Residential Segregation, Social Cohesion, and Aging in Place: Health and Mental Health Inequities.

BACKGROUND AND OBJECTIVES: Research shows that living in segregated neighborhoods may have deleterious health outcomes via social, physical, and socioeconomic contexts that deepen existing inequities. However, there has been limited scholarship examining the effects of segregation on older adults, despite an increasing focus on aging in place. Guided by the Ecological Model of Aging, we examined the effects of segregation on older adults' self-rated health and mental health, accounting for both individual characteristics and neighborhood opportunities and risks (e.g., social cohesion) and the potential moderating role of race and economic vulnerability. RESEARCH DESIGN AND METHODS: We used data from the first 4 rounds of the National Health and Aging Trends Study (2011-2014) merged with tract-level census data for a final sample size of 3,084 community-dwelling older adults in urban areas. We conducted multivariate regression analyses after conditioning on residential location selection variables. RESULTS: There was no significant association between neighborhood segregation and self-rated health or between segregation and anxiety and depression symptoms. Consistent with the literature, perceived social cohesion was protective of health in each model. DISCUSSION AND IMPLICATIONS: Our findings highlight the need for more rigorous research on segregation and older residents that utilize longitudinal and spatial data. Our findings also have implications for policies and programs that aim to support the ability to age in place for older adults who have different racial identities and live in different neighborhood contexts. Because social cohesion can be a protective factor for older adults' health and mental health, policymakers and practitioners should support initiatives to increase social cohesion.

Rural Raccoons (Procyon lotor) Not Likely to Be a Major Driver of Antimicrobial Resistant Human Salmonella Cases in Southern Ontario, Canada: A One Health Epidemiological Assessment Using Whole-Genome Sequence Data.

Non-typhoidal Salmonella infections represent a substantial burden of illness in humans, and the increasing prevalence of antimicrobial resistance among these infections is a growing concern. Using a combination of Salmonella isolate short-read whole-genome sequence data from select human cases, raccoons, livestock and environmental sources, and an epidemiological framework, our objective was to determine if there was evidence for potential transmission of Salmonella and associated antimicrobial resistance determinants between these different sources in the Grand River watershed in Ontario, Canada. Logistic regression models were used to assess the potential associations between source type and the presence of select resistance genes and plasmid incompatibility types. A total of 608 isolates were obtained from the following sources: humans (n = 58), raccoons (n = 92), livestock (n = 329), and environmental samples (n = 129). Resistance genes of public health importance, including bla CMY-2, were identified in humans, livestock, and environmental sources, but not in raccoons. Most resistance genes analyzed were significantly more likely to be identified in livestock and/or human isolates than in raccoon isolates. Based on a 3,002-loci core genome multi-locus sequence typing (cgMLST) scheme, human Salmonella isolates were often more similar to isolates from livestock and environmental sources, than with those from raccoons. Rare instances of serovars S. Heidelberg and S. Enteritidis in raccoons likely represent incidental infections and highlight possible acquisition and dissemination of predominantly poultry-associated Salmonella by raccoons within these ecosystems. Raccoon-predominant serovars were either not identified among human isolates (S. Agona, S. Thompson) or differed by more than 350 cgMLST loci (S. Newport). Collectively, our findings suggest that the rural population of raccoons on swine farms in the Grand River watershed are unlikely to be major contributors to antimicrobial resistant human Salmonella cases in this region.

A farm-to-fork quantitative risk assessment model for Salmonella Heidelberg resistant to third-generation cephalosporins in broiler chickens in Canada.

Salmonella Heidelberg resistant to ceftiofur (a third-generation cephalosporin antimicrobial agent) in broiler chicken products pose a risk to public health in Canada. The objective of this study was to assess the extent of that risk and to evaluate the effect of intervention measures along the agri-food chain. A stochastic farm-to-fork quantitative microbial risk assessment model was developed following the Codex Alimentarius Guidelines for Risk Analysis of Foodborne Antimicrobial Resistance. Different scenarios were analyzed to assess the individual relative effects of 18 possible interventions in comparison to a baseline scenario. The baseline scenario represented the first year of on-farm antimicrobial use surveillance in the Canadian broiler industry and the year before an industry-imposed ban on the preventive use of antimicrobials of very high importance to human health (2013), where 31.3% of broiler flocks consisted of birds to which ceftiofur was administered. The baseline scenario predicted an average probability of illness of 1.1 per 100,000 servings (SE: 0.064 per 100,000), corresponding to an average of 22,000 human infections (SE: 1900) with ceftiofur-resistant S. Heidelberg per year, which is likely an overestimation. This risk was reduced by 90% or 20% when two separate scenarios designed to capture the effect of withdrawing preventive ceftiofur use from poultry production were simulated using different approaches; data used for the former scenario were confounded by other potential concomitant control measures (e.g. Salmonella vaccination programme), so the true effect likely lies somewhere between the two estimates. A theoretical 'worst case' scenario where all flocks had birds exposed to ceftiofur increased the risk by 107%. A 50% reduction in the probability of human prior exposure to antimicrobials, which has a selective and competitive effect for Salmonella spp. following ingestion of contaminated products, reduced the risk by 65%. Other promising measures that could be considered for further risk management included improved cleaning and disinfection between broiler flocks on farm (risk reduction by 26%), exclusive use of air chilling (risk reduction by 34%), and the improvement of meat storage and preparation conditions, e.g., no temperature abuse at retail (risk reduction by 88%). These findings showed the importance of a structured approach to assessing and potentially implementing effective interventions to reduce the risk associated with ceftiofur-resistant S. Heidelberg at different steps along the agri-food chain. Major data gaps included information on concentrations of resistant bacteria, cross contamination at processing and how ceftiofur-resistant S. Heidelberg behave in comparison with susceptible ones, e.g., in terms of growth and survival ability, as well as pathogenicity and virulence.

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

INTRODUCTION: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.

Integrating Whole-Genome Sequencing Data Into Quantitative Risk Assessment of Foodborne Antimicrobial Resistance: A Review of Opportunities and Challenges.

Whole-genome sequencing (WGS) will soon replace traditional phenotypic methods for routine testing of foodborne antimicrobial resistance (AMR). WGS is expected to improve AMR surveillance by providing a greater understanding of the transmission of resistant bacteria and AMR genes throughout the food chain, and therefore support risk assessment activities. At this stage, it is unclear how WGS data can be integrated into quantitative microbial risk assessment (QMRA) models and whether their integration will impact final risk estimates or the assessment of risk mitigation measures. This review explores opportunities and challenges of integrating WGS data into QMRA models that follow the Codex Alimentarius Guidelines for Risk Analysis of Foodborne AMR. We describe how WGS offers an opportunity to enhance the next-generation of foodborne AMR QMRA modeling. Instead of considering all hazard strains as equally likely to cause disease, WGS data can improve hazard identification by focusing on those strains of highest public health relevance. WGS results can be used to stratify hazards into strains with similar genetic profiles that are expected to behave similarly, e.g., in terms of growth, survival, virulence or response to antimicrobial treatment. The QMRA input distributions can be tailored to each strain accordingly, making it possible to capture the variability in the strains of interest while decreasing the uncertainty in the model. WGS also allows for a more meaningful approach to explore genetic similarity among bacterial populations found at successive stages of the food chain, improving the estimation of the probability and magnitude of exposure to AMR hazards at point of consumption. WGS therefore has the potential to substantially improve the utility of foodborne AMR QMRA models. However, some degree of uncertainty remains in relation to the thresholds of genetic similarity to be used, as well as the degree of correlation between genotypic and phenotypic profiles. The latter could be improved using a functional approach based on prediction of microbial behavior from a combination of 'omics' techniques (e.g., transcriptomics, proteomics and metabolomics). We strongly recommend that methodologies to incorporate WGS data in risk assessment be included in any future revision of the Codex Alimentarius Guidelines for Risk Analysis of Foodborne AMR.

Benefit-Cost Analysis of an Innovative Program for Self-Sufficiency and Homeownership.

BACKGROUND: Federal policy has increasingly sought to build financial capability, earnings, and assets of subsidized housing recipients. OBJECTIVE: We conduct a benefit-cost analysis of the Denver Housing Authority's (DHA) innovative Home Ownership Program (HOP), which incentivizes participants to increase earnings, build wealth, and purchase homes. RESEARCH DESIGN, SUBJECTS, AND MEASURES: In assessing HOP participant benefits (earnings, home-buying, and positive exits from DHA), we use parameter estimates from quasi-experimental methods (i.e., propensity score matching) that permit drawing causal inferences of program impacts. Impact estimates are robust to alternate model specification and mostly insensitive to omitted variable bias found in the social sciences. We deploy a comprehensive accounting framework, distinguishing benefits and costs accruing to program participants, nonparticipants (other citizens, taxpayers, and governments), and society as a whole. We use Monte Carlo simulation techniques to approximate distributions of benefit and cost parameters, thereby ascertaining how reliably participation in HOP yielded net benefits compared to if families had continued to receive housing assistance during the same period. RESULTS: We estimate a net social benefit from HOP of US$6,015 per participant. The simulated standard deviation was only a third of this value and 99.9% of simulations returned positive net social benefits. CONCLUSION: We conclude with a high degree of statistical confidence that HOP produced substantial net benefits to society as a whole, program participants, and nonparticipants alike. HOP offers strong potential for poverty alleviation among housing subsidy recipients and should be replicated.

Environmental risk assessment of metformin and its transformation product guanylurea: II. Occurrence in surface waters of Europe and the United States and derivation of predicted no-effect concentrations.

Metformin (MET), CAS 1115-70-4 (Metformin hydrochloride), is an antidiabetic drug with high usage in North America and Europe and has become the subject of regulatory interest. A pharmaceutical industry working group investigated environmental risks of MET. Environmental fate and chronic effects data were collated across the industry for the present risk assessment. Predicted environmental concentrations (PECs) for MET were modeled for the USA and Europe using the PhATE and GREAT-ER models, respectively. PECs were compared with measured environmental concentrations (MECs) for the USA and Europe. A predicted no effect concentration (PNEC) of 1 mg/L for MET was derived by deterministic procedures, applying an assessment factor of 10 to the lowest no observed effect concentration (i.e., 10 mg/L) from multiple chronic studies with algae, daphnids and fish. The PEC/PNEC and MEC/PNEC risk characterization ratios were <1, indicating no significant risk for MET with high Margins of Safety (MOS) of >868. MET is known to degrade during wastewater treatment to guanylurea (GUU, CAS 141-83-3), which we have shown to further degrade. There are no GUU toxicity data in the literature; hence, chronic studies for GUU were conducted to derive a PNEC of 0.16 mg/L. PECs were derived for GUU as for MET, plus MECs were retrieved from the literature. The PEC/PNEC and MEC/PNEC risk characterization ratios for GUU were also <1, with an MOS of >6.5. Based on standard risk assessment procedures for both MET and its transformation product GUU, there is no significant risk to aquatic life.

Aging in Place in Gentrifying Neighborhoods: Implications for Physical and Mental Health.

Background and Objectives: In the United States, the older adult population and the proportion of neighborhoods experiencing gentrification are both growing. However, there is limited scholarship on the effects of gentrification on older adults, with most work focusing on those who leave rather than stay. This study examines the effects of remaining in a gentrifying neighborhood on older adults' self-rated health and mental health, with particular attention to outcomes for those who are economically vulnerable. Research Design and Methods: Data are from 6,810 community-dwelling respondents in metropolitan areas from the first wave of the National Health & Aging Trends Study combined with the 1970-2010 National Neighborhood Change Database. We estimate the effects of gentrification on self-rated health and mental health separately using a quasi-experimental approach and comparing two methods: matching design and linear regression. Results: Economically vulnerable older adults in gentrifying neighborhoods reported higher self-rated health than economically vulnerable older adults in low-income neighborhoods. Both economically vulnerable and higher-income older adults in gentrifying neighborhoods had more depression and anxiety symptoms than those living in more affluent areas. Higher-income older adults in gentrifying neighborhoods had poorer mental health than their counterparts in low-income neighborhoods. Discussion and Implications: Findings call attention to the complexity of gentrification, and the need for more research examining how the intersection of neighborhood and individual characteristics influences older adults' health. Results reinforce the need for neighborhood-level interventions as well as relocation support to promote health in later life and caution against an overemphasis on aging in place.

Reducing the Cost of the Diagnostic Odyssey in Early Onset Epileptic Encephalopathies.

Whole exome sequencing (WES) has revolutionized the way we think about and diagnose epileptic encephalopathies. Multiple recent review articles discuss the benefits of WES and suggest various algorithms to follow for determining the etiology of epileptic encephalopathies. Incorporation of WES in these algorithms is leading to the discovery of new genetic diagnoses of early onset epileptic encephalopathies (EOEEs) at a rapid rate; however, WES is not yet a universally utilized diagnostic tool. Clinical WES may be underutilized due to provider discomfort in ordering the test or perceived costliness. At our hospital WES is not routinely performed for patients with EOEE due to limited insurance reimbursement. In fact for any patient with noncommercial insurance (Medicaid) the institution does not allow sending out WES as this is not "established"/"proven to be highly useful and cost effective"/"approved test" in patients with epilepsy. Recently, we performed WES on four patients from three families and identified novel mutations in known epilepsy genes in all four cases. These patients had State Medicaid as their insurance carrier and were followed up for several years for EOEE while being worked up using the traditional/approved testing methods. Following a recently proposed diagnostic pathway, we analyzed the cost savings (US dollars) that could be accrued if WES was performed earlier in the diagnostic odyssey. This is the first publication that addresses the dollar cost of traditional testing in EOEE as performed in these four cases versus WES and the potential cost savings.

Age-friendly environments and self-rated health: an exploration of Detroit elders.

While a number of organizations and government entities have encouraged the development of more "age-friendly" environments, to date there has been limited research linking these environment features to elder outcomes. Using a representative sample of older adults living in Detroit, this study examined the association between age-friendly environment factors and self-rated health. Results indicated that access to health care, social support, and community engagement were each associated with better self-rated health, while neighborhood problems were associated with poorer self-rated health. Moreover, individual-level income and education no longer predicted self-rated health once age-friendly environment factors were taken into account. These findings highlight the need for more research documenting the effects of age-friendly environments, particularly across diverse contexts and populations.

Pre-capture multiplexing improves efficiency and cost-effectiveness of targeted genomic enrichment.

BACKGROUND: Targeted genomic enrichment (TGE) is a widely used method for isolating and enriching specific genomic regions prior to massively parallel sequencing. To make effective use of sequencer output, barcoding and sample pooling (multiplexing) after TGE and prior to sequencing (post-capture multiplexing) has become routine. While previous reports have indicated that multiplexing prior to capture (pre-capture multiplexing) is feasible, no thorough examination of the effect of this method has been completed on a large number of samples. Here we compare standard post-capture TGE to two levels of pre-capture multiplexing: 12 or 16 samples per pool. We evaluated these methods using standard TGE metrics and determined the ability to identify several classes of genetic mutations in three sets of 96 samples, including 48 controls. Our overall goal was to maximize cost reduction and minimize experimental time while maintaining a high percentage of reads on target and a high depth of coverage at thresholds required for variant detection. RESULTS: We adapted the standard post-capture TGE method for pre-capture TGE with several protocol modifications, including redesign of blocking oligonucleotides and optimization of enzymatic and amplification steps. Pre-capture multiplexing reduced costs for TGE by at least 38% and significantly reduced hands-on time during the TGE protocol. We found that pre-capture multiplexing reduced capture efficiency by 23 or 31% for pre-capture pools of 12 and 16, respectively. However efficiency losses at this step can be compensated by reducing the number of simultaneously sequenced samples. Pre-capture multiplexing and post-capture TGE performed similarly with respect to variant detection of positive control mutations. In addition, we detected no instances of sample switching due to aberrant barcode identification. CONCLUSIONS: Pre-capture multiplexing improves efficiency of TGE experiments with respect to hands-on time and reagent use compared to standard post-capture TGE. A decrease in capture efficiency is observed when using pre-capture multiplexing; however, it does not negatively impact variant detection and can be accommodated by the experimental design.

Hearing loss in Union Army veterans from 1862 to 1920.

OBJECTIVES: To examine the prevalence of hearing loss (HL) in Union Army (UA) veterans by year, birth cohort, and occupation, and to compare Civil War pension and contemporary disability programs by examining monthly dollar awards. STUDY DESIGN: A retrospective review of medical records for 17,722 UA veteran pension applicants, a subset of some 35,000 soldiers retrieved randomly from the Military Archives. METHODS: The diagnosis of HL was based on review of medical records, which used gross measurements because of the unavailability of audiometric testing. RESULTS: One third (5,891 or 33%) of pensioners sampled received compensation for HL. The veterans with HL suffered predominantly from left-sided HL (4,091 or 70%), which is consistent with noise-induced HL in a right-handed individual firing a rifle. Comparison of civilian occupations reveals minimal variation in prevalence of HL. Civil War pensions for unilateral HL averaged $134.04 per year, representing nearly one third of the average annual income in 1890. Bilateral HL received nearly twice that amount. Today, military veterans receive $1,248 annually for unilateral loss and $27,288 annually for bilateral loss. Social Security disability benefits are granted only for bilateral HL, with an average 60-year-old individual receiving $11,400 per year. CONCLUSION: HL was a common disability among UA Civil War veterans, with noise exposure a likely etiology for the HL. The differing levels of compensation for HL may reflect differing perceptions on the incapacitating effects of HL.