Menopausal hormone therapy and change in physical activity in the Women's Health Initiative hormone therapy clinical trials.

OBJECTIVE: The menopausal transition results in a progressive decrease in circulating estrogen levels. Experimental evidence in rodents has indicated that estrogen depletion leads to a reduction of energy expenditure and physical activity. It is unclear whether treatment with estrogen therapy increases physical activity level in postmenopausal women. METHODS: A total of 27,327 postmenopausal women aged 50-79 years enrolled in the Women's Health Initiative randomized double-blind trials of menopausal hormone therapy. Self-reported leisure-time physical activity at baseline, and years 1, 3, and 6 was quantified as metabolic equivalents (MET)-h/wk. In each trial, comparison between intervention and placebo groups of changes in physical activity levels from baseline to follow-up assessment was examined using linear regression models. RESULTS: In the CEE-alone trial, the increase in MET-h/wk was greater in the placebo group compared with the intervention group at years 3 ( P = 0.002) and 6 ( P < 0.001). Similar results were observed when analyses were restricted to women who maintained an adherence rate ≥80% during the trial or who were physically active at baseline. In the CEE + MPA trial, the primary analyses did not show significant differences between groups, but the increase of MET-h/wk was greater in the placebo group compared with the intervention group at year 3 ( P = 0.004) among women with an adherence rate ≥80%. CONCLUSIONS: The results from this clinical trial do not support the hypothesis that estrogen treatment increases physical activity among postmenopausal women.

Changes in physical activity after joining a bikeshare program: a cohort of new bikeshare users.

BACKGROUND: There are hundreds of bikeshare programs worldwide, yet few health-related evaluations have been conducted. We enrolled a cohort of new bikeshare members in Philadelphia (Pennsylvania, USA) to assess whether within-person moderate and vigorous physical activity (MVPA) increased with higher use of the program and whether effects differed for vulnerable sub-groups. METHODS: During 2015-2018, 1031 new members completed baseline and one-year follow-up online surveys regarding their personal characteristics and past 7-day MVPA minutes per week (minutes per week with- and without walking). Participants were linked to their bikeshare trips to objectively assess program use. Negative binomial (for continuous outcomes) and multinomial (for categorical outcomes) regression adjusted for person characteristics (socio-demographics, health), weather, biking-infrastructure, and baseline biking. RESULTS: Participant median age was 30, 25% were of Black or Latino race/ethnicity, and 30% were socioeconomically disadvantaged. By follow-up, personal bike ownership increased and 75% used bikeshare, although most used it infrequently. Per 10 day change in past year (PY) bikeshare use, non-walking MVPA min/wk increased 3% (roughly 6 min/wk, P < 0.014). More days of bikeshare was also associated with change from inactive to more active (odds ratio for ≥ 15 days in PY vs. no bikeshare use 1.80, CI 1.05-3.09, P < 0.03). Results were consistent across vulnerable sub-groups. In general, impacts on MVPA were similar when exposure was personal bike or bikeshare. CONCLUSIONS: Bikeshare facilitated increases in cycling, slightly increased non-walking MVPA, and showed potential for activating inactive adults; however, for larger program impact, members will need to use it more frequently.

Shortcomings of the normalized difference vegetation index as an exposure metric.

The health benefits of exposure to trees and plants is a rapidly expanding field of study. Research has shown that exposure is associated with improvements in a wide range of health outcomes including cardiovascular disease, birth outcomes, respiratory disease, cancer, mental health and all-cause mortality1. One of the challenges that these studies face is characterizing participants' exposure to trees and plants. A common approach is to use the normalized difference vegetation index, a greenness index typically derived from satellite imagery. Reliance on the normalized difference vegetation index is understandable; for decades, the imagery required to calculate the normalized difference vegetation index has been available for the entire Earth's surface and is updated at regular intervals. However, the normalized difference vegetation index may do a poor job of fully characterizing the human experience of being exposed to trees and plants, because scenes with the same normalized difference vegetation index value can appear different to the human eye. We demonstrate this phenomenon by identifying sites in Portland, Oregon that have the same normalized difference vegetation index value as a large, culturally significant elm tree. These sites are strikingly different aesthetically, suggesting that use of the normalized difference vegetation index may lead to exposure misclassification. Where possible, the normalized difference vegetation index should be supplemented with other exposure metrics.

Association of Retail Environment and Neighborhood Socioeconomic Status With Mortality Among Community-Dwelling Older Adults in the United States: Cardiovascular Health Study.

BACKGROUND: Few studies have examined the association of neighborhood environment and mortality among community-dwelling older populations. Geographic Information Systems-based measures of neighborhood physical environment may provide new insights on the health effects of the social and built environment. METHOD: We studied 4 379 community-dwelling older adults in the United States aged 65 years and older from the Cardiovascular Health Study. Principal component analysis was used to identify neighborhood components from 48 variables assessing facilities and establishments, demographic composition, socioeconomic status, and economic prosperity. We used a Cox model to evaluate the association of neighborhood components with 5-year mortality. Age, sex, race, education, income, marital status, body mass index, smoking status, disability, coronary heart disease, and diabetes were included as covariates. We also examined the interactions between neighborhood components and sex and race (Black vs White or other). RESULTS: We identified 5 neighborhood components, representing facilities and resources, immigrant communities, community-level economic deprivation, resident-level socioeconomic status, and residents' age. Communities' economic deprivation and residents' socioeconomic status were significantly associated with 5-year mortality. We did not find interactions between sex or race and any of the 5 neighborhood components. The results were similar in a sensitivity analysis where we used 10-year mortality as the outcome. CONCLUSIONS: We found that communities' economic status but not facilities in communities was associated with mortality among older adults. These findings revealed the importance and benefits living in a socioeconomically advantaged neighborhood could have on health among older residents with different demographic backgrounds.

Life expectancy and mortality in 363 cities of Latin America.

The concept of a so-called urban advantage in health ignores the possibility of heterogeneity in health outcomes across cities. Using a harmonized dataset from the SALURBAL project, we describe variability and predictors of life expectancy and proportionate mortality in 363 cities across nine Latin American countries. Life expectancy differed substantially across cities within the same country. Cause-specific mortality also varied across cities, with some causes of death (unintentional and violent injuries and deaths) showing large variation within countries, whereas other causes of death (communicable, maternal, neonatal and nutritional, cancer, cardiovascular disease and other noncommunicable diseases) varied substantially between countries. In multivariable mixed models, higher levels of education, water access and sanitation and less overcrowding were associated with longer life expectancy, a relatively lower proportion of communicable, maternal, neonatal and nutritional deaths and a higher proportion of deaths from cancer, cardiovascular disease and other noncommunicable diseases. These results highlight considerable heterogeneity in life expectancy and causes of death across cities of Latin America, revealing modifiable factors that could be amenable to urban policies aimed toward improving urban health in Latin America and more generally in other urban environments.

Postmenopausal Breast Cancer and Physical Function Change: A Difference-in-Differences Analysis.

BACKGROUND/OBJECTIVES: While breast cancer and associated therapies can influence physical function (PF), findings for breast cancer's effects on PF among postmenopausal women are not consistent. This research evaluates the effect of breast cancer on change in PF. DESIGN: Longitudinal cohort study analyzed using difference-in-differences (DID) method to compare the changes in PF over time between women with and without breast cancer, by invasive status, stage, and age. SETTING AND PARTICIPANTS: Women's Health Initiative participants, aged 50 to 79 years at baseline, with four completed functional status assessments were eligible for inclusion (mean age = 62.1 ± 6.9 years). Women with breast cancer diagnosed between the 3rd and 11th enrollment year (n = 1636) were compared to women without breast cancer (n = 35 660). MEASUREMENTS: PF was measured using the Medical Outcomes Study Short Form 36 at baseline and years 3, 11, and 12. RESULTS: Compared with women without breast cancer, women with breast cancer experienced greater PF decline (P < .0001), after adjustment for age, race, education, income, study/trial arm, and body mass index. Overall, functional declines were greatest among women with invasive breast cancer (DID = -4.87; 95% confidence interval = -7.12 to -2.62). In stratified analyses, the breast cancer effect on PF was greater among women in older age groups. CONCLUSION: Women diagnosed with breast cancer experienced a significant decline in PF beyond what is observed in typical aging in this cohort. To optimally address survivorship issues, disease sequelae need to be distinguished from normal aging in studies incorporating a cancer-free comparison group. J Am Geriatr Soc 68:1029-1036, 2020.

Shifts in Women's Paid Employment Participation During the World War II Era and Later Life Health.

PURPOSE: The greatest proportional increase in female labor force participation of the 20th century occurred post-World War II (WWII) when shifts in policy and growth in service and clerical work spurred an influx of women into the labor force. Research has yet to demonstrate how variation in women's employment participation during this era related to their later life health. We examined how shifts in women's employment patterns during the WWII era influenced their disease and mortality risk. METHODS: Using data from the Women's Health Initiative Observational Study, we evaluated the employment history of a cohort of 6,158 women across the U.S. during the WWII era. We fit logistic regression models estimating the association between involvement in the workforce over 5-year intervals and health (i.e., cancer, cardiovascular disease, and mortality). We also ran models with a younger cohort (n = 12,435) of women to assess how associations between work and health varied between cohorts. RESULTS: The older cohort of women who entered the workforce before the onset of WWII showed mixed to no differences in health relative to homemakers. The younger cohort of women who entered the workforce during WWII tended to show negative relationships between work during their late/post-childbearing years and health, experiencing higher risks for mortality. CONCLUSIONS: The policies, social forces, and broader environment in which women live appear to significantly influence how involvement in the workforce over the life course influences health. Women whose entry into the workforce was initially encouraged socially but were later confronted with opposition experienced increased health risks.

Association between exposure to the natural environment, rurality, and attention-deficit hyperactivity disorder in children in New Zealand: a linkage study.

BACKGROUND: Several small experimental studies and cross-sectional observational studies have shown that exposure to the natural environment might protect against attention-deficit hyperactivity disorder (ADHD) or moderate the symptoms of ADHD in children. We aimed to assess whether exposure to the natural environment protects against ADHD and whether this hypothesised protective effect varies across a child's life course. METHODS: We did a longitudinal study with data collected from all children born in New Zealand in 1998, excluding those without an address history, those who were not singleton births, and those who died or emigrated before 18 years of age. We used Statistics New Zealand's Integrated Data Infrastructure to identify children with ADHD and to define covariates. ADHD was defined according to hospital diagnosis or pharmacy records (two or more prescriptions for ADHD drugs). Exposure to green space for each year of a child's life (from gestation to 18 years of age) was estimated at the meshblock level (the smallest geographical unit for which the New Zealand Census reports data) using normalised difference vegetation index (NDVI), and land-use data from Landcare Research New Zealand. We used logit models to assess the associations between ADHD prevalence and minimum, maximum, and mean lifetime NDVI, as well as rural living, controlling for sex, ethnicity, mother's educational level, mother's smoking status, mother's age at parturition, birth order, antibiotic use, and low birthweight. FINDINGS: Of the 57 450 children born in New Zealand in 1998, 49 923 were eligible and had available data, and were included in the analysis. Children who had always lived in a rural area after 2 years of age were less likely to develop ADHD (odds ratio [OR] 0·670 [95% CI 0·461-0·974), as were those with increased minimum NDVI exposure after age 2 years (standardised OR for exposure vs first quartile: second quartile 0·841 [0·707-0·999]; third quartile 0·809 [0·680-0·963]; fourth quartile 0·664 [0·548-0·805]). In early life (prenatal to age 2 years), neither rural living nor NDVI were protective against ADHD. Neither mean nor maximum greenness was significantly protective against ADHD. INTERPRETATION: Rurality and increased minimum greenness were strongly and independently associated with a reduced risk of ADHD. Increasing a child's minimum lifetime greenness exposure, as opposed to maximum or mean exposure, might provide the greatest increment of protection against the disorder. FUNDING: None.

Occupational Physical Activity and Coronary Heart Disease in Women's Health Initiative Observational Study.

BACKGROUND: Women comprise nearly half of the labor force in our society, but the impact of the occupational psychical activity on women's heart health in later life was unclear. We conducted a case-cohort study to assess the association of occupational physical activity (OPA), alone and jointly with leisure-time physical activity (LTPA) and risk of coronary heart disease (CHD). METHODS: We included women enrolled in Women's Health Initiative Observational Study who provided an occupational history at baseline and were followed until 2013 for the first occurrence of myocardial infarction or death from CHD (mean age ± SD = 63.4 ± 7.2). A total of 5,243 women free of CHD at baseline were randomly selected into a subcohort and 3,421 CHD events were adjudicated during follow-up. Through linkage of Standard Occupational Classification codes to the Occupational Information Network, we assessed cumulative and most recent exposure of OPA. LTPA was assessed through Women's Health Initiative's physical activity questionnaire. Weighted Cox proportional hazard models were used to evaluate CHD risk. RESULTS: After adjustment for demographic and socioeconomic factors, levels of OPA were not associated with CHD risk. Compared with women with low OPA and high LTPA, women with moderate to high cumulative OPA and low LTPA had relative high CHD risk (hazard ratio [HR]: 1.54, 95% confidence interval [CI]: 1.26, 1.88 for moderate OPA and HR: 1.46. 95% CI: 1.20, 1.78 for high OPA). DISCUSSION: Results from this study suggest no overall association between lifetime OPA and CHD risk in women, but the impact of OPA varies by LTPA levels.

Longitudinal Associations of Local Cigarette Prices and Smoking Bans with Smoking Behavior in the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Few studies have examined associations of geographically proximal cigarette prices with within-person changes in smoking outcomes or assessed interactions between cigarette prices and smoking bans. METHODS: We linked neighborhood cigarette prices (inflation-adjusted) at chain supermarkets and drug stores and bar/restaurant smoking ban policies to cohort participants (632 smokers from the Multi-Ethnic Study of Atherosclerosis, 2001-2012, baseline mean age 58 years) using geocoded retailer and participant addresses. We used fixed-effects models to investigate associations of within-person changes in price and ban exposures with within-person changes in five smoking outcomes: current smoking, heavy (≥10 cigarettes) smoking, cessation, relapse, and intensity (average number of cigarettes smoked per day, natural log transformed). We assessed intensity associations among all smokers, and heavy (≥10 cigarettes per day) and light (<10) baseline smokers. Finally, we tested interactions between cigarette price and bans. RESULTS: A $1 increase in price was associated with a 3% reduction in risk of current smoking (adjusted risk ratio [aRR]: 0.97; 95% confidence interval [CI] = 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93; CI = 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR: 1.2; CI = 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65; CI = 0.45, 0.93). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans. CONCLUSIONS: Results underscore the importance of local prices, but not hospitality smoking bans, in influencing older adults' smoking behaviors.

Post-diagnosis social networks, and lifestyle and treatment factors in the After Breast Cancer Pooling Project.

OBJECTIVE: Larger social networks have been associated with better breast cancer survival. To investigate potential mediators, we evaluated associations of social network size and diversity with lifestyle and treatment factors associated with prognosis. METHODS: We included 9331 women from the After Breast Cancer Pooling Project who provided data on social networks within approximately two years following diagnosis. A social network index was derived from information about the presence of a spouse or intimate partner, religious ties, community participation, friendship ties, and numbers of living relatives. Diversity was assessed as variety of ties, independent of size. We used logistic regression to evaluate associations with outcomes and evaluated whether effect estimates differed using meta-analytic techniques. RESULTS: Associations were similar across cohorts though analyses of smoking and alcohol included US cohorts only because of low prevalence of these behaviors in the Shanghai cohort. Socially isolated women were more likely to be obese (OR = 1.21, 95% CI:1.03-1.42), have low physical activity (<10 MET-hours/week, OR = 1.55, 95% CI:1.36-1.78), be current smokers (OR = 2.77, 95% CI:2.09-3.68), and have high alcohol intake (≥15 g/d, OR = 1.23, 95% CI:1.00-1.51), compared with socially integrated women. Among node positive cases from three cohorts, socially isolated women were more likely not to receive chemotherapy (OR = 2.10, 95% CI:1.30-3.39); associations differed in a fourth cohort. Other associations (nonsignificant) were consistent with less intensive treatment in socially isolated women. Low social network diversity was independently associated with more adverse lifestyle, but not clinical, factors. CONCLUSIONS: Small, less diverse social networks measured post-diagnosis were associated with more adverse lifestyle factors and less intensive cancer treatment. Copyright © 2016 John Wiley & Sons, Ltd.

Postdiagnosis social networks and breast cancer mortality in the After Breast Cancer Pooling Project.

BACKGROUND: Large social networks have been associated with better overall survival, though not consistently with breast cancer (BC)-specific outcomes. This study evaluated associations of postdiagnosis social networks and BC outcomes in a large cohort. METHODS: Women from the After Breast Cancer Pooling Project (n = 9267) provided data on social networks within approximately 2 years of their diagnosis. A social network index was derived from information about the presence of a spouse/partner, religious ties, community ties, friendship ties, and numbers of living first-degree relatives. Cox models were used to evaluate associations, and a meta-analysis was used to determine whether effect estimates differed by cohort. Stratification by demographic, social, tumor, and treatment factors was performed. RESULTS: There were 1448 recurrences and 1521 deaths (990 due to BC). Associations were similar in 3 of 4 cohorts. After covariate adjustments, socially isolated women (small networks) had higher risks of recurrence (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.15-1.77), BC-specific mortality (HR, 1.64; 95% CI, 1.33-2.03), and total mortality (HR, 1.69; 95% CI, 1.43-1.99) than socially integrated women; associations were stronger in those with stage I/II cancer. In the fourth cohort, there were no significant associations with BC-specific outcomes. A lack of a spouse/partner (P = .02) and community ties (P = .04) predicted higher BC-specific mortality in older white women but not in other women. However, a lack of relatives (P = .02) and friendship ties (P = .01) predicted higher BC-specific mortality in nonwhite women only. CONCLUSIONS: In a large pooled cohort, larger social networks were associated with better BC-specific and overall survival. Clinicians should assess social network information as a marker of prognosis because critical supports may differ with sociodemographic factors. Cancer 2017;123:1228-1237. © 2016 American Cancer Society.

Cross-sectional and longitudinal associations of neighbourhood social environment and smoking behaviour: the multiethnic study of atherosclerosis.

BACKGROUND: Social features of neighbourhood environments may influence smoking by creating a stressful environment or by buffering stress through social cohesion. However, the association of the overall neighbourhood social environment (NSE) with smoking, and the association of specific neighbourhood social factors with change in smoking behaviour over time, has rarely been examined. METHODS: This study included 5856 adults aged 45-84 years from the Multi-Ethnic Study of Atherosclerosis (2000-2012, average follow-up: 7.8 years). Outcomes included current smoking status and smoking intensity (average number of cigarettes smoked per day among baseline smokers). NSE was assessed as a composite score composed of aesthetic quality, safety and social cohesion scales (derived from neighbourhood surveys). Generalised linear mixed models evaluated the association of baseline NSE (composite score and individual scales) with current smoking (modified Poisson models) and smoking intensity (negative binomial models) cross-sectionally and longitudinally. RESULTS: Each SD increase in baseline NSE composite score was associated with 13% lower prevalence of smoking at baseline (adjusted prevalence ratio (aPR) 0.87 (95% CI 0.78 to 0.98). Neighbourhood safety and aesthetic quality were similarly associated with lower smoking prevalence (aPR 0.87 (0.78 to 0.97) and aPR 0.87 (0.77 to 0.99), respectively) but the association with social cohesion was weaker or null. No significant associations were observed for smoking intensity among baseline smokers. Baseline NSE was not associated with changes in smoking risk or intensity over time. CONCLUSIONS: Results suggest that neighbourhood social context influences whether older adults smoke, but does not promote smoking cessation or reduction over time.

Using an epiphytic moss to identify previously unknown sources of atmospheric cadmium pollution.

Urban networks of air-quality monitors are often too widely spaced to identify sources of air pollutants, especially if they do not disperse far from emission sources. The objectives of this study were to test the use of moss bio-indicators to develop a fine-scale map of atmospherically-derived cadmium and to identify the sources of cadmium in a complex urban setting. We collected 346 samples of the moss Orthotrichum lyellii from deciduous trees in December, 2013 using a modified randomized grid-based sampling strategy across Portland, Oregon. We estimated a spatial linear model of moss cadmium levels and predicted cadmium on a 50m grid across the city. Cadmium levels in moss were positively correlated with proximity to two stained-glass manufacturers, proximity to the Oregon-Washington border, and percent industrial land in a 500m buffer, and negatively correlated with percent residential land in a 500m buffer. The maps showed very high concentrations of cadmium around the two stained-glass manufacturers, neither of which were known to environmental regulators as cadmium emitters. In addition, in response to our findings, the Oregon Department of Environmental Quality placed an instrumental monitor 120m from the larger stained-glass manufacturer in October, 2015. The monthly average atmospheric cadmium concentration was 29.4ng/m(3), which is 49 times higher than Oregon's benchmark of 0.6ng/m(3), and high enough to pose a health risk from even short-term exposure. Both stained-glass manufacturers voluntarily stopped using cadmium after the monitoring results were made public, and the monthly average cadmium levels precipitously dropped to 1.1ng/m(3) for stained-glass manufacturer #1 and 0.67ng/m(3) for stained-glass manufacturer #2.

Beyond crosswalks: reliability of exposure assessment following automated coding of free-text job descriptions for occupational epidemiology.

Epidemiologists typically collect narrative descriptions of occupational histories because these are less prone than self-reported exposures to recall bias of exposure to a specific hazard. However, the task of coding these narratives can be daunting and prohibitively time-consuming in some settings. The aim of this manuscript is to evaluate the performance of a computer algorithm to translate the narrative description of occupational codes into standard classification of jobs (2010 Standard Occupational Classification) in an epidemiological context. The fundamental question we address is whether exposure assignment resulting from manual (presumed gold standard) coding of the narratives is materially different from that arising from the application of automated coding. We pursued our work through three motivating examples: assessment of physical demands in Women's Health Initiative observational study, evaluation of predictors of exposure to coal tar pitch volatiles in the US Occupational Safety and Health Administration's (OSHA) Integrated Management Information System, and assessment of exposure to agents known to cause occupational asthma in a pregnancy cohort. In these diverse settings, we demonstrate that automated coding of occupations results in assignment of exposures that are in reasonable agreement with results that can be obtained through manual coding. The correlation between physical demand scores based on manual and automated job classification schemes was reasonable (r = 0.5). The agreement between predictive probability of exceeding the OSHA's permissible exposure level for polycyclic aromatic hydrocarbons, using coal tar pitch volatiles as a surrogate, based on manual and automated coding of jobs was modest (Kendall rank correlation = 0.29). In the case of binary assignment of exposure to asthmagens, we observed that fair to excellent agreement in classifications can be reached, depending on presence of ambiguity in assigned job classification (κ = 0.5-0.8). Thus, the success of automated coding appears to depend on the setting and type of exposure that is being assessed. Our overall recommendation is that automated translation of short narrative descriptions of jobs for exposure assessment is feasible in some settings and essential for large cohorts, especially if combined with manual coding to both assess reliability of coding and to further refine the coding algorithm.

The association between neighborhood social capital and cancer screening.

OBJECTIVES: To examine the association between social capital and adherence to cancer screening exams. METHODS: Data from a population-based survey assessed perceived neighborhood social capital as well as cancer screening behavior. We analyzed the influence of social capital on adherence to screening guidelines for cervical, breast, and colorectal cancer. RESULTS: Data from 2668 adults documented that those with greater perceived neighborhood social capital were more likely to be screened for cancer. The effect was strongest for colorectal cancer and weakest for cervical cancer. CONCLUSIONS: Research on understanding the effect of the neighborhood social environment on efforts related to cancer screening behavior may be helpful for increasing cancer screening rates.

Using inpatient hospital discharge data to monitor patient safety events.

The development of systematic and sustainable surveillance systems is necessary for the creation of patient safety prevention programs and the evaluation of improvement resulting from innovations. To that end, inpatient hospital discharges collected by the Pennsylvania Health Care Cost Containment Council were used to investigate patient safety events (PSEs) in Pennsylvania in 2006. PSEs were identified using external cause of injury codes (E-codes) in combination with the Agency for Healthcare Research and Quality's patient safety indicators (PSIs). Encounters with and without PSEs were compared with regard to patient age, sex, race, length of stay, and cost. Approximately 9% of all Pennsylvania inpatient discharges had a PSE in 2006. Patients with a PSE were on average older, male, and white. The average length of stay for a PSE was 3 days longer and $35 000 more expensive than a non-PSE encounter. It was concluded that E-codes and PSIs were useful tools for the surveillance of PSEs in Pennsylvania, and that administrative data from healthcare organizations provide a consistent source of standardized data related to patient encounters, creating an opportunity to describe PSEs at the population level.

Geriatric syndromes and incident disability in older women: results from the women's health initiative observational study.

OBJECTIVES: To determine how the number of geriatric syndromes is associated with incident disability in community-based populations of older adults. DESIGN: Longitudinal analysis from the Women's Health Initiative Observational Study (WHI-OS). SETTING: Community. PARTICIPANTS: Twenty-nine thousand five hundred forty-four women aged 65 and older enrolled in the WHI-OS and free of disability in activities of daily living (ADLs) at baseline. MEASUREMENTS: Geriatric syndromes (high depressive symptoms, dizziness, falls, hearing or visual impairment, osteoporosis, polypharmacy, syncope, sleep disturbance, and urinary incontinence) were self-reported at baseline and 3-year follow-up. Disability was defined as dependence in any ADL and was assessed at baseline and follow-up. Chronic diseases were measured according to a modified Charlson Index. RESULTS: Geriatric syndromes were common in this population of women; 76.3% had at least one syndrome at baseline. Greater number of geriatric syndromes at baseline was significantly associated with greater risk of incident ADL disability at follow-up (P ≤ .001). Adjusted risk ratios were 1.21 (95% confidence interval (CI) = 0.78-1.87) for a single syndrome and 6.64 (95% CI = 4.15-10.62) for five or more syndromes compared with no syndromes. These results were only slightly attenuated after adjustment for number of chronic diseases or pain. CONCLUSION: Geriatric syndromes are significantly associated with onset of disability in older women; this association is not simply a result of chronic disease or pain. A better understanding of how these conditions contribute to disablement is needed. Geriatric syndrome assessment should be considered along with chronic disease management in the prevention of disability in older women.

Environmental influences on children's physical activity and eating habits in a rural Oregon County.

PURPOSE. To identify environmental barriers and facilitators of children's physical activity and healthy eating in a rural county. DESIGN. Community-based participatory research using mixed methods, primarily qualitative. SETTING. A rural Oregon county. SUBJECTS. Ninety-five adults, 6 high school students, and 41 fifth-grade students. MEASURES. In-depth interviews, focus groups, Photovoice, and structured observations using the Physical Activity Resource Assessment, System for Observing Play and Leisure Activity, Community Food Security Assessment Toolkit, and School Food and Beverage Marketing Assessment Tool. ANALYSIS. Qualitative data were coded by investigators; observational data were analyzed using descriptive statistics. The findings were triangulated to produce a composite of environmental barriers and assets. RESULTS. Limited recreational resources, street-related hazards, fear of strangers, inadequate physical education, and denial of recess hindered physical activity, whereas popularity of youth sports and proximity to natural areas promoted physical activity. Limited availability and high cost of healthy food, busy lifestyles, convenience stores near schools, few healthy meal choices at school, children's being permitted to bring snacks to school, candy used as incentives, and teachers' modeling unhealthy eating habits hindered healthy eating, whereas the agricultural setting and popularity of gardening promoted healthy eating. CONCLUSIONS. This study provides data on a neglected area of research, namely environmental determinants of rural childhood obesity, and points to the need for multifaceted and multilevel environmental change interventions.