Prevalence of indications of alcohol and drug use among patients treated for injurious falls by Emergency Medical Services.

Objective: To describe the distribution of alcohol and drug involvement in injurious falls by location and subtype of fall. Methods: Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset we identified 1,854,909 patients injured from falls requiring an Emergency Medical Services (EMS) response and determined the fall location (e.g. indoors or on street/sidewalk) and the EMS clinician's notation of alcohol or drug involvement. We analyzed substance involvement by fall subtype, location of fall and patient demographics. Results: Overall, for 7.4% of injurious falls there was a notation of substance use: 6.5% for alcohol alone, 0.6% for drugs and 0.3% for alcohol and drugs. 21.2% of falls that occurred on a street or sidewalk had a notation of substance use; alcohol use alone for 18.5% of falls, drugs alone for 1.7% of falls and alcohol and drugs for 0.9% of falls. Substance use prevalence was highest, at 30.3%, in the age group 21 to 64 years, for falls occurring on streets and sidewalks, without syncope or heat illness as contributing factors; alcohol use alone for 26.3%, drugs alone for 2.6%, and alcohol and drugs for 1.4%. Reported substance use involvement was more frequent for men compared to women for each location type. Conclusions: Overall, 1-in-5 injurious falls on streets and sidewalks and requiring EMS attention involved substance use, and these numbers likely underestimate the true burden. As cities seek to expand nightlife districts, design strategies to protect pedestrians from falls should be enacted.

Development and validation of mortality prediction models based on the social determinants of health.

BACKGROUND: There is no standardised approach to screening adults for social risk factors. The goal of this study was to develop mortality risk prediction models based on the social determinants of health (SDoH) for clinical risk stratification. METHODS: Data were used from REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based, longitudinal cohort of black and white Americans aged ≥45 recruited between 2003 and 2007. Analysis was limited to participants with available SDoH and mortality data (n=20 843). All-cause mortality, available through 31 December 2018, was modelled using Cox proportional hazards with baseline individual, area-level and business-level SDoH as predictors. The area-level Social Vulnerability Index (SVI) was included for comparison. All models were adjusted for age, sex and sampling region and underwent internal split-sample validation. RESULTS: The baseline prediction model including only age, sex and REGARDS sampling region had a c-statistic of 0.699. An individual-level SDoH model (Model 1) had a higher c-statistic than the SVI (0.723 vs 0.708, p<0.001) in the testing set. Sequentially adding area-level SDoH (c-statistic 0.723) and business-level SDoH (c-statistics 0.723) to Model 1 had minimal improvement in model discrimination. Structural racism variables were associated with all-cause mortality for black participants but did not improve model discrimination compared with Model 1 (p=0.175). CONCLUSION: In conclusion, SDoH can improve mortality prediction over 10 years relative to a baseline model and have the potential to identify high-risk patients for further evaluation or intervention if validated externally.

Clinical Trauma Severity of Indoor and Outdoor Injurious Falls Requiring Emergency Medical Service Response.

Background: Injurious falls represent a significant public health burden. Research and polices have primarily focused on falls occurring indoors despite evidence that outdoor falls account for 47-58% of all falls requiring some medical attention. This study compared the clinical trauma severity of indoor versus outdoor injurious falls requiring Emergency Medical Services (EMS) response. Methods: Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset, we identified the location of patients injured from falls that required EMS response. We classified injury severity using 1) the Revised Trauma Score for Triage (T-RTS): ≤ 11 indicated the need for transport to a Trauma Center; 2) Glasgow Coma Scale (GCS): ≤8 and 9-12 indicated moderate and severe neurologic injury; and 3) patient clinical acuity by EMS: Dead, Critical, Emergent, Low. Results: Of 1,854,909 encounters for patients with injurious falls, the vast majority occurred indoors (n=1,596,860) compared to outdoors (n=152,994). The proportions of patients with moderate or severe GCS scores, were comparable between those with indoor falls (3.0%) and with outdoor falls on streets or sidewalks (3.8%), T-RTS scores indicating need for transport to a Trauma Center (5.2% vs 5.9%) and EMS acuity rated as Emergent or Critical (27.7% vs 27.1%).Injurious falls were more severe among male patients compared to females: and males injured by falling on streets or sidewalks had higher percentages for moderate or severe GCS scores (4.8% vs 3.6%) and T-RTS scores indicating the need for transport to a Trauma Center (7.3% vs 6.5%) compared to indoor falls. Young and middle-aged patients whose injurious falls occurred on streets or sidewalks were more likely to have a T-RTS score indicating the need for Trauma Center care compared to indoor falls among this subgroup. Yet older patients injured by falling indoors were more likely to have a T-RTS score indicating the need for Trauma Center than older patients who fell on streets or sidewalks. Conclusions: There was a similar proportion of patients with severe injurious falls that occurred indoors and on streets or sidewalks. These findings suggest the need to determine outdoor environmental risks for outdoor falls to support location-specific interventions.

Population-Level Surveillance of Domestic Assaults in the Home Using the National Emergency Medical Services Information System (NEMSIS).

Violence in the home, including partner violence, child abuse, and elder abuse, is pervasive in the United States. An informatics approach allowing automated analysis of administrative data to identify domestic assaults and release timely and localized data would assist preventionists to identify geographic and demographic populations of need and design tailored interventions. This study examines the use of an established national dataset, the NEMSIS 2019, as a potential annual automated data source for domestic assault surveillance. An algorithm was used to identify individuals who utilized emergency medical services (EMS) for a physical assault in a private residence (N = 176,931). Descriptive analyses were conducted to define the identified population and disposition of patients. A logistic regression was performed to predict which characteristics were associated with consistent domestic assault identification by the on-scene EMS clinician and dispatcher. The sample was majority female (52.2%), White (44.7%), urban (85.5%), and 21-29 years old (24.4%). A disproportionate number of those found dead on scene were men (74.5%), and female patients more often refused treatment (57.8%) or were treated and then released against medical advice (58.4%). Domestic assaults against children and seniors had higher odds of being consistently identified by both the dispatcher and EMS clinician than those 21-49, and women had lower odds of consistent identification than men. While a more specific field to identify the type of domestic assault (e.g., intimate partner) would help inform specialized intervention planning, these data indicate an opportunity to systematically track domestic assaults in communities and describe population-specific needs.

Disadvantaged groups have greater spatial access to pharmacies in New York state.

BACKGROUND: The accessibility of pharmacies has been associated with overall health and wellbeing. Past studies have suggested that low income and racial minority communities are underserved by pharmacies. However, the literature is inconsistent in finding links between area-level income or racial and ethnic composition and access to pharmacies. Here we aim to assess area-level spatial access to pharmacies across New York State (NYS), hypothesizing that Census Tracts with higher poverty rates and higher percentages of Black and Hispanic residents would have lower spatial access. METHODS: The population weighted mean shortest road network distance (PWMSD) to a pharmacy in 2018 was calculated for each Census Tract in NYS. This statistic was calculated from the shortest road network distance to a pharmacy from the centroid of each Census block within a tract, with the mean across census blocks weighted by the population of the census block. Cross-sectional analyses were conducted to assess links between Tract-level socio demographic characteristics and Tract-level PWMSD to a pharmacy. RESULTS: Overall the mean PWMSD to a pharmacy across Census tracts in NYS was 2.07 Km (SD = 3.35, median 0.85 Km). Shorter PWMSD to a pharmacy were associated with higher Tract-level % poverty, % Black/African American (AA) residents, and % Hispanic/Latino residents and with lower Tract-level % of residents with a college degree. Compared to tracts in the lowest quartile of % Black/AA residents, tracts in the highest quartile had a 70.7% (95% CI 68.3-72.9%) shorter PWMSD to a pharmacy. Similarly, tracts in the highest quartile of % poverty had a 61.3% (95% CI 58.0-64.4%) shorter PWMSD to a pharmacy than tracts in the lowest quartile. CONCLUSION: The analyses show that tracts in NYS with higher racial and ethnic minority populations and higher poverty rates have higher spatial access to pharmacies.

Rhinorrhea and watery eyes in infancy and risk of attention-deficit hyperactivity disorder in school-age children.

Increased parasympathetic nervous system (PNS) activity is associated with attention-deficit/hyperactivity disorder (ADHD) inattentive symptoms, but not hyperactive-impulsive symptoms, and may contribute to inattentive subtype etiology. Guided by prior work linking infant rhinorrhea and watery eyes without a cold (RWWC) to PNS dysregulation, we examined associations between infant RWWC and childhood ADHD symptoms in a longitudinal cohort of Black and Latinx children living in the context of economic disadvantage (N = 301 youth: 158 females, 143 males). Infant RWWC predicted higher inattentive (relative risk [RR] 2.16, p < .001) but not hyperactive-impulsive (RR 1.53, p = .065) ADHD symptoms (DuPaul scale), administered to caregivers at child age 8-14 years. Stratified analyses revealed that these associations were present in females but not males, who were three times more likely to have higher ADHD current total symptoms if they had infant RWWC than if they did not. Additionally, associations between RWWC and inattention symptoms were observed only in females. RWWC may thus serve as a novel risk marker of ADHD inattentive-type symptoms, especially for females.

Inverse associations of cord blood mitochondrial DNA copy number with childhood adiposity.

OBJECTIVE: The objective of this study was to examine associations between umbilical cord mitochondrial DNA copy number (mtDNAcn) and adiposity across childhood. METHODS: In a prospective birth cohort of Dominican and African American children from New York City, New York (1998-2006), mtDNAcn was measured in cord blood. Children (N = 336) were evaluated for their height, weight, and bioimpedance at age 5, 7, 9, and 11 years. We used linear mixed-effects models to assess associations of mtDNAcn tertiles in cord blood with child BMI, BMI z scores, fat mass index, and body fat percentage. Latent class growth models and interactions between mtDNAcn and child age or child age2 were used to assess associations between age and adiposity trajectories. RESULTS: BMI was, on average, 1.5 kg/m2 higher (95% CI: 0.58, 2.5) in individuals with mtDNAcn in the low- compared with the middle-mtDNAcn tertile. Results were similar for BMI z score, fat mass index, and body fat percentage. Moreover, children in the low-mtDNAcn group had increased odds of being in an "increasing" or "high-stable" adiposity class. CONCLUSIONS: Lower mtDNAcn at birth may predict greater childhood adiposity, highlighting the potential key role of perinatal mitochondrial function in adiposity during development.

Patterns of B-cell lymphocyte expression changes in pre- and post-malignant prostate tissue are associated with prostate cancer progression.

BACKROUND: Inflammation characterized by the presence of T and B cells is often observed in prostate cancer, but it is unclear how T- and B-cell levels change during carcinogenesis and whether such changes influence disease progression. METHODS: The study used a retrospective sample of 73 prostate cancer cases (45 whites and 28 African Americans) that underwent surgery as their primary treatment and had a benign prostate biopsy at least 1 year before diagnosis. CD3+, CD4+, and CD20+ lymphocytes were quantified by immunohistochemistry in paired pre- and post-diagnostic benign prostate biopsy and tumor surgical specimens, respectively. Clusters of similar trends of expression across two different timepoints and three distinct prostate regions-benign biopsy glands (BBG), tumor-adjacent benign glands (TAG), and malignant tumor glandular (MTG) regions-were identified using Time-series Anytime Density Peaks Clustering (TADPole). A Cox proportional hazards model was used to estimate the hazard ratio (HR) of time to biochemical recurrence associated with region-specific lymphocyte counts and regional trends. RESULTS: The risk of biochemical recurrence was significantly reduced in men with an elevated CD20+ count in TAG (HR = 0.81, p = 0.01) after adjusting for covariates. Four distinct patterns of expression change across the BBG-TAG-MTG regions were identified for each marker. For CD20+, men with low expression in BBG and higher expression in TAG compared to MTG had an adjusted HR of 3.06 (p = 0.03) compared to the reference group that had nominal differences in CD20+ expression across all three regions. The two CD3+ expression patterns that featured lower CD3+ expression in the BBG compared to the TAG and MTG regions had elevated HRs ranging from 3.03 to 4.82 but did not reach statistical significance. CONCLUSIONS: Longitudinal and spatial expression patterns of both CD3+ and CD20+ suggest that increased expression in benign glands during prostate carcinogenesis is associated with an aggressive disease course.

Sex-Specific Depressive Symptom Trajectories Among Adolescents in Los Angeles County, 2013 to 2017.

Objective: After remaining stable for many years, the prevalence of depression among adolescents increased over the past decade, particularly among girls. In this study, we used longitudinal data from a cohort of high school students to characterize sex-specific trajectories of depressive symptoms during this period of increasing prevalence and widening gender gap in adolescent depression. Method: Using data from the Health and Happiness Cohort, a longitudinal 8-wave study of high school students residing in Los Angeles County from 2013 to 2017 (N = 3,393), we conducted a multiple-group, latent class growth analysis by sex to differentiate developmental trajectories in depressive symptoms scores measured by the Center for Epidemiological Studies- Depression (CES-D) scale (range, 0-60). Results: A 4-class solution provided the best model fit for both girls and boys. Trajectories among girls included low stable (35.1%), mild stable (42.8%), moderate decreasing (16.2%), and high arching (5.9%). Trajectories among boys included low stable (49.2%), mild increasing (34.7%), moderate decreasing (12.2%), and high increasing (3.9%). Average scores consistently exceeded or crossed the threshold for probable depression (≥16). Across comparable sex-specific trajectory groups, the average CES-D scores of girls were higher than those of boys, whose average scores increased over time. Conclusion: In a diverse cohort of students in Los Angeles County, depressive symptom trajectories were comparable to prior time periods but with a higher proportion of students in trajectories characterized by probable depression. Trajectories differed by sex, suggesting that future research should consider differential severity and onset of depression between boys and girls.

Defining Spatial Epidemiology: A Systematic Review and Re-Orientation.

BACKGROUND: Spatial epidemiology has emerged as an important subfield of epidemiology over the past quarter century. We trace the origins of spatial epidemiology and note that its emergence coincided with technological developments in spatial statistics and geography. We hypothesize that spatial epidemiology makes important contributions to descriptive epidemiology and analytic risk factor studies, but is not yet aligned with epidemiology's current focus on causal inference and intervention. METHODS: We conducted a systematic review of studies indexed in PubMed that used the term "spatial epidemiolog*" in the title, abstract, or keywords. Excluded papers were not written in English, examined disease in animals, or reported biologic pathogen distribution only. We coded the included papers into five categories (review, demonstration of method, descriptive, analytic, intervention) and recorded the unit of analysis (i.e., individual vs. ecological). We additionally examined papers coded as analytic ecologic studies using scales for lexical content. RESULTS: A total of 482 papers met the inclusion criteria, including 76 reviews, 117 demonstrations of methods, 122 descriptive studies, 167 analytic studies, and 0 intervention studies. Demonstration studies were most common from 2006 to 2014, and analytic studies were most common after 2015. Among the analytic ecologic studies, those published in later years used more terms relevant to spatial statistics (IRR =1.3, 95%CI: 1.1, 1.5) and causal inference (IRR =1.1, 95%CI: 1.1, 1.2). CONCLUSIONS: Spatial epidemiology is an important and growing subfield of epidemiology. We suggest a re-orientation to help align its practice with the goals of contemporary epidemiology.

Examining racial and ethnic heat exposure disparities in New York City (NYC) across different spatial and political scales through geographic effect measure modification.

Structural racism in the United States has resulted in neighborhoods with higher proportions of non-Hispanic Black (Black) or Hispanic/Latine residents having more features that intensify, and less that cool, the local-heat environment. This study identifies areas of New York City (NYC) where racial/ethnic heat exposure disparities are concentrated. We analyzed data from the 2013-2017 American Community Survey, U.S Landsat-8 Analysis Ready Data on summer surface temperatures, and NYC Land Cover Dataset at the census tract-level (n = 2098). Four cross-sectional regression modeling strategies were used to estimate the overall City-wide association, and associations across smaller intra-city areas, between tract-level percent of Black and percent Hispanic/Latine residents and summer day surface temperature, adjusting for altitude, shoreline, and nature-cover: overall NYC linear, borough-specific linear, Community District-specific linear, and geographically weighted regression models. All three linear regressions identified associations between neighborhood racial and ethnic composition and summer day surface temperatures. The geographically weighted regression models, which address the issue of spatial autocorrelation, identified specific locations (such as northwest Bronx, central Brooklyn, and uptown Manhattan) within which racial and ethnic disparities for heat exposures are concentrated. Through examining the overall effects and geographic effect measure modification across spatial scales, the results of this study identify specific geographic areas for intervention to mitigate heat exposure disparities experienced by Black and Hispanic/Latine NYC residents.

The CHANGE (Climate Health ANalysis Grading Evaluation) tool for weight of evidence reviews on climate change and health research.

BACKGROUND: Climate change has been identified as one of the biggest threats to human health. Despite this claim, there are no standardized tools that assess the rigor of published literature for use in weight of evidence (WOE) reviews. Standardized assessment tools are essential for creating clear and comparable WOE reviews. As such, we developed a standardized tool for evaluating the quality of climate change and health studies focused on evaluating studies that quantify exposure-response relationships and studies that implement and/or evaluate adaptation interventions. METHODS: The authors explored systematic-review methodology to enhance transparency and increase efficiency in summarizing and synthesizing findings from studies on climate change and health research. The authors adapted and extended existing WOE methods to develop the CHANGE (Climate Health ANalysis Grading Evaluation) tool. The resulting assessment tool has been refined through application and subsequent team input. RESULTS: The CHANGE tool is a two-step standardized tool for systematic review of climate change and health studies of exposure-response relationships and adaptation intervention studies. Step one of the CHANGE tool aims to classify studies included in weight-of-evidence reviews and step two assesses the quality and presence of bias in the climate change and health studies. CONCLUSION: The application of the CHANGE tool in WOE reviews of climate change and health will lead to increased comparability, objectivity, and transparency within this research area.

A National Study on the Comparative Burden of Pedestrian Injuries from Falls Relative to Pedestrian Injuries from Motor Vehicle Collisions.

Pedestrian injuries from falls are an understudied cause of morbidity. Here, we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 118,520 injurious pedestrian falls and 33,915 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty-two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 19% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.1 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was 3.9 for individuals 50 years and older and 6.1 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy, and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the USA.

Robot-Assisted Surgery and Racial and Ethnic Disparities in Post-Prostatectomy Outcomes Among Prostate Cancer Patients.

BACKGROUND: We sought to determine whether the differences in short-term outcomes between patients undergoing robot-assisted radical prostatectomy (RARP) and those treated with open radical prostatectomy (ORP) differ by race and ethnicity. METHODS: This observational study used New York State Cancer Registry data linked to discharge records and included patients undergoing radical prostatectomy for localized prostate cancer during 2008-2018. We used logistic regression to examine the association between race and ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic), surgical approach (RARP, ORP), and postoperative outcomes (major events, prolonged length of stay [pLOS], 30-day re-admission). We tested interaction between race and ethnicity and surgical approach on multiplicative and additive scales. RESULTS: The analytical cohort included 18,926 patients (NHW 14,215 [75.1%], NHB 3195 [16.9%], Hispanic 1516 [8.0%]). The average age was 60.4 years (standard deviation 7.1). NHB and Hispanic patients had lower utilization of RARP and higher risks of postoperative adverse events than NHW patients. NHW, NHB, and Hispanic patients all had reduced risks of adverse events when undergoing RARP versus ORP. The absolute reductions in the risks of major events and pLOS following RARP versus ORP were larger among NHB {relative excess risk due to interaction (RERI): major events -0.32 [95% confidence interval (CI) -0.71 to -0.03]; pLOS -0.63 [95% CI -0.98 to -0.35]) and Hispanic (RERI major events -0.27 [95% CI -0.77 to 0.09]; pLOS -0.93 [95% CI -1.46 to -0.51]) patients than among NHW patients. The interaction was absent on the multiplicative scale. CONCLUSIONS: RARP use has not penetrated and benefited all racial and ethnic groups equally. Increasing utilization of RARP among NHB and Hispanic patients may help reduce disparities in patient outcomes after radical prostatectomy.

A Segmented Regression Analysis of Household Income and Recurrent Falls Among Adults in a National Cohort Study.

Falls can have life-altering consequences for older adults, including extended recovery periods and compromised independence. Higher household income may mitigate the risk of falls by providing financial resources for mobility tools, remediation of environmental hazards, and needed supports, or it may buffer the impact of an initial fall on subsequent risk through improved assistance and care. Household income has not had a consistently observed association with falls in older adults; however, a segmented association may exist such that associations are attenuated above a certain income threshold. In this study, we utilized segmented negative binomial regression analysis to examine the association between household income and recurrent falls among 2,302 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study recruited between 2003 and 2007. Income-fall association segments separated by changes in slope were considered. Model results indicated a 2-segment association between household income and recurrent falls in the past year. In the range below the breakpoint, household income was negatively associated with the rate of recurrent falls across all age groups examined; in a higher income range (from $20,000-$49,999 to ≥$150,000), the association was attenuated (weaker negative trend) or reversed (positive trend). These findings point to potential benefits of ensuring that incomes for lower-income adults exceed the threshold needed to confer a reduced risk of recurrent falls.

Racial and Ethnic Disparities in the Use of Robot-Assisted Surgery and Minimally Invasive Surgery in Pelvic Cancer Treatment: A Systematic Review.

Surgical innovations for cancer treatment may penetrate differentially across racial and ethnic groups and contribute to disparities in health and health care quality. We summarized the current evidence of racial and ethnic disparities in robot-assisted surgery (RAS) and minimally invasive surgery (MIS) use in four major pelvic cancer treatments. We identified studies related to racial and ethnic disparities in RAS and/or MIS use in the treatment of prostate, endometrial, bladder, and rectal cancers during 2001 to 2022 from PubMed, EMBASE, and the Cochrane database. Twenty-eight studies were selected (prostate = 7, endometrial = 14, bladder = 1, rectal = 5, multiple cancers = 1) and all were retrospective. Thirteen and 23 studies examined racial and ethnic differences in individual patients' receipt of RAS and MIS, respectively. Black patients were less likely to receive RAS/MIS than White patients in most studies. Hispanic patients were less likely to receive RAS/MIS than White patients in just over half of the studies. Studies of Asian patients were few and reported mixed results. Three studies examined disparities on the center level and found that racial and ethnic minority prostate cancer patients were less likely to be treated at RAS-performing or high-technology facilities. More work is needed to improve understanding of the mechanisms underlying racial and ethnic disparities in RAS and MIS use and their impact on disparities in health outcomes.

Precocious infant fecal microbiome promotes enterocyte barrier dysfuction, altered neuroendocrine signaling and associates with increased childhood obesity risk.

Early life gut microbiome composition has been correlated with childhood obesity, though microbial functional contributions to disease origins remain unclear. Here, using an infant birth cohort (n = 349) we identify a distinct fecal microbiota composition in 1-month-old infants with the lowest rate of exclusive breastfeeding, that relates with higher relative risk for obesity and overweight phenotypes at two years. Higher-risk infant fecal microbiomes exhibited accelerated taxonomic and functional maturation and broad-ranging metabolic reprogramming, including reduced concentrations of neuro-endocrine signals. In vitro, exposure of enterocytes to fecal extracts from higher-risk infants led to upregulation of genes associated with obesity and with expansion of nutrient sensing enteroendocrine progenitor cells. Fecal extracts from higher-risk infants also promoted enterocyte barrier dysfunction. These data implicate dysregulation of infant microbiome functional development, and more specifically promotion of enteroendocrine signaling and epithelial barrier impairment in the early-life developmental origins of childhood obesity.