Impacts of heat and wildfire on preterm birth.

BACKGROUND: Climate change continues to increase the frequency, intensity, and duration of heat events and wildfires, both of which are associated with adverse pregnancy outcomes. Few studies simultaneously evaluated exposures to these increasingly common exposures. OBJECTIVES: We investigated the relationship between exposure to heat and wildfire smoke and preterm birth (PTB). METHODS: In this time-stratified case-crossover study, participants consisted of 85,806 California singleton PTBs (20-36 gestational weeks) from May through October of 2015-2019. Birthing parent ZIP codes were linked to high-resolution daily weather, PM2.5 from wildfire smoke, and ambient air pollution data. Heat day was defined as a day with apparent temperature >98th percentile within each ZIP code and heat wave was defined as ≥2 consecutive heat days. Wildfire-smoke day was defined as a day with any exposure to wildfire-smoke PM2.5. Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (CI) comparing exposures during a hazard period (lags 0-6) compared to control periods. Analyses were adjusted for relative humidity, fine particles, and ozone. RESULTS: Wildfire-smoke days were associated with 3.0% increased odds of PTB (ORlag0: 1.03, CI: 1.00-1.05). Compared with white participants, associations appeared stronger among Black, Hispanic, Asian, and American Indians/Alaskan Native participants. Heatwave days (ORlag2: 1.07, CI: 1.02-1.13) were positively associated with PTB, with stronger associations among those simultaneously exposed to wildfire smoke days (ORlag2: 1.19, CI: 1.11-1.27). Similar findings were observed for heat days and when other temperature metrics (e.g., maximum, minimum) were used. DISCUSSION: Heat and wildfire increased PTB risk with evidence of synergism. As the occurrence and co-occurrence of these events increase, exposure reduction among pregnant people is critical, especially among racial/ethnic minorities.

Gestational Diabetes and Subsequent Metabolic Dysfunction: An National Health and Nutrition Examination Survey Analysis (2011-2018).

Background: Gestational diabetes mellitus (GDM) complicates ∼10% of pregnancies, with the highest rates among Asian women. Evidence suggests that GDM is associated with an increased risk for future chronic health conditions, yet data for Asian women are sparse. We explored the association between prior GDM and metabolic dysfunction with nationally representative data to obtain Asian-specific estimates. Methods: For this cross-sectional study, data were drawn from the National Health and Nutrition Examination Survey for 7195 women with a prior pregnancy. GDM (yes/no) was defined using the question "During pregnancy, were you ever told by a doctor or other health professional that you had diabetes, sugar diabetes, or gestational diabetes?." Current metabolic dysfunction (yes/no) was based on having at least one of four indicators: systolic blood pressure (SBP, ≥130 mmHg), waist circumference (≥88 cm), high-density lipoprotein (HDL) cholesterol (<50 mg/dL), and glycosylated hemoglobin (HbA1c) (≥6.5%). Logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between prior GDM and metabolic outcomes, overall and by race. Models included sampling weights and demographic and behavioral factors. Results: Overall, women with prior GDM had 46% greater odds of high waist circumference (OR: 1.5; 95% CI: 1.1-2.0) and 200% greater odds (OR: 3.0; 95% CI: 2.1-4.2) of high HbA1c. Prior GDM was not associated with high blood pressure or low HDL cholesterol. In race-specific analyses, prior GDM was associated with increased risk of elevated HbA1c among Asian (OR: 6.6; 95% CI: 2.5-17.2), Mexican American (OR: 3.0; 95% CI: 1.5-5.8), Black (OR: 3.0; 95% CI: 1.7-5.5), and White (OR: 2.6; 95% CI: 1.5-4.6) women. Prior GDM was associated with elevated SBP among Mexican American women and low HDL among Black women. Discussion: Prior GDM is associated with elevated HbA1c among all women, yet is a stronger predictor of elevated HbA1c among Asian women than other women. Race-specific associations between prior GDM and metabolic dysfunction were observed among Mexican American and Black women. Further research is warranted to understand the observed race/ethnic-specific associations.

Pesticide Take-Home Pathways, Storage, and Application Methods Among Hmong Farmers in Central Valley, California.

OBJECTIVE: Pesticide exposure via take-home pathways is a major health concern among farmers. However, little is known about the effects of pesticide take-home pathways on small-scale Hmong farmers in the Central Valley. This study explored factors that contribute to pesticide exposure via the take-home pathway among small-scale Hmong farmers in the Central Valley. METHODS: Detailed ethnographic observations of small-scale farms and corresponding homes were coupled with in-depth qualitative interviews with Hmong farmers to assess the extent of the pesticide take-home pathway. RESULTS: The study found daily challenges and numerous ways that pesticide particles may be introduced into farmers' homes. Given the paucity of research about Hmong farmers' pesticide take-home pathways, the study's findings advance the scholarship on pesticide exposures in the Hmong farmer community. CONCLUSION: This study advocates for more culturally and linguistically appropriate pesticide exposure training and educational programs tailored to Hmong farmers in the United States.

Testing the effectiveness of narrative messages using critical health communication.

BACKGROUND: Latinos suffer from health disparities associated with excessive consumption of sugar-sweetened beverages. This study aimed to test the effectiveness of messaging using critical health communication approaches and delivered by two narrative modalities (video and comic book) with similar content that aims to empower Latinos to advocate for social change and to make individual behavior change related to sugary beverage consumption. METHODS: Participants (N = 129 Mexican American women between 18 and 29 years) completed an online survey before and after exposure to an embedded stimulus. Participants were randomly assigned to a stimulus, a narrative message in video or comic book format, both developed using critical health communication approaches that focused on individual harms and social causes of sugary beverage consumption. RESULTS: Paired sample t-test results showed that both narrative messages increased intentions to reduce sugary beverage consumption (Video: P < 0.01; d = 0.43; Comic: P = 0.03; d = 0.28). Both groups also demonstrated significant improvements in sugary beverage-related media literacy (Video: P = 0.01, d = 0.34; Comic: P = 0.05, d = 0.25), public health literacy (Video: P = 0.05, d = 0.24; Comic: P = 0.01, d = 0.32), and empowerment to engage in sugary beverage-related community movements (Video: P = 0.003, d = 0.38; Comic: P = 0.034, d = 0.27). CONCLUSIONS: This study provides initial evidence indicating the effectiveness of narrative messages in two modalities using critical health communication for promoting individual behavioral intention and social activation in reducing sugary beverage consumption.

Measures of Racism and Discrimination in Preterm Birth Studies.

OBJECTIVE: Preterm birth (any birth at less than 37 weeks of gestation) disproportionally affects Black birthing people and is associated with adverse perinatal and fetal health outcomes. Racism increases the risk of preterm birth, but standardized measurement metrics are elusive. This narrative synthesis examines literature on measures of racial discrimination used in preterm birth research. DATA SOURCES: Six databases (CINAHL, Cochrane, EMBASE, PubMed [MEDLINE], Scopus, Web of Science) and ClinicalTrials.gov were searched. Search terms were categorized into three groups (racism terms, measurement terms, preterm birth terms) to identify original research articles that explored associations between racism and preterm birth. English-language, original research articles with U.S. populations were included. METHODS OF STUDY SELECTION: Studies were excluded if conducted in only White populations, if only paternal factors were included, or if only racial differences in preterm birth were described. Articles were independently reviewed by two blinded researchers for inclusion at every stage of screening and data extraction; a third reviewer resolved discrepancies. TABULATION, INTEGRATION, AND RESULTS: Sixty studies were included in the final analysis. Articles primarily included measures examining interpersonal forms of racism (n=17) through the Experiences of Discrimination and Everyday Discrimination scales, neighborhood composition (n=22) with the Neighborhood Deprivation Index and the Index of Concentration at the Extremes, policy-level racism (n=12) through institutions such as residential racial segregation or policy inequities, or multiple forms (n=9). CONCLUSION: Among studies, assessment methods and application of constructs varied. This heterogeneity poses significant challenges to understanding associations between racial discrimination and preterm birth and to describing potential etiologic pathways of preterm birth, which ultimately hinders development of effective intervention. Strategies to capture multilevel exposures to racism require the development and expansion of metrics that are culturally inclusive, empirically valid, and reliable among Black pregnant populations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022327484.

Beyond the infant in your arms: effects of climate change last for generations.

Climate change is the biggest global health threat of the 21st century. In addition to short-term reproductive health impacts, climate-related events will influence the risks of long-term and intergenerational mortality and morbidity for both birthing parents and offspring. As climate conditions continue to deteriorate in future generations, less healthy parents will give birth to less healthy offspring, who themselves will experience increased risk of reproductive outcomes. This intergenerational process causes a repeating cycle of poor parental preconception health, gestational complications, and poor offspring health, which leads to suboptimal preconception health among those offspring when they reach reproductive age. Because our ongoing efforts mostly focus on helping families achieve and maintain a healthy pregnancy, a critical need to think beyond the infant in our arms and consider the long-term implications of climate change exists. Such efforts may involve policy strengthening efforts to reduce emissions, further engaging health care providers as active advocates, ensuring equitable and sustainable mitigation and adaptable strategies, and conducting more research that yields actionable data to guide policy efforts, especially in regions and populations most affected by climate change.

The Changing Climate and Pregnancy Health.

PURPOSE OF REVIEW: Climate change is the biggest public health threat of the twenty-first century but its impact on the perinatal period has only recently received attention. This review summarizes recent literature regarding the impacts of climate change and related environmental disasters on pregnancy health and provides recommendations to inform future adaptation and mitigation efforts. RECENT FINDINGS: Accumulating evidence suggests that the changing climate affects pregnancy health directly via discrete environmental disasters (i.e., wildfire, extreme heat, hurricane, flood, and drought), and indirectly through changes in the natural and social environment. Although studies vary greatly in design, analytic methods, and assessment strategies, they generally converge to suggest that climate-related disasters are associated with increased risk of gestational complication, pregnancy loss, restricted fetal growth, low birthweight, preterm birth, and selected delivery/newborn complications. Window(s) of exposure with the highest sensitivity are not clear, but both acute and chronic exposures appear important. Furthermore, socioeconomically disadvantaged populations may be more vulnerable. Policy, clinical, and research strategies for adaptation and mitigation should be continued, strengthened, and expanded with cross-disciplinary efforts. Top priorities should include (a) reinforcing and expanding policies to further reduce emission, (b) increasing awareness and education resources for healthcare providers and the public, (c) facilitating access to quality population-based data in low-resource areas, and (d) research efforts to better understand mechanisms of effects, identify susceptible populations and windows of exposure, explore interactive impacts of multiple exposures, and develop novel methods to better quantify pregnancy health impacts.

Protocol: Effectiveness of message content and format on individual and collective efficacy in reducing the intention to consume sugar-sweetened beverages.

The strategic use of media is a common approach to promote health. A large body of evidence identifies specific features that increase message efficacy, including tailoring messages to the target audience and using a storytelling format. Yet most message testing research has focused on individual-level outcomes, ignoring the social and environmental determinants of health behaviors, which require collective action and political will to change. Grounded in an ecological approach to communication, we will carry out two double-blinded randomized experiments to test the relative effectiveness of message tailoring (culturally-tailored vs. standard) and format (narrative vs. didactic) to increase the intention to reduce individual sugar-sweetened beverage consumption, the understanding of social and commercial determinants of health, and the sense of empowerment among young adult Latinas. Based on power analyses (80% power at alpha = 0.05), we will randomize 438 participants to two groups (traditional standard infographic and culturally-tailored infographic) in the first study, and 662 participants to two groups (culturally-tailored infographic and culturally-tailored comic book) in the second study. All participants will be measured by a pre-treatment test and an immediate post-treatment test. We hypothesize that culturally-tailored comic book will be most effective, and traditional standard infographic will be least effective, on all levels of outcomes. This study will provide empirical evidence in communication strategies to help young Latinos or other racial/ethnic minority young people to pursue positive dietary behaviors that both benefit themselves and contribute to change of social norms.

Air pollution and preterm birth: A time-stratified case-crossover study in the San Joaquin Valley of California.

BACKGROUND: Air pollution is linked to preterm birth (PTB), but existing studies are primarily focused on chronic exposures, conducted in areas with moderate pollution, and/or subject to confounding. OBJECTIVES: We investigated short-term associations between two pollutants [particulate matter <2.5 microns (PM2.5 ) and ozone] and PTB, and estimated excess PTB cases potentially attributed to these pollutants. METHODS: This time-stratified case-crossover study includes 196,970 singleton pregnancies affected by PTB and early term birth from the San Joaquin Valley (SJV), California, USA (2007-2015). Daily ozone and PM2.5 concentrations were estimated by the SJV Air Pollution Control District and geospatially linked to maternal zip code. We used conditional logistic regression models to estimate the odds ratio (OR) and 95% confidence intervals (CI) for the associations between an interquartile range (IQR) increase in pollutants and very preterm (VPTB, 20-34 weeks), moderate preterm (MPTB, 34-36 weeks) and early term births (ETB, 37-38 weeks). We adjusted all models for co-pollutants and meteorological factors. RESULTS: During warm seasons (May-October), an IQR increase in ozone was associated with 9-11% increased odds of VPTB from lag 0 (ORlag0 1.09, 95% CI 1.04,1.16) to lag 7 (ORlag7 1.11, 95% CI 1.04,1.16). Findings were consistent for MPTB and ETB. Ozone was potentially responsible for an excess of 3-6 VPTBs, 7-9 PTBs and 24-42 ETBs per 1,000 singleton deliveries. During cold seasons (November-April), increased PM2.5 exposure was associated with 5-6% increased odds of VPTB beginning at lag 3 (ORlag3 1.06, 95% CI 1.02,1.11). PM2.5 was associated with an excess of 1-3 VPTBs, 0-3 MPTBs and 6-18 ETBs per 1,000 singleton deliveries. CONCLUSIONS: PM2.5 and ozone are associated with increased risk of VPTB, MPTB and ETB within one week of exposure and are potential contributors to the increasing PTB trend. More research is needed to further understand the role of air pollution on PTB risk.

Risk factors for hyperthermia mortality among emergency department patients.

PURPOSE: This study examines risk factors for heat-related mortality due to hyperthermia in emergency department patients, a vulnerable population. METHODS: This matched case-control study used statewide, longitudinally linked emergency department (ED) data and death records from California. Cases comprised California residents (≥18 years) who presented to a state-licensed ED and died of hyperthermia during the study period (2009-2012). For each case, up to five ED patients were randomly selected as live controls and matched on sex and age. Patients' demographic characteristics and history of ED utilization for alcohol use, drug use, psychiatric disorders, heart-related conditions, chronic respiratory disease, neurodegenerative disorders, and cerebrovascular disease were assessed in relationship to hyperthermia mortality. RESULTS: Using multivariate conditional logistic regression models, hyperthermia mortality cases had higher odds of prior ED utilization for alcohol use (OR = 11.16, 95% CI = 3.87, 32.17) compared to controls. Cases were also more likely than controls to have Medicare insurance (OR = 5.80, 95% CI = 1.70, 15.15) or self-pay (OR = 5.39, 95% CI = 1.73, 16.79), at their most recent ED visit. CONCLUSIONS: ED patients presenting with alcohol problems may face increased risk of hyperthermia mortality. To help reduce heat-related mortality, EDs should consider interventions that target patients vulnerable to heat exposure.

Joint effects of ethnic enclave residence and ambient volatile organic compounds exposure on risk of gestational diabetes mellitus among Asian/Pacific Islander women in the United States.

BACKGROUND: Asian/Pacific Islander (API) communities in the United States often reside in metropolitan areas with distinct social and environmental attributes. Residence in an ethnic enclave, a socially distinct area, is associated with lower gestational diabetes mellitus (GDM) risk, yet exposure to high levels of air pollution, including volatile organic compounds (VOCS), is associated with increased GDM risk. We examined the joint effects of ethnic enclaves and VOCs to better understand GDM risk among API women, the group with the highest prevalence of GDM. METHODS: We examined 9069 API births in the Consortium on Safe Labor (19 hospitals, 2002-2008). API ethnic enclaves were defined as areas ≥66th percentile for percent API residents, dissimilarity (geographic dispersal of API and White residents), and isolation (degree that API individuals interact with another API individual). High levels of 14 volatile organic compounds (VOC) were defined as ≥75th percentile. Four joint categories were created for each VOC: Low VOC/Enclave (reference group), Low VOC/No Enclave, High VOC/Enclave, High VOC/No Enclave. GDM was reported in medical records. Hierarchical logistic regression estimated odds ratios (OR) and 95% confidence intervals (95%CI) between joint exposures and GDM, adjusted for maternal factors and area-level poverty. Risk was estimated for 3-months preconception and first trimester exposures. RESULTS: Enclave residence was associated with lower GDM risk regardless of VOC exposure. Preconception benzene exposure was associated with increased risk when women resided outside enclaves [High VOC/No Enclave (OR:3.45, 95%CI:1.77,6.72)], and the effect was somewhat mitigated within enclaves, [High VOC/Enclave (OR:2.07, 95%:1.09,3.94)]. Risks were similar for 12 of 14 VOCs during preconception and 10 of 14 during the first trimester. CONCLUSIONS: API residence in non-enclave areas is associated with higher GDM risk, regardless of VOC level. Ethnic enclave residence may mitigate effects of VOC exposure, perhaps due to lower stress levels. The potential benefit of ethnic enclaves warrants further study.

Associations between Disability and Infertility among U.S. Reproductive-Aged Women.

We aim to evaluate the association between self-reported disabilities and infertility and whether disabilities are associated with decreased likelihood of seeking infertility-related care. This US nationally representative cross-sectional analysis includes 3789 non-pregnant women aged 18-49 years without history of hysterectomy or oophorectomy (NHANES, 2013-2018). Disabilities and infertility were both self-reported in personal interviews with trained interviewers. Logistic regression models estimated the adjusted odds ratio (aOR) and 95% confidence intervals for the association between disabilities and infertility and related care seeking. Models adjusted for potential confounders and complex probability sampling. Compared to women without disabilities, women with disabilities (WWD) had higher odds of infertility (aOR: 1.78 (1.31-2.40)). Similar findings were observed for sensory (2.32 (1.52-3.52)) and cognitive disabilities (1.77 (1.28-2.44)). Among women with infertility, WWD were less likely to seek infertility-related care (0.68 (0.32-1.44)) but these estimates were not statistically significant. WWD have increased odds of reporting infertility, and if affected, are less likely to visit a health care provider for this condition. While more research is needed to understand reproductive health issues and needs among WWD, it is important to push for more equitable policies and practices to address the health needs of this underserved population.

Air pollution and neurological development in children.

Pregnancy and early childhood are periods with high plasticity in neurological development. Environmental perturbations during these sensitive windows can have lifelong developmental consequences. This review summarizes key findings relevant to the effects of air pollution on neurological development. Mounting evidence suggests that exposure to air pollution, both during pregnancy and childhood, is associated with childhood developmental outcomes ranging from changes in brain structures to subclinical deficits in developmental test scores, and, ultimately, developmental disorders such as attention-deficit/hyperactivity disorders or autism spectrum disorders. Although the biological mechanisms of effects remain to be elucidated, multiple pathways are probably involved and include oxidative stress, inflammation, and/or endocrine disruption. Given the alarming global increase in developmental disorders in recent years, and increased human exposures to pollution, it is critical to reduce personal and community-level exposures through tight collaboration of interdisciplinary and multi-level bodies including community partners, physicians, industry partners, policy makers, public health practitioners, and researchers. WHAT THIS PAPER ADDS: Exposure to air pollution is associated with a range of childhood developmental complications. Biological mechanisms may include oxidative stress, inflammation, and endocrine disruption.

Ambient temperature and stillbirth: Risks associated with chronic extreme temperature and acute temperature change.

BACKGROUND: Ambient temperature events are increasing in frequency and intensity. Our prior work in a U.S. nationwide study suggests a strong association between both chronic and acute temperature extremes and stillbirth risk. OBJECTIVE: We attempted to replicate our prior study by assessing stillbirth risk associated with average whole-pregnancy temperatures and acute ambient temperature changes in a low-risk U.S. METHODS: Singleton deliveries in the NICHD Consecutive Pregnancies Study (Utah, 2002-2010; n = 112,005) were identified using electronic medical records. Ambient temperature was derived from the Weather Research and Forecasting model. Binary logistic regression determined the adjusted odds ratio (aOR) and 95% confidence interval (95% CI) for stillbirth associated with whole-pregnancy exposure to extreme cold (<10th percentile) and hot (>90th percentile) versus moderate (10th-90th percentiles) average temperature, adjusting for maternal demographics, season of conception, hypertensive disorders of pregnancy, and gestational diabetes. In a case-crossover analysis, we estimated the stillbirth aOR and 95% CI for each 1° Celsius increase during the week prior to delivery using conditional logistic regression. In both models, we adjusted for relative humidity, ozone, and fine particulates. RESULTS: We observed 500 stillbirth cases among 498 mothers. Compared to moderate temperatures, whole-pregnancy exposure to extreme cold (aOR: 4.42, 95% CI:3.43, 5.69) and hot (aOR: 5.06, 95% CI: 3.34, 7.68) temperatures were associated with stillbirth risk. Case-crossover models observed a 7% increased odds (95% CI: 1.04, 1.10) associated with each 1° Celsius increase during the week prior to delivery. DISCUSSION: Both chronic and acute ambient temperature were associated with odds of stillbirth in this low-risk population, similar to our prior nationwide findings. Future increases in temperature extremes are likely and the observed risk in a low-risk population suggests this association merits attention.

Air Pollution Exposure Monitoring among Pregnant Women with and without Asthma.

Background: We monitored exposure to fine particulates (PM2.5), ozone, nitrogen dioxide (NO2), and ambient temperature for pregnant women with and without asthma. Methods: Women (n = 40) from the Breathe-Well-Being, Environment, Lifestyle, and Lung Function Study (2015-2018) were enrolled during pregnancy and monitored for 2-4 days. Daily pollutants were measured using personal air monitors, indoor air monitors, and nearest Environmental Protection Agency's stationary monitors based on GPS tracking and home address. Results: Personal-monitor measurements of PM2.5, ozone, and NO2 did not vary by asthma status but exposure profiles significantly differed by assessment methods. EPA stationary monitor-based methods appeared to underestimate PM2.5 and temperature exposure and overestimate ozone and NO2 exposure. Higher indoor-monitored PM2.5 exposures were associated with smoking and the use of gas appliances. The proportion of waking-time during which personal monitors were worn was ~56%. Lower compliance was associated with exercise, smoking, being around a smoker, and the use of a prescription drug. Conclusions: Exposure did not vary by asthma status but was influenced by daily activities and assessment methods. Personal monitors may better capture exposures but non-compliance merits attention. Meanwhile, larger monitoring studies are warranted to further understand exposure profiles and the health effects of air pollution during pregnancy.

Ethnic Enclaves and Pregnancy and Behavior Outcomes Among Asian/Pacific Islanders in the USA.

OBJECTIVES: Ethnic enclaves are ethnically, spatially, and socially distinct communities that may promote health through access to culturally appropriate resources and reduced exposure to discrimination. This study examined ethnic enclave residence and pregnancy outcomes among Asian/Pacific Islander (API) women in the USA. DESIGN: We examined 9206 API births in the Consortium on Safe Labor (2002-2008). Ethnic enclaves were defined as hospital regions with high percentage of API residents (> 4%), high dissimilarity index (> 0.41; distribution of API and white residents within a geographic area), and high isolation index (> 0.03; interaction between API and white residents in an area). Gestational diabetes mellitus (GDM), preterm birth (PTB), small for gestational age (SGA), and smoking and alcohol use during pregnancy were reported in medical records supplemented with ICD-9 codes. Hierarchical logistic regression models estimated associations between ethnic enclaves and pregnancy outcomes, adjusted for maternal factors, area-level poverty, and air pollution. RESULTS: Women in enclaves had lower odds of GDM (OR 0.61; 95%CI 0.45, 0.82), PTB (OR 0.74; 95%CI 0.56, 0.99), and SGA (OR 0.68; 95%CI 0.52, 0.89) compared with women in non-enclaves. Prenatal smoking and alcohol use appeared less likely in enclaves, but estimates were imprecise. Within enclaves, about 10.5% of homes speak an API language, compared with 6.0% in non-enclaves. The mean percent of foreign-born API populations was 67.4% in enclaves and 68.8% in non-enclaves. CONCLUSIONS: API women residing in ethnic enclaves had better pregnancy outcomes than API women residing in non-enclave areas. Access to culturally appropriate social supports and resources may be important for health promotion among API populations.

Extrapulmonary Coccidioidomycosis Among Children in Central California: A Retrospective Review.

BACKGROUND: The literature on pediatric extrapulmonary coccidioidomycosis is limited. We reviewed the clinical course, diagnostic studies, treatment and outcomes of children with extrapulmonary coccidioidomycosis followed at a tertiary care center in central California. METHODS: Retrospective study of 78 patients ≤21 years old with extrapulmonary coccidioidomycosis diagnosed over 10 years (1/1/07-12/31/16). RESULTS: The median age was 9.7 years (interquartile range, 4.5-14.8). The majority of patients were males (55%), Hispanic (65%) and without comorbid conditions (85%). Over two-thirds (68%) had concurrent pulmonary disease. Organ involvements included bones and joints (33%), mediastinum (19%), central nervous system (19%), cervical lymph nodes (15%), larynx (6%) and skin (5%). Most cases (84%) resolved and/or became stable on maintenance therapy, 14% experienced relapse and/or progressive disease, and 2% were fatal. Children ≥10 years of age tended to have >1 site of involvement (47% vs. 25%, P = 0.06), and more relapsed/progressive/fatal disease (21% vs. 5%, P = 0.06) compared with those <10 years. They also required longer durations of treatment (median, 611 vs. 349 days, P = 0.02). Non-Hispanics were more likely to require >1 drug therapy (85% vs. 70%, P = 0.04) and tended to have Coccidioides complement fixation titers ≥1:32 (89% vs. 72%, P = 0.04) compared with Hispanics. CONCLUSIONS: Extrapulmonary coccidioidomycosis in children can be severe and spread to multiple sites and requires prolonged treatment. Non-Hispanics and those ≥10 years of age are more likely to experience severe disease, suggesting a need for early recognition and intervention in these populations.

Prenatal and early life exposures to ambient air pollution and development.

BACKGROUND: Residential proximity to major roadways, and prenatal exposures to particulate matter <2.5 µm (PM2.5) and ozone (O3) are linked to poor fetal outcomes but their relationship with childhood development is unclear. OBJECTIVES: We investigated whether proximity to major roadways, or prenatal and early-life exposures to PM2.5 and O3 increase the risk of early developmental delays. STUDY DESIGN: Prospective cohort. SETTINGS: New York State excluding New York City. PARTICIPANTS: 4089 singletons and 1016 twins born between 2008 and 2010. EXPOSURES: Proximity to major roadway was calculated using road network data from the NY Department of Transportation. Concentrations of PM2.5 and O3 estimated by the Environmental Protection Agency Downscaler models were spatiotemporally linked to each child's prenatal and early-life addresses incorporating residential history, and locations of maternal work and day-care. OUTCOMES: Parents reported their children's development at ages 8, 12, 18, 24, 30 and 36 months in five domains using the Ages and Stages Questionnaire. Generalized mixed models estimated the relative risk (RR) and 95% CI for failing any developmental domain per 10 units increase in PM2.5 and O3, and for those living <1000 m away from a major roadway compared to those living further. Models adjusted for potential confounders. RESULTS: Compared to those >1000 m away from a major roadway, those resided 50-100 m [RR: 2.12 (1.00-4.52)] and 100-500 m [RR: 2.07 (1.02-4.22)] away had twice the risk of failing the communication domain. Prenatal exposures to both PM2.5 and ozone during various pregnancy windows had weak but significant associations with failing any developmental domain with effects ranging from 1.6% to 2.7% for a 10 µg/m3 increase in PM2.5 and 0.7%-1.7% for a 10 ppb increase in ozone. Average daily postnatal ozone exposure was positively associated with failing the overall screening by 8 months [3.3% (1.1%-5.5%)], 12 months [17.7% (10.4%-25.5%)], and 30 months [7.6%, (1.3%-14.3%)]. Findings were mixed for postnatal PM2.5 exposures. CONCLUSIONS: In this prospective cohort study, proximity to major roadway and prenatal/early-life exposures to PM2.5 and O3 were associated with developmental delays. While awaiting larger studies with personal air pollution assessment, efforts to minimize air pollution exposures during critical developmental windows may be warranted.