Chronic Traumatic Encephalopathy in the Brains of Military Personnel.

BACKGROUND: Persistent neuropsychiatric sequelae may develop in military personnel who are exposed to combat; such sequelae have been attributed in some cases to chronic traumatic encephalopathy (CTE). Only limited data regarding CTE in the brains of military service members are available. METHODS: We performed neuropathological examinations for the presence of CTE in 225 consecutive brains from a brain bank dedicated to the study of deceased service members. In addition, we reviewed information obtained retrospectively regarding the decedents' histories of blast exposure, contact sports, other types of traumatic brain injury (TBI), and neuropsychiatric disorders. RESULTS: Neuropathological findings of CTE were present in 10 of the 225 brains (4.4%) we examined; half the CTE cases had only a single pathognomonic lesion. Of the 45 brains from decedents who had a history of blast exposure, 3 had CTE, as compared with 7 of 180 brains from those without a history of blast exposure (relative risk, 1.71; 95% confidence interval [CI], 0.46 to 6.37); 3 of 21 brains from decedents with TBI from an injury during military service caused by the head striking a physical object without associated blast exposure (military impact TBI) had CTE, as compared with 7 of 204 without this exposure (relative risk, 4.16; 95% CI, 1.16 to 14.91). All brains with CTE were from decedents who had participated in contact sports; 10 of 60 contact-sports participants had CTE, as compared with 0 of 165 who had not participated in contact sports (point estimate of relative risk not computable; 95% CI, 6.16 to infinity). CTE was present in 8 of 44 brains from decedents with non-sports-related TBI in civilian life, as compared with 2 of 181 brains from those without such exposure in civilian life (relative risk, 16.45; 95% CI, 3.62 to 74.79). CONCLUSIONS: Evidence of CTE was infrequently found in a series of brains from military personnel and was usually reflected by minimal neuropathologic changes. Risk ratios for CTE were numerically higher among decedents who had contact-sports exposure and other exposures to TBI in civilian life than among those who had blast exposure or other military TBI, but the small number of CTE cases and wide confidence intervals preclude causal conclusions. (Funded by the Department of Defense-Uniformed Services University Brain Tissue Repository and Neuropathology Program and the Henry M. Jackson Foundation for the Advancement of Military Medicine.).

The effect of geographic origin and destination on congenital heart disease outcomes: a retrospective cohort study.

BACKGROUND: Congenital heart disease (CHD) is a common and significant birth defect, frequently requiring surgical intervention. For beneficiaries of the Department of Defense, a new diagnosis of CHD may occur while living at rural duty stations. Choice of tertiary care center becomes a function of geography, referring provider recommendations, and patient preference. METHODS: Using billing data from the Military Health System over a 5-year period, outcomes for beneficiaries age < 10 years undergoing CHD surgery were compared by patient origin (rural versus urban residence) and the distance to treatment (patient's home and the treating tertiary care center). These beneficiaries include children of active duty, activated reserves, and federally activated National Guard service members. Analysis of the outcomes were adjusted for procedure complexity risk. Treatment centers were further stratified by annual case volume and whether they publicly reported results in the society of thoracic surgery (STS) outcomes database. RESULTS: While increasing distance was associated with the cost of admission, there was no associated risk of inpatient mortality, one year mortality, or increased length of stay. Likewise, rural origination was not significantly associated with target outcomes. Patients traveled farther for STS-reporting centers (STS-pr), particularly high-volume centers. Such high-volume centers (> 50 high complexity cases annually) demonstrated decreased one year mortality, but increased cost and length of stay. CONCLUSIONS: Together, these findings contribute to the national conversation of rural community medicine versus regionalized subspecialty care; separation of patients between rural areas and more urban locations for initial CHD surgical care does not increase their mortality risk. In fact, traveling to high volume centers may have an associated mortality benefit.

A health systems assessment of genetic counseling in cardiovascular care in a large health system: Adherence to genetics recommendations in the Military Health System.

Genetic counseling and genetic testing are important tools for diagnosis, screening, and employment of effective medical management strategies for hereditary cardiovascular diseases. Despite widespread recognition of the benefits of genetic counseling and testing in cardiovascular care, little is published regarding their use in large healthcare systems. We conducted a retrospective cross-sectional study using administrative claims data in the US Military Health System to assess the state of recommended genomic counseling in clinical cardiovascular care. Logistic regression models were used to examine associations of genetic counseling among beneficiaries with hereditary cardiovascular conditions. Approximately 0.44% of beneficiaries in fiscal year 2018 had a diagnosis of a hereditary cardiovascular condition. Among the 23,364 patients with a diagnosis of hereditary cardiovascular disease, only 175 (0.75%) had documented genetic counseling and 196 (0.84%) had documented genetic testing. Genetic counseling did not differ by race, sex, service, or diagnosis. Age group, Active Duty status, rank as a proxy for socioeconomic status, and geographic location contributed significantly to the likelihood of receiving genetic counseling. These findings suggest that genetic counseling is underutilized in clinical cardiovascular care in the Military Health System and may be more broadly, despite expert consensus recommendations for its use and potential life-saving benefits. Unlike previous studies in the US civilian health sector, there did not appear to be disparities in genetic counseling by race or sex in the Military Health System. Strategies to improve care for cardiovascular disease should address the underutilization of recommended genetics evaluations for heritable diagnoses and the challenges of assessing use in large health systems studies.

Assessing mean corpuscular volume as a screening tool for gestational vitamin B12 deficiency based on NHANES.

Vitamin B12 can lead to neurological deficits. We assessed whether the mean corpuscular volume (MCV) could be a sufficiently sensitive measurement for abnormal serum methylmalonic Acid (MMA) and total plasma homocysteine (tHCY) (biomarkers of vitamin B12 or folate deficiency) and if so, at what cutoff value. A total of 26,397 participants (12,730 males and 13,667 females) were included in the analysis. Weighted analysis was performed using NHANES data to calculate crude/adjusted associations between MCV-MMA/tHCY, using linear regression. Unadjusted odds ratios (OR) 95% CIs were estimated from logistic regression models. Receiver Operating Curve and the Youden Index were used to identify the MCV level that most accurately distinguished those with abnormal MMA and tHCY (dependent variables) from those without. A positive and significant correlation between MCV-MMA/tHCY was found in the general population between ages 18-85, 0.95 (95% C.I. 0.75-1.17) and 2.61 (95% C.I. 2.15-3.08). In pregnant women, for every unit increase in MCV there was a 19% increase in odds of abnormal MMA, OR 1.19 (95% C.I. 1.08-1.31), p=0.001 and the Area Under the Curve for MCV as a test for abnormal MMA was 78%. An MCV cutoff of 93.1 correctly identified abnormal MMA in pregnant women with 81% sensitivity and 77% specificity. In the general population the MCV test performed poorly in identifying abnormal MMA/tHCY. MCV is an inexpensive measurement that may be useful to screen asymptomatic pregnant women for vitamin B12 abnormalities. This may have a significant impact on reducing adverse neurological outcomes in their children.

Durability of Antibody Response and Frequency of SARS-CoV-2 Infection 6 Months after COVID-19 Vaccination in Healthcare Workers.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies decay but persist 6 months postvaccination; lower levels of neutralizing titers persist against Delta than wild-type virus. Of 227 vaccinated healthcare workers tested, only 2 experienced outpatient symptomatic breakthrough infections, despite 59/227 exhibiting serologic evidence of SARS-CoV-2 infection, defined as presence of nucleocapsid protein antibodies.

Examination of the Interaction between Parental Military-Status and Race among Non-Hispanic Black and Non-Hispanic White Adolescents with Overweight/Obesity.

OBJECTIVES: Adolescent military-dependents experience distinct risk and protective factors, which may necessitate additional clinical considerations. In civilian youth, overweight/obesity is associated with eating, internalizing, and externalizing difficulties, with some studies reporting more difficulties among non-Hispanic White (vs. non-Hispanic Black) youth. It is unknown if these disparities exist among adolescent military-dependents, or between civilian and military-dependent youth. METHODS: Non-Hispanic Black (187 civilian, 38 military-dependent) and non-Hispanic White (205 civilian, 84 military-dependent) adolescents with overweight/obesity (14.7 ± 1.6 years; 73.9% girls; body mass index adjusted for age and sex 1.9 ± 0.5) completed a disordered-eating interview; parents completed a measure assessing their child's internalizing and externalizing difficulties. Multiple linear regressions examined parental military-status as a moderator of the relationship of participant race with eating, internalizing, and externalizing difficulties. RESULTS: White civilian youth with overweight/obesity reported significantly greater disordered-eating than their Black peers (p < .001); there were no other significant racial differences. In all regressions, parental military-status significantly moderated the association between race and each dependent variable (ps < .047). Black military-dependents (vs. civilians) reported more disordered-eating and internalizing difficulties (ps = .01). White military-dependents (vs. civilians) reported fewer externalizing difficulties (p = .01). CONCLUSIONS: Black adolescent military-dependents with overweight/obesity may experience more eating and internalizing difficulties (vs. civilians), a pattern not observed among White participants. Future work should examine if being a military-dependent and a historically marginalized racial group member accounts for these findings. Such data may inform providers of youth with intersecting minority identities.

The Effects of Berry Extracts on Oxidative Stress in Cultured Cardiomyocytes and Microglial Cells: A Potential Cardioprotective and Neuroprotective Mechanism.

Oxidative stress is a key underlying factor in cognitive decline and atherosclerosis. Oxidative stress occurs at the cellular level with an imbalance between reactive oxygen species and reactive nitrogen species and a deficiency in antioxidants. Mounting evidence suggests that berry flavonoids may promote cellular health by exerting antioxidant properties. Black currant and various berry extracts were tested in microglia (BV-2) and cardiomyocyte (HL-1) cell lines to study their biological effects. The principal ingredients in black currant and cranberry extract-delphinidin 3-rutinoside (D3R) and cyanidin 3-glucoside (C3G), were also assessed. A menadione-induced oxidative stressor was used, and its output was quantified to detect oxidative stress (CellROXTM). Black currant extract had similar antioxidant effects as N-acetylcysteine (NAC) in HL-1 cells with regard to cellular protection, whereas cranberry extract was ineffective. In contrast, cranberry extract was comparable in effectiveness to black currant extract in BV-2 cells. D3R and C3G also reduced oxidative stress similarly to whole berry extracts, which indicates that these ingredients may confer the antioxidant effects of berries. Black currant and cranberry extracts inhibit oxidative stress in microglial and cardiomyocyte cell lines. Black currant extract was more effective in reducing oxidative stress in the HL-1 cells, whereas cranberry extract was comparable in reducing oxidative stress in the BV-2 cells. The results suggest that berry flavonoids exert neuro- and cardioprotective effects.

Prospective Assessment of SARS-CoV-2 Seroconversion (PASS) study: an observational cohort study of SARS-CoV-2 infection and vaccination in healthcare workers.

BACKGROUND: SARS-CoV-2 is a recently emerged pandemic coronavirus (CoV) capable of causing severe respiratory illness. However, a significant number of infected people present as asymptomatic or pauci-symptomatic. In this prospective assessment of at-risk healthcare workers (HCWs) we seek to determine whether pre-existing antibody or T cell responses to previous seasonal human coronavirus (HCoV) infections affect immunological or clinical responses to SARS-CoV-2 infection or vaccination. METHODS: A cohort of 300 healthcare workers, confirmed negative for SARS-CoV-2 exposure upon study entry, will be followed for up to 1 year with monthly serology analysis of IgM and IgG antibodies against the spike proteins of SARS-CoV-2 and the four major seasonal human coronavirus - HCoV-OC43, HCoV-HKU1, HCoV-229E, and HCoV-NL63. Participants will complete monthly questionnaires that ask about Coronavirus Disease 2019 (COVID-19) exposure risks, and a standardized, validated symptom questionnaire (scoring viral respiratory disease symptoms, intensity and severity) at least twice monthly and any day when any symptoms manifest. SARS-CoV-2 PCR testing will be performed any time participants develop symptoms consistent with COVID-19. For those individuals that seroconvert and/or test positive by SARS-CoV-2 PCR, or receive the SARS-CoV-2 vaccine, additional studies of T cell activation and cytokine production in response to SARS-CoV-2 peptide pools and analysis of Natural Killer cell numbers and function will be conducted on that participant's cryopreserved baseline peripheral blood mononuclear cells (PBMCs). Following the first year of this study we will further analyze those participants having tested positive for COVID-19, and/or having received an authorized/licensed SARS-CoV-2 vaccine, quarterly (year 2) and semi-annually (years 3 and 4) to investigate immune response longevity. DISCUSSION: This study will determine the frequency of asymptomatic and pauci-symptomatic SARS-CoV-2 infection in a cohort of at-risk healthcare workers. Baseline and longitudinal assays will determine the frequency and magnitude of anti-spike glycoprotein antibodies to the seasonal HCoV-OC43, HCoV-HKU1, HCoV-229E, and HCoV-NL63, and may inform whether pre-existing antibodies to these human coronaviruses are associated with altered COVID-19 disease course. Finally, this study will evaluate whether pre-existing immune responses to seasonal HCoVs affect the magnitude and duration of antibody and T cell responses to SARS-CoV-2 vaccination, adjusting for demographic covariates.

Parental deployment and distress, and adolescent disordered eating in prevention-seeking military dependents.

OBJECTIVE: Parental military deployment can lead to stress in the family system due to concerns about the deployed service-member's safety and increased responsibilities for those not deployed. Parent-related stress can impact adolescent disordered eating. Given the important role that stress plays in disordered eating and obesity, it is crucial to understand the impacts of unique stressors to which vulnerable populations are exposed. METHOD: We studied 126 adolescent (14.3 ± 1.6 years; 59.5% girls; 44.4% non-Hispanic White; BMI-z, 1.91 ± .39) military dependents prior to entering an obesity and binge-eating disorder prevention trial. The Eating Disorder Examination was used to assess adolescent disordered eating. Parents self-reported their own distress and family deployment history that occurred during the adolescent's lifetime. RESULTS: Parental distress interacted with frequency of parental deployments such that for those with high parental distress, more frequent deployment was associated with greater adolescent shape and weight concerns (ß = .21, p = .012) and global eating pathology (ß = .18, p = .024). DISCUSSION: In this hypothesis-generating study, the combination of number of deployments and parental distress may be associated with disordered eating among adolescent military dependents seeking prevention of binge-eating disorder and adult obesity. If these preliminary findings are supported longitudinally, interventions to reduce parental stress related to deployment may be warranted to reduce disordered eating in adolescent dependents.

Examination of the Interpersonal Model With Adolescent Military Dependents at High Risk for Adult Obesity.

OBJECTIVE: Adolescent military dependents may be at higher risk for psychosocial stressors and disordered eating compared with civilian youths, but the mechanisms underlying these risks are unclear. Interpersonal theory proposes that difficult relationships lead to negative affect, thereby promoting emotional eating, which has been linked to and predictive of disordered eating. The interpersonal model may have particular relevance for understanding disordered eating among adolescent military dependents, given the unique stressors related to their parents' careers. This study aimed to examine the premise of the interpersonal model (that negative emotions mediate the association between multiple aspects of social functioning and emotional eating) among a cohort of adolescent military dependents. METHODS: Military dependents (N=136; 56% female, mean±SD age=14±2 years, body mass index adjusted for age and sex [BMIz]=2.0±0.4) at risk for adult obesity and binge eating disorder, as indicated by reported loss-of-control eating and/or anxiety symptoms, were assessed prior to participation in a study of excess weight-gain prevention. Bootstrapped mediation analyses were conducted to examine depressive symptoms as a potential mediator of the relationship between social functioning and emotional eating. Analyses were adjusted for age, sex, race-ethnicity, BMIz, and presence of reported loss-of-control eating and anxiety. RESULTS: Depressive symptoms were a significant mediator of the relationship between multiple domains of social functioning, including loneliness, social adjustment related to family and friends, attachment to father and peers, and emotional eating (p<0.05). CONCLUSIONS: The interpersonal model may contribute to our understanding of excess weight gain and binge eating disorder among adolescent military dependents. Prospective data are needed to determine the utility of interpersonal theory in predicting treatment response and outcomes among this population.

Indirect Effects of a Cognitive-Behavioral Intervention on Adolescent Weight and Insulin Resistance Through Decreasing Depression in a Randomized Controlled Trial.

OBJECTIVE: Depression is linked to excess weight, insulin resistance, and type 2 diabetes (T2D). We previously reported that in adolescent girls at-risk for T2D with moderately elevated depression, randomization to cognitive-behavioral therapy (CBT) produced greater decreases in depression at post-treament and greater decreases in fasting/2-h insulin at 1 year, compared to health education (HE). The current study is a secondary analysis of this parallel-group randomized controlled trial. We examined whether decreasing depression explained intervention effects on body composition and insulin outcomes. We hypothesized that decreases in depression would be an explanatory mediator and that indirect effects would be strongest at higher levels of baseline depression. METHODS: Participants were 12-17 years girls with overweight/obesity and family history of T2D randomized to 6-week group CBT (n = 58) or HE (n = 61). Procedures took place at an outpatient pediatric clinic. At baseline, post-treatment, and 1 year, adolescents completed the Center for Epidemiologic Studies-Depression Scale to assess depression symptoms; body mass index (BMI [kg/m2]) was measured from height/fasting weight; insulin resistance was derived from 2-h oral glucose testing. Adiposity was assessed with dual-energy X-ray absorptiometry at baseline and 1 year. Indirect effects of intervention were tested on 1-year changes in BMI, adiposity, and insulin through decreases in depression. Baseline depression was tested as a moderator of mediation. RESULTS: There was an indirect effect of CBT on decreased 1-year fasting insulin via decreases in depression during treatment, among adolescents with more elevated baseline depression. CONCLUSIONS: Decreasing elevated depression may be one mechanism in the targeted prevention of T2D in at-risk adolescents.

Pathogenetic insights from quantification of the cerebriform connective tissue nevus in Proteus syndrome.

BACKGROUND: The plantar cerebriform connective tissue nevus (CCTN) is the most common and problematic cutaneous manifestation of Proteus syndrome. OBJECTIVE: To gain insights into CCTN pathogenesis and natural history. METHODS: The size and location of plantar CCTN was measured on 152 images from 22 individuals with Proteus syndrome by 2 independent, blinded reviewers. Average measures of plantar CCTN were transformed into a linear mixed model to estimate proportionate change in size with age. RESULTS: Median patient age was 6.9 years at study onset. The intraclass correlation coefficient between 2 blinded reviewers was 0.946 for CCTN single measures. The CCTN relative area increased with age in children (n = 18, P < .0001) by 5.6% per year. Confluent papules and nodules extending beyond the boundaries of CCTNs were gradually replaced by typical CCTN over time. The location of CCTN in different individuals overlapped near the ball of the foot. A positive relationship between CCTN growth rate and AKT1 mutant allele frequency was observed (0.62, P = .10, n = 8). LIMITATIONS: This was a retrospective review using photographs. CONCLUSION: CCTN growth is affected by age and extent of the CCTN precursor lesion. Monitoring of CCTN size might prove useful for evaluating drug response in the treatment of Proteus syndrome.

Childhood adverse life events, disordered eating, and body mass index in US Military service members.

OBJECTIVE: US service members appear to be at high-risk for disordered eating. Further, the military is experiencing unprecedented prevalence of overweight and obesity. US service members also report a high prevalence of childhood adverse life event (ALE) exposure. Despite consistent links between early adversity with eating disorders and obesity, there is a dearth of research examining the association between ALE exposure and disordered eating and weight in military personnel. METHOD: An online survey study was conducted in active duty personnel to examine childhood ALE history using the Life Stressor Checklist - Revised, disordered eating using the Eating Disorder Examination - Questionnaire total score, and self-reported body mass index (BMI, kg/m2 ). RESULTS: Among 179 respondents, multiple indices of childhood ALE were positively associated with disordered eating. Traumatic childhood ALE and subjective impact of childhood ALE were associated with higher BMI and these associations were mediated by disordered eating. DISCUSSION: Findings support evaluating childhood ALE exposure among service members with disordered eating and weight concerns. Moreover, findings support the need for prospective research to elucidate these relationships.

Remission of loss of control eating and changes in components of the metabolic syndrome.

OBJECTIVE: Pediatric loss of control (LOC) eating prospectively predicts the worsening of metabolic syndrome components. However, it is unknown if remission of LOC eating is associated with improvements in metabolic health. Therefore, we conducted a secondary analysis of a trial that enrolled adolescent girls with LOC eating, examining whether LOC remission (vs. persistence) at end-of-treatment was associated with changes in metabolic syndrome components at 6-month follow-up. METHOD: One hundred three adolescent girls (age 14.5 ± 1.7 years; BMI-z 1.5 ± 0.3; 56.3% non-Hispanic White, 24.3% non-Hispanic Black) with elevated weight (75th-97th BMI %ile) and reported LOC eating were assessed for metabolic syndrome components at baseline and again six months following the interventions. The main effects of LOC status at end-of-treatment (persistence vs. remission) on metabolic syndrome components (waist circumference, lipids, glucose, and blood pressure) at 6-month follow-up were examined, adjusting for baseline age, depressive symptoms, LOC frequency, fat mass, and height, as well as race, change in height, change in fat mass, and the baseline value of each respective component. RESULTS: Youth with LOC remission at end-of-treatment had lower glucose (83.9 ± 6.4 vs. 86.5 ± 5.8 mg/dL; p = .02), higher high-density lipoprotein cholesterol (50.3 ± 11.8 vs. 44.8 ± 11.9 mg/dL; p = .01), and lower triglycerides (84.4 ± 46.2 vs. 96.9 ± 53.7 mg/dL; p = .02) at 6-month follow-up when compared with youth with persistent LOC, despite no baseline differences in these components. No other component significantly differed by LOC eating status (ps > .05). DISCUSSION: Reducing LOC eating in adolescent girls may have a beneficial impact on some components of the metabolic syndrome.

Postpartum contraception: initiation and effectiveness in a large universal healthcare system.

BACKGROUND: Repeat pregnancies after a short interpregnancy interval are common and are associated with negative maternal and infant health outcomes. Few studies have examined the relative effectiveness of postpartum contraceptive choices. OBJECTIVE: We aimed to determine the initiation trends and relative effectiveness of postpartum contraceptive methods, with typical use, on prevention of short delivery intervals (≤27 months) among women with access to universal healthcare, including coverage that entails no co-payments and allows unlimited contraceptive method switching. STUDY DESIGN: This retrospective cohort study included women who were enrolled in the United States military healthcare system who were admitted for childbirth between October 2010 and March 2015, with ≥6 months postpartum enrollment. With the use of insurance records, we determined the most effective contraceptive method initiated during the first 6 months after delivery, even if subsequently discontinued. Rates of interdelivery intervals of ≤27 months, as proxies for interpregnancy intervals ≤18 months, were determined with the use of the Kaplan-Meier estimator. Women who were disenrolled, who reached 27 months after delivery without another delivery, or who reached the end of the study period were censored. The influence of sociodemographic variables and contraceptive choices on time to subsequent delivery was evaluated by Cox regression analysis, which accounted for a possible correlation among multiple deliveries by an individual woman. RESULTS: During the study timeframe, 373,840 women experienced a total of 450,875 postpartum intervals. Women averaged 27 (standard deviation, 5.3) years of age at the time of delivery; 33.9% of them were <25 years old; 15.5% of them were active duty service members, and 31.6% of them had insurance sponsors of junior enlisted rank (which suggests lower income). Postpartum contraceptive methods that were initiated included self or partner sterilization (7%), intrauterine device (13.5%), etonogestrel implant (3.4%), depot medroxyprogesterone acetate (2.5%), and pill, patch, or ring (36.8%). Furthermore, 36.7% of them did not initiate a prescription method. Etonogestrel implant initiation increased from 1.7% of postpartum women in the first year of our study to 5.3% in the final year. The estimated short interdelivery interval rate was 17.4%, but rates varied with contraceptive method: 1% with sterilization, 6% with long-acting reversible contraception, 12% with depot medroxyprogesterone, 21% with pill, patch, or ring, and 23% with no prescription method. In a multivariable analysis, the adjusted hazard of a short interdelivery interval was highest among women who were younger, on active duty, or with officer insurance sponsors. Compared with nonuse of any prescription contraceptive, the use of an intrauterine device reduced the hazard of a subsequent delivery (adjusted hazard ratio, 0.19; 95% confidence interval, 0.18-0.20), as did etonogestrel implant (adjusted hazard ratio, 0.21; 95% confidence interval, 0.19-0.23); the pill, patch, or ring had less effect (adjusted hazard ratio, 0.80; 95% confidence interval, 0.78-0.81). CONCLUSION: Postpartum initiation of long-acting reversible contraception is highly effective at the prevention of short interdelivery intervals, whereas pill, patch, or ring methods are associated with rates of short interdelivery intervals similar to users of no prescription contraception. This study supports long-acting reversible contraception as first-line recommendations for postpartum women who wish to retain fertility but avoid early repeat pregnancy.

Prevention of insulin resistance in adolescents at risk for type 2 diabetes with depressive symptoms: 1-year follow-up of a randomized trial.

BACKGROUND: Depression is associated with poor insulin sensitivity. We evaluated the long-term effects of a cognitive behavioral therapy (CBT) program for prevention of depression on insulin sensitivity in adolescents at risk for type 2 diabetes (T2D) with depressive symptoms. METHODS: One-hundred nineteen adolescent females with overweight/obesity, T2D family history, and mild-to-moderate depressive symptoms were randomized to a 6-week CBT group (n = 61) or 6-week health education (HE) control group (n = 58). At baseline, posttreatment, and 1 year, depressive symptoms were assessed, and whole body insulin sensitivity (WBISI) was estimated from oral glucose tolerance tests. Dual energy X-ray absorptiometry assessed fat mass at baseline and 1 year. Primary outcomes were 1-year changes in depression and insulin sensitivity, adjusting for adiposity and other relevant covariates. Secondary outcomes were fasting and 2-hr insulin and glucose. We also evaluated the moderating effect of baseline depressive symptom severity. RESULTS: Depressive symptoms decreased in both groups (P < .001). Insulin sensitivity was stable in CBT and HE (ΔWBISI: .1 vs. .3) and did not differ between groups (P = .63). However, among girls with greater (moderate) baseline depressive symptoms (N = 78), those in CBT developed lower 2-hr insulin than those in HE (Δ-16 vs. 16 µIU/mL, P < .05). Additional metabolic benefits of CBT were seen for this subgroup in post hoc analyses of posttreatment to 1-year change. CONCLUSIONS: Adolescent females at risk for T2D decreased depressive symptoms and stabilized insulin sensitivity 1 year following brief CBT or HE. Further studies are required to determine if adolescents with moderate depression show metabolic benefits after CBT.

A randomized, comparative pilot trial of family-based interpersonal psychotherapy for reducing psychosocial symptoms, disordered-eating, and excess weight gain in at-risk preadolescents with loss-of-control-eating.

OBJECTIVE: Preadolescent loss-of-control-eating (LOC-eating) is a risk factor for excess weight gain and binge-eating-disorder. We evaluated feasibility and acceptability of a preventive family-based interpersonal psychotherapy (FB-IPT) program. FB-IPT was compared to family-based health education (FB-HE) to evaluate changes in children's psychosocial functioning, LOC-eating, and body mass. METHOD: A randomized, controlled pilot trial was conducted with 29 children, 8 to 13 years who had overweight/obesity and LOC-eating. Youth-parent dyads were randomized to 12-week FB-IPT (n = 15) or FB-HE (n = 14) and evaluated at post-treatment, six-months, and one-year. Changes in child psychosocial functioning, LOC-eating, BMI, and adiposity by dual-energy-X-ray-absorptiometry were assessed. Missing follow-up data were multiply imputed. RESULTS: FB-IPT feasibility and acceptability were indicated by good attendance (83%) and perceived benefits to social interactions and eating. Follow-up assessments were completed by 73% FB-IPT and 86% FB-HE at post-treatment, 60% and 64% at six-months, and 47% and 57% at one-year. At post-treatment, children in FB-IPT reported greater decreases in depression (95% CI -7.23, -2.01, Cohen's d = 1.23) and anxiety (95% CI -6.08, -0.70, Cohen's d = .79) and less odds of LOC-eating (95% CI -3.93, -0.03, Cohen's d = .38) than FB-HE. At six-months, children in FB-IPT had greater reductions in disordered-eating attitudes (95% CI -0.72, -0.05, Cohen's d = .66) and at one-year, tended to have greater decreases in depressive symptoms (95% CI -8.82, 0.44, Cohen's d = .69) than FB-HE. There was no difference in BMI gain between the groups. DISCUSSION: Family-based approaches that address interpersonal and emotional underpinnings of LOC-eating in preadolescents with overweight/obesity show preliminary promise, particularly for reducing internalizing symptoms. Whether observed psychological benefits translate into sustained prevention of disordered-eating or excess weight gain requires further study.

Validity of computed tomography in predicting scaphoid screw prominence: a cadaveric study.

BACKGROUND: Studies of hardware protrusion into joint spaces following fracture fixation have been performed to address whether or not there is discrepancy between the actual and radiographic appearance of screw prominence. The purpose of our study was to prove that, with respect to the scaphoid, prominence as visualized on CT scan is real and not a result of metal artifact. METHODS: Forty-two cadaveric wrists were separated into four allotted groups with 21 control specimens and 21 study specimens. All specimens were radiographically screened to exclude those with inherent carpal abnormalities. Acutrak® headless compression screws were placed into all specimens using an open dorsal approach. Cartilage was removed from screw insertion site at the convex surface of the scaphoid proximal pole. Control specimens had 0 mm screw head prominence. The studied specimens had 1, 2, and 3 mm head prominence measured with a digital caliper. Computed tomography, with direct sagittal acquisition and metal suppression technique, was then performed on all specimens following screw placement. Two staff radiologists blinded to the study groups interpreted the images. RESULTS: Results revealed that only one of 21 control specimens was interpreted as prominent. Comparatively, in the studied groups, 90% were accurately interpreted as prominent. CONCLUSIONS: CT provides an accurate assessment of scaphoid screw head prominence. When a screw appears prominent on CT scan, it is likely to be truly prominent without contribution from metallic artifact.

A Randomized Controlled Trial to Prevent Depression and Ameliorate Insulin Resistance in Adolescent Girls at Risk for Type 2 Diabetes.

BACKGROUND: Prospective data suggest depressive symptoms worsen insulin resistance and accelerate type 2 diabetes (T2D) onset. PURPOSE: We sought to determine whether reducing depressive symptoms in overweight/obese adolescents at risk for T2D would increase insulin sensitivity and mitigate T2D risk. METHOD: We conducted a parallel-group, randomized controlled trial comparing a 6-week cognitive-behavioral (CB) depression prevention group with a 6-week health education (HE) control group in 119 overweight/obese adolescent girls with mild-to-moderate depressive symptoms (Center for Epidemiological Studies-Depression Scale [CES-D] ≥16) and T2D family history. Primary outcomes were baseline to post-intervention changes in CES-D and whole body insulin sensitivity index (WBISI), derived from 2-h oral glucose tolerance tests. Outcome changes were compared between groups using ANCOVA, adjusting for respective baseline outcome, puberty, race, facilitator, T2D family history degree, baseline age, adiposity, and adiposity change. Multiple imputation was used for missing data. RESULTS: Depressive symptoms decreased (p < 0.001) in CB and HE from baseline to posttreatment, but did not differ between groups (ΔCESD = -12 vs. -11, 95 % CI difference = -4 to +1, p = 0.31). Insulin sensitivity was stable (p > 0.29) in CB and HE (ΔWBISI = 0.1 vs. 0.2, 95 % CI difference = -0.6 to +0.4, p = 0.63). Among all participants, reductions in depressive symptoms were associated with improvements in insulin sensitivity (p = 0.02). CONCLUSIONS: Girls at risk for T2D displayed reduced depressive symptoms following 6 weeks of CB or HE. Decreases in depressive symptoms related to improvements in insulin sensitivity. Longer-term follow-up is needed to determine whether either program causes sustained decreases in depressive symptoms and improvements in insulin sensitivity. TRIAL REGISTRATION NUMBER: The trial was registered with clinicaltrials.gov (NCT01425905).

Effect of adapted interpersonal psychotherapy versus health education on mood and eating in the laboratory among adolescent girls with loss of control eating.

OBJECTIVE: Interpersonal psychotherapy (IPT) is aimed at improving negative affect that is purported to contribute to the development and maintenance of loss-of-control (LOC) eating. Although youth who report LOC over eating tend to consume more snack-foods than those without LOC, it is unknown if IPT impacts objective energy intake. METHODS: To test if IPT improves mood and eating in the laboratory, we examined a sample of 88 girls with LOC eating who were randomized to either IPT (n = 46) or a standard-of-care health education (HE) group program. At baseline, and 6-month (follow-up 1) and 1-year (follow-up 2) following the initiation of the groups, girls consumed lunch from a multi-item meal with an instruction designed to model a LOC episode. Girls also reported mood state immediately before each meal. RESULTS: Girls in IPT experienced no significant changes in pre-meal state depressive affect, while girls in HE experienced a non-significant improvement by follow-up 1 and then returned to baseline by follow-up 2 (p < .04). We found no significant group difference for changes in total intake relative to girls' daily energy needs (p's ≥ .25). However, IPT reduced, while HE increased, the percentage of daily energy needs consumed from snack-foods by follow-up 2 (p = .04). Within-groups, HE increased their snack food intake from follow-up 1 to follow-up 2 (p = .01). CONCLUSIONS: In adolescent girls with LOC, IPT did not change total intake at the test meal and was associated with reduced snack-food intake. Data are required to determine if IPT effectively prevents excess weight gain in the longer-term. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:490-498).