Firearm-Related Juvenile Death Rates Correlate With Gun Ownership Rates, Measures of Guns in Circulation, and Leniency of Existing Firearm Laws Among U.S. States.

INTRODUCTION: Firearms now represent the leading cause of death in U.S. children. Therefore, this study aimed to determine if state-level rates of gun ownership, guns in circulation, and strictness of firearm-related laws are related to firearm-related mortality among both juveniles and overall populations. MATERIALS AND METHODS: State firearm mortality rates among the juvenile and overall populations were obtained from 2010 to 2020. The number of weapons registered with the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) and federal firearms licensees for each state were also recorded. Giffords Law Center Scorecard Rankings, a relative measure of the restrictiveness of each state's gun laws, were also collected. Unadjusted linear regressions modeled the relationships between firearm-associated mortality and ATF-registered weapons, federal firearm licensees, Giffords Center rankings, and gun ownership rates. Multivariable (adjusted) analyses were performed to control for poverty, unemployment, and poor mental health. RESULTS: Unadjusted analyses demonstrated that higher gun ownership rates and more lenient gun laws were associated with increased firearm-associated mortality among juveniles. Similarly, these measures as well as increased ATF-registered weapons and ATF federal firearm licensees were associated with increased firearm mortality in the overall population. In the adjusted analyses, more ATF-registered weapons, more ATF federal firearm licensees, higher gun ownership rates, and more lenient firearm laws were associated with increased firearm-related mortality in the overall population, while increased gun ownership and higher Giffords Center rankings were associated with increased firearm-associated mortality in the pediatric population. CONCLUSIONS: To reduce the toll of gun violence in the United States, policymakers should focus on implementing more restrictive firearm laws and reducing the prevalence of guns in their communities.

Medicaid expansion in California and breast cancer incidence across neighborhoods with varying social vulnerabilities.

PURPOSE: To investigate changes in breast cancer incidence rates associated with Medicaid expansion in California. METHODS: We extracted yearly census tract-level population counts and cases of breast cancer diagnosed among women aged between 20 and 64 years in California during years 2010-2017. Census tracts were classified into low, medium and high groups according to their social vulnerability index (SVI). Using a difference-in-difference (DID) approach with Poisson regression models, we estimated the incidence rate, incidence rate ratio (IRR) during the pre- (2010-2013) and post-expansion periods (2014-2017), and the relative IRR (DID estimates) across three groups of neighborhoods. RESULTS: Prior to the Medicaid expansion, the overall incidence rate was 93.61, 122.03, and 151.12 cases per 100,000 persons among tracts with high, medium, and low-SVI, respectively; and was 96.49, 122.07, and 151.66 cases per 100,000 persons during the post-expansion period, respectively. The IRR between high and low vulnerability neighborhoods was 0.62 and 0.64 in the pre- and post-expansion period, respectively, and the relative IRR was 1.03 (95% CI 1.00 to 1.06, p = 0.026). In addition, significant DID estimate was only found for localized breast cancer (relative IRR = 1.05; 95% CI, 1.01 to 1.09, p = 0.049) between high and low-SVI neighborhoods, not for regional and distant cancer stage. CONCLUSIONS: The Medicaid expansion had differential impact on breast cancer incidence across neighborhoods in California, with the most pronounced increase found for localized cancer stage in high-SVI neighborhoods. Significant pre-post change was only found for localized breast cancer between high and low-SVI neighborhoods.

Associations of a plant-centered diet and lung function across early to mid-adulthood: The CARDIA Lung Study.

BACKGROUND: Lung function throughout adulthood predicts morbidity and mortality even among adults without chronic respiratory disease. Diet quality may represent a modifiable risk factor for lung function impairment later in life. We investigated associations between nutritionally-rich plant-centered diet and lung function across early and middle adulthood from the Coronary Artery Risk Development in Young Adults (CARDIA) Study. METHODS: Diet was assessed at baseline and years 7 and 20 of follow-up using the validated CARDIA diet history questionnaire. Plant-centered diet quality was scored using the validated A Priori Diet Quality Score (APDQS), which weights food groups to measure adherence to a nutritionally-rich plant-centered diet for 20 beneficially rated foods and 13 adversely rated foods. Scores were cumulatively averaged over follow-up and categorized into quintiles. The primary outcome was lung function decline, including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC), measured at years 0, 2, 5, 10, 20, and 30. We estimated the association of APDQS with annual pulmonary function changes and cross-sectional differences in a repeated measures regression model, adjusting for clinically relevant covariates. RESULTS: The study included 3,787 Black and White men and women aged 18-30 in 1985-86 and followed for 30 years. In multivariable repeated measures regression models, individuals in the lowest APDQS quintile (poorest diet) had declines in FEV1 that were 1.6 ml/year greater than individuals in the highest quintile (35.0 vs. 33.4 ml/year, ß ± SE per 1 SD change APDQS 0.94 ± 0.36, p = 0.009). Additionally, declines in FVC were 2.4 ml/year greater in the lowest APDQS quintile than those in the highest quintile (37.0 vs 34.6 ml/year, ß ± SE per 1 SD change APDQS 1.71 ± 0.46, p < 0.001). The association was not different between never and ever smokers (pint = 0.07 for FVC and 0.32 for FEV1). In sensitivity analyses where current asthma diagnosis and cardiorespiratory fitness were further adjusted, results remained similar. Cross-sectional analysis at each exam year also showed significant differences in lung function according to diet after covariate adjustment. CONCLUSIONS: In this 30-year longitudinal cohort study, long-term adherence to a nutritionally-rich plant-centered diet was associated with cross-sectional differences in lung function as well as slower decline in lung function, highlighting diet quality as a potential treatable trait supporting long-term lung health.

Medical financial hardship between young adult cancer survivors and matched individuals without cancer in the United States.

BACKGROUND: Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties young adult cancer survivors in the United States experience in the post-Patient Protection and Affordable Care Act period. METHOD: We identified 1009 cancer survivors aged 18 to 39 years from the National Health Interview Survey (2015-2022) and matched 963 (95%) cancer survivors to 2733 control individuals using nearest-neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and to assess whether this association varied by age, sex, race and ethnicity, and region of residence. RESULTS: Compared with those who did not have a history of cancer, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio = 1.65, 95% confidence interval = 1.50 to 1.81) and behavior-related financial hardship (34.3% vs 24.4%; odds ratio = 1.62, 95% confidence interval = 1.49 to 1.76) but not psychological financial hardship (52.6% vs 50.9%; odds ratio = 1.07, 95% confidence interval = 0.99 to 1.16). Young adult cancer survivors who were Hispanic or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts. CONCLUSIONS: We found that young adult cancer survivors were more likely to experience material and behavior-related financial hardship than young adults without a history of cancer. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.

Trends in mortality due to tracheal, bronchial, and lung cancer across the BRICS: An age-period-cohort analysis based on the Global Burden of Disease Study 1990-2019.

BACKGROUND: Tracheal, bronchus, and lung cancer (TBL) is a major cause of mortality and top contributor to productivity loss in large emerging economies such as the BRICS (Brazil, Russia, India, China, and South Africa). We examined the time trends of TBL mortality across the BRICS to better understand the disease burden in these countries and inform public health and healthcare resource allocation. METHODS: TBL mortality-related data between 1990 and 2019 were obtained from the Global Burden of Disease Study 2019 and analyzed using age-period-cohort models. Net drift (local drift) was used to describe the expected age-adjusted TBL mortality rate over time overall (each age group); the longitudinal age curve was used to reflect the age effect; the period rate ratios (RRs) were used to reflect the period effect; and the cohort RR was used to reflect the cohort effect. RESULTS: In 2019, there were 958.3 thousand TBL deaths across the BRICS, representing 46.9% of the global TBL deaths. From 1990 to 2019, the age-standardized mortality rate (ASMR) of TBL decreased in Russia, Brazil, and South Africa while increased in China and India, with the largest reduction reported in Russia (-29.6%) and the largest increase in China (+22.4%). India showed an overall increase (+15.7%) in TBL mortality but the mortality risk decreased among individuals born after 1990 (men) and 1995 (women). Although South Africa and Brazil experienced an overall decline in TBL mortality, their recent birth cohorts, such as Brazilian individuals born after 1985 (men) and 1980 (women), and South African men born after 1995, had an increasing TBL mortality risk. China has experienced an overall increase in TBL mortality, with the mortality risk rising among individuals born after 1995 for both men and women. Russia, which had the highest TBL mortality among the BRICS countries in 1990, has demonstrated significant improvement over the past three decades. CONCLUSIONS: Over the past 30 years, the BRICS accounted for an increasing proportion of global TBL mortality. TBL mortality increased in older women in all the BRICS countries except Russia. Among the recent birth cohort, the risk of TBL mortality increased in Brazil, China, and South Africa. More effective efforts are needed in the BRICS to reduce the burden of TBL and help achieve the United Nation's Sustainable Development Goals.

Spatiotemporal Patterns of Hospitalizations Among Older Adults With Co-Presence of Cancer and Dementia in US Counties: 2013-2018.

We assessed the spatiotemporal patterns of hospitalization with comorbid cancer and dementia. Using the 2013-2018 inpatient claims data for Medicare fee-for-service (FFS) beneficiaries, we calculated hospitalization rates by dividing the total admissions from individuals with the co-presence of a major cancer (breast, prostate, lung, and colorectal) and dementia diagnoses with the total counts of FFS beneficiaries aged 65 or older. We identified 22 hotspots with high hospitalization rates that showed heterogeneous spatial and temporal utilization patterns. The odds of a county being a hotspot increased significantly with the county-level percentage of dual Medicare-Medicaid beneficiaries (aOR 1.05; 95% CI: 1.04-1.07) and the prevalence of cancer (aOR 1.73; 95% CI: 1.59-1.89), while decreased significantly with increasing degree of rurality (aOR .82; 95% CI: .79-.85) and decreased yearly over time (aOR .72; 95% CI: .68-.75). The identified hotspots and factors at the county-level may help understand healthcare utilization patterns and assess resource allocation for this unique patient group.

Utilizing residential histories to assess environmental exposure and socioeconomic status over the life course among mesothelioma patients.

Background: Exposure misclassification based solely on the address at cancer diagnosis has been widely recognized though not commonly assessed. Methods: We linked 1,015 mesothelioma cases diagnosed during 2011-2015 from the New York State Cancer Registry to inpatient claims and LexisNexis administrative data and constructed residential histories. Percentile ranking of exposure to ambient air toxics and socioeconomic status (SES) were based on the National Air Toxic Assessment and United States Census data, respectively. To facilitate comparisons over time, relative exposures (REs) were calculated by dividing the percentile ranking at individual census tract by the state-level average and subtracting one. We used generalized linear regression models to compare the RE in the past with that at cancer diagnosis, adjusting for patient-level characteristics. Results: Approximately 43.7% of patients had residential information available for up to 30 years, and 96.0% up to 5 years. The median number of unique places lived was 4 [interquartile range (IQR), 2-6]. The time-weighted-average RE from all addresses available had a median of -0.11 (IQR, -0.50 to 0.30) for air toxics and -0.28 (IQR, -0.65 to 0.25) for SES. RE associated with air toxics (but not SES) was significantly higher for earlier addresses than addresses at cancer diagnosis for the 5-year [annual increase =1.24%; 95% confidence interval (CI): 0.71-1.77%; n=974] and 30-year (annual increase =0.36%; 95% CI: 0.25-0.48%; n=444) look-back windows, respectively. Conclusions: Environmental exposure to non-asbestos air toxics among mesothelioma patients may be underestimated if based solely on the address at diagnosis. With geospatial data becoming more readily available, incorporating cancer patients' residential history would lead to reduced exposure misclassification and accurate health risk estimates.

Sex Differences in Diet and Physical Activity Behaviors Among Racial/Ethnic Minority Adolescents with High Metabolic Risk.

Certain dietary and physical activity (PA) behaviors may differentially predispose male and female adolescents to obesity and diabetes; however, sex differences in dietary and PA behaviors and in factors that impact these behaviors (e.g., self-efficacy, social support) in this population remain unknown. Using data from a community-based adolescent diabetes prevention intervention conducted in East Harlem in New York City, we examined sex differences in baseline characteristics including clinical measurements, lifestyle behaviors, and behavioral determinants. Among 147 overweight/obese adolescents aged 13-19 years, 61.9% were girls, 69.7% were of Hispanic ethnicity, 24.8% were non-Hispanic Black, and 60.5% were diagnosed with prediabetes. Boys had higher metabolic risk scores than girls (3.8 vs. 3.3, p = 0.002) despite girls reporting more perceived barriers to healthy eating and PA. Boys reported doing more moderate to vigorous PA but also had more sedentary behaviors than girls. Boys reported higher self-efficacy and more peer support for PA. Girls reported more depressive symptoms and were more likely to compare their body images to those in magazines/social media. Overall, among a sample of urban adolescents with high metabolic risk, we found significant sex differences in many dietary and PA behaviors and related factors, which could be used to inform tailored strategies for weight management to reduce cardiometabolic risk among youth from similar high-risk populations.

Longitudinal Assessment of Association Between Tobacco Use and Tobacco Dependence Among Adults: Latent Class Analysis of the Population Assessment of Tobacco and Health Study Waves 1-4.

INTRODUCTION: With increasing tobacco product varieties, understanding tobacco use (TU) profiles and their associations with tobacco dependence (TD) has also become increasingly challenging. AIMS AND METHODS: We aimed to identify TU profiles and their associations with TD over time, and to identify subgroups with high risk of TD. We included 3463 adult recent tobacco users who had complete TU and TD data across waves 1-4 of the Population Assessment of Tobacco and Health (PATH) study. We used a composite index of TD and a summed TD score from an established 16-item TD measure. We applied a latent class analysis to identify TU profiles based on participants' usage of eight common tobacco product groups at each survey wave and to check the stability of the TU profiles over time. We then used generalized estimating equations regressions to evaluate the longitudinal TU-TD association, adjusting for potential confounders. RESULTS: We identified three distinct TU profiles that remained consistent across four survey waves: Dominant cigarette users (62%-68%), poly users with high propensity of using traditional cigarettes, e-cigarettes, and cigars (24%-31%), and dominant smokeless product users (7%-9%). Covariate-adjusted models showed that TD was significantly lower among the poly users and the dominant smokeless users, compared to that among the dominant cigarette users. CONCLUSIONS: Both TU profiles and their associations with TD were stable over time at the population level. Poly users and smokeless product users were consistently associated with lower TD than cigarette-dominant users, suggesting the need for tailored tobacco cessation interventions for users with different TU profiles. IMPLICATIONS: The finding of consistent TU profiles across four survey waves extends the current literature in capturing TU patterns in an evolving tobacco product landscape. The finding of the overall higher level of TD among the cigarette-dominant users compared to the other TU latent profiles (the Cig+eCig+Cigar dominant poly users and the dominant smokeless product users) can help identify high-risk groups for potential interventions. Our application of innovative statistical methods to high-quality longitudinal data from the PATH study helps improve the understanding of the dynamic TU-TD relationship over time.

Comfort levels in discussing tobacco smoking among hospital staff in a children's hospital.

INTRODUCTION: Hospital staff discussing smoking with children and their families can impact tobacco control, which is crucial in reducing the harmful effects of tobacco smoke exposure. Our study aims to assess staff comfort level in discussing smoking with patients or their families, and coworkers, after the implementation of a hospital-wide tobacco control policy. METHODS: This cross-sectional study included 2340 staff members who completed an anonymous online survey in a large urban children's hospital in 2019. The main outcomes of interest were the comfort level in discussing smoking with patients or their families, and co-workers. We used multivariable logistic regression to identify whether the comfort level varied by sex, age, job type, and smoking status. RESULTS: Most of the respondents (83.8%) were female, 41.2% were aged 18-35 years, 57.6% worked as clinical staff, and 15.5% were ever smokers. Compared to males, females were less likely to feel very comfortable in asking patients or their families about their smoking tobacco (adjusted odds ratio, AOR=0.72; 95% CI: 0.56-0.92) or talking to co-workers about the health risks associated with their smoking (AOR=0.71; 95% CI: 0.54-0.93). Staff who were non-smokers were less likely to feel very comfortable in talking to co-workers about the health risks associated with their smoking (AOR=0.60; 95% CI: 0.45-0.78). The odds of feeling very comfortable in discussing smoking were consistently lower among those aged 18-35 years than their older counterparts. Clinical staff were more likely than non-clinical staff to feel very comfortable in discussing with patients and their parents about smoking, but there was no difference when talking to co-workers. CONCLUSIONS: We found differences in staff comfort level in discussing smoking with patients or their families, and coworkers, by sex, age, job type, and smoking status. These results can guide training and identify potential barriers and improve tailored tobacco control training programs and policies for hospital staff.

Improving the understanding of PI-RADS in practice: characters of PI-RADS 4 and 5 lesions with negative biopsy.

The Prostate Imaging Reporting and Data System (PI-RADS) has good ability to identify the nature of lesions on prostate magnetic resonance imaging (MRI). However, some lesions are still reported as PI-RADS 4 and 5 but are biopsy-proven benign. Herein, we aimed to summarize the reasons for the negative prostate biopsy of patients who were assessed as PI-RADS 4 and 5 by biparameter MRI. We retrospectively sorted out the prostate MRI, treatment, and follow-up results of patients who underwent a biparameter MRI examination of the prostate in The First Affiliated Hospital of Nanjing Medical University (Nanjing, China) from August 2019 to June 2021 with PI-RADS 4 and 5 but a negative biopsy. We focused on reviewing the MRI characteristics. A total of 467 patients underwent transperineal prostate biopsy. Among them, biopsy pathology of 93 cases were negative. After follow-up, 90 patients were ruled out of prostate cancer. Among the 90 cases, 40 were considered to be overestimated PI-RADS after review. A total of 22 cases were transition zone (TZ) lesions with regular appearance and clear boundaries, and 3 cases were symmetrical lesions. Among 15 cases, the TZ nodules penetrated the peripheral zone (PZ) and were mistaken for the origin of PZ. A total of 17 cases of lesions were difficult to distinguish from prostate cancer. Among them, 5 cases were granulomatous inflammation (1 case of prostate tuberculosis). A total of 33 cases were ambiguous lesions, whose performance was between PI-RADS 3 and 4. In summary, the reasons for "false-positive MRI diagnosis" included PI-RADS overestimation, ambiguous images giving higher PI-RADS, diseases that were really difficult to distinguish, and missed lesion in the initial biopsy; and the first two accounted for the most.

Physical Activity Patterns and Cognitive Health among Older Adults in the United States.

We assessed the association between physical activity (PA) patterns and cognitive health. Using the 2011-2014 National Health and Nutrition Examination Survey data among older adults (≥60 years), we defined scoring below the 25th percentile in the average z-scores from 3 cognitive tests as having low cognitive performance. We used latent class analysis to categorize PA patterns and examined their association with cognitive performance using logistic regressions while adjusting for relevant covariates. We identified three PA groups: inactive (50.2%), moderate intensity leisure (34.5%), and high intensity multiple activities (15.3%). Compared to the inactive group, the moderate intensity leisure and high intensity multiple activities groups were less likely to have low cognitive performance (adjusted proportion ratio .85; 95% CI: .75, .94; and .76; 95% CI: .57, .96). The results highlight the need for improving cognitive health of a large proportion of physically inactive older adults by promoting multiple types of PA.

Utilizing Residential History to Examine Heterogeneous Exposure Trajectories: A Latent Class Mixed Modeling Approach Applied to Mesothelioma Patients.

Background: Life-course exposure assessment, as opposed to a one-time snapshot assessment based on the address at cancer diagnosis, has become increasingly possible with available cancer patients' residential history data. To demonstrate a novel application of residential history data, we examined the heterogeneous trajectories of the nonasbestos air toxic exposures among mesothelioma patients, and compared the patients' residential locations with the spatiotemporal clusters estimated from the National Air Toxic Assessment (NATA) data. Methods: Patients' residential histories were obtained by linking mesothelioma cases diagnosed during 2011-2015 in the New York State (NYS) Cancer Registry to LexisNexis administrative data and inpatient claims data. To compare cancer risks over time, yearly relative exposure (RE) was calculated by dividing the NATA cancer risk at individual census tracts by the NYS average and subtracting 1. We used a latent class mixed model to identify distinct exposure trajectories among patients with a 15-year residential history prior to cancer diagnosis (n = 909). We further examined patient characteristics by the latent trajectory groups using bivariate comparisons and a logistic regression model. The spatiotemporal clusters of RE were generated based on all NATA data (n = 72,079) across the contiguous United States and using the SaTScan software. Results: The median number of addresses lived was 2 (IQR, 1-4), with a median residential duration of 8 years (IQR, 4.7-13.2 years). We identified 3 distinct exposure trajectories: persistent low exposure (27%), decreased low exposure (41%), and increased high exposure (32%). Patient characteristics did not differ across trajectory groups, except for race and Hispanic ethnicity (P < .0001) and residential duration (P = .03). Compared to their counterparts, non-Hispanic White patients had a significantly lower odds of belonging to the increased high exposure group (adjusted odds ratio, 0.14; 95% CI, 0.09-0.23) than the persistent low exposure and decreased low exposure groups. Patients in the increased high exposure group tended to reside in New York City (NYC), which was covered by one of the high-RE clusters. On the other hand, patients in the persistent low exposure group tended to reside outside of NYC within NYS, which was largely covered by 2 low-RE clusters. Conclusion: Using mesothelioma as an example, we quantified the heterogeneous trajectories of nonasbestos air toxic exposure based on patients' residential histories. We found that patients' race and ethnicity differed across the latent groups, likely reflecting the differences in patients' residential mobility before their cancer diagnoses. Our method can be used to study cancer types that do not have a clear etiology and may have a higher attributable risk due to environmental exposures as well as socioeconomic conditions.

Correlates of cancer prevalence across census tracts in the United States: A Bayesian machine learning approach.

Preventive measures, health behaviors, environmental exposures, and sociodemographic characteristics affect individual-level cancer risks. It is unclear how they influence neighborhood-level cancer risks. We developed a large-scale neighborhood health dataset for 72,337 census tracts in the United States by combining data from three publicly available sources. We used Bayesian additive regression trees to identify the most important predictors of tract-level cancer prevalence among adults (age ≥18 years), and examined their impact on cancer prevalence using partial dependence plots. The five most important census tract-level correlates of cancer prevalence were the proportion of population who were aged 65 years and older, had routine checkup and were non-Hispanic White, the proportion of houses built before 1960, and the proportion of population living below the poverty line. The identified predictors of neighborhood-level cancer prevalence may inform public health practitioners and policymakers to prioritize the improvement of environmental and neighborhood factors in reducing the cancer burden.

Estimating uncertainty in a socioeconomic index derived from the American community survey.

Socioeconomic indexes are widely used in public health to facilitate neighborhood-scale analyses. Although they are calculated with high levels of precision, they are rarely reported with accompanying measures of uncertainty (e.g., 90% confidence intervals). Here we use the variance replicate tables that accompany the United States Census Bureau's American Community Survey to report confidence intervals around the Yost Index, a socioeconomic index comprising seven variables that is frequently used in cancer surveillance. The Yost Index is reported as a percentile score from 1 (most affluent) to 100 (most deprived). We find that the average uncertainty for a census tract in the United States is plus or minus 8 percentiles, with the uncertainty a function of the value of the index itself. Scores at the extremes of the distribution are more precise and scores near the center are less precise. Less-affluent tracts have greater uncertainty than corresponding more-affluent tracts. Fewer than 50 census tracts of 72,793 nationally have unusual distributions of socioeconomic conditions that render the index uninformative. We demonstrate that the uncertainty in a census-based socioeconomic index is calculable and can be incorporated into any analysis using such an index.

Association between Diet Quality and Adolescent Wheezing: Effect Modification by Environmental Tobacco Smoke Exposure.

Rationale: Protective effects of a high-quality diet on respiratory health, particularly among youths exposed to environmental tobacco smoke (ETS), are unknown. Objectives: To assess if a higher-quality diet is associated with improved respiratory symptoms and lung function among adolescents and if these associations are modified by ETS exposure. Methods: This was a cross-sectional study on 7,026 nonsmoking adolescents of the 2003-2012 National Health and Nutrition Examination Survey. Diet quality was assessed using the Healthy Eating Index-2010 score (HEI-2010), categorized into quintiles. ETS exposure was measured using serum cotinine, dichotomized as high (>2.99 ng/ml) or low (⩽2.99 ng/ml). Outcomes included the presence of wheezing and cough symptoms in the past 12 months and, in a subgroup, spirometric lung function. Survey design-adjusted logistic and linear models evaluated associations between diet and 1) respiratory symptoms, and 2) lung function, respectively, and assessed the interaction between HEI-2010 and serum cotinine. Results: Although there were no significant associations between diet quality and respiratory symptoms, there was a significant interaction between HEI-2010 and serum cotinine on wheezing (Pint = 0.011). In models stratified by serum cotinine, adolescents with high serum cotinine and the healthiest diet (fifth quintile HEI-2010) experienced lower wheezing odds (odds ratio, 0.10; 95% confidence interval, 0.02-0.61) than those with the poorest diet (first quintile HEI-2010). In contrast, among adolescents with low serum cotinine, there were no significant differences in any respiratory symptoms between those with the highest compared with the lowest diet quality. Of the subgroup with spirometry data (n = 3,166), there was a trend toward better lung function with improving diet quality, although this did not achieve statistical significance. There was no effect modification by ETS exposure on the relationship between diet quality and lung function. Conclusions: Consuming a higher-quality diet was associated with lower wheezing odds in adolescents with substantial ETS exposure. Although longitudinal studies are needed, public health interventions to improve diet quality in vulnerable, environmentally exposed populations merit consideration.

Characterizing astigmatism in the United States.

PURPOSE: To study astigmatism and astigmatism rule by (1) determining changes in prevalence in the United States between 1971 to 1975 and 1999 to 2008 and (2) identifying associations with demographic factors. SETTING: National survey. DESIGN: Retrospective cross-sectional study. METHODS: Participants of the 1971 to 1975 and 1999 to 2008 National Health and Nutrition Examination Survey (NHANES) aged 20 to 74 years representing the U.S population were included. The 1971 to 1975 NHANES measured astigmatism in participants using an algorithm based on presenting visual acuity, lensometry, and objective refraction. Similar methods were implemented using the 1999 to 2008 NHANES data for comparison. Prevalence of clinically significant astigmatism (≥1.0 diopters [D]) was identified, and logistic regression models were used to assess demographic associations with rule of astigmatism. RESULTS: A total of 3371 and 13 10 participants were included from the 1970s and 2000s NHANES. Main outcomes were prevalence estimates of astigmatism and odds ratios estimating associations with demographic characteristics. There was an increase in astigmatism from the 1970s to 2000s (14% [95% CI: 13.2-14.5] vs 24% [22.8-24.6], which was more pronounced in men (12% [10.8-12.7] vs 23% [21.9-24.2]) than in women (16% [14.9-16.8] vs 24% [23.0-25.7]). In adjusted analysis of the 2000s cohort, myopic patients had 8.34 (CI: 7.30-9.54) times greater odds of astigmatism than nonmyopic patients. In the 2000s, there was increased odds of against-the-rule (ATR) astigmatism in men (odds ratio [OR], 1.4; 95% CI: 1.1-1.8) compared with women, in nonmyopic patients (OR, 2.3; 95% CI: 1.7-3.1) compared with myopic patients, and in patients aged 60 to 74 years (OR, 3.7; 95% CI: 2.7-5.1) compared with those aged 20 to 39 years. CONCLUSIONS: There is greater prevalence of astigmatism and ATR astigmatism in 1999 to 2008 compared with 30 years before in the U.S. Factors associated with ATR astigmatism were being male, White, and nonmyopic.

Disparities in Marijuana and Tobacco Smoke Incursions Among New York City Families During Early Months of the COVID-19 Pandemic.

OBJECTIVES: Once the COVID-19 pandemic arrived in New York City (NYC), stay-at-home orders led to more time spent indoors, potentially increasing exposure to secondhand marijuana and tobacco smoke via incursions from common areas or neighbors. The objective of this study was to characterize housing-based disparities in marijuana and tobacco incursions in NYC housing during the pandemic. DESIGN: We surveyed a random sample of families from May to July 2020 and collected sociodemographic data, housing characteristics, and the presence, frequency, and pandemic-related change in incursions. SETTING: Five pediatric practices affiliated with a large NYC health care system. PARTICIPANTS: In total, 230 caregivers of children attending the practices. MAIN OUTCOME MEASURES: Prevalence and change in tobacco and marijuana smoke incursions. RESULTS: Tobacco and marijuana smoke incursions were reported by 22.9% and 30.7%, respectively. Twenty-two percent of families received financial housing support (public housing, Section-8). Compared with families in private housing, families with financial housing support had 3.8 times the odds of tobacco incursions (95% CI, 1.4-10.1) and 3.7 times the odds of worsening incursions during pandemic (95% CI, 1.1-12.5). Families with financially supported housing had 6.9 times the odds of marijuana incursions (95% CI, 2.4-19.5) and 5 times the odds of worsening incursions during pandemic (95% CI, 1.9-12.8). Children in financially supported housing spent more time inside the home during pandemic (median 24 hours vs 21.6 hours, P = .02) and were more likely to have asthma (37% vs 12.9%, P = .001) than children in private housing. CONCLUSIONS: Incursions were higher among families with financially supported housing. Better enforcement of existing regulations (eg, Smoke-Free Public Housing Rule) and implementation of additional policies to limit secondhand tobacco and marijuana exposure in children are needed. Such actions should prioritize equitable access to cessation and mental health services and consider structural systems leading to poverty and health disparities.

Telemedicine Utilization in the Ambulatory Palliative Care Setting: Are There Disparities?

CONTEXT: Given a shortage of specialty palliative care clinicians and geographic variation in availability, telemedicine has been proposed as one way to improve access to palliative care services for patients with cancer. However, the enduring digital divide raises questions about whether unequal access will exacerbate healthcare disparities. OBJECTIVES: To examine factors associated with utilization of telemedicine as compared to in-person visits by patients with cancer in the ambulatory palliative care setting. METHODS: We collected data on patients seen in Supportive Oncology clinic by palliative care clinicians with an in-person or telemedicine visit from March 1 to December 30, 2020. A logistic regression with generalized estimating equation was fit to assess the association between visit type and patient characteristics. RESULTS: A total of 491 patients and 1783 visits were identified, including 1061 (60%) in-person visits and 722 (40%) telemedicine visits. Female patients were significantly more likely to utilize telemedicine than male patients (OR 1.46; 95% CI 1.11-1.90). Spanish-speaking patients (OR 0.32, 95% CI 0.17-0.61), those without insurance (OR 0.28, 95% CI 0.15-0.52), and those without an activated patient portal (Inactivated: OR 0.46, 95% CI 0.26-0.82; Pending Activation: OR 0.29, 95% CI 0.18-0.48) were less likely to utilize telemedicine. CONCLUSION: Our study reveals disparities in telemedicine utilization in the ambulatory palliative care setting for patients with cancer who are male, Spanish-speaking, uninsured, or do not have an activated patient portal. In the wake of the COVID-19 pandemic, we can better meet the palliative care needs of patients with cancer through telemedicine only if equity is kept at the forefront of our discussions.