Early Adoption of an Improved Household Energy System in Urban Rwanda.

Cooking with solid fuels and inefficient cookstoves has adverse consequences for health, environment, and human well-being. Despite the promise of improved cookstoves to reduce these impacts, adoption rates are relatively low. Using a 2-wave sample of 144 households from the baseline and first midline of an ongoing 4-year randomized controlled trial in Rwanda, we analyze the drivers and associations of early adoption of a household energy intervention marketed by a private sector firm. Households sign an annual contract to purchase sustainably produced biomass pellets and lease a fan micro-gasification cookstove with verified emissions reductions in laboratory settings. Using difference-in-differences and fixed effects estimation techniques, we examine the association between take-up of the improved cooking system and household fuel expenditures, health outcomes, and time use for primary cooks. Thirty percent of households adopted the pellet and improved cookstove system. Adopting households had more assets, lower per capita total expenditures and cooking fuel expenditures, and higher per capita hygiene expenditures. Households with married household heads and female cooks were significantly more likely to adopt. Adjusting for confounders, we find significant reduction in primary cooks' systolic blood pressure, self-reported prevalence of shortness of breath, an indicator of respiratory illness, time spent cooking, and household expenditures on charcoal. Our findings have implications for marketing of future clean fuel and improved cookstove programs in urban settings or where stoves and fuel are purchased. Analysis of follow-up surveys will allow for estimation of long-term impacts of adoption of interventions involving pellets and fan micro-gasification cookstoves.

Pollen concentration and asthma exacerbations in Wake County, North Carolina, 2006-2012.

Pollen has been generally linked to an increased risk for asthma exacerbation. However, the delayed effect (lag), the length of effect duration, and the association heterogeneity by pollen types have not been well characterized. Short-term associations between ambient concentration of various pollen types (tree, grass, and weed) and emergency department (ED) visits for asthma were assessed using data in Wake County, North Carolina, during 2006-2012. Distributed lag nonlinear models (DLNM) were used to characterize the associations, while adjusting for air pollutants, meteorological, and temporal factors. A strong association between same-day tree pollen and asthma ED visits was detected. This association lasted four days, with a 4-day cumulative risk ratio (RR) up to 2.10 (3500 grains/m(3) vs. 0 grains/m(3), 95% confidence interval [CI]=1.21-3.65). The associations of asthma ED visits with weed pollen and grass pollen were weak, suggestively starting from lag 2 and lasting 3 days, with the strongest association a 3-day cumulative RR of 1.08 (32 grains/m(3) vs. 0 grains/m(3), 95% CI=1.01-1.15) and 1.05 (11 grains/m(3) vs. 0 grains/m(3), 95% CI=1.00-1.11). Our results indicate that the association of ambient pollen and asthma exacerbation vary by pollen type, both quantitatively and temporally. These findings have important implications for optimizing targeted allergic disease prevention and management, and helping understand the etiology of ambient exposure-induced allergic diseases.

The Regional Asthma Disease Management Program (RADMP) for low income underserved children in rural western North Carolina: a National Asthma Control Initiative Demonstration Project.

BACKGROUND: A substantial proportion of low-income children with asthma living in rural western North Carolina have suboptimal asthma management. To address the needs of these underserved children, we developed and implemented the Regional Asthma Disease Management Program (RADMP); RADMP was selected as one of 13 demonstration projects for the National Asthma Control Initiative (NACI). METHODS: This observational intervention was conducted from 2009 to 2011 in 20 rural counties and the Eastern Band Cherokee Indian Reservation in western North Carolina. Community and individual intervention components included asthma education in-services and environmental assessments/remediation. The individual intervention also included clinical assessment and management. RESULTS: Environmental remediation was conducted in 13 childcare facilities and 50 homes; over 259 administrative staff received asthma education. Fifty children with mild to severe persistent asthma were followed for up to 2 years; 76% were enrolled in Medicaid. From 12-month pre-intervention to 12-month post-intervention, the total number of asthma-related emergency department (ED) visits decreased from 158 to 4 and hospital admissions from 62 to 1 (p < 0.0001). From baseline to intervention completion, lung function FVC, FEV1, FEF 25-75 increased by 7.2%, 13.2% and 21.1%, respectively (all p < 0.001), and average school absences dropped from 17 to 8.8 days. Healthcare cost avoided 12 months post-intervention were approximately $882,021. CONCLUSION: The RADMP program resulted in decreased ED visits, hospitalizations, school absences and improved lung function and eNO. This was the first NACI demonstration project to show substantial improvements in healthcare utilization and clinical outcomes among rural asthmatic children.

Defining emergency department asthma visits for public health surveillance, North Carolina, 2008-2009.

INTRODUCTION: When using emergency department (ED) data sets for public health surveillance, a standard approach is needed to define visits attributable to asthma. Asthma can be the first (primary) or a subsequent (2nd through 11th) diagnosis. Our study objective was to develop a definition of ED visits attributable to asthma for public health surveillance. We evaluated the effect of including visits with an asthma diagnosis in primary-only versus subsequent positions. METHODS: The study was a cross-sectional analysis of population-level ED surveillance data. Of the 114 North Carolina EDs eligible to participate in a statewide surveillance system in 2008-2009, we used data from the 111 (97%) that participated during those years. Included were all ED visits with an ICD-9-CM diagnosis code for asthma in any diagnosis position (1 through 11). We formed 11 strata based on the diagnosis position of asthma and described common chief complaint and primary diagnosis categories for each. Prevalence ratios compared each category's proportion of visits that received either asthma- or cardiac-related procedure codes. RESULTS: Respiratory diagnoses were most common in records of ED visits in which asthma was the first or second diagnosis, while primary diagnoses of injury and heart disease were more common when asthma appeared in positions 3-11. Asthma-related chief complaints and procedures were most common when asthma was the first or second diagnosis, whereas cardiac procedures were more common in records with asthma in positions 3-11. CONCLUSION: ED visits should be defined as asthma-related when asthma is in the first or second diagnosis position.

A prospective examination of asthma symptom monitoring: provider, caregiver and pediatric patient influences on peak flow meter use.

OBJECTIVE: This study examined whether provider, caregiver and child communication predicted peak flow meter (PFM) use one month later. METHODS: Five practices, 35 providers and 296 children with persistent asthma and their caregivers comprised the study sample. Audio-recorded provider-caregiver-child communication during the baseline medical visit captured discussion of the PFM; and child and caregiver baseline interviews after the medical visit collected factors associated with PFM use. Child- and caregiver-reported PFM availability and use, and observed child use of PFM were collected one-month later in the family's home. RESULTS: During the medical visit, provider communication about PFM use was infrequent (10% maximum) and child- or caregiver-initiated communication was nearly absent (0%-2%). Despite this, children demonstrated good use of the PFM one month later. Children were significantly more likely to perform at least six PFM steps correctly one month later when there was more communication about PFM during the medical visit. Few other factors predicted availability and use. CONCLUSIONS: Few providers discussed use of a PFM; observed performance was predicted by having talked about it with the child's provider. Provider communication should be targeted in future interventions to improve asthma management skills.

Social ecology of asthma: engaging stakeholders in integrating health behavior theories and practice-based evidence through systems mapping.

This article describes a process for integrating health behavior and social science theories with practice-based insights using participatory systems thinking and diagramming methods largely inspired by system dynamics methods. This integration can help close the gap between research and practice in health education and health behavior by offering a systematic approach to bring together stakeholders across multiple domains. In this process we create a diagram using constructs from multiple health behavior theories at all levels of the social ecological framework as variables in causal loop diagrams. The goal of this process is to elucidate the reciprocal relationships between explanatory factors at various levels of the social ecological framework that render so many public health problems intractable. To illustrate, we detail a theory-based, replicable process for creating a qualitative diagram to enrich understanding of caregiver and provider behavior around adherence to pediatric asthma action plans. We describe how such diagramming can serve as the foundation for translating evidence into practice to address real-world challenges. Key insights gained include recognition of the complex, multilevel factors affecting whether, and how effectively, parents/caregivers and medical providers co-create an asthma action plan, and important "feedback" dynamics at play that can support or derail ongoing collaboration. Although this article applies this method to asthma action plan adherence in children, the method and resulting diagrams are applicable and adaptable to other health behaviors requiring continuous, daily action.

Active learning by design: an undergraduate introductory public health course.

Principles of active learning were used to design and implement an introductory public health course. Students were introduced to the breadth and practice of public health through team and individual-based activities. Team assignments covered topics in epidemiology, biostatistics, health behavior, nutrition, maternal and child health, environment, and health policy. Students developed an appreciation of the population perspective through an "experience" trip and related intervention project in a public health area of their choice. Students experienced several key critical component elements of a public health undergraduate major; they explored key public health domains, experience public health practice, and integrated concepts with their assignments. In this paper, course assignments, lessons learned, and student successes are described. Given the increased growth in the undergraduate public health major, these active learning assignments may be of interest to undergraduate public health programs at both liberal arts colleges and research universities.

Nitrogen dioxide and allergic sensitization in the 2005-2006 National Health and Nutrition Examination Survey.

BACKGROUND: Allergic sensitization is a risk factor for asthma and allergic diseases. The relationship between ambient air pollution and allergic sensitization is unclear. OBJECTIVE: To investigate the relationship between ambient air pollution and allergic sensitization in a nationally representative sample of the US population. METHODS: We linked annual average concentrations of nitrogen dioxide (NO2), particulate matter ≤10 µm (PM10), particulate matter ≤2.5 µm (PM2.5), and summer concentrations of ozone (O3), to allergen-specific immunoglobulin E (IgE) data for participants in the 2005-2006 National Health and Nutrition Examination Survey (NHANES). In addition to the monitor-based air pollution estimates, we used the Community Multiscale Air Quality (CMAQ) model to increase the representation of rural participants in our sample. Logistic regression with population-based sampling weights was used to calculate adjusted prevalence odds ratios per 10 ppb increase in O3 and NO2, per 10 µg/m(3) increase in PM10, and per 5 µg/m(3) increase in PM2.5 adjusting for race, gender, age, socioeconomic status, smoking, and urban/rural status. RESULTS: Using CMAQ data, increased levels of NO2 were associated with positive IgE to any (OR 1.15, 95% CI 1.04, 1.27), inhalant (OR 1.17, 95% CI 1.02, 1.33), and indoor (OR 1.16, 95% CI 1.03, 1.31) allergens. Higher PM2.5 levels were associated with positivity to indoor allergen-specific IgE (OR 1.24, 95% CI 1.13, 1.36). Effect estimates were similar using monitored data. CONCLUSIONS: Increased ambient NO2 was consistently associated with increased prevalence of allergic sensitization.

Hospitalizations and return visits after chronic obstructive pulmonary disease ED visits.

PURPOSE: The aim of this study was to describe population-based patterns of chronic obstructive pulmonary disease (COPD)-related emergency department (ED) visits. METHODS: We analyzed all COPD-related ED visits made by North Carolina residents 45 years or older in 2008 to 2009 using statewide surveillance system data. Return visits were identified when patients returned to the same ED within 3 or 14 days of a prior COPD-related visit. We quantify the prevalence of hospitalization and return visits by age, sex, and payment method and describe ED disposition patterns. RESULTS: Nearly half (46.3%) of the 97 511 COPD-related ED visits resulted in hospital admission. The percent of visits preceded by another COPD-related visit within 3 and 14 days was 1.6% and 6.2%, respectively. Emergency department-related hospitalizations increased with age; there were no differences by sex. Hospitalizations were less likely for uninsured, Medicare, and Medicaid visits than for privately insured visits. In contrast, 3- and 14-day return visits were more likely to be uninsured, Medicare, and Medicaid visits than privately insured visits. Fourteen-day returns were more likely to be made by men. Return visits initially increased with age compared with the 45- to 49-year age group, then decreased steadily after age 65 years. When return visits were made, discharge at both visits was the most common disposition pattern. However, 33.7% of 3-day returns and 22.7% of 14-day returns were discharged at the first visit and hospitalized upon returning to the ED. CONCLUSIONS: Chronic obstructive pulmonary disease-related hospital admissions and short-term return ED visits were common and varied by age and insurance status. Chronic obstructive pulmonary disease management remains a critical area for intervention and quality improvement.

PROMIS Pediatric Peer Relationships Scale: development of a peer relationships item bank as part of social health measurement.

OBJECTIVE: This study's objective was to develop a measure of social health using item response theory as part of the Patient Reported Outcomes Measurement Information System (PROMIS). METHODS: After candidate items were generated from review of prior literature, focus groups, expert input, and cognitive interviews, items were administered to youth aged 8-17 as part of the PROMIS pediatric large scale testing. Exploratory and confirmatory factor analyses were used to assess dimensionality and to identify instances of local dependence. Items that met the unidimensionality criteria were subsequently calibrated using Samejima's Graded Response Model. Differential item functioning was examined by gender and age. RESULTS: The sample included 3,048 youth who completed the questionnaire (51.8% female, 60% white, and 22.7% with chronic illness). The initial conceptualization of social function and sociability did not yield unidimensional item banks. Rather, factor analysis revealed dimensions contrasting peer relationships and adult relationships. The analysis also identified dimensions formed by responses to positively versus negatively worded items. The resulting 15-item bank measures quality of peer relationships and has strong psychometric characteristics as a full bank or an 8-item short form. CONCLUSIONS: The PROMIS pediatric peer relationships scale demonstrates good psychometric characteristics and addresses an important aspect of child health.

The relationship between patient-provider communication and quality of life for children with asthma and their caregivers.

OBJECTIVE: This study examined whether patient-provider communication is associated with asthma-related quality of life (QOL) and asthma outcomes among children with asthma and their caregivers. METHODS: Children ages 8-16 years with asthma and their caregivers (n = 296) were recruited at five pediatric practices in North Carolina. Children and caregivers reported demographic and clinical characteristics immediately after an audio-taped medical visit with their health care provider. During a home visit that took place 1 month after the medical visit, children and caregivers reported asthma-related QOL, and caregivers reported child asthma outcomes, including asthma symptom days and missed school days. Generalized estimating equations were used to determine whether patient-provider communication during the medical visit was associated with child and caregiver QOL and child asthma outcomes 1 month later. RESULTS: On average, providers asked caregivers 4.5 questions and asked children 3 questions per visit, whereas caregivers and children asked less than 1 question per visit. Providers asked children more asthma-related questions, caregivers reported better QOL and fewer asthma symptom days 1 month later. Children and caregivers with higher asthma-management self-efficacy at the office visit reported better QOL 1 month later. CONCLUSIONS: Mirroring national guideline recommendations, our results suggest that providers should ask children about their asthma during medical visits. Future longitudinal studies should conduct mediation analyses to determine whether asking children asthma-related questions during medical visits increases children's asthma management self-efficacy and ultimately improve outcomes, such as QOL, health care utilization, symptom days and missed school days.

Hazard assessment of United Arab Emirates (UAE) incense smoke.

Incense burning inside the home, a common practice in Arabian Gulf countries, has been recognized as a potentially modifiable source of indoor air pollution. To better understand potential adverse effects of incense burning in exposed individuals, we conducted a hazard assessment of incense smoke exposure. The goals of this study were first to characterize the particles and gases emitted from Arabian incense over time when burned, and secondly to examine in vitro human lung cells responses to incense smoke. Two types of incense (from the United Arab Emirates) were burned in a specially designed indoor environmental chamber (22 m(3)) to simulate the smoke concentration in a typical living room and the chamber air was analyzed. Both particulate (PM) concentrations and sizes were measured, as were gases carbon monoxide (CO), sulfur dioxide (SO2), oxides of nitrogen (NOx), formaldehyde (HCHO), and carbonyls. During the burn, peak concentrations were recorded for PM (1.42 mg/m(3)), CO (122 pm), NOx (0.3 ppm), and HCHO (85 ppb) along with pentanal (71.9 µg/m(3)), glyoxal (84.8 µg/m(3)), and several other carbonyls. Particle sizes ranged from 20 to 300 nm with count median diameters ranging from 65 to 92 nm depending on time post burn-out. PM, CO, and NOx time-weighted averages exceeded current government regulation values and emissions seen previously from environmental tobacco smoke. Charcoal emissions were the main contributor to both the high CO and NOx concentrations. A significant cell inflammatory response was observed in response to smoke components formed from incense burning. Our hazard evaluation suggests that incense burning contributes to indoor air pollution and could be harmful to human health.

Population-based burden of COPD-related visits in the ED: return ED visits, hospital admissions, and comorbidity risks.

BACKGROUND: Little is known about the population-based burden of ED care for COPD. METHODS: We analyzed statewide ED surveillance system data to quantify the frequency of COPD-related ED visits, hospital admissions, and comorbidities. RESULTS: In 2008 to 2009 in North Carolina, 97,511 COPD-related ED visits were made by adults ≥ 45 years of age, at an annual rate of 13.8 ED visits/1,000 person-years. Among patients with COPD (n = 33,799), 7% and 28% had a COPD-related return ED visit within a 30- and 365-day period of their index visit, respectively. Compared with patients on private insurance, Medicare, Medicaid, and noninsured patients were more likely to have a COPD-related return visit within 30 and 365 days and have three or more COPD-related visits within 365 days. There were no differences in return visits by sex. Fifty-one percent of patients with COPD were admitted to the hospital from the index ED visit. Subsequent hospital admission risk in the cohort increased with age, peaking at 65 to 69 years (risk ratio [RR], 1.41; 95% CI, 1.26-1.57); there was no difference by sex. Patients with congestive heart failure (RR, 1.29; 95% CI, 1.22-1.37), substance-related disorders (RR, 1.35; 95% CI, 1.13-1.60), or respiratory failure/supplemental oxygen (RR, 1.25; 95% CI, 1.19-1.31) were more likely to have a subsequent hospital admission compared with patients without these comorbidities. CONCLUSIONS: The population-based burden of COPD-related care in the ED is significant. Further research is needed to understand variations in COPD-related ED visits and hospital admissions.

Cardiovascular outcomes and the physical and chemical properties of metal ions found in particulate matter air pollution: a QICAR study.

BACKGROUND: This paper presents an application of quantitative ion character-activity relationships (QICAR) to estimate associations of human cardiovascular (CV) diseases (CVDs) with a set of metal ion properties commonly observed in ambient air pollutants. QICAR has previously been used to predict ecotoxicity of inorganic metal ions based on ion properties. OBJECTIVES: The objective of this work was to examine potential associations of biological end points with a set of physical and chemical properties describing inorganic metal ions present in exposures using QICAR. METHODS: Chemical and physical properties of 17 metal ions were obtained from peer-reviewed publications. Associations of cardiac arrhythmia, myocardial ischemia, myocardial infarction, stroke, and thrombosis with exposures to metal ions (measured as inference scores) were obtained from the Comparative Toxicogenomics Database (CTD). Robust regressions were applied to estimate the associations of CVDs with ion properties. RESULTS: CVD was statistically significantly associated (Bonferroni-adjusted significance level of 0.003) with many ion properties reflecting ion size, solubility, oxidation potential, and abilities to form covalent and ionic bonds. The properties are relevant for reactive oxygen species (ROS) generation, which has been identified as a possible mechanism leading to CVDs. CONCLUSION: QICAR has the potential to complement existing epidemiologic methods for estimating associations between CVDs and air pollutant exposures by providing clues about the underlying mechanisms that may explain these associations.

Development and psychometric properties of the PROMIS(®) pediatric fatigue item banks.

PURPOSE: This paper reports on the development and psychometric properties of self-reported pediatric fatigue item banks as part of the Patient-Reported Outcomes Measurement Information System (PROMIS). METHODS: Candidate items were developed by using PROMIS qualitative methodology. The resulting 39 items (25 tiredness related and 14 energy related) were field tested in a sample that included 3,048 participants aged 8-17 years. We used confirmatory factor analysis (CFA) to evaluate dimensionality and differential item functioning (DIF) analysis to evaluate parameter stability between genders and by age; we examined residual correlations to evaluate local dependence (LD) among items and estimated the parameters of item response theory (IRT) models. RESULTS: Of 3,048 participants, 48 % were males, 60 % were white, and 23 % had at least one chronic condition. CFA results suggest two moderately correlated factors. Two items were removed due to high LD, and three due to gender-based DIF. Two item banks were calibrated separately using IRT: Tired and (Lack of) Energy, which consisted of 23 and 11 items, respectively; 10- and 8-item short-forms were created. CONCLUSION: The PROMIS assessment of self-reported fatigue in pediatrics includes two item banks: Tired and (Lack of) Energy. Both demonstrated satisfactory psychometric properties and can be used for research settings.

Knowledge, attitude and practices of diabetic patients in the United Arab Emirates.

INTRODUCTION: Diabetes self-management education is a cornerstone of diabetes care. However, many diabetics in the United Arab Emirates (UAE) lack sufficient knowledge about their disease due to illiteracy. Thus, before considering any possible intervention it was imperative to assess present knowledge, attitudes, and practices of patients towards the management of diabetes. METHODS: A random sample of 575 DM patients was selected from diabetes outpatient's clinics of Tawam and Al-Ain hospitals in Al-Ain city (UAE) during 2006-2007, and their knowledge attitude and practice assessed using a questionnaire modified from the Michigan Diabetes Research Training Center instrument. RESULTS: Thirty-one percent of patients had poor knowledge of diabetes. Seventy-two had negative attitudes towards having the disease and 57% had HbA(1c) levels reflecting poor glycemic control. Only seventeen percent reported having adequate blood sugar control, while 10% admitted non-compliance with their medications. Knowledge, practice and attitude scores were all statistically significantly positively, but rather weakly, associated, but none of these scores was significantly correlated with HbA(1c). CONCLUSIONS: The study showed low levels of diabetes awareness but positive attitudes towards the importance of DM care and satisfactory diabetes practices in the UAE. Programs to increase patients' awareness about DM are essential for all diabetics in the UAE in order to improve their understanding, compliance and management and, thereby, their ability to cope with the disease.

Conducting environmental health research in the Arabian Middle East: lessons learned and opportunities.

BACKGROUND: The Arabian Gulf nations are undergoing rapid economic development, leading to major shifts in both the traditional lifestyle and the environment. Although the pace of change is brisk, there is a dearth of environmental health research in this region. OBJECTIVE: We describe challenges and successes of conducting an environmental epidemiologic study in the United Arab Emirates (UAE), a Gulf nation in the Middle East, with an inter-disciplinary team that includes in-country academic and government collaborators as well as U.S. academic collaborators. DISCUSSION: We present several issues, including study and data collection design, exposure assessment, scheduling and time coordination, quality assurance and quality control, and institutional review board protocols. These topics are considered in a cultural context. Benefits of this research included building linkages among multinational, interdisciplinary team members, generating data for local environmental decision making, and developing local epidemiologic research capacity. The Middle Eastern culture of hospitality greatly benefited the project team. CONCLUSION: Cultural differences impact multiple aspects of epidemiologic research and should be respectfully addressed. Conducting international population-based environmental research poses many challenges; these challenges can be met successfully with careful planning, cultural knowledge, and flexibility. Lessons learned are applicable to interdisciplinary research all over the world. The research conducted will benefit the environmental and public health agencies of the UAE and provide the nation's leadership with country-specific environmental health data that can be used to protect the public's health in a rapidly changing environment.

Indoor air pollutants and health in the United Arab Emirates.

BACKGROUND: Comprehensive global data on the health effects of indoor air pollutants are lacking. There are few large population-based multi-air pollutant health assessments. Further, little is known about indoor air health risks in the Middle East, especially in countries undergoing rapid economic development. OBJECTIVES: To provide multifactorial indoor air exposure and health data, we conducted a population-based study of indoor air pollution and health in the United Arab Emirates (UAE). METHODS: We conducted a cross-sectional study in a population-based sample of 628 households in the UAE. Indoor air pollutants [sulfur dioxide (SO2), nitrogen dioxide (NO2), hydrogen sulfide (H2S), formaldehyde (HCHO), carbon monoxide (CO), and particulate matter] were measured using passive samplers over a 7-day period. Health information was collected from 1,590 household members via in-person interviews. RESULTS: Participants in households with quantified SO2, NO2, and H2S (i.e., with measured concentrations above the limit of quantification) were twice as likely to report doctor-diagnosed asthma. Participants in homes with quantified SO2 were more likely to report wheezing symptoms {ever wheezing, prevalence odds ratio [POR] 1.79 [95% confidence interval (CI) 1.05, 3.05]; speech-limiting wheeze, POR 3.53 (95% CI: 1.06, 11.74)}. NO2 and H2S were similarly associated with wheezing symptoms. Quantified HCHO was associated with neurologic symptoms (difficulty concentrating POR 1.47; 95% CI: 1.02, 2.13). Burning incense daily was associated with increased headaches (POR 1.87; 95% CI: 1.09, 3.21), difficulty concentrating (POR 3.08; 95% CI: 1.70, 5.58), and forgetfulness (POR 2.68: 95% CI: 1.47, 4.89). CONCLUSIONS: This study provides new information regarding potential health risks from pollutants commonly found in indoor environments in the UAE and other countries. Multipollutant exposure and health assessments in cohort studies are needed to better characterize health effects of indoor air pollutants.

PROMIS Pediatric Anger Scale: an item response theory analysis.

PURPOSE: The Patient-Reported Outcomes Measurement Information System (PROMIS) aims to develop patient-reported outcome (PROs) instruments for use in clinical research. The PROMIS pediatrics (ages 8-17) project focuses on the development of PROs across several health domains (physical function, pain, fatigue, emotional distress, social role relationships, and asthma symptoms). The objective of the present study was to report on the psychometric properties of the PROMIS Pediatric Anger Scale. METHODS: Participants (n = 759) were recruited from public school settings, hospital-based outpatient, and subspecialty pediatrics clinics. The anger items (k = 10) were administered on one test form. A hierarchical confirmatory factor analytic model (CFA) was conducted to evaluate scale dimensionality and local dependence. Item response theory (IRT) analyses were then used to finalize the item scale and short form. RESULTS: CFA confirmed that the anger items are representative of a unidimensional scale, and items with local dependence were removed, resulting in a six-item short form. The IRT-scaled scores from summed scores and each score's conditional standard error were calculated for the new six-item PROMIS Pediatric Anger Scale. CONCLUSIONS: This study provides initial calibrations of the anger items and creates the PROMIS Pediatric Anger Scale, version 1.0.

Associations between ozone and morbidity using the Spatial Synoptic Classification system.

BACKGROUND: Synoptic circulation patterns (large-scale tropospheric motion systems) affect air pollution and, potentially, air-pollution-morbidity associations. We evaluated the effect of synoptic circulation patterns (air masses) on the association between ozone and hospital admissions for asthma and myocardial infarction (MI) among adults in North Carolina. METHODS: Daily surface meteorology data (including precipitation, wind speed, and dew point) for five selected cities in North Carolina were obtained from the U.S. EPA Air Quality System (AQS), which were in turn based on data from the National Climatic Data Center of the National Oceanic and Atmospheric Administration. We used the Spatial Synoptic Classification system to classify each day of the 9-year period from 1996 through 2004 into one of seven different air mass types: dry polar, dry moderate, dry tropical, moist polar, moist moderate, moist tropical, or transitional. Daily 24-hour maximum 1-hour ambient concentrations of ozone were obtained from the AQS. Asthma and MI hospital admissions data for the 9-year period were obtained from the North Carolina Department of Health and Human Services. Generalized linear models were used to assess the association of the hospitalizations with ozone concentrations and specific air mass types, using pollutant lags of 0 to 5 days. We examined the effect across cities on days with the same air mass type. In all models we adjusted for dew point and day-of-the-week effects related to hospital admissions. RESULTS: Ozone was associated with asthma under dry tropical (1- to 5-day lags), transitional (3- and 4-day lags), and extreme moist tropical (0-day lag) air masses. Ozone was associated with MI only under the extreme moist tropical (5-day lag) air masses. CONCLUSIONS: Elevated ozone levels are associated with dry tropical, dry moderate, and moist tropical air masses, with the highest ozone levels being associated with the dry tropical air mass. Certain synoptic circulation patterns/air masses in conjunction with ambient ozone levels were associated with increased asthma and MI hospitalizations.