Integrated HIV surveillance finds recent adult hepatitis B virus (HBV) transmission and intermediate HBV prevalence among military in uncharacterized Caribbean country.

BACKGROUND: Guyana expanded its HIV response in 2005 but the epidemiology of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections has not been characterized. METHODS: The 2011 Seroprevalence and Behavioral Epidemiology Risk Survey for HIV and STIs collected biologic specimens with demographic and behavioral data from a representative sample of Guyana military personnel. Diagnostics included commercial serum: HIV antibody; total antibody to hepatitis B core (anti-HBc); IgM anti-HBc; hepatitis B surface antigen (HBsAg); anti-HBs; antibody to HCV with confirmatory testing; and HBV DNA sequencing with S gene fragment phylogenetic analysis. Chi-square, p-values and prevalence ratios determined statistical significance. RESULTS: Among 480 participants providing serologic specimens, 176 (36.7%) tested anti-HBc-positive. Overall, 19 (4.0%) participants tested HBsAg-positive; 17 (89.5%) of the HBsAg-positive participants also had detectable anti-HBc, including 1 (5.3%) IgM anti-HBc-positive male. Four (6.8%) females with available HBV testing were HBsAg-positive, all aged 23-29 years. Sixteen (16, 84.2%) HBsAg-positive participants had sufficient specimen for DNA testing. All 16 had detectable HBV DNA, 4 with viral load >2x104IU/ml. Sequencing found: 12 genotype (gt) A1 with 99.9% genetic identity between 1 IgM anti-HBc-positive and 1 anti-HBc-negative; 2 gtD1; and 2 with insufficient specimen. No statistically significant associations between risk factors and HBV infection were identified. CONCLUSIONS: Integrated HIV surveillance identified likely recent adult HBV transmission, current HBV infection among females of reproductive age, moderate HBV infection prevalence (all gtA1 and D1), no HCV infections and low HIV frequency among Guyana military personnel. Integrated HIV surveillance helped characterize HBV and HCV epidemiology, including probable recent transmission, prompting targeted responses to control ongoing HBV transmission and examination of hepatitis B vaccine policies.

The impact of social services interventions in developing countries: a review of the evidence of impact on clinical outcomes in people living with HIV.

BACKGROUND: Social service interventions have been implemented in many countries to help people living with HIV (PLHIV) and household members cope with economic burden as a result of reduced earning or increased spending on health care. However, the evidence for specific interventions-economic strengthening and legal services-on key health outcomes has not been appraised. METHODS: We searched electronic databases from January 1995 to May 2014 and reviewed relevant literature from resource-limited settings on the impact of social service interventions on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission and their cost-effectiveness. RESULTS: Of 1685 citations, 8 articles reported the health impact of economic strengthening interventions among PLHIV in resource-limited settings. None reported on legal services. Six of the 8 studies were conducted in sub-Saharan Africa: 1 reported on all 5 outcomes and 2 reported on 4 and 2 outcomes, respectively. The remaining 5 reported on 1 outcome each. Seven studies reported on quality of life. Although all studies reported some association between economic strengthening interventions and HIV care outcomes, the quality of evidence was rated fair or poor because studies were of low research rigor (observational or qualitative), had small sample size, or had other limitations. The expected impact of economic strengthening interventions was rated as high for quality of life but uncertain for all the other outcomes. CONCLUSIONS: Implementation of economic strengthening interventions is expected to have a high impact on the quality of life for PLHIV but uncertain impact on mortality, morbidity, retention in care, and HIV transmission. More rigorous research is needed to explore the impact of more targeted intervention components on health outcomes.

Impact of support groups for people living with HIV on clinical outcomes: a systematic review of the literature.

BACKGROUND: Support groups for people living with HIV are integrated into HIV care and treatment programs as a modality for increasing patient literacy and as an intervention to address the psychosocial needs of patients. However, the impact of support groups on key health outcomes has not been fully determined. METHODS: We searched electronic databases from January 1995 through May 2014 and reviewed relevant literature on the impact of support groups on mortality, morbidity, retention in HIV care, quality of life (QOL), and ongoing HIV transmission, as well as their cost-effectiveness. RESULTS: Of 1809 citations identified, 20 met the inclusion criteria. One reported on mortality, 7 on morbidity, 5 on retention in care, 7 on QOL, and 7 on ongoing HIV transmission. Eighteen (90%) of the articles reported largely positive results on the impact of support group interventions on key outcomes. Support groups were associated with reduced mortality and morbidity, increased retention in care, and improved QOL. Because of study limitations, the overall quality of evidence was rated as fair for mortality, morbidity, retention in care, and QOL, and poor for HIV transmission. CONCLUSIONS: Implementing support groups as an intervention is expected to have a high impact on morbidity and retention in care and a moderate impact on mortality and QOL of people living with HIV. Support groups improve disclosure with potential prevention benefits but the impact on ongoing transmission is uncertain. It is unclear whether this intervention is cost-effective given the paucity of studies in this area.

The relationship of adverse childhood experiences to a history of premature death of family members.

BACKGROUND: To assess the association between adverse childhood experiences (ACEs), including childhood abuse and neglect, and serious household dysfunction, and premature death of a family member. Because ACEs increase the risk for many of the leading causes of death in adults and tend to be familial and intergenerational, we hypothesized that persons who report having more ACEs would be more likely to have family members at risk of premature death. METHODS: We used data from 17,337 adult health plan members who completed a survey about 10 types of ACEs and whether a family member died before age 65. The prevalence of family member premature death and its association with ACEs were assessed. RESULTS: Family members of respondents who experienced any type of ACEs were more likely to have elevated prevalence for premature death relative to those of respondents without such experience (p < 0.01). The highest risk occurred among those who reported having been physically neglected and living with substance abusing or criminal family members during childhood. A powerful graded relationship between the number of ACEs and premature mortality in the family was observed for all age groups, and comparison between groups reporting 0 ACE and >or= 4 ACEs yielded an OR of 1.8 (95%CI, 1.6-2.0). CONCLUSION: Adverse childhood experiences may be an indicator of a chaotic family environment that results in an increased risk of premature death among family members.

[Study on the influencing factors related to suicide ideation among undergraduates in Anhui province].

OBJECTIVE: To explore the relationships between quality of life, negative life events, social support and suicide ideation among undergraduates in colleges. METHODS: 3517 undergraduates in colleges were recruited by multistage stratified random clustered sampling method. Factors associated with suicide ideation were analyzed with logistic regression by scores of Beck Scale for Suicide Ideation(BSSI), Generic Quality of Life Inventory (GQOLI), Adolescent Self-rate Life Events Checklist (ASLEC), Social Support Rating Scale (SSRS) and a questionnaire on background information. RESULTS: The rate of suicide ideation within 7 days was 14.1%, especially in females (15.96%), with single parent (23.79%) and disabled undergraduates (25.00%). The primary risk factors for suicide ideation were with low psychological function, material life, family/social support, lower availability of support and more negative life events. CONCLUSION: The prevalence of suicide ideation among these undergraduates was high, appropriate measures focusing on these risk factors should be implemented.

Parental alcoholism, adverse childhood experiences, and later risk of personal alcohol abuse among Chinese medical students.

OBJECTIVE: To determine the status of adverse childhood experiences (ACEs) and the association of multiple ACEs with both parental alcoholism and later personal alcohol abuse among Chinese medical students with a view of improving adolescent health and reducing alcohol abuse among them. METHODS: In this cross-sectional study, 2073 Chinese medical students completed a survey on ten categories of ACEs in Anhui province of China. The association of parental alcoholism with ACEs and personal alcohol abuse was assessed by logistic regression analyses. RESULTS: The adjusted odds ratio (OR) for each category of ACEs in the subjects whose parents (either fathers or mothers or both) had alcohol abuse was 2 to 14 times higher than that in those with parental alcoholism (P<0.05). Subjects with bi-parental alcoholism had the highest likelihood of ACEs. Compared with the subjects without ACEs, therisk of personal alcohol abuse was increased by 2-4-folds in the subjects with ACEs, irrespective of parental alcoholism (P<0.05). The total number of ACEs (ACE score) had a graded relationship to 4 categories of personal alcohol abuse with or without parental alcoholism. The prevalence of personal alcohol abuse among the subjects with parental alcoholism was higher, which was independent of ACE scores. CONCLUSION: The prevalence of ACEs is generally serious in China. Efforts should be made to prevent and treat children with ACEs and subsequently to reduce alcohol abuse and later problems.

Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence.

PURPOSE: Alcohol is the most common and frequently used drug and has the potential to cause multiple deleterious effects throughout the lifespan. Because early age at initiation of alcohol use increases this potential and programs and laws are in place to attempt to delay the onset of alcohol use, we studied the relationship between multiple adverse childhood experiences (ACEs) and both the likelihood of ever drinking and the age at initiating alcohol use. METHODS: This was a retrospective cohort study of 8417 adult health maintenance organization (HMO) members in California who completed a survey about ACEs, which included childhood abuse and neglect, growing up with various forms of household dysfunction and alcohol use in adolescence and adulthood. The main outcomes measured were ever drinking and age at initiating alcohol use among ever-drinkers for four age categories: < or = 14 years (early adolescence), 15 to 17 years (mid adolescence), and 18 to 20 years (late adolescence); age > or = 21 years was the referent. The relationship between the total number of adverse childhood experiences (ACE score) and early initiation of alcohol use (< or =14 years) among four birth cohorts dating back to 1900 was also examined. RESULTS: Eighty-nine percent of the cohort reported ever drinking; all individual ACEs except physical neglect increased the risk of ever using alcohol (p < .05). Among ever drinkers, initiating alcohol use by age 14 years was increased two- to threefold by individual ACEs (p < .05). ACEs also accounted for a 20% to 70% increased likelihood of alcohol use initiated during mid adolescence (15-17 years). The total number of ACEs (ACE score) had a very strong graded relationship to initiating alcohol use during early adolescence and a robust but somewhat less strong relationship to initiation during mid adolescence. For each of the four birth cohorts, the ACE score had a strong, graded relationship to initiating alcohol use by age 14 years (p < .05). CONCLUSIONS: Adverse childhood experiences are strongly related to ever drinking alcohol and to alcohol initiation in early and mid adolescence, and the ACE score had a graded or "dose-response" relationship to these alcohol use behaviors. The persistent graded relationship between the ACE score and initiation of alcohol use by age 14 for four successive birth cohorts dating back to 1900 suggests that the stressful effects of ACEs transcend secular changes, including the increased availability of alcohol, alcohol advertising, and the recent campaigns and health education programs to prevent alcohol use. These findings strongly suggest that efforts to delay the age of onset of drinking must recognize the contribution of multiple traumatic and stressful events to alcohol-seeking behavior among children and adolescents.

Childhood residential mobility and multiple health risks during adolescence and adulthood: the hidden role of adverse childhood experiences.

BACKGROUND: Throughout US history, US society has been characterized by its high degree of residential mobility. Previous data suggest a relationship between mobility and increased health risk, but this relationship might be confounded by unmeasured adverse childhood experiences (ACEs). OBJECTIVES: To examine the relationship of childhood residential mobility to health problems during adolescence and adulthood and to determine how much these apparent relationships may result from underlying ACEs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 8116 adults who completed a survey that included childhood residential mobility, ACEs (childhood abuse, childhood neglect, and household dysfunction), and multiple health problems. MAIN OUTCOME MEASURES: Number of childhood residential moves and number of ACEs (ACE score) were assessed for relationships to depressed affect, attempted suicide, alcoholism, smoking, early sexual initiation, and teenaged pregnancy. RESULTS: After adjustment for demographic variables, the risk of high residential mobility during childhood (> or = 8 moves) was 1.7- to 3.1-fold for each ACE, and increased with the number of ACEs. Compared with respondents who never moved, the odds of health risk for respondents with high mobility during childhood ranged from 1.3 (for smoking) to 2.5 (for suicide). However, when the number of ACEs was entered into multivariate models, the relationship between mobility and health problems was greatly reduced. CONCLUSIONS: Adverse childhood experiences are strongly associated with frequent residential mobility. Moreover, the apparent relationship between childhood mobility and various health risks is largely explained by ACEs. Thus, previous studies showing a relationship between residential mobility and negative outcomes were likely confounded by unmeasured ACEs.

Long-term consequences of childhood sexual abuse by gender of victim.

BACKGROUND: Childhood sexual abuse (CSA) is a worldwide problem. Although most studies on the long-term consequences of CSA have focused on women, sexual abuse of both boys and girls is common. Thus, a comparison of the long-term effects of CSA by gender of the victim will provide perspective on the need for future research, prevention activities, and treatment of survivors. METHODS: A retrospective cohort study was conducted from 1995 to 1997 among 17,337 adult HMO members in San Diego, California. Participants completed a survey about abuse or household dysfunction during childhood, and multiple other health-related issues. Multivariate logistic regression was used to examine the relationships between severity of CSA (intercourse vs no intercourse) and long-term health and social problems (substance use and abuse, mental illness, and current problems with marriage and family) by gender of victim. Models controlled for exposure to other forms of adverse childhood experiences that co-occur with CSA. Among men, the relationship between the gender of the CSA perpetrator to the outcomes was also examined. RESULTS: Contact CSA was reported by 16% of males and 25% of females. Men reported female perpetration of CSA nearly 40% of the time, and women reported female perpetration of CSA 6% of the time. CSA significantly increased the risk of the outcomes. The magnitude of the increase was similar for men and women. For example, compared to reporting no sexual abuse, a history of suicide attempt was more than twice as likely among both men and women who experienced CSA (p<0.05). Compared with those who did not report CSA, men and women exposed to CSA were at a 40% increased risk of marrying an alcoholic, and a 40% to 50% increased risk of reporting current problems with their marriage (p<0.05). CONCLUSIONS: In this cohort of adult HMO members, experiencing CSA was common among both men and women. The long-term impact of CSA on multiple health and social problems was similar for both men and women. These findings strongly indicate that boys and girls are vulnerable to this form of childhood maltreatment; the similarity in the likelihood for multiple behavioral, mental, and social outcomes among men and women suggests the need to identify and treat all adults affected by CSA.

Insights into causal pathways for ischemic heart disease: adverse childhood experiences study.

BACKGROUND: The purpose of this study was to assess the relation of adverse childhood experiences (ACEs), including abuse, neglect, and household dysfunction, to the risk of ischemic heart disease (IHD) and to examine the mediating impact on this relation of both traditional IHD risk factors and psychological factors that are associated with ACEs. METHODS AND RESULTS: Retrospective cohort survey data were collected from 17,337 adult health plan members from 1995 to 1997. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACE-IHD relation and the mediating impact of IHD risk factors in this relation. Nine of 10 categories of ACEs significantly increased the risk of IHD by 1.3- to 1.7-fold versus persons with no ACEs. The adjusted odds ratios for IHD among persons with > or =7 ACEs was 3.6 (95% CI, 2.4 to 5.3). The ACE-IHD relation was mediated more strongly by individual psychological risk factors commonly associated with ACEs than by traditional IHD risk factors. We observed significant association between increased likelihood of reported IHD (adjusted ORs) and depressed affect (2.1, 1.9 to 2.4) and anger (2.5, 2.1 to 3.0) as well as traditional risk factors (smoking, physical inactivity, obesity, diabetes and hypertension), with ORs ranging from 1.2 to 2.7. CONCLUSIONS: We found a dose-response relation of ACEs to IHD and a relation between almost all individual ACEs and IHD. Psychological factors appear to be more important than traditional risk factors in mediating the relation of ACEs to the risk of IHD. These findings provide further insights into the potential pathways by which stressful childhood experiences may increase the risk of IHD in adulthood.

The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction.

OBJECTIVE: Childhood abuse and other adverse childhood experiences (ACEs) have historically been studied individually, and relatively little is known about the co-occurrence of these events. The purpose of this study is to examine the degree to which ACEs co-occur as well as the nature of their co-occurrence. METHOD: We used data from 8,629 adult members of a health plan who completed a survey about 10 ACEs which included: childhood abuse (emotional, physical, and sexual), neglect (emotional and physical), witnessing domestic violence, parental marital discord, and living with substance abusing, mentally ill, or criminal household members. The bivariate relationship between each of these 10 ACEs was assessed, and multivariate linear regression models were used to describe the interrelatedness of ACEs after adjusting for demographic factors. RESULTS: Two-thirds of participants reported at least one ACE; 81%-98% of respondents who had experienced one ACE reported at least one additional ACE (median: 87%). The presence of one ACE significantly increased the prevalence of having additional ACEs, elevating the adjusted odds by 2 to 17.7 times (median: 2.8). The observed number of respondents with high ACE scores was notably higher than the expected number under the assumption of independence of ACEs (p <.0001), confirming the statistical interrelatedness of ACEs. CONCLUSIONS: The study provides strong evidence that ACEs are interrelated rather than occurring independently. Therefore, collecting information about exposure to other ACEs is advisable for studies that focus on the consequences of a specific ACE. Assessment of multiple ACEs allows for the potential assessment of a graded relationship between these childhood exposures and health and social outcomes.

Mortality patterns among workers exposed to styrene in the reinforced plastic boatbuilding industry: an update.

BACKGROUND: Mortality was updated through 1998 for 5,204 workers exposed to styrene between 1959 and 1978 at two reinforced plastic boatbuilding plants. The a priori hypothesis: leukemia and lymphoma excesses would be found. METHODS: Standardized mortality ratios (SMR) and 95% confidence intervals (CI) used Washington State and U.S. rates. RESULTS: Overall, 860 deaths occurred (SMR 1.09, CI 1.02-1.17), with excess mortality for esophageal cancer (n = 12, SMR 2.30, CI 1.19-4.02), prostate cancer (n = 24, SMR 1.71, CI 1.09-2.54), and accidents (n = 99, SMR 1.26, CI 1.02-1.53). Among 2,062 highly exposed workers, urinary tract cancer (n = 6, SMR 3.44, CI 1.26-7.50) and respiratory disease (n = 12, SMR 2.54, CI 1.31-4.44) rates were elevated. Urinary tract cancer SMR increased with duration of employment. CONCLUSIONS: We found no excess leukemia or lymphoma mortality. Unanticipated excess urinary tract cancer and respiratory disease mortality, possibly associated with styrene exposure, are difficult to interpret and could be chance findings.

Adverse childhood experiences and self-reported liver disease: new insights into the causal pathway.

OBJECTIVE: To examine the relationship of adverse childhood experiences (ACEs), including abuse, neglect, and forms of household dysfunction, to the risk of liver disease by assessing the role of risk behaviors, such as substance abuse and high-risk sexual activity, as mediators of the ACEs-liver disease relationship. METHODS: Retrospective cohort study data were collected from 17 337 adult health plan members through a survey. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACEs-liver disease relationship and the impact of the mediators in this relationship. RESULTS: Each of 10 ACEs increased the risk of liver disease 1.2 to 1.6 times (P<.001). The number of ACEs (ACE score) had a graded relationship to liver disease (P<.001). Compared with persons with no ACEs, the adjusted odds ratio of ever having liver disease among persons with 6 or more ACEs was 2.6 (P<.001). The ACE score also had a strong graded relationship to risk behaviors for liver disease. The strength of the ACEs-liver disease association was reduced 38% to 50% by adjustment for these risk behaviors, suggesting they are mediators of this relationship. CONCLUSIONS: The ACE score showed a graded relationship to the risk of liver disease that appears to be mediated substantially by behaviors that increase the risk of viral and alcohol-induced liver disease. Understanding the effect of ACEs on the risk of liver disease and development of these behaviors provides insight into causal pathways, which may prove useful in the prevention of liver disease.

The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900.

BACKGROUND: We examined the relationship of the number of adverse childhood experiences (ACE score) to six health problems among four successive birth cohorts dating back to 1900 to assess the strength and consistency of these relationships in face of secular influences the 20th century brought in changing health behaviors and conditions. We hypothesized that the ACE score/health problem relationship would be relatively "immune" to secular influences, in support of recent studies documenting the negative neurobiologic effects of childhood stressors on the developing brain. METHODS: A retrospective cohort study of 17,337 adult health maintenance organization (HMO) members who completed a survey about childhood abuse and household dysfunction, as well as their health. We used logistic regression to examine the relationships between ACE score and six health problems (depressed affect, suicide attempts, multiple sexual partners, sexually transmitted diseases, smoking, and alcoholism) across four successive birth cohorts: 1900-1931, 1932-1946, 1947-1961, and 1962-1978. RESULTS: The ACE score increased the risk for each health problem in a consistent, strong, and graded manner across four birth cohorts (P < 0.05). For each unit increase in the ACE score (range: 0-8), the adjusted odds ratios (ORs) for depressed affect, STDs, and multiple sexual partners were increased within a narrow range (ORs: 1.2-1.3 per unit increase) for each of the birth cohorts; the increase in risk for suicide attempts was stronger but also in a narrow range (ORs: 1.5-1.7). CONCLUSIONS: Growing up with ACEs increased the risk of numerous health behaviors and outcomes for 20th century birth cohorts, suggesting that the effects of ACEs on the risk of various health problems are unaffected by social or secular changes. Research showing detrimental and lasting neurobiologic effects of child abuse on the developing brain provides a plausible explanation for the consistency and dose-response relationships found for each health problem across birth cohorts, despite changing secular influences.

The relationship of exposure to childhood sexual abuse to other forms of abuse, neglect, and household dysfunction during childhood.

OBJECTIVE: This study assesses the relationship of childhood sexual abuse (CSA) to nine other categories of Adverse Childhood Experiences (ACEs), including childhood abuse, neglect, and multiple types of household dysfunction. METHODS: Retrospective cohort study data were collected from 17,337 adult health plan members who responded to a survey questionnaire. Regression models adjusted for age, race, and education were used to estimate the strength of the association of CSA to each of the other nine ACEs and a graded relationship between measures of the severity of CSA and the number of other ACEs (ACE score). RESULTS: CSA was reported by 25% of women and 16% of men. In comparison with persons who were not exposed to CSA, the likelihood of experiencing each category of ACE increased 2- to 3.4-fold for women and 1.6- to 2.5-fold for men (p < 0.05). The adjusted mean ACE score showed a significant positive graded relationship to the severity, duration, and frequency of CSA and an inverse relationship to age at first occurrence of CSA (p < 0.01). CONCLUSIONS: CSA is strongly associated with experiencing multiple other forms of ACEs. The strength of this association appears to increase as the measures of severity of the CSA increases. The understanding of the interrelatedness of CSA with multiple ACEs should be considered in the design of studies, treatment, and programs to prevent CSA as well as other forms of ACEs.

Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study.

OBJECTIVE: Illicit drug use is identified in Healthy People 2010 as a leading health indicator because it is associated with multiple deleterious health outcomes, such as sexually transmitted diseases, human immunodeficiency virus, viral hepatitis, and numerous social problems among adolescents and adults. Improved understanding of the influence of stressful or traumatic childhood experiences on initiation and development of drug abuse is needed. METHODS: We examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age categories: or=19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use. RESULTS: Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug addiction, and parenteral drug use. Compared with people with 0 ACEs, people with >or=5 ACEs were 7- to 10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use. The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%, 64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong graded relationship to lifetime drug use. CONCLUSIONS: The ACE score had a strong graded relationship to the risk of drug initiation from early adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to account for one half to two third of serious problems with drug use, progress in meeting the national goals for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing childhood experiences by pediatric practice.

Indoor particles and symptoms among office workers: results from a double-blind cross-over study.

BACKGROUND: We studied the effects of removing small airborne particles in an office building without unusual contaminant sources or occupant complaints. METHODS: We conducted a double-blind crossover study of enhanced particle filtration in an office building in the Midwest United States in 1993. We replaced standard particle filters, in separate ventilation systems on two floors, with highly efficient filters on alternate floors weekly over 4 weeks. Repeated-measures models were used to analyze data from weekly worker questionnaires and multiple environmental measurements. RESULTS: Bioaerosol concentrations were low. Enhanced filtration reduced concentrations of the smallest airborne particles by 94%. This reduction was not associated with reduced symptoms among the 396 respondents, but three performance-related mental states improved; for example, the confusion scale decreased (-3.7%; 95% confidence limits (CL) = -6.5, -0.9). Most environmental dissatisfaction variables also improved; eg, "stuffy" air, -5.3% (95% CL = -10.3, -0.4). Cooler temperatures within the recommended comfort range were associated with remarkably large improvement in most outcomes; for example, chest tightness decreased -23.4% (95% CL = -38.1, -8.7) for every 1 degrees C decrease. CONCLUSIONS: Benefits of enhanced filtration require assessment in buildings with higher particulate contaminant levels in studies controlling for temperature effects. Benefits from lower indoor temperatures need confirmation.