A Macroscopic Quantum Three-Box Paradox: Finding Consistency with Weak Macroscopic Realism.

The quantum three-box paradox considers a ball prepared in a superposition of being in any one of three boxes. Bob makes measurements by opening either box 1 or box 2. After performing some unitary operations (shuffling), Alice can infer with certainty that the ball was detected by Bob, regardless of which box he opened, if she detects the ball after opening box 3. The paradox is that the ball would have been found with certainty by Bob in either box if that box had been opened. Resolutions of the paradox include that Bob's measurement cannot be made non-invasively or else that realism cannot be assumed at the quantum level. Here, we strengthen the case for the former argument by constructing macroscopic versions of the paradox. Macroscopic realism implies that the ball is in one of the boxes prior to Bob or Alice opening any boxes. We demonstrate the consistency of the paradox with macroscopic realism, if carefully defined (as weak macroscopic realism, wMR) to apply to the system at the times prior to Alice or Bob opening any boxes but after the unitary operations associated with preparation or shuffling. By solving for the dynamics of the unitary operations and comparing with mixed states, we demonstrate agreement between the predictions of wMR and quantum mechanics: the paradox only manifests if Alice's shuffling combines both local operations (on box 3) and nonlocal operations, on the other boxes. Following previous work, the macroscopic paradox is shown to correspond to a violation of a Leggett-Garg inequality, which implies failure of non-invasive measurability if wMR holds.

Association of Incomplete Neurovascular Imaging After Emergency Department Encounters for Transient Ischemic Attack and Odds of Subsequent Stroke: A National Medicare Analysis.

BACKGROUND. Multisociety guidelines recommend urgent brain and neurovascular imaging for patients with transient ischemic attack (TIA), to identify and treat modifiable stroke risk factors. Prior research suggests that most patients with TIA who present to the emergency department (ED) do not receive prompt neurovascular imaging. OBJECTIVE. The purpose of this study was to evaluate the association between incomplete neurovascular imaging workup during ED encounters for TIA and the odds of subsequent stroke. METHODS. This retrospective study obtained data from the Medicare Standard Analytical Files for calendar years 2016 and 2017; these files contain 100% samples of claims for Medicare beneficiaries. Information was extracted using ICD 10th revision (ICD-10) and CPT codes. Those patients who were discharged from an ED encounter with a TIA diagnosis and who underwent brain CT or brain MRI during or within 2 days of the encounter were identified. Patients were considered to have complete neurovascular imaging if they underwent cross-sectional vascular imaging of both the brain (brain CTA or brain MRA) and neck (neck CTA, neck MRA, or carotid ultrasound) during or within 2 days of the encounter. The association between incomplete neurovascular imaging and a new stroke diagnosis within the subsequent 90 days was tested by multivariable logistic regression analysis. RESULTS. The sample included 111,417 patients (47,370 men, 64,047 women; 26.0% older than 84 years) who had TIA ED encounters. A total of 37.3% of patients (41,592) had an incomplete neurovascular imaging workup. A new stroke diagnosis within 90 days of the TIA ED encounter occurred in 4.4% (3040/69,825) of patients with complete neurovascular imaging versus 7.0% (2898/41,592) of patients with incomplete neurovascular imaging. Incomplete neurovascular imaging was associated with increased likelihood of stroke within 90 days (OR, 1.30 [95% CI, 1.23-1.38]) after adjustment for patient characteristics (age, sex, race and ethnicity, high-risk comorbidities, median county household income) and hospital characteristics (region, rurality, number of beds, major teaching hospital designation). CONCLUSION. TIA ED encounters with incomplete neurovascular imaging were associated with higher odds of subsequent stroke occurring within 90 days. CLINICAL IMPACT. Increased access to urgent neurovascular imaging for patients with TIA may represent a target that could facilitate detection and treatment of modifiable stroke risk factors.

American Indian Alaska Native (AIAN) adolescents and obesity: the influence of social determinants of health, mental health, and substance use.

OBJECTIVE: To explore the prevalence of obesity among American Indian and Alaska Native (AIAN) adolescents aged 12-19 years in association with social determinants of health (SDOH), and mental health and substance use disorders. METHODS: Guided by the World Health Organization's Social Determinants of Health Framework, we examined data from the Indian Health Service (IHS) Improving Health Care Delivery Data Project from Fiscal Year 2013, supplemented by county-level data from the U.S. Census and USDA. Our sample included 26,226 AIAN adolescents ages 12-19 years. We described obesity prevalence in relationship to SDOH and adolescents' mental health and substance use disorder status. We then fit a multivariable logit generalized linear mixed model to estimate the relationships after adjusting for other individual and county level characteristics. RESULTS: We observed a prevalence of 32.5% for obesity, 13.8% for mental health disorders, and 5.5% for substance use disorders. Females had lower odds of obesity than males (OR = 0.76, p < 0.001), which decreased with age. Having Medicaid coverage (OR = 1.09, p < 0.01), residing in a county with lower education attainment (OR = 1.17, p < 0.05), and residing in a county with higher rates of poverty (OR = 1.51, p < 0.001) were each associated with higher odds of obesity. Residing in a county with high access to a grocery store (OR = 0.73, p < 0.001) and residing in a county with a higher proportion of AIANs (OR = 0.83, p < 0.01) were each associated with lower odds of obesity. Those with mental health disorders had higher odds of obesity (OR = 1.26, p < 0.001); substance use disorders were associated with decreased odds of obesity (OR = 0.73, p < 0.001). CONCLUSIONS: Our findings inform future obesity prevention and treatment programs among AIAN youth; in particular, the need to consider mental health, substance use, and SDOH.

Social Determinants of Health and Body Mass Index in American Indian/Alaska Native Children.

Objective: To examine the associations between social determinants of health (SDOH) and prevalent overweight/obesity status and change in adiposity status among American Indian and Alaska Native (AI/AN) children. Methods: The study sample includes 23,950 AI/AN children 2-11 years of age, who used Indian Health Service (IHS) from 2010 to 2014. Multivariate generalized linear mixed models were used to examine the following: (1) cross-sectional associations between SDOH and prevalent overweight/obesity status and (2) longitudinal associations between SDOH and change in adiposity status over time. Results: Approximately 49% of children had prevalent overweight/obesity status; 18% had overweight status and 31% had obesity status. Prevalent severe obesity status was 20% in 6-11-year olds. In adjusted cross-sectional models, children living in counties with higher levels of poverty had 28% higher odds of prevalent overweight/obesity status. In adjusted longitudinal models, children 2-5 years old living in counties with more children eligible for free or reduced-priced lunch had 15% lower odds for transitioning from normal-weight status to overweight/obesity status. Conclusions: This work contributes to accumulating knowledge that economic instability, especially poverty, appears to play a large role in overweight/obesity status in AI/AN children. Research, clinical practice, and policy decisions should aim to address and eliminate economic instability in childhood.

Weak versus Deterministic Macroscopic Realism, and Einstein-Podolsky-Rosen's Elements of Reality.

The violation of a Leggett-Garg inequality confirms the incompatibility between quantum mechanics and the combined premises (called macro-realism) of macroscopic realism (MR) and noninvasive measurability (NIM). Arguments can be given that the incompatibility arises because MR fails for systems in a superposition of macroscopically distinct states-or else, that NIM fails. In this paper, we consider a strong negation of macro-realism, involving superpositions of coherent states, where the NIM premise is replaced by Bell's locality premise. We follow recent work and propose the validity of a subset of Einstein-Podolsky-Rosen (EPR) and Leggett-Garg premises, referred to as weak macroscopic realism (wMR). In finding consistency with wMR, we identify that the Leggett-Garg inequalities are violated because of failure of both MR and NIM, but also that both are valid in a weaker (less restrictive) sense. Weak MR is distinguished from deterministic macroscopic realism (dMR) by recognizing that a measurement involves a reversible unitary interaction that establishes the measurement setting. Weak MR posits that a predetermined value for the outcome of a measurement can be attributed to the system after the interaction, when the measurement setting is experimentally specified. An extended definition of wMR considers the "element of reality" defined by EPR for system A, where one can predict with certainty the outcome of a measurement on A by performing a measurement on system B. Weak MR posits that this element of reality exists once the unitary interaction determining the measurement setting at B has occurred. We demonstrate compatibility of systems violating Leggett-Garg inequalities with wMR but point out that dMR has been shown to be falsifiable. Other tests of wMR are proposed, the predictions of wMR agreeing with quantum mechanics. Finally, we compare wMR with macro-realism models discussed elsewhere. An argument in favour of wMR is presented: wMR resolves a potential contradiction pointed out by Leggett and Garg between failure of macro-realism and assumptions intrinsic to quantum measurement theory.

Associations Between Rurality, pre-pregnancy Health Status, and Macrosomia in American Indian/Alaska Native Populations.

OBJECTIVES: To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care. METHODS: The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health. RESULTS: Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia.

A Practical Guide to Use of Publicly Available Data Sets for Observational Research in Interventional Radiology.

Observational data research studying access, utilization, cost, and outcomes of image-guided interventions using publicly available "big data" sets is growing in the interventional radiology (IR) literature. Publicly available data sets offer insight into real-world care and represent an important pillar of IR research moving forward. They offer insights into how IR procedures are being used nationally and whether they are working as intended. On the other hand, large data sources are aggregated using complex sampling frames, and their strengths and weaknesses only become apparent after extensive use. Unintentional misuse of large data sets can result in misleading or sometimes erroneous conclusions. This review introduces the most commonly used databases relevant to IR research, highlights their strengths and limitations, and provides recommendations for use. In addition, it summarizes methodologic best practices pertinent to all data sets for planning and executing scientifically rigorous and clinically relevant observational research.

Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging.

PURPOSE: Imaging guidelines for transient ischemic attack (TIA) recommend that patients undergo urgent brain and neurovascular imaging within 48 hours of symptom onset. Prior research suggests that most patients with TIA discharged from the emergency department (ED) do not complete recommended TIA imaging workup during their ED encounters. The purpose of this study was to determine the nationwide percentage of patients with TIA discharged from EDs with incomplete imaging workup who complete recommended imaging after discharge. METHODS: Patients discharged from EDs with the diagnosis of TIA were identified from the Medicare 5% sample for 2017 and 2018 using International Classification of Diseases, tenth rev, Clinical Modification codes. Imaging performed was identified using Current Procedural Terminology codes. Incomplete imaging workup was defined as a TIA encounter without cross-sectional brain, brain-vascular, and neck-vascular imaging performed within the subsequent 30 days of the initial ED encounter. Patient- and hospital-level factors associated with incomplete TIA imaging were analyzed in a multivariable logistic regression. RESULTS: In total, 6,346 consecutive TIA encounters were analyzed; 3,804 patients (59.9%) had complete TIA imaging workup during their ED encounters. Of the 2,542 patients discharged from EDs with incomplete imaging, 761 (29.9%) completed imaging during the subsequent 30 days after ED discharge. Among patients with TIA imaging workup completed after ED discharge, the median time to completion was 5 days. For patients discharged from EDs with incomplete imaging, the odds of incomplete TIA imaging at 30 days after discharge were highest for black (odds ratio, 1.84; 95% confidence interval, 1.27-2.66) and older (≥85 years of age; odds ratio, 2.41; 95% confidence interval, 1.78-3.26) patients. Reference values were age cohort 65 to 69 years; male gender; white race; no co-occurring diagnoses of hypertension, hyperlipidemia, or diabetes mellitus; household income > $63,029; hospital in the Northeast region; urban hospital location; hospital size > 400 beds; academically affiliated hospital; and facility with access to MRI. CONCLUSIONS: Most patients discharged from EDs with incomplete TIA imaging workup do not complete recommended imaging within 30 days after discharge.

Social determinants of obesity in American Indian and Alaska Native peoples aged ≥ 50 years.

OBJECTIVE: American Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years. DESIGN: We conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level. SETTING: Indian Health Service (IHS) data for AI/ANs who used IHS services in FY2013. PARTICIPANTS: 27,696 AI/ANs aged ≥ 50 years without diabetes. RESULTS: Mean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese. CONCLUSIONS: Our findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs.

American Indian and Alaska Native veterans in the Indian Health Service: Health status, utilization, and cost.

PURPOSE: Many rural American Indian and Alaska Native (AIAN) veterans receive care from the Indian Health Service (IHS). United States Department of Veterans Affairs (VA) has reimbursement agreements with some IHS facilities and tribal programs and seeks to expand community partnerships in tribal areas, but details of how AIAN veterans use IHS are unknown. We aimed to assess the health status, service utilization patterns, and cost of care of veterans who use IHS. METHODS: We used comprehensive and integrated IHS data to compare health status, health service utilization and treatment cost of veterans (n = 12,242) to a matched sample of non-veterans (n = 12,242). We employed logistic, linear, or negative binomial regressions as appropriate, by sex and overall. FINDINGS: Compared to non-veterans, veterans had lower odds of having hypertension, renal disease, all-cause dementia, and alcohol or drug use disorders, but had similar burden of other conditions. In service utilization, veterans had lower hospital inpatient days; patterns were mixed across outpatient services. Unadjusted treatment costs for veterans and non-veterans were $3,923 and $4,145, respectively; veteran adjusted treatment costs were statistically lower. Differences in significance by sex were found for health conditions and service use. CONCLUSIONS: AIAN veterans, compared to AIAN non-veterans, were not less healthy, nor did they require more intensive or more costly care under IHS. Our results indicate the viability and importance of expanding IHS-VA partnerships in community care.

Diabetes Prevention and Care Capacity at Urban Indian Health Organizations.

American Indian and Alaska Native (AI/AN) people suffer a disproportionate burden of diabetes and cardiovascular disease. Urban Indian Health Organizations (UIHOs) are an important source of diabetes services for urban AI/AN people. Two evidence-based interventions-diabetes prevention (DP) and healthy heart (HH)-have been implemented and evaluated primarily in rural, reservation settings. This work examines the capacity, challenges and strengths of UIHOs in implementing diabetes programs. Methods: We applied an original survey, supplemented with publicly-available data, to assess eight organizational capacity domains, strengths and challenges of UIHOs with respect to diabetes prevention and care. We summarized and compared (Fisher's and Kruskal-Wallis exact tests) items in each organizational capacity domain for DP and HH implementers vs. non-implementers and conducted a thematic analysis of strengths and challenges. Results: Of the 33 UIHOs providing services in 2017, individuals from 30 sites (91% of UIHOs) replied to the survey. Eight UIHOs (27%) had participated in either DP (n = 6) or HH (n = 2). Implementers reported having more staff than non-implementers (117.0 vs. 53.5; p = 0.02). Implementers had larger budgets, ~$10 million of total revenue compared to $2.5 million for non-implementers (p = 0.01). UIHO strengths included: physical infrastructure, dedicated leadership and staff, and community relationships. Areas to strengthen included: staff training and retention, ensuring sufficient and consistent funding, and data infrastructure. Conclusions: Strengthening UIHOs across organizational capacity domains will be important for implementing evidence-based diabetes interventions, increasing their uptake, and sustaining these interventions for AI/AN people living in urban areas of the U.S.

Objective Quantum Fields, Retrocausality and Ontology.

We compare different approaches to quantum ontology. In particular, we discuss an interpretation of quantum mechanics that we call objective quantum field theory (OQFT), which involves retrocausal fields. Here, objective implies the existence of fields independent of an observer, but not that the results of conjugate measurements are predetermined: the theory is contextual. The ideas and analyses of Einstein and Bohr through to more recent approaches to objective realism are discussed. We briefly describe measurement induced projections, the guided wave interpretation, many-universes, consistent histories and modal theories. These earlier interpretations are compared with OQFT. We argue that this approach is compatible both with Bohr's quantum complementarity and Einstein's objective realism.

Redundant Imaging in Transient Ischemic Attack: Evidence From the Nationwide Emergency Department Sample.

PURPOSE: Increasing emergency department (ED) compliance with transient ischemic attack (TIA) imaging guidelines has previously been demonstrated, along with a substantial rise in imaging utilization over the past decade. The purpose of this study was to characterize the most commonly used combinations of imaging studies during ED workup of TIA and to quantify prevalence of redundant imaging (RI). METHODS: TIA discharges from EDs in the United States from 2006 to 2017 were identified in the Nationwide Emergency Department Sample. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. RI was defined as an ED encounter with any duplicate cross-sectional brain, brain-vascular, or neck-vascular imaging. Patient demographics and hospital characteristics were incorporated into a multivariable logistic regression analysis to identify significant associations with RI. RESULTS: There were 184,870 discharges with TIA from EDs in 2017. RI (brain) was observed in 55,513 (30%) of encounters. RI (brain-vascular) and RI (neck-vascular) imaging was identified in 5,149 (2.8%) and 1,325 (0.7%) of encounters, respectively. Decreased odds of obtaining RI was observed in Medicaid patients (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.64-0.81), non-trauma centers (OR: 0.49, 95% CI: 0.26-0.93), rural hospital locations (OR: 0.18, 95% CI: 0.11-0.29), and weekend encounters (OR: 0.9, 95% CI: 0.85-0.96). Trend analysis from 2006 to 2017 demonstrated a rise in RI (brain) from 2.3% of encounters in 2006 to 30% of encounters in 2017. RI for patients discharged from EDs with TIA in 2017 resulted in additional charges of approximately US$8,670,832. CONCLUSION: Increased imaging utilization for TIA workup across EDs in the United States is associated with rising use of redundant imaging. We identify imaging practices that could be targeted to mitigate health care expenditures while adhering to TIA imaging guidelines.

Patient Outcomes Associated With Utilization of Education, Case Management, and Advanced Practice Pharmacy Services by American Indian and Alaska Native Peoples With Diabetes.

BACKGROUND: The burden of diabetes is exceptionally high among American Indian and Alaska Native (AI/AN) peoples. The Indian Health Service (IHS) and Tribal health programs provide education, case management, and advanced practice pharmacy (ECP) services for AI/ANs with diabetes to improve their health outcomes. OBJECTIVE: The objective of this study was to evaluate patient outcomes associated with ECP use by AI/AN adults with diabetes. RESEARCH DESIGN: This observational study included the analysis of IHS data for fiscal years (FY) 2011-2013. Using propensity score models, we assessed FY2013 patient outcomes associated with FY2012 ECP use, controlling for FY2011 baseline characteristics. SUBJECTS: AI/AN adults with diabetes who used IHS and Tribal health services (n=28,578). MEASURES: We compared health status and hospital utilization outcomes for ECP users and nonusers. RESULTS: Among adults with diabetes, ECP users, compared with nonusers, had lower odds of high systolic blood pressure [odds ratio (OR)=0.85, P<0.001] and high low-density lipoprotein cholesterol (OR=0.89, P<0.01). Among adults with diabetes absent cardiovascular disease (CVD) at baseline, 3 or more ECP visits, compared with no visits, was associated with lower odds of CVD onset (OR=0.79, P<0.05). Among adults with diabetes and CVD, any ECP use was associated with lower odds of end-stage renal disease onset (OR=0.60, P<0.05). ECP users had lower odds of 1 or more hospitalizations (OR=0.80, P<0.001). CONCLUSIONS: Findings on positive patient outcomes associated with ECP use by adults with diabetes may inform IHS and Tribal policies, funding, and enhancements to ECP services to reduce disparities between AI/ANs and other populations in diabetes-related morbidity and mortality.

Effectiveness of Shorter Versus Longer Durations of Therapy for Common Inpatient Infections Associated With Bacteremia: A Multicenter, Propensity-Weighted Cohort Study.

BACKGROUND: National guidelines for pneumonia (PNA), urinary tract infection (UTI), and acute bacterial skin and skin structure infection (ABSSSI) do not address treatment duration for infections associated with bacteremia. We evaluated clinical outcomes of patients receiving shorter (5-9 days) versus longer (10-15 days) duration of antibiotics. METHODS: This was a multicenter retrospective cohort study of inpatients with uncomplicated PNA, UTI, or ABSSSI and associated bacteremia. The primary outcome was clinical failure, a composite of rehospitalization, reinitiation of antibiotics, or all-cause mortality within 30 days of antibiotic completion. Secondary outcomes included individual components of the primary outcome, Clostridioides difficile infection, and antibiotic-related adverse effects necessitating change in therapy. A propensity score-weighted logistic regression model was used to mitigate potential bias associated with nonrandom assignment of treatment duration. RESULTS: Of 408 patients included, 123 received a shorter treatment duration (median 8 days) and 285 received a longer duration (median 13 days). In the propensity-weighted analysis, the probability of the primary outcome was 13.5% in the shorter group and 11.1% in the longer group (average treatment effect, 2.4%; odds ratio [OR], 1.25; 95% confidence interval [CI], .65-2.40; P = .505). However, shorter courses were associated with higher probability of restarting antibiotics (OR, 1.62; 95% CI, 1.01-2.61; P = .046) and C. difficile infection (OR, 4.01; 95% CI, 2.21-7.59; P < .0001). CONCLUSIONS: Shorter courses of antibiotic treatment for PNA, UTI, and ABSSSI with bacteremia were not associated with increased overall risk of clinical failure; however, prospective studies are needed to further evaluate the effectiveness of shorter treatment durations.

Nonlocal Pair Correlations in a Higher-Order Bose Gas Soliton.

The truncated Wigner and positive-P phase-space representations are used to study the dynamics of a one-dimensional Bose gas. This allows calculations of the breathing quantum dynamics of higher-order solitons with 10^{3}-10^{5} particles, as in realistic Bose-Einstein condensation experiments. Although classically stable, these decay quantum mechanically. Our calculations show that there are large nonlocal correlations and nonclassical quantum entanglement.

Quantum fidelity measures for mixed states.

Applications of quantum technology often require fidelities to quantify performance. These provide a fundamental yardstick for the comparison of two quantum states. While this is straightforward in the case of pure states, it is much more subtle for the more general case of mixed quantum states often found in practice. A large number of different proposals exist. In this review, we summarize the required properties of a quantum fidelity measure, and compare them, to determine which properties each of the different measures has. We show that there are large classes of measures that satisfy all the required properties of a fidelity measure, just as there are many norms of Hilbert space operators, and many measures of entropy. We compare these fidelities, with detailed proofs of their properties. We also summarize briefly the applications of these measures in teleportation, quantum memories and quantum computers, quantum communications, and quantum phase-space simulations.

Robustness of quantum Fourier transform interferometry.

We analyze the effect of decoherence and noise on quantum Fourier transform interferometry, in which a boson sampling photonic network is used to measure optical phase gradients. This novel type of metrology is shown to be robust against phase decoherence. One can also measure gradients using lower-order correlations without substantial degradation. Our results involve the estimation of up to a 100×100 matrix permanent.

Housing Quality and Mental Health: the Association between Pest Infestation and Depressive Symptoms among Public Housing Residents.

Housing quality, which includes structural and environmental risks, has been associated with multiple physical health outcomes including injury and asthma. Cockroach and mouse infestations can be prime manifestations of diminished housing quality. While the respiratory health effects of pest infestation are well documented, little is known about the association between infestation and mental health outcomes. To address this gap in knowledge and given the potential to intervene to reduce pest infestation, we assessed the association between household pest infestation and symptoms of depression among public housing residents. We conducted a cross-sectional study in 16 Boston Housing Authority (BHA) developments from 2012 to 2014 in Boston, Massachusetts. Household units were randomly selected and one adult (n = 461) from each unit was surveyed about depressive symptoms using the Center for Epidemiologic Study-Depression (CES-D) Scale, and about pest infestation and management practices. In addition, a home inspection for pests was performed. General linear models were used to model the association between pest infestation and high depressive symptoms. After adjusting for important covariates, individuals who lived in homes with current cockroach infestation had almost three times the odds of experiencing high depressive symptoms (adjusted OR = 2.9, 95% CI 1.9-4.4) than those without infestation. Dual infestation (cockroach and mouse) was associated with over five times the odds (adjusted odds = 5.1, 95% CI 3.0-8.5) of experiencing high depressive symptoms. Using a robust measure of cockroach and mouse infestation, and a validated depression screener, we identified associations between current infestation and depressive symptoms. Although the temporal directionality of this association remains uncertain, these findings suggest that the health impact of poor housing conditions extend beyond physical health to include mental health. The study adds important information to the growing body of evidence that housing contributes to population health and improvements in population health may not be possible without addressing deficiencies in the housing infrastructure.