Water recreation and illness severity.

The health endpoint of prior studies of water recreation has been the occurrence of gastrointestinal (GI) illness. This dichotomous measure fails to take into account the range of symptom severity among those with GI illness, and those who develop GI symptoms but who do not satisfy the definition of GI illness. Data from two US cohort studies were used to assess use of ordinal and semi-continuous measures of GI symptoms, such as duration of GI symptoms and responses to those symptoms such as medication use, interference with daily activities, and utilization of healthcare service. Zero-inflated negative binomial and logistic regression models were used to assess associations between severity and either the degree of water exposure or water quality. Among 37,404 water recreators without baseline GI symptoms, we observed individuals with relatively low severity satisfying the case definition of GI illness, while others with high severity not satisfying that definition. Severity metrics were associated with water exposure. The dichotomous GI illness outcome could be improved by considering symptom severity in future studies. Modeling ordinal and semi-continuous outcomes may improve our understanding of determinants of the burden of illness rather than simply the number of cases of illness attributable to environmental exposures.

Community drinking water quality monitoring data: utility for public health research and practice.

CONTEXT: Environmental Public Health Tracking (EPHT) tracks the occurrence and magnitude of environmental hazards and associated adverse health effects over time. The EPHT program has formally expanded its scope to include finished drinking water quality. OBJECTIVES: Our objective was to describe the features, strengths, and limitations of using finished drinking water quality data from community water systems (CWSs) for EPHT applications, focusing on atrazine and nitrogen compounds in 8 Midwestern states. METHODS: Water quality data were acquired after meeting with state partners and reviewed and merged for analysis. RESULTS: Data and the coding of variables, particularly with respect to censored results (nondetects), were not standardized between states. Monitoring frequency varied between CWSs and between atrazine and nitrates, but this was in line with regulatory requirements. Cumulative distributions of all contaminants were not the same in all states (Peto-Prentice test P < .001). Atrazine results were highly censored in all states (76.0%-99.3%); higher concentrations were associated with increased measurement frequency and surface water as the CWS source water type. Nitrate results showed substantial state-to-state variability in censoring (20.5%-100%) and in associations between concentrations and the CWS source water type. CONCLUSIONS: Statistical analyses of these data are challenging due to high rates of censoring and uncertainty about the appropriateness of parametric assumptions for time-series data. Although monitoring frequency was consistent with regulations, the magnitude of time gaps coupled with uncertainty about CWS service areas may limit linkage with health outcome data.

A multifaceted community-based asthma intervention in Chicago: effects of trigger reduction and self-management education on asthma morbidity.

OBJECTIVES: Home-based, multifaceted interventions have been effective in reducing asthma morbidity in children. However, identification of independent components that contribute to outcomes and delineating effectiveness by level of asthma symptoms would help to refine the intervention and target appropriate populations. METHODS: A community health educator led asthma intervention implemented in a low-income African-American neighborhood included asthma management education, individually tailored low-cost asthma home trigger remediation, and referrals to social and medical agencies, when appropriate. Changes in asthma morbidity measures were assessed in relation to implementation of individual intervention components using multivariable logistic regression. RESULTS: Among the 218 children who completed the year-long program, there were significant reductions in measures of asthma morbidity, including symptoms, urgent care visits, emergency department (ED) visits, hospitalizations, missed school days, and missed work days for caretakers. We also found significant decreases in the prevalence of many home asthma triggers and improvements in asthma management practices. Improvement in caretaker's ability to manage the child's asthma was associated with reduction in ED visits for asthma and uncontrolled asthma. Specific home interventions, such as repair of water leaks and reduced exposure to plants, dust, clutter and stuffed toys, may be related to reduction in asthma morbidity. CONCLUSIONS: This program was effective in reducing asthma morbidity in low-income African-American children and identified specific interventions as possible areas to target in future projects. Furthermore, the intervention was useful in children with persistent asthma symptoms as well as those with less frequent asthma exacerbations.

Evaluating screening age for colonoscopy: a quality assurance assessment.

OBJECTIVE: To evaluate colonoscopies in patients aged 40 to 49 and 50 to 59 years from multiple endoscopy surgery centers serving a wide geographical area. METHODS: An observational prospective multicenter quality assurance review was conducted in 49 Ambulatory Surgery Centers in 17 states with 315 gastroenterologists. Care of patients and routine of gastroenterologists continued as standard practice with patients attending for purposes of screening, surveillance, and symptoms. RESULTS: There were 1688 and 5090 consecutive qualified patients aged 40 to 49 and 50 to 59 years, respectively, receiving colonoscopies in a designated 4 week period. There was no significant difference (P=0.55) in the screening category between ages 40 to 49 (n=420) and 50 to 59 years (n=2705) in incidence of colon polyps although the older age group had more than 6 times the number of patients than the younger age group. Age group of 40 to 49-year-old males (21.5%) are at similar risk to 40 to 49-year-old females (21.1%) in development of carcinoma and adenoma polyps combined. Age group of 50 to 59-year-old males (31.3%) appear at greater risk (P<0.0001) than age 50 to 59-year-old females (18.4%) in development of carcinoma and adenoma polyps combined in the screening category. For surveillance and symptom categories significant differences (P<0.05) occurred between both age groups 40 to 49 and 50 to 59 years for males but not females in development of carcinoma and adenoma polyps combined. CONCLUSIONS: The equal risk of colon polyps in screening colonoscopies for age 40 to 49 and 50 to 59 years suggest reexamination of current recommendations for 50 years as the beginning age for screening colonoscopy. Further studies are needed to examine sex differences and cost effectiveness of screening colonoscopies beginning at age 40 years and to explore these factors as well in surveillance and symptom categories.

Withdrawal times and associated factors in colonoscopy: a quality assurance multicenter assessment.

OBJECTIVE: To evaluate the use and impact of the recommended withdrawal time of at least 6 minutes from the cecum in colonoscopy in multiple gastroenterology endoscopy ambulatory surgery centers serving a wide geographical area. METHODS: An observational prospective multicenter quality assurance review was conducted in 49 ambulatory surgery centers in 17 states with 315 gastroenterologists. There was no intervention with this quality assessment program as care of patients and the routine of gastroenterologists continued as standard practice. Multivariable analysis was applied to the database to examine factors affecting withdrawal time and polyp detection. RESULTS: There were 15,955 consecutive qualified patients receiving colonoscopies in a designated 4-week period. Gastroenterologists with average withdrawal times of 6 minutes or more in patients with no polyps were 1.8 times more likely to detect 1 or more polyps and had a significantly higher rate (P<0.0001) of polyp detection in patients with findings of polyps compared to gastroenterologists with average withdrawal times of less than 6 minutes in patients with no polyps. For patients with no pathology, the mean time of withdrawal was 6.98 (SD=4.34) minutes and for patients with pathology mean time of withdrawal was 11.27 (SD=6.71) minutes. Strongest predictors of withdrawal time of 6 minutes or more were presence of carcinoma (3.7 times more likely than those with no pathology), adenoma (2.0 times more likely than those with no pathology), and number of polyps visualized (1.7 times more likely for each polyp). CONCLUSIONS: This quality assurance assessment from standard colonoscopy practices of 315 gastroenterologists in 49 endoscopic ambulatory surgery centers serving a wide geographical area provides support for the merits of a colonoscopy withdrawal time from the cecum of 6 minutes or more to improve the detection of polyps.

Inner-city asthma: the role of the community.

Asthma morbidity and mortality are disproportionately high in low-income minority populations. Variations in environmental exposures, stress, and access to appropriate health care all contribute to these disparities. The complex nature of asthma with strong contributions from environmental, psychosocial, and biological factors suggest that community-based approaches focused on the unique needs of high-risk populations may be effective. The few previous randomized trials suggest that case management with professionals and/or community health educators may reduce asthma morbidity. Health-educator programs should be lodged in stable infrastructures with training and funding for community health workers to obtain long-term sustainability. Factors not amenable to individual intervention, however, such as poor condition of homes, outdoor pollution, and lack of access to appropriate care, will require collaborative efforts of community groups, academic professionals, public agencies, and health-care providers.