A multilevel intervention in pediatric primary care for youth tobacco control: Outcomes of implementing an Ask, Advise, and Connect model.

Multilevel interventions in healthcare settings (e.g. Ask, Advise, and Connect; AAC) can reduce tobacco product use among adult patients: their effectiveness in pediatric practice is largely unknown. We implemented an AAC model in pediatric primary care to deter children's tobacco use, and evaluated its effectiveness in a single-arm trial. At wellness visits, young patients (ages 12-17) completed a tablet-based assessment (Ask) of lifetime and current tobacco use. These data were made available within the electronic health record to pediatric primary care providers for preventive counseling (Advise). Providers then referred patients to an e-health evidence-based tobacco control intervention (Connect). Tobacco control outcomes were examined in the clinic population (N = 2219) and in a sample of patients (N = 388, 62% female, 39% non-White, M age = 15) over time, along with intervention engagement. Population use of tobacco products decreased following introduction of AAC (more than 2-fold). At the patient level, most children (80.9%) engaged with the intervention: those who were Black or African American, who never used tobacco products/were not susceptible to use, and who used fewer non-cigarette tobacco products were more likely to engage, but only after multiple prompts versus a single prompt. Engagement was positively associated with lowering children's susceptibility to using tobacco at follow-up. A pediatric AAC model holds promise in deterring youth tobacco use, including among historically marginalized populations who may require additional support.

By implementing a multilevel Ask, Advise, and Connect intervention, pediatric tobacco use declined in a clinical population, with high intervention engagement and improved outcomes.

Factors Associated With Disordered Eating Behavior Among Adolescent Girls: Screening and Education.

INTRODUCTION/OBJECTIVES: An unhealthy relationship with food can lead to disordered eating in adolescence, highlighting the importance of screening. This study describes the frequency of disordered eating behavior among female adolescents, as well as associated characteristics and health behaviors. METHODS: Data are from a multidimensional risk factor screening survey administered at a university medical center's adolescent clinic from 2016 to 2018. The instrument was adapted from existing screening tools such as the Rapid Assessment for Adolescent Preventive Services (RAAPS), the American Medical Association's Guidelines for Adolescent Preventive Services (GAPS), and the Youth Risk Behavior Survey (YRBS). Analysis was limited to self-reported responses provided by females aged 10 to 21 years (N = 915). Statistical analyses included chi-square tests and independent sample T-tests. RESULTS: Of the N = 915 females who reported on disordered eating behavior, n = 57 (6.2%) had engaged in some form of disordered eating behavior within the past 12 months. Disordered eating was significantly associated (P < .001) with not consistently wearing a helmet while biking, having tried e-cigarettes, being bullied in the past 30 days, having an adverse childhood experience (ACE), and being African American (P = .005). Subgroup analysis of the relationship between disordered eating and bullying, by race, yielded significant findings: disordered eating was more highly associated with being bullied in the past 30 days among African American females (P = .038). The relationship between disordered eating and ACE was also significant (P < .001) among Caucasian girls when stratified by race. CONCLUSIONS: Adolescent risk behaviors often co-occur, and disordered eating behavior may be differentially observed by race. Findings highlight the importance of education and screening to prevent the development of disordered eating, and identify those who may be struggling. These results can be useful to community health education and in healthcare to develop and implement health promotion and eating disorder prevention strategies. Further studies are needed to assess additional factors that promote or protect against disordered eating to improve prevention.

Enhanced Delivery of Neuroactive Drugs via Nasal Delivery with a Self-Healing Supramolecular Gel.

This paper reports the use of a self-assembling hydrogel as a delivery vehicle for the Parkinson's disease drug l-DOPA. Based on a two-component combination of an l-glutamine amide derivative and benzaldehyde, this gel has very soft rheological properties and self-healing characteristics. It is demonstrated that the gel can be formulated to encapsulate l-DOPA. These drug-loaded gels are characterized, and rapid release of the drug is obtained from the gel network. This drug-loaded hydrogel has appropriate rheological characteristics to be amenable for injection. This system is therefore tested as a vehicle for nasal delivery of neurologically-active drugs-a drug delivery strategy that can potentially avoid first pass liver metabolism and bypass the blood-brain barrier, hence enhancing brain uptake. In vitro tests indicate that the gel has biocompatibility with respect to nasal epithelial cells. Furthermore, animal studies demonstrate that the nasal delivery of a gel loaded with 3 H-labeled l-DOPA out-performed a simple intranasal l-DOPA solution. This is attributed to longer residence times of the gel in the nasal cavity resulting in increased blood and brain concentrations. It is demonstrated that the likely routes of brain penetration of intranasally-delivered l-DOPA gel involve the trigeminal and olfactory nerves connecting to other brain regions.

Catalytic Gels for a Prebiotically Relevant Asymmetric Aldol Reaction in Water: From Organocatalyst Design to Hydrogel Discovery and Back Again.

This paper reports an investigation into organocatalytic hydrogels as prebiotically relevant systems. Gels are interesting prebiotic reaction media, combining heterogeneous and homogeneous characteristics with a structurally organized active "solid-like" catalyst separated from the surrounding environment, yet in intimate contact with the solution phase and readily accessible via "liquid-like" diffusion. A simple self-assembling glutamine amide derivative 1 was initially found to catalyze a model aldol reaction between cyclohexanone and 4-nitrobenzaldehyde, but it did not maintain its gel structure during reaction. In this study, it was observed that compound 1 could react directly with the benzaldehyde to form a hydrogel in situ based on Schiff base 2 as a low-molecular-weight gelator (LMWG). This new dynamic gel is a rare example of a two-component self-assembled LMWG hydrogel and was fully characterized. It was demonstrated that glutamine amide 1 could select an optimal aldehyde component and preferentially assemble from mixtures. In the hunt for an organocatalyst, reductive conditions were applied to the Schiff base to yield secondary amine 3, which is also a highly effective hydrogelator at very low loadings with a high degree of nanoscale order. Most importantly, the hydrogel based on 3 catalyzed the prebiotically relevant aldol dimerization of glycolaldehyde to give threose and erythrose. In buffered conditions, this reaction gave excellent conversions, good diastereoselectivity, and some enantioselectivity. Catalysis using the hydrogel of 3 was much better than that using non-assembled 3-demonstrating a clear benefit of self-assembly. The results suggest that hydrogels offer a potential strategy by which prebiotic reactions can be promoted using simple, prebiotically plausible LMWGs that can selectively self-organize from complex mixtures. Such processes may have been of prebiotic importance.

Adolescent Beliefs About Hookah and Hookah Tobacco Use and Implications for Preventing Use.

INTRODUCTION: Hookah tobacco use is popular among youths and there is evidence that perceived risks and normative beliefs are associated with hookah use. The aim of this study was to further examine associations between perceived risks of hookah use, normative beliefs, and lifetime hookah use among youths. METHODS: Participants were adolescents aged 12 to 17 years (n = 257, mean [standard deviation] age, 14.9 [1.6] years, 40% nonwhite, 66% female) attending well-visit checkups at an urban pediatric clinic. Participants completed a survey of measures of cigarette smoking, risk factors for smoking, hookah use, perceived risks, and normative beliefs. Analyses examined associations among lifetime hookah use, beliefs about hookah use, and other smoking risk factors. RESULTS: Overall, 15% of the sample had ever tried hookah smoking and 60% had ever tried cigarette smoking or were susceptible to cigarette smoking. Of those who had tried hookah smoking, 84% had also tried cigarettes or were susceptible to trying cigarettes (P < .001). One-third (33%) indicated that hookah smoking was less harmful than cigarettes, 38% indicated hookah smoking is less addictive than cigarettes, and 48% perceived that hookah smoking is somewhat or very socially acceptable among friends. In multivariable analyses adjusting for demographic and cigarette smoking-related factors, perceiving hookah use to be somewhat or very socially acceptable was associated with a significantly higher odds of ever having tried hookah smoking. CONCLUSION: The study findings indicate that stronger perceived social acceptability of hookah use is associated with a higher likelihood of trying hookah smoking among youths. These normative beliefs may be important targets of interventions aimed at preventing hookah use among youths.

The effects of framed messages for engaging adolescents with online smoking prevention interventions.

Messages emphasizing the harms of smoking (loss-framed) or the benefits of not smoking (gain-framed) may be effective for engaging adolescents with tobacco prevention resources. This novel approach could help to close a gap in tobacco prevention intervention delivery in the pediatric primary care setting. To examine the effects of framed messages for engaging adolescents with an evidence-based smoking prevention website, adolescents ages 12 to 17 presenting for primary care well-visits were recruited for a three-arm experiment. Participants completed baseline measures including demographics, smoking behavior, and smoking susceptibility and were randomized to view 1 of 3 messages introducing an evidence-based smoking prevention website: (1) gain-framed communicating the benefits of avoiding smoking, (2) loss-framed communicating the harms of smoking, or (3) neutral. Self-reported website engagement was assessed at 1-month follow-up. Participants (279) (87% of those enrolled) completed a follow-up (M age 14.9 years, 66% female, 32% non-white race, 47% non-susceptible never smokers, 53% susceptible never smokers/ever smokers). Overall, 26% of participants reported website engagement. After adjusting for baseline intentions to visit the website, engagement was significantly greater in response to the loss-framed message than the gain-framed (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.51, 6.15) and neutral (OR 2.31, 95% CI 1.15, 4.63) messages. The message framing effects did not differ by baseline smoking risk. Loss-framed messages emphasizing the harms of smoking may be effective for engaging adolescents with smoking prevention resources.

A Qualitative Study of Adolescent Perceptions of Electronic Cigarettes and Their Marketing: Implications for Prevention and Policy.

This study examined youths' perceptions of electronic cigarettes ("e-cigarettes"), sources of e-cigarettes exposure, and preferred sources of e-cigarette health information. Participants (n = 25, M age 15.0 years) recruited during primary care visits completed an in-depth qualitative interview assessing these topics. Most participants (72%) perceived e-cigarettes as "healthier" than cigarettes and reported e-cigarette advertising exposure (80%) and interpersonal exposure (60%). Participants reported advertisements portray e-cigarettes as less harmful than cigarettes and novel products. Most (72%) indicated their doctor was their preferred source of e-cigarette health information, suggesting pediatric health care providers are well-positioned to counsel patients to prevent e-cigarette use.

Correlates of Sun Safety Practices in a Racially and Ethnically Diverse Sample of Adolescents: Implications for Skin Cancer Prevention Interventions.

To guide skin cancer preventive interventions, this study examined correlates of sun safety behaviors in a racially and ethnically diverse sample of 407 adolescents completing a self-report survey at the time of their pediatric wellness visit. Adolescents regularly practiced few sun safety behaviors, and greater interest in cancer prevention was associated with more sun safety behaviors, ever smoking cigarettes was associated with fewer sun safety behaviors, and nonwhite minority adolescents practiced fewer sun safety behaviors than non-Hispanic whites. Clinical preventive interventions to increase sun safety practices among adolescents of all racial and ethnic backgrounds could be integrated into general cancer prevention education, including combining skin cancer prevention with antismoking counseling.

Pediatric to adult transition: a quality improvement model for primary care.

PURPOSE: To examine the relationship between quality improvement activities with pediatric and adult primary care practices and improvements in transition from pediatric to adult care. METHODS: This was a time-series comparative study of changes in pediatric and adult practices involving five large pediatric and adult academic health centers in the District of Columbia. Using the Health Care Transition Index (pediatric and adult versions), we examined improvements in specific indicators of transition performance, including development of an office transition policy, provider knowledge and skills related to transition, identification of transitioning youth, transition preparation of youth, transition planning, and transfer of care. RESULTS: Improvements took place in all six transition quality indicators in the pediatric and adult practices that participated in a 2-year learning collaborative to implement the "Six Core Elements of Health Care Transition," a quality improvement intervention modeled after the American Academy of Pediatrics/American Academy of Family Physicians/American College of Physicians Clinical Report on Transition. All sites established a practice-wide policy on transition and created an organized clinical process for tracking transition preparation. The pediatric sites conducted transition readiness assessments with 88% of eligible youth and prepared transition plans for 29% of this group. The adult sites conducted transition readiness assessments with 73% of eligible young adults and developed plans for 33%. A total of 50 were transferred in a systematic way to adult primary care practices. CONCLUSIONS: Quality improvement using the Six Core Elements of Health Care Transition resulted in the development of a systematic clinical transition process in pediatric and adult academic primary care practices.

Systemic levels of neuropeptide Y and dipeptidyl peptidase activity in patients with Ewing sarcoma--associations with tumor phenotype and survival.

BACKGROUND: Ewing sarcoma (ES) is driven by fusion of the Ewing sarcoma breakpoint region 1 gene (EWSR1) with an E26 transformation-specific (ETS) transcription factor (EWS-ETS), most often the Friend leukemia integration 1 transcription factor (FLI1). Neuropeptide Y (NPY) is an EWS-FLI1 transcriptional target; it is highly expressed in ES and exerts opposing effects, ranging from ES cell death to angiogenesis and cancer stem cell propagation. The functions of NPY are regulated by dipeptidyl peptidase IV (DPPIV), a hypoxia-inducible enzyme that cleaves the peptide and activates its growth-promoting actions. The objective of this study was to determine the clinically relevant functions of NPY by identifying the associations between patients' ES phenotype and their NPY concentrations and DPP activity. METHODS: NPY concentrations and DPP activity were measured in serum samples from 223 patients with localized ES and 9 patients with metastatic ES provided by the Children's Oncology Group. RESULTS: Serum NPY levels were elevated in ES patients compared with the levels in a healthy control group and an osteosarcoma patient population, and the elevated levels were independent of EWS-ETS translocation type. Significantly higher NPY concentrations were detected in patients with ES who had tumors of pelvic and bone origin. A similar trend was observed in patients with metastatic ES. There was no effect of NPY on survival in patients with localized ES. DPP activity in sera from patients with ES did not differ significantly from that in healthy controls and patients with osteosarcoma. However, high DPP levels were associated with improved survival. CONCLUSIONS: Systemic NPY levels are elevated in patients with ES, and these high levels are associated with unfavorable disease features. DPPIV in serum samples from patients with ES is derived from nontumor sources, and its high activity is correlated with improved survival.

Trait hostility and hostile interpretation biases in daily smokers: associations with reasons for smoking, motivation to quit, and early smoking lapse.

Hostility has emerged as an important predictor of smoking cessation difficulties, though the mechanisms underlying the hostility and smoking relationship are poorly understood. Further, research has yet to explore relations between hostile interpretation biases and different aspects of smoking behavior. In the present study, current daily smokers (N = 106) were administered measures of smoking characteristics, smoking motivation, reasons for quitting, hostility, and hostile interpretation bias. Neither trait hostility nor hostile interpretation bias were uniquely associated with motivation to quit, reasons for quitting, nicotine dependence, or problematic symptoms following past cessation attempts. However, hostility and hostile interpretation biases were uniquely associated with different reasons for smoking. Additionally, greater hostile interpretation bias (but not hostility) was uniquely associated with early relapse following past cessation attempts. The current findings add uniquely to the growing, but still relatively small, literature on hostility and smoking and implicate hostile interpretation bias as a potential treatment target in smoking cessation interventions.

Effect of anger and trait forgiveness on cardiovascular risk in young adult females.

High trait anger is linked to adverse cardiovascular outcomes. A potential antidote to the cardiotoxic influence of anger is trait forgiveness (TF), as it has shown associations with improved blood pressure (BP) and cardiovagal tone regulation in cardiac patients. However, it has yet to be determined if anger and forgiveness independently predict cardiovascular parameters. Trait anger (State-Trait Anger Expression Inventory-2) and TF (Tendency to Forgive Scale) were evaluated in 308 (M = 21.11years ± SD = 2.52) healthy female volunteers allocated to 3 related, yet distinct, studies. Hierarchical multiple regressions tested the incremental contribution of TF after accounting for anger. Study 1 assessed autonomic modulation through beat-to-beat BP and spectral analysis to examine sympathovagal balance and baroreflex functioning. Study 2 used tonometry and pulse wave analysis for aortic hemodynamics. Study 3 assessed 24-hour ambulatory BP and ambulatory arterial stiffness index. Hierarchical models demonstrated that anger was significantly associated with increased sympathovagal tone, increased hemodynamic indices, high ambulatory BPs, and attenuated BP variability and baroreflex. In contrast, TF was associated with more favorable hemodynamic effects (i.e., decreased ventricular work and myocardial oxygen consumption). In conclusion, these results demonstrate divergent cardiovascular effects of anger and forgiveness, such that anger is associated with a more cardiotoxic autonomic and hemodynamic profile, whereas TF is associated with a more cardioprotective profile. These findings suggest that interventions aimed at decreasing anger while increasing forgiveness may be clinically relevant.

Multiple facets of problematic anger among regular smokers: exploring associations with smoking motives and cessation difficulties.

INTRODUCTION: Research has implicated problematic anger in multiple smoking outcomes, including nicotine dependence and difficulties with cessation. However, the mechanisms underlying the role of anger in smoking behavior and cessation difficulties remain unclear. The current study examined associations between different facets of anger with smoking motives, problematic symptoms during past quit attempts, reasons for quitting, and perceived barriers to cessation. METHODS: Current smokers (N = 93) were administered measures assessing the relevant constructs. RESULTS: After controlling for gender and negative affectivity, greater trait anger was uniquely related to more severe symptoms during past cessation attempts, perceived internal and external barriers to cessation, social influence reasons for quitting, and negative affect reduction and sensorimotor smoking motivations. CONCLUSIONS: These findings add uniquely to the literature on anger and smoking and suggest anger plays a role in everyday smoking behavior. Smokers with problematic anger might benefit from treatment focused on reducing anger and improving interpersonal functioning. Reducing trait anger may help reduce problematic symptoms during quitting, making relapse less likely.

An examination of the relationship between anger and suicide risk through the lens of the interpersonal theory of suicide.

Research has implicated a relationship between anger and suicidality, though underlying mechanisms remain unclear. The current study examined this relationship through the lens of the interpersonal theory of suicide (ITS). According to the ITS, individuals who experience thwarted belongingness, perceived burdensomeness, and elevated acquired capability for suicide are at increased risk for death by suicide. The relationships between anger and these variables were examined and these variables were examined as potential mediators between anger and suicidal ideation and behavior. Additionally, exposure to painful and provocative events was examined as a potential mediator between anger and acquired capability. As part of intake at a community mental health clinic, 215 outpatients completed questionnaires assessing depression, suicidal ideation, anger, perceived burdensomeness, thwarted belongingness, and acquired capability. Regression analyses revealed unique relationships between anger and both thwarted belongingness and perceived burdensomeness, covarying for depression. The association between anger and acquired capability trended toward significance. The links between anger and suicidal ideation and behavior were fully mediated by thwarted belongingness and perceived burdensomeness, but this effect was driven by perceived burdensomeness. Additionally, the link between anger and acquired capability was fully mediated by experience with painful and provocative events. In conclusion, results suggest that anger is uniquely associated with perceived burdensomeness and thwarted belongingness. Anger is associated with suicidal ideation and behavior via perceived burdensomeness and with greater acquired capability for suicide via experiences with painful and provocative events. Treatment for problematic anger may be beneficial to decrease risk for suicide.

A test of the unique and interactive roles of anger experience and expression in suicidality: findings from a population-based study.

This study examined the unique and interactive roles of anger experience and expression in suicidality (suicidal ideation, plans, and attempts) in a large, nationally representative sample. Participants included 5692 adults from the National Comorbidity Survey-Replication, a nationally representative survey. Anger experience was assessed through a continuous measure, whereas anger expression problems were determined by the presence of an intermittent explosive disorder diagnosis. Tests of unique associations revealed that for the overall sample, anger experience and expression each predicted a unique variance in all outcomes of suicidality. Among the individuals reporting lifetime suicidal ideation, anger experience and expression were uniquely related to suicide attempts. Analyses also revealed anger experience and expression to interact in the prediction of suicidal ideation, suggesting that these have independent and additive effects on risk for suicide. The findings suggest that both anger experience and expression contribute to suicidality and the progression from suicidal ideation to plans and attempts.

The effects of nicotine on intrusive memories in nonsmokers.

Correlational research suggests that smoking increases risk of posttraumatic stress disorder (PTSD), though such research by nature cannot rule out third variable explanations for this relationship. The present study used an analogue trauma film design to experimentally test the effects of nicotine on the occurrence of intrusive memories. Fifty-four healthy nonsmokers were randomly assigned to ingest either a nicotine or placebo lozenge before viewing a film depicting motor vehicle accidents. Participants recorded intrusive memories immediately after the film and for a week via diary. Participants in the nicotine condition reported significantly more intrusive memories immediately after watching the film, yet no group differences emerged on intrusions or intrusion-related distress reported during the following week. Among participants low in dispositional rumination, those who had ingested a nicotine lozenge reported more intrusions in the subsequent week than those in the placebo condition. These findings provide novel experimental evidence for the role of nicotine in increasing risk of PTSD and suggest that nicotine may contribute to trauma-related rumination but not heightened reactivity to trauma cues.

Effects of interpretation training on hostile attribution bias and reactivity to interpersonal insult.

Research suggests that individuals high in anger have a bias for attributing hostile intentions to ambiguous situations. The current study tested whether this interpretation bias can be altered to influence anger reactivity to an interpersonal insult using a single-session cognitive bias modification program. One hundred thirty-five undergraduate students were randomized to receive positive training, negative training, or a control condition. Anger reactivity to insult was then assessed. Positive training led to significantly greater increases in positive interpretation bias relative to the negative group, though these increases were only marginally greater than the control group. Negative training led to increased negative interpretation bias relative to other groups. During the insult, participants in the positive condition reported less anger than those in the control condition. Observers rated participants in the positive condition as less irritated than those in the negative condition and more amused than the other two conditions. Though mediation of effects via bias modification was not demonstrated, among the positive condition posttraining interpretation bias was correlated with self-reported anger, suggesting that positive training reduced anger reactivity by influencing interpretation biases. Findings suggest that positive interpretation training may be a promising treatment for reducing anger. However, the current study was conducted with a non-treatment-seeking student sample; further research with a treatment-seeking sample with problematic anger is necessary.

Priming of courageous behavior: contrast effects in spider fearful women.

OBJECTIVE: Recently, researchers have called for therapeutic applications of behavioral primes (Shalev & Bargh, 2011). We evaluated whether courageous approach behavior might be facilitated through priming in a sample of spider fearful women. METHOD: Undergraduate student women reporting elevated spider fear (N = 33, Age mean = 18.88) were recruited for this study. Participants completed self-report measures of spider fear and dispositional courage. They then completed either a courage or neutral word search prime, which was followed by a behavioral approach task involving a tarantula. RESULTS: Consistent with predictions, among those reporting lower dispositional courage, the courage prime led to reduced approach behavior relative to the neutral prime. However, no group differences were found among those high in dispositional courage. CONCLUSIONS: These findings point to the importance of self-perceptions in moderating the effects of behavioral primes and suggest limitations to the use of such interventions with individuals with psychological dysfunction.

Delineating a relationship between problematic anger and cigarette smoking: a population-based study.

BACKGROUND: Research implicates a potentially important relationship between anger and smoking, though extant work suffers from a number of limitations, including the absence of controls for psychiatric comorbidity and the use of treatment-seeking samples. The current study sought to examine the unique associations between problematic anger and smoking behavior in a large representative sample. METHODS: Participants included 5,692 adults from the National Comorbidity Survey-Replication, a nationally representative survey. Assessments of psychiatric diagnoses, smoking behavior, and problematic anger were administered. RESULTS: Results indicated that problems of anger experience were significantly associated with past-year daily smoking, heavy smoking, and nicotine dependence. After controlling for demographics and psychiatric comorbidity, anger experience was uniquely associated with each of these outcomes. Anger experience also was uniquely associated with lifetime history of smoking cessation failure. CONCLUSIONS: Overall, these population-based data suggest an important relationship between problematic anger and numerous aspects of smoking behavior.