Effects of air pollution on adverse birth outcomes and pregnancy complications in the U.S. state of Kansas (2000-2015).

Neonatal mortality and morbidity are often caused by preterm birth and lower birth weight. Gestational diabetes mellitus (GDM) and gestational hypertension (GH) are the most prevalent maternal medical complications during pregnancy. However, evidence on effects of air pollution on adverse birth outcomes and pregnancy complications is mixed. Singleton live births conceived between January 1st, 2000, and December 31st, 2015, and reached at least 27 weeks of pregnancy in Kansas were included in the study. Trimester-specific and total pregnancy exposures to nitrogen dioxide (NO2), particulate matter with an aerodynamic diameter less than 2.5 µm (PM2.5), and ozone (O3) were estimated using spatiotemporal ensemble models and assigned to maternal residential census tracts. Logistic regression, discrete-time survival, and linear models were applied to assess the associations. After adjustment for demographics and socio-economic status (SES) factors, we found increases in the second and third trimesters and total pregnancy O3 exposures were significantly linked to preterm birth. Exposure to the second and third trimesters O3 was significantly associated with lower birth weight, and exposure to NO2 during the first trimester was linked to an increased risk of GDM. O3 exposures in the first trimester were connected to an elevated risk of GH. We didn't observe consistent associations between adverse pregnancy and birth outcomes with PM2.5 exposure. Our findings indicate there is a positive link between increased O3 exposure during pregnancy and a higher risk of preterm birth, GH, and decreased birth weight. Our work supports limiting population exposure to air pollution, which may lower the likelihood of adverse birth and pregnancy outcomes.

The Association Between Ambient Temperature and Snakebite in Georgia, USA: A Case-Crossover Study.

The World Health Organization has identified snakebite envenoming as a highest priority neglected tropical disease, yet there is a dearth of epidemiologic research on environmental risk factors, including outdoor temperature. Temperature may affect snakebites through human behavior or snake behavior; snakes are ectotherms, meaning outdoor temperatures influence their internal body temperature and thus their behavior. Here we investigate the relationship between short-term temperature and snakebites in Georgia, one of the most biodiverse US states in terms of herpetofauna. We acquired emergency department (ED) visit data for Georgia between 1 January 2014 and 31 December 2020. Visits for venomous and non-venomous snakebites were identified using diagnosis codes. For comparison, we also considered visits for non-snake (e.g., insects, spiders, scorpions) envenomation. Daily meteorology from the Daymet 1 km product was linked to patient residential ZIP codes. We applied a case-crossover design to estimate associations of daily maximum temperature and snakebite ED visits. During the 7-year study period, there were 3,908 visits for venomous snakebites, 1,124 visits for non-venomous bites and 65,187 visits for non-snake envenomation. Across the entire period, a 1°C increase in same-day maximum temperature was associated with a 5.6% (95%CI: 4.0-7.3) increase in the odds of venomous snakebite and a 5.8% (95%CI: 3.0-8.8) increase in non-venomous snakebite. Associations were strongest in the spring. We also observed a positive and significant (p < 0.05) association for non-snake envenomation, albeit slightly smaller and more consistent across seasons compared to those for snakebites.

Acute Effects of Ambient Air Pollution on Asthma Emergency Department Visits in Ten U.S. States.

BACKGROUND: Previous studies of short-term ambient air pollution exposure and asthma morbidity in the United States have been limited to a small number of cities and/or pollutants and with limited consideration of effects across ages. OBJECTIVES: To estimate acute age group-specific effects of fine and coarse particulate matter (PM), major PM components, and gaseous pollutants on emergency department (ED) visits for asthma during 2005-2014 across the United States. METHODS: We acquired ED visit and air quality data in regions surrounding 53 speciation sites in 10 states. We used quasi-Poisson log-linear time-series models with unconstrained distributed exposure lags to estimate site-specific acute effects of air pollution on asthma ED visits overall and by age group (1-4, 5-17, 18-49, 50-64, and 65+ y), controlling for meteorology, time trends, and influenza activity. We then used a Bayesian hierarchical model to estimate pooled associations from site-specific associations. RESULTS: Our analysis included 3.19 million asthma ED visits. We observed positive associations for multiday cumulative exposure to all air pollutants examined [e.g., 8-d exposure to PM2.5: rate ratio of 1.016 with 95% credible interval (CI) of (1.008, 1.025) per 6.3-µg/m3 increase, PM10-2.5: 1.014 (95% CI: 1.007, 1.020) per 9.6-µg/m3 increase, organic carbon: 1.016 (95% CI: 1.009, 1.024) per 2.8-µg/m3 increase, and ozone: 1.008 (95% CI: 0.995, 1.022) per 0.02-ppm increase]. PM2.5 and ozone showed stronger effects at shorter lags, whereas associations of traffic-related pollutants (e.g., elemental carbon and oxides of nitrogen) were generally stronger at longer lags. Most pollutants had more pronounced effects on children (<18 y old) than adults; PM2.5 had strong effects on both children and the elderly (>64 y old); and ozone had stronger effects on adults than children. CONCLUSIONS: We reported positive associations between short-term air pollution exposure and increased rates of asthma ED visits. We found that air pollution exposure posed a higher risk for children and older populations. https://doi.org/10.1289/EHP11661.

Monitoring vs. modeled exposure data in time-series studies of ambient air pollution and acute health outcomes.

BACKGROUND: Population-based short-term air pollution health studies often have limited spatiotemporally representative exposure data, leading to concerns of exposure measurement error. OBJECTIVE: To compare the use of monitoring and modeled exposure metrics in time-series analyses of air pollution and cardiorespiratory emergency department (ED) visits. METHODS: We obtained daily counts of ED visits for Atlanta, GA during 2009-2013. We leveraged daily ZIP code level concentration estimates for eight pollutants from nine exposure metrics. Metrics included central monitor (CM), monitor-based (inverse distance weighting, kriging), model-based [community multiscale air quality (CMAQ), land use regression (LUR)], and satellite-based measures. We used Poisson models to estimate air pollution health associations using the different exposure metrics. The approach involved: (1) assessing CM-based associations, (2) determining if non-CM metrics can reproduce CM-based associations, and (3) identifying potential value added of incorporating full spatiotemporal information provided by non-CM metrics. RESULTS: Using CM exposures, we observed associations between cardiovascular ED visits and carbon monoxide, nitrogen dioxide, fine particulate matter, elemental and organic carbon, and between respiratory ED visits and ozone. Non-CM metrics were largely able to reproduce CM-based associations, although some unexpected results using CMAQ- and LUR-based metrics reduced confidence in these data for some spatiotemporally-variable pollutants. Associations with nitrogen dioxide and sulfur dioxide were only detected, or were stronger, when using metrics that incorporate all available monitoring data (i.e., inverse distance weighting and kriging). SIGNIFICANCE: The use of routinely-collected ambient monitoring data for exposure assignment in time-series studies of large metropolitan areas is a sound approach, particularly when data from multiple monitors are available. More sophisticated approaches derived from CMAQ, LUR, or satellites may add value when monitoring data are inadequate and if paired with thorough data characterization. These results are useful for interpretation of existing literature and for improving exposure assessment in future studies. IMPACT STATEMENT: This study compared and interpreted the use of monitoring and modeled exposure metrics in a daily time-series analysis of air pollution and cardiorespiratory emergency department visits. The results suggest that the use of routinely-collected ambient monitoring data in population-based short-term air pollution and health studies is a sound approach for exposure assignment in large metropolitan regions. CMAQ-, LUR-, and satellite-based metrics may allow for health effects estimation when monitoring data are sparse, if paired with thorough data characterization. These results are useful for interpretation of existing health effects literature and for improving exposure assessment in future air pollution epidemiology studies.

Factors influencing the success of male introductions into groups of female rhesus macaques: Introduction technique, male characteristics and female behavior.

In captive populations of rhesus macaques, novel adult males are commonly introduced to female groups every few years to prevent inbreeding, which mimics male dispersal in wild macaque populations. However, introducing adult males is challenging because macaques are aggressive to newcomers, which can result in serious injuries. Efforts to reduce trauma risk during the introduction process and increase the probability of success are needed. Here we investigate the impact of multiple factors, including male attributes (e.g., age, weight, rank, and experience), introduction method (punctuated vs. continual exposure to females), and female behavior, on males' trauma risk and integration success. We studied eight introductions of multimale cohorts (3-7 males each; N = 36 total) into existing female groups of rhesus macaques at the Yerkes National Primate Research Center. Four cohorts were introduced using the punctuated exposure method where adult males were moved each morning from run housing to the females' indoor enclosure and returned to run housing in the afternoon, and four cohorts were introduced using the continual exposure method where adult males were moved to an introduction enclosure attached to the females' outdoor compound, allowing males to live in protected contact next to the female group continuously. Generalized linear mixed models fitted to trauma risk (e.g., latency to first trauma; total trauma count) and success or failure to integrate (i.e., continual residence within the female group for greater than 53% of days within a 28-day window after first overnight stay) showed that continual exposure to females in the introduction enclosure reduced male trauma risk and increased the likelihood of successful integration compared to punctuated exposure. Males received less trauma when they received a higher rate of grooming from females. Male attributes had no effect. These findings highlight the importance of introduction technique and female behavior in the process of males' social integration into female groups.

Time-series analysis of daily ambient temperature and emergency department visits in five US cities with a comparison of exposure metrics derived from 1-km meteorology products.

BACKGROUND: Ambient temperature observations from single monitoring stations (usually located at the major international airport serving a city) are routinely used to estimate heat exposures in epidemiologic studies. This method of exposure assessment does not account for potential spatial variability in ambient temperature. In environmental health research, there is increasing interest in utilizing spatially-resolved exposure estimates to minimize exposure measurement error. METHODS: We conducted time-series analyses to investigate short-term associations between daily temperature metrics and emergency department (ED) visits for well-established heat-related morbidities in five US cities that represent different climatic regions: Atlanta, Los Angeles, Phoenix, Salt Lake City, and San Francisco. In addition to airport monitoring stations, we derived several exposure estimates for each city using a national meteorology data product (Daymet) available at 1 km spatial resolution. RESULTS: Across cities, we found positive associations between same-day temperature (maximum or minimum) and ED visits for heat-sensitive outcomes, including acute renal injury and fluid and electrolyte imbalance. We also found that exposure assessment methods accounting for spatial variability in temperature and at-risk population size often resulted in stronger relative risk estimates compared to the use of observations at airports. This pattern was most apparent when examining daily minimum temperature and in cities where the major airport is located further away from the urban center. CONCLUSION: Epidemiologic studies based on single monitoring stations may underestimate the effect of temperature on morbidity when the station is less representative of the exposure of the at-risk population.

Using logic regression to characterize extreme heat exposures and their health associations: a time-series study of emergency department visits in Atlanta.

BACKGROUND: Short-term associations between extreme heat events and adverse health outcomes are well-established in epidemiologic studies. However, the use of different exposure definitions across studies has limited our understanding of extreme heat characteristics that are most important for specific health outcomes or subpopulations. METHODS: Logic regression is a statistical learning method for constructing decision trees based on Boolean combinations of binary predictors. We describe how logic regression can be utilized as a data-driven approach to identify extreme heat exposure definitions using health outcome data. We evaluated the performance of the proposed algorithm in a simulation study, as well as in a 20-year time-series analysis of extreme heat and emergency department visits for 12 outcomes in the Atlanta metropolitan area. RESULTS: For the Atlanta case study, our novel application of logic regression identified extreme heat exposure definitions that were associated with several heat-sensitive disease outcomes (e.g., fluid and electrolyte imbalance, renal diseases, ischemic stroke, and hypertension). Exposures were often characterized by extreme apparent minimum temperature or maximum temperature over multiple days. The simulation study also demonstrated that logic regression can successfully identify exposures of different lags and duration structures when statistical power is sufficient. CONCLUSION: Logic regression is a useful tool for identifying important characteristics of extreme heat exposures for adverse health outcomes, which may help improve future heat warning systems and response plans.

Use of Introduction Enclosures to Integrate Multimale Cohorts into Groups of Female Rhesus Macaques (Macaca mulatta).

Integrating animals into a new group is a challenge for both free-ranging and captive adult male rhesus monkeys (Macaca mulatta), and for females in groups receiving new males. To ensure the genetic viability of the population, however, male transfers must occur in both natural and captive settings. To facilitate the introduction of groups of adult males to adult females, we designed a new enclosure that is attached to the outdoor compound where females are housed. Here we describe the construction of 3 introduction enclosures, their use during 4 introductions of groups of adult males to adult females, a brief comparison of introduction success rates associated with the new introduction enclosures with those of our traditional male introduction method, and a critique by the various groups of staff members working with the new enclosures. Overall, the introduction enclosures benefitted both the macaques and the facility personnel and appear to be a useful enhancement to our process of integrating breeding groups.

Early developmental changes in visual social engagement in infant rhesus monkeys.

Impairments in social interaction in Autism Spectrum Disorder (ASD) differ greatly across individuals and vary throughout an individual's lifetime. Yet, an important marker of ASD in infancy is deviations in social-visual engagement, such as the reliably detectable early deviations in attention to the eyes or to biological movement (Klin et al., 2015). Given the critical nature of these early developmental periods, understanding its neurobehavioral underpinnings by means of a nonhuman primate model will be instrumental to understanding the pathophysiology of ASD. Like humans, rhesus macaques 1) develop in rich and complex social behaviors, 2) progressively develop social skills throughout infancy, and 3) have high similarities with humans in brain anatomy and cognitive functions (Machado and Bachevalier, 2003). In this study, male infant rhesus macaques living with their mothers in complex social groups were eye-tracked longitudinally from birth to 6 months while viewing full-faced videos of unfamiliar rhesus monkeys differing in age and sex. The results indicated a critical period for the refinement of social skills around 4-8 weeks of age in rhesus macaques. Specifically, infant monkeys' fixation to the eyes shows an inflection in developmental trajectory, increasing from birth to 8 weeks, decreasing slowly to a trough between 14-18 weeks, before increasing again. These results parallel the developmental trajectory of social visual engagement published in human infants (Jones & Klin, 2013) and suggest the presence of a switch in the critical networks supporting these early developing social skills that is highly conserved between rhesus macaque and human infant development.

Effects of chronic oxytocin on attention to dynamic facial expressions in infant macaques.

Studies in a variety of species have reported enhanced prosocial effects after an acute administration of the neuromodulating hormone, oxytocin (OT). Although the exact mechanisms underlying these effects are not fully understood, there is broad interest in developing OT into a treatment for social deficits. Only a few studies, however, have examined the effects of OT if given repeatedly during early development, the period when early intervention is likely to have the greatest benefits for reversing the progression towards social impairment. Those studies, exclusively in rodents, report mixed results. Some have shown enhancement of prosocial behavior, including increased social exploration, but others have shown anti-social effects, including increased aggression. In the present study, infant rhesus macaques were treated with a high-frequency (3× per week) or low-frequency (1× per week) dose of intranasal oxytocin (IN-OT) or placebo (IN-saline) between two and six months of age, after which their reactions to dynamic facial expressions (neutral, lipsmacking and threats) were measured. Results showed that IN-OT, compared to placebo, increased the time monkeys spent viewing the expression videos, but selectively reduced attention to the eyes in neutral faces in a dose dependent manner. The mechanism for this non-prosocial effect may be that repeated IN-OT administration down-regulates the expression of OT receptors in brain regions important for regulating social attention. Consequently, our results raise questions about the efficacy of implementing chronic IN-OT as a pharmacotherapy for the treatment of social deficits, particularly if given early in development. More work is needed, not only to identify optimal treatment schedules, but also to understand how IN-OT exerts its influences on the brain and behavior.

Practice patterns in the evaluation and management of dementia by primary care residents, primary care physicians, and geriatricians.

With the aim of determining if specialty type or the amount of geriatric training during primary care residencies correlated with the rate of and comfort with dementia identification and management in patients 65 years and older, physician practice patterns were compared through a web-based survey. The survey was sent to family medicine, internal medicine, and geriatric physicians in Dallas County and the HealthTexas Provider Network as well as third-year family medicine and internal medicine residents in Texas. Chi-square analyses revealed no relationship between the quantity of geriatric training and either dementia screening rates or comfort with dementia diagnosis. However, there was a significant difference in these areas based on specialty: more geriatricians reported asking senior patients about memory problems and being very comfortable in making a diagnosis of dementia, while fewer family medicine and internal medicine physicians reported being very comfortable in making the dementia diagnosis. Most physicians surveyed supported instituting routine screening and evaluation of senior patients during residency training. Further research is needed to determine if brief screening modalities, enhanced training, and institution of national guidelines would result in earlier identification and management of dementia in primary care.

Management of attention-deficit hyperactivity disorder in adults: focus on methylphenidate hydrochloride.

Attention-deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in young adults and causes significant psychosocial impairment and economic burden to society. Because of the paucity of long-term evidence and lack of national guidelines for diagnosis and management of adult ADHD, most of the data are based on experience derived from management of childhood ADHD. This article reviews the current evidence for the diagnosis and management of adult ADHD with special emphasis on the role of methylphenidate hydrochloride preparations in its treatment. Methylphenidate hydrochloride, a stimulant that acts through the dopaminergic and adrenergic pathways, has shown more than 75% efficacy in controlling the symptoms of adult ADHD. Although concern for diversion of the drug exists, recent data have shown benefits in preventing substance use disorders in patients with adult ADHD.

Attention deficit/hyperactivity disorder in adults.

Attention deficit/hyperactivity disorder (ADHD), characterized by inattention, hyperactivity/impulsivity, or a combination of these, is being increasingly recognized in adults. Adult ADHD prevalence rates range from 1% to 4%. The pathophysiology of adult ADHD is likely multifactorial, including genetic, environmental, and neurobiological influences. Though ADHD diagnostic criteria per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) were developed based on child samples, the symptoms are believed to be similar in adults, with some developmental differences in symptom presentation. This article identifies common presenting complaints of adults who have ADHD and provides information useful for differential diagnosis of these patients. Specific strategies for pharmacological and nonpharmacological intervention are also presented.

Wellness and Impairment Content in Schools of Medicine Curricula in the United States and Canada.

Medical students experience numerous stressors, ranging from academic demands to financial strain. These stressors contribute to medical students having a substantial incidence of psychological problems, substance abuse, and seeking of mental health treatment. Left untreated, these problems can result in dysfunctional habit development and subsequent professional impairment. Research has demonstrated the benefits of wellness-impairment educational programs in medical education, but it is unknown to what degree the topics of wellness and impairment are included in medical school curricula. To assess this, a 13-item survey instrument was sent to associate deans in 142 schools of allopathic medicine; 71 (50.0%) responded. The majority of respondents reported that physician impairment (95.8%) and wellness (77.5%) are addressed in their school of medicine curricula, although the degree to which these topics were included varied. Access to other health-promoting resources on campus was also assessed and is discussed. Results suggested that there is a disparity between primary and secondary prevention approaches on school of medicine campuses. Implications for curricula and directions for future research are discussed.