also tested whether self-concept-mediated associations between relationships with teachers or coaches and 30-day substance use. Results: More perceived teacher support was associated with lower odds of marijuana and other drug use and better academic and behavioral self-concepts. Behavioral self-concept mediated the associations between teacher support and substance use. Conclusions: By facilitating relationships with adults and improving teachers' capacity to build supportive environments, schools may positively shape how adolescents see themselves, which might help reduce adolescent substance use.

BackgroundThe stigma of HIV-infection may profoundly affect the lives of persons living with HIV/AIDS (PLHA). However few studies have examined the association of HIV stigma with multiple components of HIV treatment and care.ObjectivesTo estimate the association between HIV stigma and: self-reported access to care, regular source of HIV care, and antiretroviral therapy adherence; and to test whether mental health mediates these associations.DesignCross-sectional study.Participants202 PLHA living in Los Angeles County in 2007.MeasurementsParticipants completed an anonymous survey, assessing internalized HIV stigma (28-items, alpha = 0.93), self-reported access to medical care (six items, alpha = 0.75), regular source of HIV care, and antiretroviral therapy (ART) adherence.ResultsOne-third of participants reported high levels of stigma; 77% reported poor access to care; 42.5% reported suboptimal ART adherence; and 10.5% reported no regular source of HIV care. In unadjusted analysis, those reporting a high level of stigma were more likely to report poor access to care (OR = 4.97, 95% CI 2.54-9.72), regular source of HIV care (OR = 2.48, 95% CI 1.00-6.19), and ART adherence (OR = 2.45, 95% CI 1.23-4.91). In adjusted analyses, stigma was significantly associated with poor access to care (OR = 4.42, 95% CI 1.88-10.37), but not regular source of HIV care or ART adherence. Mental health mediated the relationship between stigma and ART adherence, but not poor access to care or regular source of HIV care.ConclusionsThe association of stigma with self-reported access to care and adherence suggests that efforts to improve these components of HIV care will require a better understanding of the possible effects of stigma and its mediators.

African Americans have higher cancer mortality rates than whites. Understanding the relative contribution of cancer incidence, stage at diagnosis and survival after diagnosis to the racial gap in life expectancy has important implications for directing future health disparity interventions toward cancer prevention, screening and treatment.We estimated the degree to which higher cancer mortality among African Americans is due to higher incidence rates, later stage at diagnosis or worse survival after diagnosis.Stochastic model of cancer incidence and survival after diagnosis.Surveillance and Epidemiology End Result cancer registry and National Health Interview Survey data.Life expectancy if African Americans had the same cancer incidence, stage and survival after diagnosis as white adults.African-American men and women live 1.47 and 0.91 fewer years, respectively, than whites as the result of all cancers combined. Among men, racial differences in cancer incidence, stage at diagnosis and survival after diagnosis account for 1.12 (95% CI: 0.52 to 1.36), 0.17 (95% CI: −0.03 to 0.33) and 0.21 (95% CI: 0.05 to 0.34) years of the racial gap in life expectancy, respectively. Among women, incidence, stage and survival after diagnosis account for 0.41 (95% CI: −0.29 to 0.60), 0.26 (95% CI: −0.06 to 0.40) and 0.31 (95% CI: 0.05 to 0.40) years, respectively. Differences in stage had a smaller impact on the life expectancy gap compared with the impact of incidence. Differences in cancer survival after diagnosis had a significant impact for only two cancers—breast (0.14 years; 95% CI: 0.05 to 0.16) and prostate (0.05 years; 95% CI 0.01 to 0.09).In addition to breast and colorectal cancer screening, national efforts to reduce disparities in life expectancy should also target cancer prevention, perhaps through smoking cessation, and differences in survival after diagnosis among persons with breast and prostate cancer.

ObjectivesTo use logistic regression modeling to identify factors associated with high self-efficacy for sexual negotiation and condom use in a sample of South African youth.MethodsThe Reproductive Health and HIV Research Unit (RHRU) National Youth Survey examined a nationally representative sample of 7409 sexually active South African youth aged 15 to 24 years. We used logistic regression modeling in this sample to identify factors associated with the main outcome of high self-efficacy.ResultsAmong female respondents (n = 3890), factors associated with high self-efficacy in the adjusted model were knowing how to avoid HIV (odds ratio [OR] = 2.30, 95% confidence interval [CI]: 1.05 to 5.00), having spoken with someone other than a parent or guardian about HIV/AIDS (OR = 1.46, 95% CI: 1.01 to 2.10), and having life goals (OR = 1.28, 95% CI: 1.10 to 1.48). Not using condoms during their first sexual encounter (OR = 0.61, 95% CI: 0.50 to 0.76), a history of unwanted sex (OR = 0.66, 95% CI: 0.51 to 0.86), and believing that condom use implies distrust in one's partner (OR = 0.57, 95% CI: 0.51 to 0.86) were factors associated with low self-efficacy among female respondents. Male respondents (n = 3519) with high self-efficacy were more likely to take HIV seriously (OR = 4.03, 95% CI: 1.55 to 10.52), to believe they are not at risk for HIV (OR = 1.38, 95% CI: 1.12 to 1.70), to report that getting condoms is easy (OR = 1.85, 95% CI: 1.23 to 2.77), and to have life goals (OR = 1.30, 95% CI: 1.10 to 1.54). Not using condoms during their first sexual experience (OR = 0.51, 95% CI: 0.39 to 0.67), a history of having unwanted sex (OR = 0.47, 95% CI: 0.34 to 0.64), believing condom use is a sign of not trusting one's partner (OR = 0.63, 95% CI: 0.46 to 0.87), and refusing to be friends with HIV-infected persons (OR = 0.52, 95% CI: 0.32 to 0.85) were factors associated with low self-efficacy among male respondents in the fully adjusted model.ConclusionsWe used the social cognitive model (SCM) to identify factors associated with self-efficacy for condom use and sexual negotiation. Many of these factors are modifiable and suggest potential ways to improve self-efficacy and reduce HIV sexual risk behavior in South African youth.

BackgroundNew strategies to increase physical activity among sedentary older adults are urgently needed.ObjectiveTo examine whether low expectations regarding aging (age-expectations) are associated with low physical activity levels among older adults.DesignCross-sectional survey.ParticipantsSix hundred and thirty-six English- and Spanish-speaking adults aged 65 years and above attending 14 community-based senior centers in the Los Angeles region. Over 44% were non-Latino whites, 15% were African American, and 36% were Latino. The mean age was 77 years (range 65 to 100).MeasurementsSelf-administered written surveys including previously tested measures of age-expectations and physical activity level in the previous week.ResultsOver 38% of participants reported

Keywords: CAM; integrative medicine; spirituality; religiosity; survivors 139 Role of Religiosity and Spirituality in Complementary and Alternative Medicine Use Among Cancer Survivors in California SAGE Publications, Inc.200810.1177/1534735408322847 An-FuHsiao MD, PhD [...]

Perceived stigma in clinical settings may discourage HIV-infected individuals from accessing needed health care services. Having good access to care is imperative for maintaining the health, well being, and quality of life of persons living with HIV/AIDS (PLWHAs). The purpose of this prospective study, which took place from January 2004 through June 2006, was to evaluate the relationship between perceived stigma from a health care provider and access to care among 223 low income, HIV-infected individuals in Los Angeles County. Approximately one fourth of the sample reported perceived stigma from a health care provider at baseline, and about one fifth reported provider stigma at follow up. We also found that access to care among this population was low, as more than half of the respondents reported difficulty accessing care at baseline and follow up. Perceived stigma was found to be associated with low access to care both at baseline (odds ratio [OR] = 3.29; 95% confidence interval [CI] = 1.55, 7.01) and 6-month follow up (2.85; 95% CI = 1.06, 7.65), even after controlling for sociodemographic characteristics and most recent CD4 count. These findings are of particular importance because lack of access or delayed access to care may result in clinical presentation at more advanced stages of HIV disease. Interventions are needed to reduce perceived stigma in the health care setting. Educational programs and modeling of nonstigmatizing behavior can teach health care providers to provide unbiased care.

Approximately 28% of HIV-infected people in treatment in the United States report using illicit drugs. Illicit drug users have poorer course of HIV disease than non-drug users, which is thought to be due to their irregular use of HIV medical services. We examined associations between type (cocaine versus opioids) and pattern of drug use (drug use at baseline, 6-month follow-up, both periods, and nonuse) and health care utilization for a large sample of HIV-infected individuals drawn from a multisite project that evaluated the impact of medical outreach interventions for populations at risk of poor retention in HIV care. Across all types and patterns of drug use, drug users were more likely to have suboptimal ambulatory care, miss scheduled appointments, use the emergency department, have unmet support services needs, and were less likely to take antiretroviral medications. Additionally, while people who started using drugs during the follow-up period and consistently used drugs across both periods differed from nonusers on missed appointments (odds ratio [OR] = 2.20 for starters versus nonusers, OR = 2.92 for consistent users versus nonusers), emergency department use (OR = 4.93 for starters versus nonusers, OR = 2.24 for consistent users versus nonusers), and antiretroviral medication use at follow-up (OR = 0.23 starters versus nonusers, OR = 0.19 for consistent users versus nonusers), those who stopped using drugs after the baseline period did not differ from nonusers. We conclude that health care utilization is poorer for people who use illicit drugs than those who do not, and stopping drug use may facilitate improvements in health care utilization and HIV outcomes for this population.

This cross-sectional study examined factors associated with the receipt of HIV medical care among people who know their HIV status and are not newly diagnosed with HIV. Interviews were conducted with 1133 HIV-positive individuals between October 2003 and July 2005 who enrolled in 1 of 10 outreach programs across the country. The sample was predominantly nonwhite (86%), male (59%), and unstably housed (61%), with a past history of cocaine use (68%). Twelve percent had received no HIV medical care in the 6 months prior to the interview. Those with no care were similar to those who received some HIV care in sociodemographic characteristics, but in multivariate analysis were less likely to have a case manager (p < 0.001) or use mental health services (p < .001), had lower mental health status scores (p < 0.05), were more likely to be active drug users (p < 0.01), had greater unmet support service needs (p < 0.05) and reported that health beliefs were a barrier to care (p < 0.001). Interventions to engage people in HIV medical care need to address barriers to care through linkages with mental health, substance abuse treatment and support services, and address the health beliefs that deter people from seeking care.

To benefit from HIV treatment advances individuals must utilize ambulatory primary care services. Few studies focus on marginalized populations, which tend to have poor health care utilization patterns. This study examined factors associated with health care utilization in hard-to-reach marginalized HIV-infected individuals. As part of a multisite initiative evaluating outreach programs that target underserved HIV-infected individuals, 610 participants were interviewed about their HIV disease, health services utilization, substance use, mental health, and case management. Primary outcomes included ambulatory, emergency department, and inpatient visits. Generalized estimating equations were used in logistic regression analyses. On regression analyses ambulatory visits were associated with having insurance (adjusted odds ratio [AOR] = 2.46), mental health medications (AOR = 7.46), and case management (AOR = 4.81). Emergency department visits were associated with having insurance (AOR = 1.74), homelessness (AOR = 2.23), poor health status (AOR = 2.02), length of HIV infection (AOR = 2.02), mental health care (AOR = 1.47), mental health medications (AOR = 1.59), and heavy alcohol intake (AOR = 1.46). Hospitalizations were associated with high school education (AOR = 1.57), having insurance (AOR = 10.45), homelessness (AOR = 2.18), poor health status (AOR = 2.64), length of HIV infection (AOR = 2.03), and mental health medications (AOR = 1.87). In hard-to-reach marginalized HIV-infected individuals, having insurance, case management and mental health care were associated with increased ambulatory visits. These findings support HIV multidisciplinary care with marginalized populations. Understanding factors associated with health care utilization is essential for outreach programs to facilitate engagement in HIV care.