How the Environmental influences on Child Health Outcome (ECHO) Cohort can spur discoveries in environmental epidemiology.

NIH's Environmental influences on Child Health Outcome (ECHO) program is an innovative, large, collaborative research initiative whose mission is to enhance the health of children for generations to come. The goal of the ECHO Cohort is to examine effects of a broad array of early environmental exposures on child health and development. It includes longitudinal data and biospecimens from over 100,000 children and family members from diverse settings across the U.S. ECHO investigators have published collaborative analyses showing associations of environmental exposures--primarily in the developmentally sensitive pre-, peri-, and post-natal periods--with preterm birth and childhood asthma, obesity, neurodevelopment, and positive health. Investigators have addressed health disparities, joint effects of environmental and social determinants, and effects of mixtures of chemicals. The ECHO Cohort is now entering its second 7-year cycle (2023-2030), which will add the preconception period to its current focus on prenatal through adolescence. Through a controlled access public use database, ECHO makes its deidentified data available to the general scientific community. ECHO Cohort data provide opportunities to fill major knowledge gaps in in environmental epidemiology, and to inform policies, practices, and programs to enhance child health.

Conceptual models for implementing solution-oriented team science in large research consortia.

Large translational research initiatives can strengthen efficiencies and support science with enhanced impact when practical conceptual models guide their design, implementation, and evaluation. The National Institutes of Health (NIH) Environmental influences on Child Health Outcomes (ECHO) program brings together data from 72 ongoing maternal-child cohort studies - involving more than 50,000 children and over 1200 investigators - to conduct transdisciplinary solution-oriented research that addresses how early environmental exposures influence child health. ECHO uses a multi-team system approach to consortium-wide data collection and analysis to generate original research that informs programs, policies, and practices to enhance children's health. Here, we share two conceptual models informed by ECHO's experiences and the Science of Team Science. The first conceptual model illuminates a system of teams and associated tasks that support collaboration toward shared scientific goals. The second conceptual model provides a framework for designing evaluations for continuous quality improvement of manuscript writing teams. Together, the two conceptual models offer guidance for the design, implementation, and evaluation of translational and transdisciplinary multi-team research initiatives.

Comparison of Recruitment Strategy Outcomes in the National Children's Study.

BACKGROUND AND OBJECTIVES: In 2000, the US Congress authorized the National Institutes of Health to conduct a prospective national longitudinal study of environmental influences on children's health and development from birth through 21 years. Several recruitment methodologies were piloted to determine the optimal strategy for a main National Children's Study. METHODS: After an initial pilot recruitment that used a household enumeration strategy performed poorly, the National Children's Study Vanguard Study developed and evaluated the feasibility, acceptability, and cost of 4 alternate strategies to recruit a large prospective national probability sample of pregnant women and their newborn children. We compare household-based recruitment, provider-based recruitment, direct outreach, and provider-based sampling (PBS) strategies with respect to overall recruitment success, efficiency, cost, and fulfillment of scientific requirements. RESULTS: Although all 5 strategies achieved similar enrollment rates (63%-81%) among eligible women, PBS achieved the highest recruitment success as measured by the ratio of observed-to-expected newborn enrollees per year of 0.99, exceeding those of the other strategies (range: 0.35-0.48). Because PBS could reach the enrollment target through sampling of high volume obstetric provider offices and birth hospitals, it achieved the lowest ratio of women screened to women enrolled and was also the least costly strategy. With the exception of direct outreach, all strategies enrolled a cohort of women whose demographics were similar to county natality data. CONCLUSIONS: PBS demonstrated the optimal combination of recruitment success, efficiency, cost, and population representativeness and serves as a model for the assembly of future prospective probability-based birth cohorts.

The National Children's Study: An Introduction and Historical Overview.

The National Children's Study (NCS) was an ambitious attempt to map children's health and development in a large representative group of children in the United States. In this introduction, we briefly review the background of the NCS and the history of the multiple strategies that were tested to recruit women and children. Subsequent articles then detail the protocols and outcomes of 4 of the recruitment strategies. It is hoped that lessons learned from these attempts to define a study protocol that could achieve the initial aims of the NCS will inform future efforts to conceptualize and execute strategies to provide generalizable insights on the longitudinal health of our nation's children.

Factors influencing the periodontal referral process.

BACKGROUND: General dental practitioners (GPs) assess the periodontal status of patients and make decisions to treat patients or refer them to a periodontist. There is little information available regarding this process. The purpose of this study is to identify significant factors that GPs consider important in selecting a particular periodontist. The findings were compared and contrasted with responses of periodontists to gain perspectives from both groups involved in the referral process. METHODS: Data from an online cross-sectional survey of GPs (n = 533) and periodontists (n = 533) who practice in the southeastern region of the United States (from the databases of the American Dental Association and American Academy of Periodontology member directories) were obtained. RESULTS: The specialist's clinical skill was identified as the most important factor influencing periodontal referrals by GPs, whereas periodontists identified a previous positive experience between a GP and periodontist as the most important factor. In a descending order of importance, the top three rating averages (rated out of five) by GPs were clinical skill (4.84), a previous positive experience between a GP and periodontist (4.57), and communication (4.52). The top three factors of periodontists were a previous positive experience between a GP and periodontist (4.66), communication (4.40), and the likelihood of a good patient and periodontist rapport (4.29). CONCLUSIONS: The periodontist's clinical skill was chosen by GPs as the primary factor influencing the referral decisions of GPs. Periodontists perceived a previous positive experience between the GP and periodontist as the most influential factor. Further studies are required to gain more insight into the referral process.

Continuity of primary care clinician in early childhood.

OBJECTIVES: This study uses the first national data on well-child care for young children to 1) assess how many children have a specific clinician for well-child care; 2) identify the health insurance, health care setting, and child and family determinants of having a specific clinician; and 3) assess how parents choose pediatric clinicians. METHODS: Data from the National Survey of Early Childhood Health (NSECH), a nationally representative survey of health care quality for young children fielded by the National Center for Health Statistics in 2000, were used to describe well-child care settings for children aged 4 to 35 months. Parents reported the child's usual setting of well-child care, whether their child has a specific clinician for well-child care, and selection method for those with a clinician. Bivariate and logistic regression analyses are used to identify determinants of having a specific clinician and of provider selection method, including health care setting, insurance, managed care, and child and family characteristics. RESULTS: Nearly all young children aged 4 to 35 months in the United States (98%) have a regular setting, but only 46% have a specific clinician for well-child care. The proportion of young children who have a single clinician is highest among privately insured children (51%) and lowest among publicly insured children (37%) and uninsured children (28%). In multivariate logistic regression including health care and sociodemographic factors, odds of having a specific clinician vary little by health care setting. Odds are lower for children who are publicly insured (odds ratio [OR]: 0.7; 95% confidence interval [CI]: 0.45-0.97) and for Hispanic children with less acculturated parents (OR: 0.6; 95% CI: 0.39-0.91). Odds are higher for children in a health plan with gatekeeping requirements (OR: 1.4; 95% CI: 1.02-1.88). Approximately 13% of young children with a specific clinician were assigned to that provider. Assignment rather than parent choice is more frequent for children who are publicly insured, in managed care, cared for in a community health center/public clinic, Hispanic, and of lower income and whose mother has lower education. In multivariate logistic regression, only lack of health insurance, care in a community health center, and managed care participation are associated with lack of choice. CONCLUSIONS: Anticipatory guidance is the foundation of health supervision visits and may be most effective when there is a continuous relationship between the pediatric provider and the parent. Only half of young children in the United States are reported to have a specific clinician for well-child care. Low rates of continuity are found across health care settings. Furthermore, not all parents of children with a continuous relationship exercised choice, particularly among children in safety net health care settings. These provisional findings on a new measure of primary care continuity for children raise important questions about the prevalence and determinants of continuity.

Routine assessment of family and community health risks: parent views and what they receive.

OBJECTIVE: To examine the prevalence of parent-provider discussions of family and community health risks during well-child visits and the gaps between which issues are discussed and which issues parents would like to discuss. METHODS: Data came from the National Survey of Early Childhood Health, a nationally representative sample of parents of 2068 children aged 4 to 35 months. The outcome measures were 1) the reported discussions with pediatric clinicians about 7 family and community health risks and 2) whether the parent believes that pediatric clinicians should ask parents about each risk. RESULTS: Most parents believe that pediatric providers should discuss topics such as smoking in the household, financial difficulties, and emotional support available to the parent. However, with the exception of "household smoking," fewer than half of parents have been asked about these topics by their child's clinician. Parents of black and Hispanic children were more likely than parents of white children to be asked about several of these issues, as were parents of the youngest children and those with publicly financed health insurance. The greatest gap between parents' views and their reports of discussion with the clinician occur for parents of white children and older children. Among parents who hold the view that a topic should be discussed, parents of white and older children are less likely than others to report discussing some or all family and community health risks. CONCLUSION: The low frequency of discussions for many topics indicates potential unmet need. More universal surveillance of parents with young children might ensure that needs are not missed, particularly given that strong majorities of parents view family and community topics, with the exception of community violence, as appropriate for discussion in clinic visits.

Antimicrobial components of vaginal fluid.

OBJECTIVE: We examined the antimicrobial activity and composition of vaginal fluid. STUDY DESIGN: Vaginal fluid from preweighed tampons was assayed for pH, lactic acid, and antimicrobial polypeptides. The fluid was also fractionated by molecular filtration. Antimicrobial activity of whole fluid was determined against representative resident and exogenous microbes, and its fractions were tested against Escherichia coli. RESULTS: Vaginal fluids (5/5 donors) were permissive for Lactobacillus crispatus and vaginalis and Candida albicans, but not for Escherichia coli, Streptococcus group B, and Lactobacillus jensenii in three of five donors. The antimicrobial activity against E coli was predominantly in a <3-kd fraction and correlated with both low pH and high lactic acid content. Compared with a matched pH buffer, lactic acid markedly suppressed the growth of E coli. Concentrated 2- or 5-fold, the protein-rich fraction was active against E coli. CONCLUSION: Vaginal fluid exerts selective antimicrobial activity against nonresident bacterial species. The activity is mediated by lactic acid, low pH, and antimicrobial polypeptides.

Factors associated with smoking cessation among U.S. pregnant women.

OBJECTIVES: This study examines smoking and smoking cessation behaviors among U.S. pregnant women and seeks to identify the sociodemographic correlates of smoking cessation in pregnancy. METHODS: The 1998 NHIS Pregnancy and Smoking supplement was analyzed, including 5288 U.S. women (weighted to represent 13,714,358 women) who gave birth to a liveborn infant in the past 5 years. Four categories of smoking behavior were analyzed: nonsmoking at last pregnancy, persistent smoking throughout pregnancy, attempting unsuccessfully to quit during pregnancy, and successfully quitting during pregnancy. Logistic regression was used to isolate risk factors for each of the smoking behaviors and to examine factors associated with attempted and successful cessation. RESULTS: The women most likely to attempt to quit smoking in pregnancy were Hispanic women (OR = 3.09) and women who have smoked for less than 10 years (OR = 2.75 for women aged 18-24.) In general, for the groups at highest risk of smoking at the start of pregnancy, the odds of being a persistent smoker were higher than the odds of being an unsuccessful quitter, which in turn were higher than the odds of quitting successfully. The factors associated with attempts to quit included Hispanic ethnicity, higher education, above-poverty income, and shorter duration of smoking, while the combined effect of age and smoking duration was the only one significantly associated with successful quitting. In every age group, longer smoking duration was associated with lower likelihood of attempting to quit as well as successful quitting. CONCLUSIONS: The factors most strongly associated with attempts to quit smoking were Hispanic ethnicity and the combined effect of age and smoking duration. Future smoking cessation and relapse prevention programs should be developed, taking into consideration the critical factors of age, ethnicity, income, geography, and addiction.

Black-white differences in health care utilization among US children with frequent ear infections.

OBJECTIVE: To examine differences in patterns of and barriers to health care utilization between black and white children who have frequent ear infections (FEI). METHODS: Analysis was conducted using the 1997 and 1998 National Health Interview Survey-Sample Child Files. Data on 25 497 children under 18 years of age and 1985 who were reported by the parent/guardian to have had "3 or more ear infections during the past 12 months" were analyzed. The data were weighted and analyzed to represent all black and white children nationwide, accounting for the complex survey design. RESULTS: Of white and black children under 18 years of age in the United States, 8.0 and 6.6%, respectively, had FEI in the past year. Among those with FEI, whites and blacks exhibited significantly different patterns in the type of health insurance they had and in the usual source of care. After accounting for sociodemographic factors, health insurance, and usual source of care, there were still significant differences in health care use between whites and blacks. The affected black children had an increased risk of getting delayed care because of transportation problems (odds ratio [OR]: 2.32) and a reduced likelihood of seeing a medical specialist (OR: 0.49) and having surgery (OR: 0.39) in comparison to white children. CONCLUSION: Although black children with FEI were as likely as white children to be covered by health insurance and have a usual place of health care, they were significantly more likely to face barriers in obtaining the care, especially the more specialized care.

Human beta-defensin-2 production in keratinocytes is regulated by interleukin-1, bacteria, and the state of differentiation.

Intact human epidermis resists invasion by pathogenic microbes but the biochemical basis of its resistance is not well understood. Recently, an antimicrobial peptide, human beta-defensin-2, was discovered in inflamed epidermis. We used a recombinant baculovirus/insect cell system to produce human beta-defensin-2 and confirmed that at micromolar concentrations it has a broad spectrum of antimicrobial activity, with the striking exception of Staphylococcus aureus. Immunostaining with a polyclonal antibody to human beta-defensin-2 showed that the expression of human beta-defensin-2 peptide by human keratinocytes required differentiation of the cells (either by increased calcium concentration or by growth and maturation in epidermal organotypic culture) as well as a cytokine or bacterial stimulus. Interleukin-1alpha, interleukin-1beta, or live Pseudomonas aeruginosa proved to be the most effective stimuli whereas other bacteria and cytokines had little or no ability to induce human beta-defensin-2 synthesis. In interleukin-1alpha-stimulated epidermal cultures, human beta-defensin-2 first appeared in the cytoplasm in differentiated suprabasal layers of skin, next in a more peripheral web-like distribution in the upper layers of the epidermis, and then over a few days migrated to the stratum corneum. By semiquantitative Western blot analysis of epidermal lysates, the average concentration of human beta-defensin-2 in stimulated organotypic epidermal culture reached 15--70 microg per gram of tissue, i.e., 3.5-16 microM, well within the range required for antimicrobial activity. Because of the restricted pattern of human beta-defensin-2 distribution in the epidermis, its local concentration must be much higher. Defensins and other antimicrobial peptides of inflamed epidermis are likely to play an important antimicrobial role in host defense against cutaneous pathogens.