Disentangling impacts of multiple pollutants on acute cardiovascular events in New York city: A case-crossover analysis.

BACKGROUND: Ambient air pollution contributes to an estimated 6.67 million deaths annually, and has been linked to cardiovascular disease (CVD), the leading cause of death. Short-term increases in air pollution have been associated with increased risk of CVD event, though relatively few studies have directly compared effects of multiple pollutants using fine-scale spatio-temporal data, thoroughly adjusting for co-pollutants and temperature, in an exhaustive citywide hospitals dataset, towards identifying key pollution sources within the urban environment to most reduce, and reduce disparities in, the leading cause of death worldwide. OBJECTIVES: We aimed to examine multiple pollutants against multiple CVD diagnoses, across lag days, in models adjusted for co-pollutants and meteorology, and inherently adjusted by design for non-time-varying individual and aggregate-level covariates, using fine-scale space-time exposure estimates, in an exhaustive dataset of emergency department visits and hospitalizations across an entire city, thereby capturing the full population-at-risk. METHODS: We used conditional logistic regression in a case-crossover design - inherently controlling for all confounders not varying within case month - to examine associations between spatio-temporal nitrogen dioxide (NO2), fine particulate matter (PM2.5), sulfur dioxide (SO2), and ozone (O3) in New York City, 2005-2011, on individual risk of acute CVD event (n = 837,523), by sub-diagnosis [ischemic heart disease (IHD), heart failure (HF), stroke, ischemic stroke, acute myocardial infarction]. RESULTS: We found significant same-day associations between NO2 and risk of overall CVD, IHD, and HF - and between PM2.5 and overall CVD or HF event risk - robust to all adjustments and multiple comparisons. Results were comparable by sex and race - though median age at CVD was 10 years younger for Black New Yorkers than White New Yorkers. Associations for NO2 were comparable for adults younger or older than 69 years, though PM2.5 associations were stronger among older adults. DISCUSSION: Our results indicate immediate, robust effects of combustion-related pollution on CVD risk, by sub-diagnosis. Though acute impacts differed minimally by age, sex, or race, the much younger age-at-event for Black New Yorkers calls attention to cumulative social susceptibility.

Do respiratory virus infections modify associations of asthma exacerbation with aeroallergens or fine particulate matter? A time series study in Philadelphia PA.

Respiratory virus infections are related to over 80% of childhood asthma exacerbations. They enhance pro-inflammatory mediator release, especially for sensitized individuals exposed to pollens/molds. Using a time-series study design, we investigated possible effect modification by respiratory virus infections of the associations between aeroallergens/PM2.5 and asthma exacerbation rates. Outpatient, emergency department (ED), and inpatient visits for asthma exacerbation among children with asthma (28,540/24,444 [warm/cold season]), as well as viral infection counts were obtained from electronic health records of the Children's Hospital of Philadelphia from 2011 to 2016. Rate ratios (RRs, 90th percentile vs. 0) for late-season grass pollen were 1.00 (0.85-1.17), 1.04 (0.95-1.15), and 1.12 (0.96-1.32), respectively, for respiratory syncytial virus (RSV) counts within each tertile. However, similar trends were not observed for weed pollens/molds or PM2.5. Overall, our study provides little evidence supporting effect modification by respiratory viral infections.

Evaluation of evidence for interaction between PM2.5 and aeroallergens on childhood asthma exacerbation in Philadelphia, PA, 2011 to 2016.

Fine particulate matter (PM2.5) and aeroallergens (i.e., pollen, molds) are known triggers of asthma exacerbation. Despite mechanistic evidence suggesting synergistic effects between PM2.5 and asthma exacerbation, little epidemiologic work has been performed in children, which has exhibited inconsistency. We conducted a time-series study to explore their interactions using electronic health records (EHR) data in Philadelphia, PA, for asthma diagnoses in outpatient, emergency department [ED], and inpatient settings. Daily asthma exacerbation cases (28,540 asthma exacerbation case encounters) were linked to daily ambient PM2.5 and daily aeroallergen levels during the aeroallergen season of a six-year period (mid-March to October 2011-2016). Asthma exacerbation counts were modeled using quasi-Poisson regression, where PM2.5 and aeroallergens were fitted with distributed lag non-linear functions (lagged from 0 to 14-days), respectively, when modeled as the primary exposure variables. Regression models were adjusted for mean daily temperature/relative humidity, long-term and seasonal trends, day-of-week, and major U.S. holidays. Increasing gradient of RR estimates were observed for only a few primary exposure risk factors [PM2.5 (90th vs. 5th percentile)/aeroallergens (90th percentile vs. 0)], across different levels of effect modifiers. For example, RRs for the association between late-season grass pollen (lag1) and asthma exacerbation were higher at higher levels of PM2.5, 5-days preceding the exacerbation event (low PM2.5: RR = 1.01, 95% CI: 0.93-1.09; medium PM2.5: 1.04, 95% CI: 0.96-1.12; high PM2.5: 1.09, 95% CI: 1.01-1.19). However, most of the highest RRs for aeroallergens were instead observed for days with low- or medium- PM2.5 levels; likewise, when PM2.5 was modeled as the primary exposure with aeroallergens as the effect modifier. Most of the RR estimates did not exhibit gradients that suggested synergism, and were of relatively high imprecision. Overall, our study suggested no evidence for interactions between PM2.5 and aeroallergens in their relationships with childhood asthma exacerbation.

Gallbladder Disease and Risk of Type 2 Diabetes in Postmenopausal Women: A Women's Health Initiative Study.

Studies have suggested that adults with gallbladder disease have increased risk of type 2 diabetes. This prospective cohort study assessed the risk of type 2 diabetes in postmenopausal women with gallbladder disease. Data from women enrolled in the Women's Health Initiative from 1993 to 2005, aged 50-79 years (mean = 63.2; standard deviation, 7.2), were analyzed. Cox proportional hazards regression models were used to estimate the risk of type 2 diabetes associated with gallbladder disease. There were 8,896 new cases of type 2 diabetes after 1,025,486 person-years of follow-up. Gallbladder disease was significantly associated with type 2 diabetes (hazard ratio = 1.52; 95% confidence interval (CI): 1.38,1.67). The observed risk of type 2 diabetes in women with both gallbladder disease and central obesity was 37% higher than expected (relative excess risk due to interaction = 0.37, 95% CI: 0.11,0.63) on the additive scale. The hazard ratios for type 2 diabetes associated with gallbladder disease were 1.25 (95% CI: 1.19,1.32) and 1.48 (95% CI: 1.34,1.63) in women with and without central obesity, respectively, on the multiplicative scale. Results of this study support further studies to determine whether interventions in older women with gallbladder disease would reduce type 2 diabetes risk, especially among those with central obesity. Future research should examine the pathophysiological basis of the association between gallbladder disease and type 2 diabetes.

Disparities of COVID-19 and HIV Occurrence Based on Neighborhood Infection Incidence in Philadelphia, Pennsylvania.

Objectives. To evaluate the occurrence of HIV and COVID-19 infections in Philadelphia, Pennsylvania, through July 2020 and identify ecological correlates driving racial disparities in infection incidence. Methods. For each zip code tabulation area, we created citywide comparison Z-score measures of COVID-19 cases, new cases of HIV, and the difference between the scores. Choropleth maps were used to identify areas that were similar or dissimilar in terms of disease patterning, and weighted linear regression models helped identify independent ecological predictors of these patterns. Results. Relative to COVID-19, HIV represented a greater burden in Center City Philadelphia, whereas COVID-19 was more apparent in Northeast Philadelphia. Areas with a greater proportion of Black or African American residents were overrepresented in terms of both diseases. Conclusions. Although race is a shared nominal upstream factor that conveys increased risk for both infections, an understanding of separate structural, demographic, and economic risk factors that drive the overrepresentation of COVID-19 cases in racial/ethnic communities across Philadelphia is critical. Public Health Implications. Difference-based measures are useful in identifying areas that are underrepresented or overrepresented with respect to disease occurrence and may be able to elucidate effective or ineffective mitigation strategies. (Am J Public Health. 2022;112(3):408-416. https://doi.org/10.2105/AJPH.2021.306538).

Overdose response among trained and untrained women with a history of illicit drug use: a mixed-methods examination.

Little is known about differences in bystander behavior among people who use drugs, trained and untrained in opioid overdose prevention. We examined three types of recommended overdose response - a 911 call, rescue breathing/CPR, and naloxone administration-among Philadelphia-based, predominantly street-involved women with a history of illicit drug use. The study utilized a convergent mixed methods approach integrating data from 186 quantitative survey responses and 38 semi-structured qualitative interviews. Quantitative findings revealed that compared to untrained women, trained women were more likely to administer naloxone (32.9% vs. 5.2%) and use two recommended responses (20.0% vs. 9.5%). No significant differences were found between the two groups in calling 911 or using rescue breathing/CPR. Qualitative findings indicated that barriers to enacting recommended overdose response were either structural or situational and included the avoidance of police, inability to carry naloxone or phone due to unstable housing, and perceived lack of safety on the streets and when interacting with strangers. Our study demonstrated that overdose training improved the frequency of naloxone administration among this sample of predominantly street-involved women. Future efforts need to focus on avoiding intrusive policing, scaling-up naloxone refill sites, and providing secondary naloxone distribution via drug user networks.

Neighborhood price of healthier food relative to unhealthy food and its association with type 2 diabetes and insulin resistance: The multi-ethnic study of atherosclerosis.

This study examined the association between the price of healthier food relative to unhealthy food and type 2 diabetes prevalence, incidence and insulin resistance (IR). Data came from the Multi-Ethnic Study of Atherosclerosis exam 5 administered 2010-2012 (exam 4, five years prior, was used only for diabetes incidence) and supermarket food/beverage prices derived from Information Resources Inc. For each individual, average price of a selection of healthier foods, unhealthy foods and their ratio was computed for supermarkets within 3miles of the person's residential address. Diabetes status was confirmed at each exam and IR was assessed via the homeostasis model assessment index. Multivariable-adjusted logistic, modified Poisson and linear regression models were used to model diabetes prevalence, incidence and IR, respectively as a function of price and covariates; 2353 to 3408 participants were included in analyses (depending on the outcome). A higher ratio of healthy-to-unhealthy neighborhood food price was associated with greater IR (4.8% higher HOMA-IR score for each standard deviation higher price ratio [95% CI -0.2% to 10.1%]) after adjusting for region, age, gender, race/ethnicity, family history of diabetes, income/wealth index, education, smoking status, physical activity, and neighborhood socioeconomic status. No association with diabetes incidence (relative risk=1.11, 95% CI 0.85 to 1.44) or prevalence (odds ratio=0.95, 95% CI 0.81 to 1.11) was observed. Higher neighborhood prices of healthier food relative to unhealthy food were positively associated with IR, but not with either diabetes outcome. This study provides new insight into the relationship between food prices with IR and diabetes.

The Temporal Instability of Resting State Network Connectivity in Intractable Epilepsy.

OBJECTIVE: Focal epilepsies, such as temporal lobe epilepsy (TLE), are known to disrupt network activity in areas outside the epileptogenic zone [Tracy et al., 2015]. We devised a measure of temporal instability of resting state functional connectivity (FC), capturing temporal variations of BOLD correlations between brain regions that is less confounded than the "sliding window" approach common in the literature. METHODS: We investigated healthy controls and unilateral TLE patients (right and left seizure focus groups), utilizing group ICA to identify the default mode network (DMN), a network associated with episodic memory, a key cognitive deficit in TLE. Our instability analyses focused on: (1) connectivity between DMN region pairs, both within and between TLE patients and matched controls, (2) whole brain group differences between region pairs ipsilateral or contralateral to the epileptogenic temporal lobe. RESULTS: For both the whole brain and a more focused analysis of DMN region pairs, temporal stability appears to characterize the healthy brain. The TLE patients displayed more FC instability compared to controls, with this instability more pronounced for the right TLE patients. SIGNIFICANCE: Our findings challenge the view that the resting state signal is stable over time, providing a measure of signal coherence change that may generate insights into the temporal components of network organization. The precuneus was the region within the DMN consistently expressing this instability, suggesting this region plays a key role in large scale temporal dynamics of the DMN, with such dynamics disrupted in TLE, putting key cognitive functions at risk. Hum Brain Mapp 38:528-540, 2017. © 2016 Wiley Periodicals, Inc.

Healthy and Unhealthy Food Prices across Neighborhoods and Their Association with Neighborhood Socioeconomic Status and Proportion Black/Hispanic.

This paper evaluates variation in food prices within and between neighborhoods to improve our understanding of access to healthy foods in urbanized areas and potential economic incentives and barriers to consuming a higher-quality diet. Prices of a selection of healthier foods (dairy, fruit juice, and frozen vegetables) and unhealthy foods (soda, sweets, and salty snacks) were obtained from 1953 supermarkets across the USA during 2009-2012 and were linked to census block group socio-demographics. Analyses evaluated associations between neighborhood SES and proportion Black/Hispanic and the prices of healthier and unhealthy foods, and the relative price of healthier foods compared with unhealthy foods (healthy-to-unhealthy price ratio). Linear hierarchical regression models were used to explore geospatial variation and adjust for confounders. Overall, the price of healthier foods was nearly twice as high as the price of unhealthy foods ($0.590 vs $0.298 per serving; healthy-to-unhealthy price ratio of 1.99). This trend was consistent across all neighborhood characteristics. After adjusting for covariates, no association was found between food prices (healthy, unhealthy, or the healthy-to-unhealthy ratio) and neighborhood SES. Similarly, there was no association between the proportion Black/Hispanic and healthier food price, a very small positive association with unhealthy price, and a modest negative association with the healthy-to-unhealthy ratio. No major differences were seen in food prices across levels of neighborhood SES and proportion Black/Hispanic; however, the price of healthier food was twice as expensive as unhealthy food per serving on average.

Neighbourhood variation in the price of soda relative to milk and its association with neighbourhood socio-economic status and race.

OBJECTIVE: Soda consumption is high in the USA, especially among minorities and individuals of lower socio-economic status (SES); this may be due to its affordable price in relation to healthier alternatives. The objective of the present study was to examine geospatial variation in price of milk and soda, and the price of milk relative to soda, by neighbourhood SES and proportion of Hispanic and black individuals. DESIGN: Retailer soda and milk prices (n 2987; Information Resources, Inc. Academic Data Set 2004-2011) were linked to census block group sociodemographic characteristics (American Community Survey 2005-2009). Linear hierarchical regression models were used to adjust for confounders. SETTING: Large chain supermarkets and superstores (n 1743) in forty-one states and 1694 block groups (USA). RESULTS: For equivalent fluid ounces, price of soda on average was 62 % lower than milk ($US 0·23 v. $US 0·63 per serving) and there was high dispersion in milk price across geographic areas. After adjustment for confounding, neighbourhoods with a higher concentration of black and Hispanic individuals tended to have lower soda prices and higher milk prices (-$US 0·001 and +$US 0·007 in price per serving, respectively, for a one quintile increase in black/Hispanic population), while soda and milk both became less expensive as SES decreased (-$US 0·002 and -$US 0·015 in serving price per one sd decrease in SES index, respectively). CONCLUSIONS: Neighbourhoods with a higher concentration of blacks and Hispanics may be at greater risk of higher soda consumption due to more affordable prices, in absolute terms and relative to the price of milk.

Thoracic spine morphology of a pseudo-biped animal model (kangaroo) and comparisons with human and quadruped animals.

PURPOSE: Based on the structural anatomy, loading condition and range of motion (ROM), no quadruped animal has been shown to accurately mimic the structure and biomechanical function of the human spine. The objective of this study is to quantify the thoracic vertebrae geometry of the kangaroo, and compare with adult human, pig, sheep, and deer. METHODS: The thoracic vertebrae (T1-T12) from whole body CT scans of ten juvenile kangaroos (ages 11-14 months) were digitally reconstructed and geometric dimensions of the vertebral bodies, endplates, pedicles, spinal canal, processes, facets and intervertebral discs were recorded. Similar data available in the literature on the adult human, pig, sheep, and deer were compared to the kangaroo. A non-parametric trend analysis was performed. RESULTS: Thoracic vertebral dimensions of the juvenile kangaroo were found to be generally smaller than those of the adult human and quadruped animals. The most significant (p < 0.001) correlations (Rho) found between the human and kangaroo were in vertebrae and endplate dimensions (0.951 ≤ Rho ≤ 0.963), pedicles (0.851 ≤ Rho ≤ 0.951), and inter-facet heights (0.891 ≤ Rho ≤ 0.967). The deer displayed the least similar trends across vertebral levels. CONCLUSIONS: Similarities in thoracic spine vertebral geometry, particularly of the vertebrae, pedicles and facets may render the kangaroo a more clinically relevant human surrogate for testing spinal implants. The pseudo-biped kangaroo may also be a more suitable model for the human thoracic spine for simulating spine deformities, based on previously published similarities in biomechanical loading, posture and ROM.

Dynamic functional connectivity using state-based dynamic community structure: method and application to opioid analgesia.

We present a new method, State-based Dynamic Community Structure, that detects time-dependent community structure in networks of brain regions. Most analyses of functional connectivity assume that network behavior is static in time, or differs between task conditions with known timing. Our goal is to determine whether brain network topology remains stationary over time, or if changes in network organization occur at unknown time points. Changes in network organization may be related to shifts in neurological state, such as those associated with learning, drug uptake or experimental conditions. Using a hidden Markov stochastic blockmodel, we define a time-dependent community structure. We apply this approach to data from a functional magnetic resonance imaging experiment examining how contextual factors influence drug-induced analgesia. Results reveal that networks involved in pain, working memory, and emotion show distinct profiles of time-varying connectivity.

An updated analysis of safety climate and downstream outcomes in two convenience samples of U.S. fire departments (FOCUS 1.0 and 2.0 survey waves).

BACKGROUND: The Fire service Organizational Culture of Safety (FOCUS) survey is an assessment tool comprised of psychometrically validated metrics of safety climate, safety behavior, and downstream outcomes (organizational and injury) that are specific to the U.S. fire and rescue service. METHODS: This analysis consists of a descriptive summary of two independent survey waves (FOCUS 1.0 and 2.0). The fire departments included in these survey waves were from convenience sampling (n1.0 = 275; n2.0 = 170). In addition to department level characteristics, we examined individual level characteristics for firefighters and EMS providers in participating departments (n1.0 = 22,719; n2.0 = 16,882). We conducted regression analyses to examine the associations between safety climate and safety behaviors, organizational outcomes, and safety outcomes. All analyses were stratified by organization type (career, volunteer). RESULTS: Our analysis indicated that a majority of respondents were males (90.7%FOCUS 1.0; 90.4%FOCUS 2.0), non-officers (68.4%FOCUS 1.0; 66.4%FOCUS 2.0), and non-Hispanic Whites (70.8%FOCUS 1.0; 69.5%FOCUS 2.0). For both samples there was a higher prevalence of injuries among individuals in career departments (nFOCUS 1.0 = 3778 [17.5%]; nFOCUS 2.0 = 3072 [18.7%]) than volunteer departments (nFOCUS 1.0 = 103 [8.8%]; nFOCUS 2.0 = 34 [7.4%]). We observed an approximate 10-point difference between the mean scores of Management Commitment to Safety for career and volunteer departments in both samples. We observed associations for two organizational outcomes, Safety Behavior and Job Satisfaction, with Management Commitment to Safety and Supervisor Support for Safety overall and when stratified by organization type. We observed a decrease in the odds of injuries associated with a one-unit increase in Management Commitment to Safety (OR1.0 overall: 0.98, 95% CI 0.97-0.99; OR2.0 volunteer: 0.90, 95% CI 0.85-0.95) and Supervisor Support for Safety (OR1.0 overall: 0.95, 95% CI 0.93-0.97; OR1.0 career: 0.95, 95% CI 0.92-0.98). CONCLUSIONS: From our current study, and a prior analysis of a geographically stratified random sample of U.S. fire departments, we identified that from all the organizational outcomes, job satisfaction was most consistently associated with FOCUS safety climate. Further, firefighters in our samples consistently rated Supervisor Support for Safety higher than Management Commitment to Safety. Future interventions should support fire departments in improving their departmental Management Commitment to Safety and maintaining their Supervisor for Safety.

Obesity Weight Loss Phenotypes in CKD: Findings From the Chronic Renal Insufficiency Cohort Study.

Introduction: Although people with chronic kidney disease (CKD) and obesity have important motivations to lose weight, weight loss is also associated with health risks. We examined whether patterns of change in systolic blood pressure (SBP), serum albumin level, and fat-free mass (FFM) can help to differentiate between healthy and high-risk weight loss in this population. Methods: Using data from the Chronic Renal Insufficiency Cohort Study (CRIC), we estimated a joint multivariate latent class model with 6 classes to identify distinct trajectories of body mass index (BMI), albumin, and SBP among participants with obesity (BMI ≥30 kg/m2 at baseline), accounting for informative missingness from death. In a secondary analysis, we fit a 6-class model with BMI and FFM. Results: Among 2831 participants (median baseline BMI 35.6, interquartile range [IQR] 32.4-40.0 kg/m2), median follow-up was 6.8 (IQR 4.8-12.9) years, median age was 61 (IQR 54-67) years, 53% were male, 50% were non-Hispanic Black, and 82% were trying to control or lose weight at baseline. Latent classes were associated with mortality risk (5-year cumulative incidence of mortality 6.8% and 1.5% in class 6 and 3, respectively). Class 6 had the highest mortality rate and was characterized by early, steep BMI loss, early serum albumin decline, and late SBP increase. In the secondary analysis, a class characterized by steep BMI and FFM loss was associated with the highest death risk. Conclusions: Among adults with CKD and obesity, BMI loss with concomitant serum albumin or FFM loss was associated with a high risk of death.

Multiple Victimizations and Overdose Among Women With a History of Illicit Drug Use.

The experiences of violence and overdose are highly prevalent among women who use illicit drugs. This study sought to ascertain whether multiple victimizations during adulthood increase the frequency of women's overdose. The sample comprised 218 women recruited at Philadelphia harm reduction sites during 2016-2017. Victimization was assessed as exposure to 16 types of adulthood violence. Three measures were constructed for multiple victimizations: continuous and categorical polyvictimization, and predominant violence domain. Negative binomial regression estimated the incidence rate ratio (IRR) of lifetime overdoses from multiple victimizations. Lifetime history of opioid use (88.6%) and drug injection (79.5%) were common. Among overdose survivors (68.5%), the median of lifetime overdoses was 3. The majority of participants (58.7%) were victims of predominantly sexual violence, 26.1% experienced predominantly physical abuse/assault, and 3.7% were victims of predominantly verbal aggression/coercive control. Participants reported a mean of seven violence types; the higher-score category of polyvictimization (9-16 violence types) comprised 41.7% of the total sample. In multivariable models, one-unit increase in continuous polyvictimization was associated with 4% higher overdose rates (IRR: 1.04, 95% confidence interval [CI]: [1.00, 1.08]). Compared to women who were not victimized (11.5%), those in the higher-score category of polyvictimization (IRR: 2.01; 95% CI: [1.06, 3.80]) and exposed to predominantly sexual violence (IRR: 2.10, 95% CI: [1.13, 3.91]) were expected to have higher overdose rates. Polyvictimization and sexual violence amplified the risk of repeated overdose among drug-involved women. Female overdose survivors need to be screened for exposure to multiple forms of violence, especially sexual violence. Findings underscore the need to scale-up victimization support and overdose prevention services for disenfranchised women.

Change point estimation in multi-subject fMRI studies.

Most statistical analyses of fMRI data assume that the nature, timing and duration of the psychological processes being studied are known. However, in many areas of psychological inquiry, it is hard to specify this information a priori. Examples include studies of drug uptake, emotional states or experiments with a sustained stimulus. In this paper we assume that the timing of a subject's activation onset and duration are random variables drawn from unknown population distributions. We propose a technique for estimating these distributions assuming no functional form, and allowing for the possibility that some subjects may show no response. We illustrate how these distributions can be used to approximate the probability that a voxel/region is activated as a function of time. Further a procedure is discussed that uses a hidden Markov random field model to cluster voxels based on characteristics of their onset, duration, and anatomical location. These methods are applied to an fMRI study (n=24) of state anxiety, and are well suited for investigating individual differences in state-related changes in fMRI activity and other measures.

Developmental trajectories of illicit drug use, prescription drug misuse and cannabis practices among young adult cannabis users in Los Angeles.

INTRODUCTION AND AIMS: Young adults have the highest rates of drug use and contribute significantly to the growing population of medical cannabis patients (MCP). This study examined relationships between longitudinal patterns of illicit/prescription drug use/misuse and cannabis practices among young adult cannabis users. DESIGN AND METHODS: In 2014-2015, 210 young adult MCP and 156 nonpatient users were recruited in Los Angeles and surveyed annually over four waves. The analytical sample was limited to completers of all four waves (n = 301). Distinct developmental trajectories of illicit drug use and prescription drug misuse were identified. Fixed effects regression analysis evaluated changes in cannabis practices by trajectory groups. RESULTS: Results supported two-trajectory solutions (high/low) for illicit drug use and prescription drug misuse. Decreases in use within all four trajectories occurred by wave 4. Low illicit drug use trajectory members were more likely to self-report medical cannabis use. Membership in both types of high-use trajectories was associated with use of concentrates and edibles. The prevalence of MCP, edibles use and cannabis days decreased significantly by wave 4. DISCUSSION AND CONCLUSIONS: While alternative cannabis forms use was associated with membership in high drug use trajectories, self-reported medical cannabis use (not MCP) was negatively associated with high illicit drug use trajectory membership. Reductions in the prevalence of MCP, cannabis days, edibles use and other drug use by wave 4 alongside stable levels of self-reported medical cannabis use might reflect the changing legal status of cannabis in California, maturing out phenomenon and safer patterns of cannabis use.

Heavy precipitation, drinking water source, and acute gastrointestinal illness in Philadelphia, 2015-2017.

Runoff from heavy precipitation events can lead to microbiological contamination of source waters for public drinking water supplies. Philadelphia is a city of interest for a study of waterborne acute gastrointestinal illness (AGI) because of frequent heavy precipitation, extensive impervious landcover, and combined sewer systems that lead to overflows. We conducted a time-series analysis of the association between heavy precipitation and AGI incidence in Philadelphia, served by drinking water from Delaware River and Schuylkill River source waters. AGI cases on each day during the study period (2015-2017) were captured through syndromic surveillance of patients' chief complaint upon presentation at local emergency departments. Daily precipitation was represented by measurements at the Philadelphia International Airport and by modeled precipitation within the watershed boundaries, and we also evaluated stream flowrate as a proxy of precipitation. We estimated the association using distributed lag nonlinear models, assuming a quasi-Poisson distribution of the outcome variable and with adjustment for potential confounding by seasonal and long-term time trends, ambient temperature, day-of-week, and major holidays. We observed an association between heavy precipitation and AGI incidence in Philadelphia that was primarily limited to the spring season, with significant increases in AGI that peaked from 8 to 16 days following a heavy precipitation event. For example, the increase in AGI incidence related to airport precipitation above the 95th percentile (vs no precipitation) during spring reached statistical significance on lag day 7, peaked on day 16 (102% increase, 95% confidence interval: 16%, 252%), and declined while remaining significantly elevated through day 28. Similar associations were observed in analyses of watershed-specific precipitation in relation to AGI cases within the populations served by drinking water from each river. Our results suggest that heavy precipitation events in Philadelphia result in detectable local increases in waterborne AGI.

Putting Co-Exposures on Equal Footing: An Ecological Analysis of Same-Scale Measures of Air Pollution and Social Factors on Cardiovascular Disease in New York City.

Epidemiologic evidence consistently links urban air pollution exposures to health, even after adjustment for potential spatial confounding by socioeconomic position (SEP), given concerns that air pollution sources may be clustered in and around lower-SEP communities. SEP, however, is often measured with less spatial and temporal resolution than are air pollution exposures (i.e., census-tract socio-demographics vs. fine-scale spatio-temporal air pollution models). Although many questions remain regarding the most appropriate, meaningful scales for the measurement and evaluation of each type of exposure, we aimed to compare associations for multiple air pollutants and social factors against cardiovascular disease (CVD) event rates, with each exposure measured at equal spatial and temporal resolution. We found that, in multivariable census-tract-level models including both types of exposures, most pollutant-CVD associations were non-significant, while most social factors retained significance. Similarly, the magnitude of association was higher for an IQR-range difference in the social factors than in pollutant concentrations. We found that when offered equal spatial and temporal resolution, CVD was more strongly associated with social factors than with air pollutant exposures in census-tract-level analyses in New York City.

Illicit drug use and prescription drug misuse among young adult medical cannabis patients and non-patient users in Los Angeles.

INTRODUCTION: Young adults have the highest rates of cannabis and other drug use, as compared to other age groups, and contribute a significant proportion to the total population of medical cannabis patients (MCP). However, little is known about the relationships between various cannabis practices and illicit drug use/prescription drug misuse among young adult cannabis users with and without legal access to medical cannabis. METHODS: 210 MCP and 156 non-patient cannabis users (NPU) aged 18-26 were recruited in Los Angeles in 2014-15 for a longitudinal study assessing the impact of medical cannabis on health and substance use among emerging adults. For the present analysis, only quantitative baseline survey data were used. Logistic regression was used to examine the associations between past 90-day cannabis practices and other drug use, including illicit drug use and prescription drug misuse. RESULTS: Illicit drug use was associated with being non-Hispanic white (AOR = 3.0, 95% CI 1.8-5.1), use of cannabis concentrates (AOR = 2.8, 95% CI 1.6-4.9), while self-reported medical cannabis use was associated with lower probability of illicit drug use (AOR = 0.5, 95% CI 0.3-0.9). The odds of prescription drug misuse were increased for participants who reported use of cannabis edibles (AOR = 2.0, 95% CI 1.1-3.5), and decreased with age (AOR = 0.9, 95% CI 0.8-1.0) and for those who used cannabis alone (AOR = 0.5, 95% CI 0.3-0.9). CONCLUSION: Use of alternative cannabis forms, but not cannabis use frequency, were associated with greater odds of other drug use. Self-reported medical cannabis use, but not MCP status, decreased probability of illicit drug use.